The most radical and almost the only AIDS activism on planet Earth these days is the campaign to get AIDS drugs into African HIVers' bodies. Led by the heroic PWA Zackie Achmat and the Treatment Action Campaign (TAC) in South Africa and supported by ACT UPs in the West as well as Doctors Without Borders, the movement to save the lives of HIVers in sub-Saharan Africa has had great success in a short time. Their commitment is total, their politics are pure, and their respect for South African PWAs' self-determination -- so far as TAC defines it -- has inspired many who previously had no time for AIDS in Africa. So why is it that all the sound and fury about "AIDS drugs to Africa" makes me want to scream?
I believe that the current debate -- who will pay for getting AIDS drugs into African bodies? -- gravely mistakes the symptoms of the continent's viral genocide for its causes. The movement's primary focus on AIDS drugs -- mostly HAART, though the fight for affordable fluconazole and other necessary meds, from antibiotics to aspirin, is also on their agenda -- inadvertently, I think, precludes confronting the heart of the crisis: poverty, lack of clean water and sanitation, such infections as TB, malaria and STDs, and women's inferior status and literacy. Yes, HAART will keep HIVers healthier longer, but it is like putting a Band-Aid on a broken leg. Even if we succeeded in giving antiretrovirals to each of the world's HIVers (an estimated 1 billion by 2010) -- as well as setting up, as Brazilians and South Africans are trying to, a way to monitor drug failure, treat side effects and control all the other complications of combo therapy -- the epidemic would rage on. That's why -- when I hear TAC and their Western comrades yelling about drugs -- I want to yell back, "Now that you've birthed an international treatment activism, what about demanding a public-health campaign for Africa?"
HIVers facing death have the right to save their lives by any means necessary. So it makes profound sense to me that TAC is fighting for access to generic drugs and the reform of patent laws. That right, however, doesn't automatically make the means at ground zero the best ones for those of us on the other side of the world. Looking back on my own ACT UP days, I recall how, in our legitimate and desperate urge to survive, we acted exclusively in our own immediate best interest. We had to make our cause personal -- "AIDS drugs into our queer, junkie, hated bodies" -- in order to get an indifferent world to care. But in focusing so hard on treatment, we invariably ignored many social issues; soon other activists brought their broader agendas to the table. But for the West -- and Americans, especially -- to spend so much of our attention to the global epidemic on getting AIDS drugs to the relative few who can afford even cut-rate or generic antiretrovirals (South Africa, an exception, offers free AIDS meds on the "drug list"), instead of prioritizing a "social" strategy that may save more lives, is tragically misguided. As we learned so painfully in ACT UP, the treatment issues and the social issues are ultimately inseparable.
Through TAC and ACT UP's militancy, AIDS has captured the West's imagination in a way that other killing conditions of poverty -- diarrhea, for one -- never could. That is why it is imperative that we leverage this interest to drive home that developing-world HIVers die so much faster not only because of political and economic injustices, including scarce access to AIDS drugs, but because of the brutal biological fact that untreated TB, malaria and other endemic infections speed up HIV reproduction -- HAART or not. Not to focus on this cause-effect syndrome is a shameful waste of a unique opportunity to get the West to finally address unsexy issues like poverty. After all, the agonizing photographs of African PWAs recently published in Time could easily have been shot before AIDS appeared.
Now that the movement has fired up passions about who will pay for AIDS drugs, it's time ask whether AIDS drugs are the best way to end the epidemic. TAC and ACT UP's answer to their own question is radical and uncompromising: The murderously overpriced drugs should be produced at the lowest possible cost and purchased by local governments. But given what we know about realpolitik in general and Big Pharma and African leaders in particular, it seems doubtful that the activists will have control over the outcome. And every other possible answer may harm as much as help. Will the drug price be paid by pharmaceuticals, with reduced prices or donated product? Or by U.S. HIVers, through inflated prices or shrinking R&D dollars -- measures industry threatens if off-patent licensing and generic manufacture prevail? Or by local governments, forcing them to neglect their countries' other basic needs to meet the demand for cut-rate HAART? Or by taxpayers, with massive appropriations from Congress, justified now that the CIA has declared AIDS a "national security threat"?
The PAC-driven U.S. political system has made Congress and the White House a mere budgeting arm and chief lobbyist, respectively, for major corporations, not least the pharmaceuticals. In turn, activists, the media and the public have been hoodwinked into believing that the gift-wrapped solution for the ever-needy developing world is more money from Congress or corporations. But we Americans are greedy guzzlers of resources -- hey, I too have my SUV, my state-of-the-art HAART and all the rest. We talk a good game, but when it comes down to it, we sacrifice nothing. Africa may sacrifice, activists may sacrifice, but deep-down we in the West just don't get it. At most, we support strategies such as "AIDS drugs to Africa" that conveniently confirm our self-image as "empowering others to help themselves" while giving just enough not to let them. It is the American way. It is also, in a word, bullshit.
To be sure, the activist hoopla has made some progress on the social-issues front: There are now proposals to fund poor countries' access to drugs for a wide range of infections; South African officials view fighting AIDS as a road to reforming overall health care; a fresh new crop of organizations has sprung up to deal with global health issues; the press coverage has dramatized the reality of First/Third World inequalities in an unprecedented way. But it remains likely that "AIDS drugs to Africa" will end up benefiting the sick and dying less than it does the drug industry. And it may cause collateral damage, too, by being exploited for ends the activists never intended. Despite TAC and ACT UP's steadfast rejection of ADAP-like proposals that would slip government dollars into Big Pharma's pockets, their message that HAART is Africa's salvation may indirectly aid and abet Big Pharma's greed: In the end, our tax dollars will end up in their coffers -- it's the American way. So while retaining one of the largest profit margins of any industry, drug makers will be able to lay claim to the kind of "public service" typically reserved for a Mother Teresa.
Ironically, just as the industry's Western market is dwindling, the movement for AIDS drugs to Africa has come of age, creating a huge new demand. Given this, it seems worth asking if ACT UP and TAC may unwittingly play into Big Pharma's hands, which has mobilized to crush the growing pressure to import generic HAART and other meds. The campaign has also given cover to African leaders to take no responsibility for their own epidemics while appearing to take action simply by participating in the plea for a Western "miracle." Despite TAC's string of victories, these radicals are steering into dangerous waters. Today, for example, brought news that South Africa President Thabo Mbeki refused to call a TAC-backed AIDS "National Emergency," which would allow the country to import generic drugs.
Criticism of TAC's movement is hard to make: These people are the only ones in the streets. When was the last time you heard AIDS Action or our national ASOs agitating from their armchairs and cocktail receptions about AIDS in Africa? But being AIDS activism's lone wolf makes TAC and ACT UP even more responsible to promote a broader, long-term strategy: Because Africa's genocide will not be solved by AIDS drugs alone, they must issue a loud and clear demand for a public-health campaign. But the debate the HIV community needs to have should not be about treating either the symptoms by air-dropping HAART or the causes by signing up to build toilets. Or, for that matter, a Solomon's command to fight AIDS either in the black community at home or in sub-Saharan Africa. Both must be done -- by TAC, ACT UP and the rest of us, too.
The campaign requires a radical reallocation of resources, even more than priorities. The ideal is a national sacrifice to provide a healthy quality of life that is every human's birthright. The price is enormous: As a hundreds-of-billions-of-dollars "add on" to government programs, it would require vastly higher taxes and, consequently, less privilege. Dismiss this notion as hot air if you like. But the billions spent on the useless "War on Drugs" would pony up seed money to launch our campaign. Still, until Americans are moved enough to dig into our hearts, we will never dig into our pockets. And until we do that, everything else is just comforting chatter.
Every day, the fight against AIDS progresses further down the road to defeat. Even if HIV is eventually eradicated, the material and spiritual conditions that bred and spread it will enable other deadly infections to commit genocide. Given this long view, a single PWA's own survival can seem meaningless -- a paralyzing conclusion. That is another reason we must start acting up beyond "AIDS drugs to Africa."