AIDS and global justice

“The bottom line is, the people who are dying from AIDS don't matter in this world.”¹

Remember HIV/AIDS? This theme issue of the BMJ challenges the global community to overcome its amnesia and fatigue, mobilise its ample collective resources, and make 2002 the turning point in tackling HIV.

The theme that dominates these pages is the need for justice. In his Theory of Justice, John Rawls, perhaps the most important moral philosopher of the 20th century, argued that justice is required when there is a struggle for scarce resources and when life is brief.² Both of these conditions are met in those countries devastated by HIV. Authors in this week's BMJ demand actions that are based on justice: the distribution of antiretroviral drugs to the world's poorest people; the empowerment of women; the urgent search for an HIV vaccine; and the care and education of children orphaned by AIDS.

Wealthy countries must take the lead in acting justly. Their colonisation of the regions now struggling with rising HIV rates, like India and Africa, left behind a legacy of exploitation and oppression and an ongoing power imbalance between rich and poor countries.³,⁴ Part of this imbalance is economic. The aggregate national income of wealthy countries recently surpassed $21 trillion annually. These countries quickly came up with astounding sums of money for an antiterrorism campaign, so they could surely find the $7-10 billion needed annually to fight HIV.⁵

The creation of the new global fund to fight AIDS, tuberculosis, and malaria sent a message that the world does care about HIV/AIDS. But ever since its proposal by Kofi Annan last year, there has been intense speculation about whether the fund will be able to meet its aims,⁶ which are “to attract, manage and disburse additional resources through a new public-private partnership.”⁷ It was supposed to be operational by the end of last year. How is it performing?

On its first aim, the answer is poorly. The total pledges to the fund ($1.7bn,⁸ or about $700m for this fiscal year) are hugely disproportionate to what is needed. As for management and disbursal, these remain a mystery. There were three meetings last year of a transitional working group and a 14 member board will meet for the first time on 28 January, after which resources will be disbursed. Yet there is still almost no public knowledge about exactly what the fund will pay for (perhaps treatments, health systems support, or both), and how it will make its funding decisions. This is worrying. We need reassurance that the fund will avoid the major pitfalls—lack of governance and poor accountability—that have plagued other public-private health initiatives.⁹

In thinking about justice and the global fund, Rawls might ask a simple question. Will the fund change the life of, say, a pregnant woman with HIV living in Malawi, whose husband has died of AIDS and who is caring for three children? This depends on four things, which, echoing Rawls, we could call the “conditions of justice.”

Firstly, it must pay to treat those already infected. Treatment must include antiretroviral drugs. Yet in its statement of underlying principles, the fund′s transitional working group says it will pursue “an integrated and balanced approach.”¹⁰ Is this coded language for saying that treatment will not be a priority? Médecins Sans Frontières thinks so. In a letter to the group, Bernard Pecoul, director of Médecins Sans Frontières' access to essential medicines campaign, expressed concern that, “because donors and some in the international health community traditionally favour prevention at the expense of treatment, patients already infected will be written off as not sufficiently cost effective to treat.”¹¹ On p 247, Emily Bass, a Ugandan woman, calls on the world “to acknowledge that you cannot talk about prevention without treatment.”¹²

Secondly, the fund must respond to the local needs of the poorest countries themselves, and not to donors' priorities. The ideal scenario is arguably one in which the fund supports a poor country that has put forward a technically feasible proposal. It is promising that the fund's board will have an equal number of members from donor and recipient countries—hopefully this will translate into an equal power relationship.

Thirdly, the fund must purchase drugs at the lowest cost possible, which in some cases might be generic versions. The fund's board, however, includes a representative from the pharmaceutical industry, in a voting seat. The fund must not end up underwriting the drug patent monopolies currently enjoyed by industry.

Fourthly—and this is the most important condition of justice—the fund must show measurable success. It must do something new and different in fighting HIV/AIDS, where previous global initiatives have failed. Donor money is not flowing into the fund because donors currently see no guarantee from their investment. For the fund to thrive, it has to address this lack of confidence. It has to show that it can cut deaths due to AIDS, prevent new HIV infections, and support care of orphans.

When the philosopher Thucydides was asked when justice would come to Rome, he famously replied that it would come when those who are not injured are as indignant as those who are. So let us all feel indignant about the worsening HIV pandemic—as if “we all have AIDS”¹³—and let us make sure that the global fund turns this anger into action.