A Modest Proposal

While America debates the disposition of $5 trillion in budget surpluses over the next decade, tens of millions of impoverished people in Africa will die needlessly of AIDS and other killer diseases because they lack the minimal income needed for lifesaving drugs and medical care. Their deaths will leave behind tens of millions of orphans, who will lose the chance for an education and an emotionally secure upbringing. Neither President George W. Bush nor his political adversaries have yet to mention the poorest of the world in their debates over how to spend America's great bounty. So far, the United States and other rich countries have done almost nothing to help the poorest of the poor to fight AIDS, the greatest pandemic in modern history. The disease is hard to combat for several reasons. Most important, treatment is expensive. An annual drug regimen might cost about $500 per patient per year, but the poorest countries in Africa can afford only a few dollars per person per year in total health-care spending, an amount that in principle must cover not only AIDS, but other killers like malaria and tuberculosis that ravage the continent.

Without treatment, even prevention proves to be impossible. Effective prevention requires that individuals submit to testing for HIV, the virus that causes AIDS, and then to counseling and behavioral change if they are infected. But when treatment is not available, individuals shun testing. To be found HIV-positive is not a gateway to treatment, but a mark of certain death and therefore social and economic exclusion. It is estimated that perhaps only 5 percent of the 25 million or so in Africa who are currently HIV-positive even know that they are infected, and fewer than one in a thousand receive anti-retroviral treatment. Since the infection remains latent for many years--that is, without many clinical symptoms--infected individuals may infect many others before their AIDS becomes evident.

The rich countries have so far offered almost no funding for prevention or treatment of AIDS. It used to be said that the price for treatment was impossibly high, but now drug companies (both the major patent holders and the smaller generics producers) have signaled their readiness to supply the drugs cheaply to the poorest countries. But even at those low prices the countries are too impoverished to make use of the drugs.

The straightforward solution is for the United States and other rich countries to help pick up the tab. Washington should lead the rich-country governments in setting up a Global AIDS Trust Fund under the auspices of the World Health Organization and UNAIDS, the partnership of international agencies fighting the disease. The fund would buy drugs at low cost from the major producers, then distribute them free to the impoverished countries under strict protocols to make sure that the drugs are used effectively and don't end up in a black market. The U.S. National Institutes of Health and the Centers for Disease Control, working with leading medical schools, public-health faculties and medical associations around the world, would help the African countries increase their capacities to deliver these medicines in a safe and effective manner. Expert monitoring of drug use will be especially needed since misuse of the drugs could lead to a rapid spread of drug-resistant viruses, limiting their effectiveness.

Cost estimates suggest that the United States would need to contribute about $5 billion per year to a comprehensive effort to fight AIDS, malaria, tuberculosis and other killer diseases, which would be part of a truly global partnership on the scale of $10 billion to $20 billion per year for Africa. Would Americans stand for it? Since the U.S. annual income is now $10 trillion per year, the $5 billion would amount to around 5 cents for every $100 of American income. The bulging budget surpluses could obviously cover the needed sums. Such a modest effort would save several million lives per year, and enable Africa to break out of its tragic downward spiral of disease and poverty. The long-term savings to the United States, in terms of greater stability and development in Africa, and less risk of globally transmitted diseases, would be enormous. In addition, Americans would use their good fortunes, their technological wizardry and their compassion in the service of the world. What a bargain.

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