On a late June day that will surely have been picked by the political astrologers around him, Kofi Annan of Ghana will likely be coronated for a second five-year term as Secretary General of the United Nations. The 63-year-old Annan's first term doesn't end until December, but since there's no opposition to him, the Security Council--which decides on such things--seems inclined to formally name him in June.
The timing, of course, couldn't be better, both for Annan and the beleaguered UN system, which is hurting financially because the United States, its biggest donor, owes it more than $1.2 billion in arrears and continues to refuse to pay. A freshly crowned Annan will clearly wield re-energized clout as the General Assembly opens a special session on HIV/AIDS on June 25, a three-day conference that is expected to draw even leaders known to harbor antipathy toward the UN--such as George W. Bush.
Annan has made AIDS his special cause this year. He has established a global fund; the initial target was $7-10 billion. Bush has pledged $200 million, a sum that most AIDS activists consider inadequate. It's quite likely that Annan will coax another $300 million out of the Western Europeans. It's not at all certain that the AIDS session will end up as an exercise in effective fundraising, but its value may well lie in drawing unprecedented attention to the subject.
It's probably uncharitable to suggest that Annan's engagement with the AIDS issue flows from concern about the incipient actions of the Oslo-based Nobel Peace Prize Committee. But if Annan is honored by this body, it may well be because of the extraordinary steps he's been taking to advance public support for helping victims of HIV/AIDS. Until recently the UN's approach had been to let the issue be handled by a small, quiet unit in Geneva called UNAIDS. It is headed by a Belgian physician named Peter Piot, who has traveled the world articulating fearful statistics associated with the AIDS pandemic and gaining the reluctant cooperation of various feuding UN agencies. But Dr. Piot lacks Annan's stature and does not enjoy the benefit of his bully pulpit. Moreover, there are many competing issues within the UN system.
Whether Annan will be able to mobilize additional resources for AIDS is an open question. The world's thirty richest countries--members of the Organization for Economic Cooperation and Development--currently give less than $40 billion annually to the poorest 135 nations. The trend has been downward for several years now, since the record foreign-aid high of $75 billion some fifteen years ago. Some suggest that the $7-10 billion target for Annan's new global fund is a conservative figure, considering that the number of AIDS-affected people worldwide may well double in the next decade from the present 33 million. Most of the victims are in poor countries--especially in Africa--where economic and social development is already faltering.
Annan's strategy has been to link AIDS to the broader issues of jump-starting economic growth and insuring environmental security. The AIDS session in New York is only one of several international meetings that Annan is convening in the next eighteen months. The idea is that these conferences will serve as a sort of continuum and fashion a body of work on development issues. The idea is also to get leaders of rich and poor countries to commit at least modest new amounts of money to tackle the widening problems of poverty. And last, the idea is to project a recharged image of the UN.
Thus, a General Assembly special session on the plight of cities was held in early June; after the AIDS conference, there will be another assembly session, on the wide misuse of small arms and light weapons, especially in poor countries, where children are often employed as soldiers and vigilantes. During the summer, there will be a climate conference in Bonn, where the Bush Administration's stance against full recognition of the harmful effects of global warming--and renunciation of the 1997 Kyoto Protocol--will surely be a major item on the agenda. Then the UN will convene in Durban, South Africa, to mobilize world support against racism and other forms of discrimination. There's a summit on issues relating to children's rights and a world food summit in Rome, both in the fall; a conference on financing for development next spring in Mexico; and a conference on the problems of aging, also in the spring, in Madrid.
All these conferences will lead up to a World Summit on Sustainable Development in Johannesburg, in September 2002. Annan wants every head of state or government to attend, and he wants to review what's happened in the fields of environmental protection and poverty alleviation since the June 1992 Earth Summit in Rio de Janeiro. World leaders, including Bush the Elder, promised to act on the Earth Summit's Agenda 21, a sort of blueprint for global economic development, and said that the world's thirty richest nations should commit $125 billion each year in development assistance to the 135 poorest countries. Of course, no one's kept the promise.
Annan and India's Nitin Desai, his Under Secretary General for Economic and Social Affairs, aver that the decline in development assistance is unacceptable, especially at a time when globalization is leaving more and more people further behind. They cite the fact that despite worldwide improvements in such matters as infant mortality and literacy rates, some 2 billion people out of a global population of 6 billion live in poverty.
But Annan knows it's unlikely the rich nations will pony up more cash for development, particularly when public support for foreign aid is steadily losing ground in many wealthy countries. So he's trying to rally big business behind his plans. On the eve of the UN meeting on AIDS, former US ambassador to the UN Richard Holbrooke said that with Annan's encouragement, he has agreed to head the Global Business Council on HIV and AIDS, a UN initiative. Annan also recently persuaded outgoing Shell chairman and CEO Sir Mark Moody-Stuart to chair a new "business action council" for the Johannesburg 2002 summit. Moody-Stuart, a soft-spoken man who acknowledges that the energy industry's environmental record has been less than commendable, wants to devise ways whereby the business community can generate culturally and socially sensitive economic development in the poor countries; he says more economically healthy and socially stable societies are in everyone's self-interest: "Less confrontation, more cooperation--let's give it a try," he said in a London interview.
Nice sentiment. But already some nongovernmental organizations are alarmed that big business may unduly influence the UN at a time when the world body has never been more vulnerable financially. While it's unlikely that various UN organizations would rescind carefully negotiated protocols on subjects like the environment, it's not at all clear that the UN would be able to resist some sort of reciprocity for business largesse. What might such reciprocity consist of--co-branding, such as combining corporate logos with that of the UN? Or perhaps something more troublesome, such as designating UN personnel to serve as de facto commercial representatives?
No one is insinuating, however, that Kofi Annan can be bought. Indeed, the prevailing consensus in the donor community and in the corridors of the UN is that a cozier UN/big business relationship can bring another source of strength to the world body, not to mention burnish Annan's own reputation as a dynamic secretary general.
Third term, anyone?
An early US AIDS group employs direct action to oppose injustice everywhere.
Behind closed doors at the UN and in Western capitals, government and corporate officials are arguing over the size and governance of a fund that is going to be the primary international response to the greatest public health pandemic since the Black Death.
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Prevention and treatment require a focus on overall health and development.
"Phanzi, Pfizer, Phanzi!" "Get out, Pfizer, go!" At rallies they sing the old liberation songs, replacing the names of apartheid leaders with those of multinational pharmaceutical companies. On the streets they chant demands, no longer for the vote or a living wage or freedom, but for fluconazole and cotrimoxazole and nevirapine. Their leaders and organizers might well be human rights lawyers and healthcare professionals, but most of the foot soldiers of the Treatment Action Campaign (TAC)--which has spearheaded the campaign for affordable medicine for HIV-related illnesses in South Africa--are ordinary South African men and women, HIV-positive but too poor to afford the drugs needed to keep them alive.
For most of us, globalization remains an abstract and troubling concept, but for the TAC's activists the pharmaceutical industry's cynical abuse of international trade agreements to keep its profit margins high has meant that globalization is literally killing them. What makes their activism so compelling is that their battle for access to treatment has brought them up against the consequences of the global economy--and that they appear to be triumphant.
In mid-April, after a three-year fight, thirty-nine multinational pharmaceutical companies agreed to settle a suit against the South African government to prevent it from purchasing brand-name drugs from third parties at the cheapest rates possible. This, Big Pharma had claimed, was in violation of international trade and property agreements the South African government had signed. The withdrawal was brokered directly by UN Secretary General Kofi Annan, who had been asked by the five biggest companies to help them find a way out of what had become a public relations nightmare. Annan called South African President Thabo Mbeki, whose officials drafted a last-minute settlement that committed the country to negotiate with the multinationals before implementing its policy. The victory, however, was the TAC's: Not only had it proved that the suit was unwinnable, it had brilliantly mobilized a broad spectrum of support at home and abroad against the drug companies, which were shamed into the settlement--in effect, an honorable withdrawal.
The icon of this victory, broadcast all over the world, was the image of a large African man in the courtroom popping a bottle of champagne in a circle of jubilant celebrants. This man was Zwelinzima Vavi, the general secretary of Cosatu, South Africa's largest labor federation and the backbone of the "Revolutionary Alliance" that brought the African National Congress to power--and that keeps it there. Surrounding him was a fascinating mix of working-class activists, high-powered lobbyists from international organizations like Médecins Sans Frontières and Oxfam, and ecstatic government officials reliving, for one brief moment, the euphoria of activism.
The TAC has managed to put together the first seriously effective social movement since South Africa's transition to democracy in 1994. The keynote speaker at its first national conference, in March, was Cosatu president Willie Madisha. "There is no urgency from government," he told an audience of 500 delegates from more than 169 organizations, including major religious and healthcare groups. "Sometimes it drags its feet, at other times its HIV/AIDS work is incoherent. Broader social mobilization is essential to engage government constructively."
In 1994 most antiapartheid activists either went into government and became enmeshed in the workings of the new state or set off for the private sector to exercise their newfound freedom and follow their own interests. The result was that the broad-based social movements that brought apartheid to its knees in the 1980s ossified into bureaucracy or withered into nonexistence. The TAC offers a cogent example of the consequences: In the early 1990s, AIDS activists played a major role in the drafting of an exceptional National AIDS Plan, which was adopted by the African National Congress. But instead of mobilizing mass support to achieve the demands of the plan, AIDS activists found themselves inside the system and thus bound by the inevitable constraints of government, relying too heavily on what the TAC calls "the politics of access." Outsiders became insiders, and without the oxygen of a mass movement to keep it alive, the plan was suffocated by red tape.
But just a week before the victory against Big Pharma, TAC's chairman and chief strategist (himself a product of the antiapartheid movement), Zackie Achmat, publicly accused two senior government officials--both medical doctors and former healthcare activists themselves--of having the blood of children on their hands because they were retarding the implementation of antiretroviral programs for pregnant mothers with HIV. "We face a greater tragedy than the acts of omission of the drug companies," he said, "and that is the failure of government officials to act with courage, humility and urgency."
The accusation may have been unduly harsh--Achmat himself could be accused of understanding neither the constraints of bureaucracy nor the choices that the ill-resourced government must make--but he has a significant mass-based constituency behind him when he makes it. The TAC's brilliance was in recognizing that it had an issue that would appeal to the broad left wing of South African society not only because of the government's manifest ineptitude in the face of a horrifying pandemic (4.7 million infected out of a population of 40 million) but because the battle for treatment was a perfect vehicle for taking on the heartlessness of global capital and the perceived wrongheadedness of the ANC government's neoliberal macroeconomic policy. South Africa has been the good boy of the World Bank, the IMF and the WTO, Achmat says, and we're sicker and poorer than we've ever been.
The reason Cosatu and the left like the treatment access issue so much is that it allows them to say this; it puts flesh on their critique of the government's quest for a balanced budget in line with the World Bank's specifications, a quest that means less funding for programs like the provision of lifesaving medication. Globalization, finally, has a face. TAC activists appeared at court wearing ghostly, leering masks of Big Pharma's mandarins. Globalization is itself on trial: The masked activists were in handcuffs.
Just last year, Mbeki accused the TAC of actually being in the employ of Big Pharma because of its strident criticism of the government's AIDS policy. Now, despite the brief and effective courtroom alliance between activists and government, the same battle lines are drawn again, sharper than ever. Minister of Health Dr. Manto Tshabalala-Msimang held a press conference after the courtroom celebration at which she made it clear that providing AIDS drugs was not a government priority; the TAC shot back that it would do whatever was needed--including confronting government head on--to bring "real drugs to real people."
It remains to be seen whether the victory against Big Pharma is anything more than symbolic, whether it will have any effect at all in bringing affordable drugs to the ailing masses of South Africa. Its significance, rather, is in its creation of a mass-based, independent, critically minded social movement that takes the best of South Africa's tradition of struggle and engages it, in a sophisticated and tangible way, in a battle against the negative consequences of the global economy and the manipulation of institutions like the WTO by multinational corporations. The TAC's battle could provide the same brand of moral leadership in the global struggle that the antiapartheid movement did in decades past.
A woman two months pregnant goes to see her Ob-Gyn for prenatal care. As required by law, her doctor informs her that her condition places her at greater risk for a wide range of medical problems: hypertension and diabetes if she is overweight; complications of surgery if, like one in four women, she has a Caesarean section; permanent weight gain with its attendant problems, including heart disease; urinary tract infections and prolapsed uterus if she has had multiple pregnancies; postpartum depression or psychosis, leading in rare cases to suicide or infanticide; not to mention excruciating childbirth pain, stretch marks and death. There are ominous social possibilities, too, the doctor continues, reading from his state-supplied script: increased vulnerability to domestic violence; being or becoming a single mother, with all the struggles and poverty that entails; job and housing discrimination; the curtailment of education and professional training; and lowered income for life.
No state legislature would compel doctors to confront patients with the statistical risks of childbearing, serious though they are; a doctor who did so on his own would strike many as intrusive, offensive and out of his mind. Should a woman seek abortion, however, anti-choicers are pushing state laws requiring that she be informed of a risk most experts do not believe exists: a link between abortion and breast cancer. Like the supposedly widespread psychological trauma of abortion, which even anti-choice Surgeon General Dr. C. Everett Koop was unable to find evidence of, the abortion-breast cancer connection is being aggressively promoted by the anti-choice movement. (Even Mother Jones, always quick to take feminists down a peg, leapt on this bandwagon, with an April/May 1995 piece entitled "Abortion's Risk.")
"It's yet another example of efforts to encumber this legal choice and make it more difficult and painful for women," says Dr. Wendy Chavkin, professor of public health and clinical obstetrics and gynecology at New York's Columbia Presbyterian Hospital, and editor in chief of the Journal of the American Medical Women's Association. It's also an attempt by anti-choicers to reframe their opposition to abortion as concern for women's health, something not usually high on their list. These are, after all, the same people who fight health exceptions to "partial birth" abortion bans and who have successfully prevented poor women from receiving medically necessary abortions with Medicaid funds.
Nonetheless, such is the power of the anti-choice movement that laws have been passed in Montana and Mississippi, and bills are pending in fifteen other states, mandating a breast cancer warning (and in some cases, a waiting period for it to sink in). Along with laws come lawsuits: In Fargo, North Dakota, the Red River Women's Clinic is being sued for failing to give such a warning; a 19-year-old Pennsylvania woman is suing a New Jersey clinic for her abortion two years ago, which left her, she claims, with an overwhelming fear of contracting breast cancer. In ferociously anti-choice Louisiana, a new law permits women to sue for damages--including damages to the fetus!--up to ten years after their abortion. Given today's high rates of breast cancer, a deluge of litigation is in the making.
Does abortion cause breast cancer? Some studies have appeared to suggest a connection: Dr. Janet Daling, for example, an epidemiologist who says she is pro-choice, compared the abortion histories of 1,800 women with and without breast cancer and found that, among those who had been pregnant at least once, the risk of breast cancer was 50 percent higher for those who had abortions--but her cancer-free sample was obtained through telephone interviews with women chosen at random from the phone book. Not everyone has a phone, of course, which raises questions about the comparability of the samples, and besides, how many women would volunteer information about their abortion history to a voice on the phone? Like other studies showing a link, this one was marred by "recall bias": Cancer patients are more likely to volunteer negative information about themselves than healthy people. They are looking for an explanation for a disease--and one many feel must somehow be their fault. Demographic studies, which are free from recall bias, produce different results: Lindefors Harris, analyzing the national medical database of Swedish women in 1989, found that women did deny their abortions, that breast cancer patients were less likely to do so--and that women who had had abortions were less likely to get breast cancer. The largest study to date, of 1.5 million Danish women, found no correlation.
"The supposed link between breast cancer and abortion is motivated by politics, not medicine," says Dr. David Grimes, clinical professor of obstetrics and gynecology at the University of North Carolina. "The weight of the evidence at this time indicates no association. To force this on women is just cruel." Indeed, the National Cancer Institute, the American Cancer Society and the World Health Organization, none of which have an ax to grind, reject the notion. The standard medical textbook, Diseases of the Breast, concurs. The main figure advocating the link is Dr. Joel Brind, professor of biology and endocrinology at Baruch College, who has done no original research on this issue but is a tireless anti-choice propagandist--plug "abortion breast cancer" into a search engine and the top half dozen sites are his.
Abortion is just about the only medical procedure in which doctors and patients are hemmed about by lawmakers. No other operation has legally mandated waiting periods, although many are dangerous, life-altering and irreversible; with no other operation are doctors legally required to give specific information--certainly not information that the vast preponderance of medical opinion believes to be false or at best unproven. Good medical practice calls for discussion of the pros and cons of particular courses of treatment, not burdening the patient's choice with unsubstantiated fears. Will we ever see a law requiring doctors to tell pregnant patients that abortion is statistically safer than carrying to term--which it is? Sure, the day state lawmakers put a waiting period on Viagra prescriptions, to let male patients really consider whether an erection is worth a heart attack.
When the FDA recently released its proposed new rules regarding
genetically engineered foods Greenpeace and the Center for Food
Safety didn't like the taste.
Big Pharma's dark underside.
This is not about profits and
patents; it's about poverty and a devastating disease." That
statement did not come from AIDS activists struggling to provide
sub-Saharan Africa's 25 million HIV-positive people with access to
life-extending medications. It came from the executive vice president
of Bristol-Myers Squibb, which recently announced it would slash
prices on its two AIDS drugs and forgo patents on one of them. A week
earlier, Merck & Co. said it would lower prices on its two AIDS
drugs not just in Africa but, pending review, in other heavily
affected countries as well.
What's going on is not a
change of heart on the part of "Big Pharma"--which John le
Carré describes in this issue as a group of
"multibillion-dollar multinational corporations that view the
exploitation of the world's sick and dying as a sacred duty to their
shareholders." Far from being a humanitarian action, the price
reductions represent an attempt to preserve patent rights by
diffusing international pressure for generic manufacturing.
Revealingly, neither BMS nor Merck has withdrawn from a suit against
the South African government brought by thirty-nine pharmaceuticals
seeking to prohibit importation of generic drugs, which they claim
would violate their patents.
The Indian generic
manufacturer Cipla announced in February that it would sell the
entire AIDS triple-therapy combination at $350 per person, per year,
and other generic manufacturers, in Thailand and Brazil, currently
offer AIDS drugs at a fraction of multinational prices. By
comparison, the Wall Street Journal reported that a
combination of AIDS drugs from BMS and Merck would cost between $865
and $965 per person, per year. If those prices were multiplied by the
number of AIDS patients in, say, Zimbabwe, a relatively prosperous
country by African standards, the total would come to about 20
percent of its GDP. And that sum doesn't include the investments in
healthcare infrastructure needed to distribute and monitor the drugs'
But even if poor African countries could somehow find
the money to pay the high patent-protected prices of the drug giants
(the $26.6 billion a year it would cost to provide all Africa with
AIDS drugs is no more than about a third of what Bush's tax plan
would give to America's wealthiest 1 percent), that would not be the
end of their problems. Rather, such a course would lock them into
exclusive trade agreements with multinationals and put them at the
continual mercy of Western foreign aid budgets. As new treatments are
developed, Africa would have to negotiate new price reductions,
country by country, company by company.
If the solutions
lie with generic manufacturing (not just for AIDS medications but for
a slew of vital drugs for malaria and other ills), then circumventing
existing international patent regulations is a necessity. The trial
in South Africa over compulsory licensing is one crucial test of the
viability of this option. Another potential plan would be for the
National Institutes of Health to give patents owned by the US
government on publicly funded AIDS drugs to the World Health
Organization, thereby licensing it to oversee generic manufacturing.
Why not, in fact, let governments underwrite the entire cost of drug
research--rather than, as now, underwriting substantial amounts of
the research, which drug companies then exploit--and do away with
Whatever the recourse, and despite the
well-publicized gestures by multinational pharmaceutical companies,
the solutions to Africa's AIDS epidemic lie in sustainable
competitive drug production, not momentary self-interested