This week the 15th International AIDS Conference is being held in Bangkok. A fellow at the Harvard University School of Public Health reviews two recent books on the U.S.'s response to the catastrophe of AIDS in Tuesday's New York Times. Both authors are outraged, and there is plenty of blame to go around -- not least to a silently complicit public....

Books of the Times

By Sheri Fink

** Bush is accused of impeding the use of cheaper drugs **

New York Times
July 13, 2004
Page B06

[REVIEW of Greg Behrman, The Invisible People: How the U.S. Has Slept Through the Global AIDS Pandemic, the Greatest Humanitarian Catastrophe of Our Time (352 pages, Free Press - $25) and Anne-Christine d'Adesky, Moving Mountains: The Race to Treat Global AIDS (487 pages, Verso - $30).]

Deaths from AIDS have plummeted in the United States but are soaring in poor countries, where millions of ill adults and children lack access to life-extending medications available in wealthier countries. Framing the multitude of avoidable AIDS deaths as a monumental crime, two books dust for the fingerprints of politicians and multinational corporations while taking the wider public to task for years of complicit silence.

In The Invisible People, Greg Behrman, an AIDS policy coordinator for the Council on Foreign Relations, tracks anemic global AIDS spending through several American administrations, profiling a dizzying array of power brokers. Anne-Christine d'Adesky's Moving Mountains -- by turns journalistic, textbook-like and polemical -- discusses the myriad obstacles to preventing and treating AIDS in poor countries but highlights successes that prove it is possible. (Many of these issues are being discussed this week at the 15th International Aids Conference in Bangkok.)

The Invisible People grew from Mr. Behrman's Oxford University master's degree research on the H.I.V./AIDS pandemic as a threat to American national security. Noting that life expectancy in several African countries had dropped by more than 30 years and that the disease was spreading quickly in Asia and Eastern Europe, he began to wonder, "What had the United States done to address this crisis?"

Mr. Behrman writes that as the disease emerged in the Ronald Reagan years of the 1980's, conservative leaders imposed "a vituperative, ill-informed brand of moralism on policy, making it clear to the administration that there would be a political price to pay for engaging AIDS." The opening act in the global AIDS tragedy revealed the government's misguidedly self-interested objective: it banned foreigners with H.I.V. from entering the United States, a policy with little public health merit that remains on the books today.

Money is Mr. Behrman's useful but necessarily limited gauge of global AIDS-fighting commitment. From 1990 to 1999, as tens of millions of H.I.V. infections accrued worldwide, the majority in sub-Saharan Africa, American spending on global AIDS inched to $215 million from $100 million during the presidencies of George H. W. Bush and Bill Clinton. By comparison, the United States, with roughly one million citizens infected over the decade, invested up to $10.6 billion a year to combat the domestic epidemic.

Well researched and unsparing, The Invisible People presents many of the more maddening and inexcusable reasons for the languishing American response to global AIDS in the 1990's, including Congressional antagonism to foreign aid spending, "passive racism," and disarray among United Nations health officials, who failed to offer plausible global figures on H.I.V. prevalence until 1998. Mr. Behrman also points to the early silence of domestic AIDS activists, African-American leaders and heads of countries being ravaged by the disease, although he fails to suggest what types of health programs could have been used to fight global AIDS before effective treatments existed.

The Clinton administration takes the biggest beating in The Invisible People for not recalibrating American spending, for not viewing AIDS as a global security threat and for opposing South Africa's move to obtain low-cost generic antiretroviral medication. Inequities in drug access galvanized pioneers like Dr. Paul Farmer, Doctors Without Borders and the Brazilian government to prove what should not have needed to be proved: that residents of lower-income countries benefit from treatment and also often adhere to their drug-taking regimens better than American patients do.

To show what it took in recent years to force down the cost of effective AIDS regimens from $10,000 a year to less than $200 in some countries and to create the Global Fund to Fight AIDS, Tuberculosis and Malaria, Mr. Behrman takes us into meetings between politicians, grass-roots activists, Christian missionaries, African leaders, generic drug manufacturers and a "motley crew" of luminaries from Bill Gates to Bono to ex-President Clinton himself. Responding to the advocacy, it was ultimately President George W. Bush, making a "180-degree turn on global AIDS" in 2002, who rallied Congress to commit billions of dollars to the fight.

Were money the only gauge of effective action, then it would come as a surprise to read Ms. d'Adesky charge that the Bush administration is "the greatest barrier to access to cheap AIDS medicines for the world." Ms. d'Adesky, a novelist (Under the Bone), filmmaker ("Pills, Profits and Protest") and community organizer, aims to show that the administration has impeded the widespread use of cheaper generic versions of patented antiretroviral medications, in particular fixed-dose combinations that allow patients to take far fewer pills per day.

Both she and Mr. Behrman critique President Bush's 2003 Emergency Plan for AIDS Relief. Mr. Behrman notes that of 10 billion "new" dollars designated for AIDS prevention and treatment over five years, the multilateral Global Fund will receive only $1 billion (not $1 million, the figure Ms. d'Adesky mistakenly cites in one of many examples of sloppiness). The AIDS plan reserves 90 percent of new money for programs administered by the Agency for International Development, an American body, in focus countries that leave out populous India, Russia and China, nations experiencing an explosion of new H.I.V. infections.

Ms. d'Adesky asserts that the bilateral programs allow the administration "to promote a religiously conservative agenda." She writes: "The Bush money favors prevention programs that support sexual abstinence over the use of condoms, and opposes funding groups that support family planning services that even indirectly allow abortion."

Shifting direction, Ms. d'Adesky, with a deft hand for setting scenes, offers glimpses of the H.I.V./AIDS pandemic in eight countries, emphasizing the urgent need to fight stigma, link treatment with prevention and improve health care for prisoners, drug abusers and rural residents. In many cities and villages, medicines to treat AIDS-related infections and even painkillers are lacking.

One word -- outrage -- characterizes the tone of both books, an emotion more than justified by the grim daily toll of AIDS deaths and growing population of AIDS orphans. What is heartening in these important volumes is their celebration of the individuals and groups fighting the H.I.V./AIDS pandemic and managing, at long last, to effect change.

--Dr. Sheri Fink is the author of War Hospital: A True Story of Surgery and Survival and is a visiting fellow at FranÁois-Xavier Bagnoud Center for Health and Human Rights at the Harvard University School of Public Health.