Perhaps more than any other manifestation of global apartheid, the AIDS pandemic exposes the fact that the distribution of current suffering associated with global inequality, as in the past five centuries, is clearly linked to place and race. According to the World Health Organization (WHO), forty-four of the fifty-two countries with life expectancies of less than fifty years are in Africa (with life expectancies still declining due to AIDS). The glacial pace of the international response to AIDS reflects an entrenched double standard characteristic of the apartheid system. As Dr. Peter Piot of UNAIDS remarked just before the World AIDS conference in South Africa last year, "If this had happened with white people, the reaction would have been different."

Health is one of the fundamental human rights embodied in the 1946 constitution of the WHO and the 1948 Universal Declaration of Human Rights. Specifically, the WHO constitution says, "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." Article 25 of the Universal Declaration states that "Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services." As even mainstream economists increasingly recognize, health is one of the fundamental prerequisites for development. Along with education and income, it is one of the three components of the UN's Human Development Index, which has gained wide acceptance in theory, if not in practice, as a better benchmark than purely economic indicators like per capita income. In fact, health is the human right that in practice most visibly marks distinctions of race, or of economic or social condition.

Whether governments and international organizations actually have an obligation to enforce this right is hotly disputed. The Bush Administration, following in the steps of its predecessors, stressed in its March 30 response to the UN's draft declaration on AIDS that "for legal and constitutional reasons, the United States cannot accept a 'rights based approach' to HIV/AIDS--any more than it can accept a rights based approach to food, shelter or hunger." At the UN High Commission on Human Rights in April, the United States alone abstained on an otherwise unanimously supported Brazilian resolution recognizing "that access to medication in the context of pandemics such as HIV/AIDS is one fundamental element...of the right... to health."

The scale of the AIDS pandemic is unprecedented. But AIDS is like other widespread diseases in that it is fueled not only by unequal access to medical care but also by social and economic conditions. Poverty and gender inequality fuel the pandemic in Africa. Malnutrition reduces resistance to disease. Migrant labor patterns (well entrenched in Africa from colonialism and apartheid) raise the risk of infection. The proximate cause of the spread of AIDS is HIV, but vulnerability to infection is linked not only to behavior but especially to unequal power relations between women and men, and to poverty and living conditions [see Eileen Stillwaggon, "AIDS and Poverty in Africa," May 21]. Poverty, in turn, is linked to race and to the structural position of communities within countries and of countries within the world economy.

Thus debating what is to be done about AIDS keeps leading back to broader issues. Unless women have the freedom to negotiate the terms of sex, increased awareness and availability of condoms will have only limited impact. Health services deprived of basic resources will be unable to meet the need for treatment or prevention of AIDS. Meeting in Abuja, Nigeria, in April, African leaders agreed on a target of spending at least 15 percent of their national budgets on health, two or three times the current levels. But their chances of meeting this target are slim if they are forced to give priority to paying illegitimate foreign debts over making investments in public health (or if they choose to divert resources to war or personal gain).

Some cite such factors as excuses for inaction. Even as prices of antiretroviral drugs drop in response to protest and generic competition, the lack of health infrastructure and the inability of governments to pay even the reduced prices become new rationales for denying antiretroviral treatment to Africans. As one unidentified international health official told the Washington Post on April 23, while deploring the political stance of activists, "We may have to sit by and just see these millions of people die."

The alternate response is to address the reasons for lack of infrastructure and inability to pay. That leads back to policies imposed by international financial institutions in the 1980s and 1990s and, in a longer view, to harsh historical legacies that policy-makers still refuse to confront. Granted, corruption and policy mistakes by African leaders also play a role. But in Africa and in other developing regions, unsustainable debt and weakened health systems result in large part from economic policy conditions imposed by international creditors during the past two decades. The imposition of "user fees" for primary healthcare, for example, drove large numbers away from public health services, contributing to increased rates of sexually transmitted diseases. More generally, cutbacks in the public sector helped send health professionals to the private sector or abroad and reduced investments in healthcare delivery systems. Creditors representing a collective economic colonialism managed by the World Bank and IMF increasingly dictated public health and other policies of poor countries. Debt provided the leverage to enforce the economic diktat of global apartheid by the rich upon the poor.

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