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Amidst the poverty of Africa, I stand before you because I am able to purchase health and vigour. I am here because I can pay for life itself. To me this seems a shocking and monstrous iniquity of very considerable proportions - that, simply because of relative affluence, I should be living when others have died; that I should remain fit and healthy when illness and death beset millions of others.

Given the epidemic's two most signal changes, in demographics and in medical science, it must surely be that the most urgent challenge it offers us is to find constructive ways of bringing these life-saving drugs to the millions of people whose lives and well-being can be spared by them.

Instead of continuing to accept what has become a palpable untruth (that AIDS is of necessity a disease of debility and death), our overriding and immediate commitment should be to find ways to make accessible for the poor what is within reach of the affluent.

If this is the imperative that our circumstances impose upon us, one would have expected the four years since Vancouver to have been filled with actions directed to its attainment by those with power to change the course of history and the force of the epidemic.

Instead, from every side, those millions living with AIDS in resource-poor countries have been disappointed. International agencies, national governments, and especially those who have primary power to remedy the iniquity - the international drug companies - have failed us in the quest for accessible treatment.

In my own country, a government that in its commitment to human rights and democracy has been a shining example to Africa and the world has at almost every conceivable turn mismanaged the epidemic. So grievous has governmental ineptitude been that South Africa has since 1998 had the fastest-growing HIV epidemic in the world. It currently has one of the world's highest prevalences. Nor has there been silence, as the title of my lecture suggests. Indeed, there has been a cacophony of task groups, workshops, committees, councils, policies, drafts, proposals, statements, and pledges. But all have thus far signified piteously little.

A basic and affordable humane intervention would be a national programme to limit mother-to-child transmission of HIV through administration of short courses of anti-retroviral medication. Research has shown this will be cost-effective in South Africa. Such a programme, if implemented, would have signaled our government's appreciation of the larger problem, and its resolve to address it. To the millions of South Africans living with HIV, it would have created a ray of light. It would have promised the possibility of increasingly constructive interventions for all with HIV, including enhanced access to drug therapies.

To our shame, our country has not yet come so far as even to commit itself to implementing such a programme. The result, every month, is that 5 000 babies are born, unnecessarily and avoidably, with HIV. Their lives involve preventable infections, preventable suffering, and preventable death. And if none of that is persuasive, then from the point of view of the nation's economic self-interest, their HIV infections entail preventable expense. Yet we have done nothing.

In our national struggle to come to grips with the epidemic, perhaps the most intractably puzzling episode has been our President's flirtation with those who in the face of all reason and evidence have sought to dispute the aetiology of AIDS. This has shaken almost everyone responsible for engaging the epidemic. It has created an air of unbelief amongst scientists, confusion among those at risk of HIV, and consternation amongst AIDS workers.

One of the continent's foremost intellectuals, Dr Mamphela Rampele, has described the official sanction given to scepticism about the cause of AIDS as "irresponsibility that borders on criminality". If this aberrant and distressing interlude has delayed the implementation of life-saving measures to halt the spread of HIV and to curtail its effects, then history will not judge this pronouncement too harsh. I cannot believe that our President's address at the opening last night has done enough to alleviate the concerns.

At the international level also, there have been largely frustration and disappointment. At the launch of the International Partnership Against AIDS in Africa in December 1999, UN Secretary General Kofi Annan made an important acknowledgement. He stated: "Our response so far has failed Africa". The scale of the crisis, he said, required "a comprehensive and coordinated strategy" between governments, inter-governmental bodies, community groups, science and private corporations.

That was seven long months ago. In seven months, there are more than 200 days: days in which people have fallen sick and others have died; days on each of which, in my country alone, approximately 1 700 people have become newly infected with HIV.

In that time, the World Bank, to its credit, has made the search for an AIDS vaccine one of its priorities. President Clinton, to his credit, in an effort "to promote access to essential medicines", has issued an executive order that somewhat loosens the patent and trade throttles around the necks of African governments. And UNAIDS, to its credit, "has begun" what it describes as "a new dialogue" with five of the biggest pharmaceutical companies. The purpose is "to find ways to broaden access to care and treatment, while ensuring rational, affordable, safe and effective use of drugs for HIV/AIDS-related illnesses".

All these efforts are indisputably commendable. But, whether taken individually or together, they fail to command the urgency and sense of purpose appropriate to an emergency room where a patient is dying. The analogy is under-stated - for the patients who are dying number in their tens of millions. For each of them, and for all their families and loved ones, the emergency is dire and immediate. What is more, the treatment that can save them exists. What is needed is only that it be made accessible to them.

Amidst all these initiatives, the critical question remains drug pricing. No one denies that drug prices are "only one among many obstacles to access" in poor countries. But there are many, many persons in the resource-poor world for whom prices on their own are, right now, the sole impediment to health and well-being. A significant number of Africans with access to healthcare could pay modest amounts for the drugs now. On any scenario, therefore, lowering drug prices immediately is necessary. It should therefore be an immediate and overriding priority.

In fact, lower drug prices are an indispensable precondition to creating just and practicable access to care and treatment. This is so for a number of reasons. First, the debate about drug pricing diverts attention and energy from the other vital issues, such as creating the institutional infrastructure for delivery and monitoring in poor countries. Second, it has sadly provided some governments with a make-weight for delaying implementation of programmes to prevent mother-to-child transmission of the virus. It has delayed also consideration of more ambitious alternatives in anti-retroviral therapy.

Amidst all of this, it is hard to avoid the impression that the drug companies are shadow-boxing with the issues. There is some evidence that they, in turn, are using lack of governmental commitment on drug provision as a pretext for not lowering drug prices immediately. There certainly has been no immediate follow-through to the announcement eight weeks ago that five of the largest drug companies had undertaken to "explore" ways to reduce their prices. This has devastated the hopes of many poor people who need lower prices, now, to stay alive and healthy.

It is in this context that it is also hard to avoid the conclusion that UNAIDS - whose programme leader, Dr Peter Piot, is a perceptive man of principle who worked with Jonathan Mann in Africa - has failed to muster its institutional power with sufficient resourcefulness, sufficient creativity and sufficient force.

Amidst this disappointment, it is quite wrong to speak, as the title of my lecture does, of "the deafening silence of AIDS". There has not been a silence. Gugu Dhlamini was not silent. She paid with her life for speaking out about her HIV status. But she was not silent. And her death has not silenced many other South Africans living with AIDS, black and white, male and female - most who are less privileged than I - who have spoken out for dignity and justice in the epidemic.

There has also been the principled trumpet of treatment activism. In America, brave activists changed the course of presidential politics by challenging Vice-President Gore's stand on drug pricing and trade protection. Their actions paved the way for subsequent revisions of President Clinton's approach to the drug pricing issue.

In my own country, a small and under-resourced group of activists in the Treatment Action Campaign, under the leadership of Zackie Achmat, has emerged. In the face of considerable isolation and hostility, they have succeeded in re-ordering our national debate about AIDS. And they have focussed national attention on the imperative issues of poverty, collective action and drug access. In doing so they have energised a dispirited PWA movement with the dignity of self-assertion, and renewed within it the faith that by action we can secure justice.

In the last years of his life Jonathan Mann began speaking with increasing passion about the moral imperatives to action that challenge us all. He well understood that this involves what he called: "A challenge to the political and societal status quo."

He also understood, in his last writing, the fundamental significance of human dignity in the debate about health and human rights. His work foreshadowed the transition of health and human rights and the "HIV paradox" to a full human entitlement to health care, where the means for it are available.

Ten months before his death, in November 1997, he called on an audience to place themselves "squarely on the side of those who intervene in the present, because they believe that the future can be different".

That is the true challenge to this Conference: to make the future different. Drugs are available to make AIDS, for most people with the virus, a chronically manageable disease. But for most people with the virus, unless we intervene in the present with immediate urgency, that will not happen.

We gather here in Durban as an international grouping of influential and knowledgeable people concerned about alleviating the effects of this epidemic. By our mere presence here, we identify ourselves as the 12 000 best-resourced and most powerful people in the epidemic. By our action and resolutions and collective will, we can make the future different for many millions of people with AIDS and HIV for whom the present offers only illness and death.

This gathering can address the drug companies. It can demand not dialogue, but urgent and immediate price reductions for resource-poor countries. It can challenge the companies to permit without delay parallel imports and the manufacture under license of drugs for which they hold the patents.

Corporately and individually we can address the governments and inter-governmental organisations of the world, demanding a plan of crisis intervention that will see treatments provided under managed conditions to those who most need them.

Vancouver four years ago was a turning point in the announcement of the existence of these therapies. This Conference can be a turning point in the creation of an international impetus to secure equitable access to these drugs for all persons with AIDS in the world.

Moral dilemmas are all too easy to analyse in retrospect. Many books have been written about how ordinary Germans could have tolerated the moral iniquity that was Nazism; or how white South Africans could have countenanced the evils that apartheid inflicted, to their benefit, on the majority of their fellows.

Yet the position of people living with AIDS or HIV in Africa and other resource-poor countries poses a comparable moral dilemma for the developed world today. The inequities of drug access, pricing and distribution mirror the inequities of a world trade system that weighs the poor with debt while privileging the wealthy with inexpensive raw materials and labour.

Those of us who live affluent lives, well-attended by medical care and treatment, should not ask how Germans or white South Africans could tolerate living in proximity to moral evil. We do so ourselves today, in proximity to the impending illness and death of many millions of people with AIDS. This will happen, unless we change the present government ineptitude and corporate blocking. Available treatments are denied to those who need them for the sake of aggregating corporate wealth for shareholders who by African standards are already unimaginably affluent.

That cannot be right, and it cannot be allowed to happen. No more than Germans in the Nazi era, nor more than white South Africans during apartheid, can we at this Conference say that we bear no responsibility for 30 million people in resource-poor countries who face death from AIDS unless medical care and treatment is made accessible to them.

The world has become a single sphere, in which communication, finance, trade and travel occur within a single entity. How we live our lives affects how others live theirs. We cannot wall off the plight of those whose lives are proximate to our own.

That is Mann's call - the clarity of his call - his legacy to the world of AIDS policy; and it is the challenge of his memory to this Conference today.



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