TCS Daily

AID And AIDS In Africa

By Roger Bate - April 19, 2002 12:00 AM

It is not often the head of an aid agency comes in for the kind of vitriol usually reserved for fat-cat businessmen and despotic politicians.

But at a recent concert, Bono, the lead singer of U2, called Andrew Natsios, the head of the U.S. Agency for International Aid (USAID), "Nazi-os," and this was swiftly followed up by several Harvard academics, who called for his firing.

What the pop star and Harvard men were objecting to was Natsios' refusal to spend USAID money on antiretroviral AIDS treatment in developing countries. As the academics put it, "Natsios' recent comments on preventing and treating AIDS in developing countries from Africa disclose not only a profound factual ignorance of this problem, but a deep-seated contempt for the impoverished Africans his agency is supposed to help".

But are the academics or Natsios correct?

Natsios has argued against giving the most advanced antiretroviral drug treatment to the 25-million Africans infected with HIV, thereby, as the Harvard academics put it, "condemning them to premature death along with the tens of millions they are sure to infect".

But unlike South African President Thabo Mbeki and many other African leaders, who prefer not to discuss AIDS at all or if they do consider that treatment doesn't work, Natsios at least believes that AIDS is treatable with AIDS drug cocktails. He just thinks that USAID should not be spending U.S. taxpayers' money on the drugs, since monitoring of drug delivery by African physicians and by the patients themselves is failing.

Natsios has a point. There is a lack of infrastructure to deliver drug company donations. Furthermore, compared with combating other diseases, some AIDS drug cocktails must be taken at precise times, several sessions a day, for many weeks. The result is that complying with drug regimes is less likely in an African setting than in the United States. Furthermore, mistimed and especially not completed treatments can cause great harm, as they lower efficacy and encourage resistance among new strains of the disease that then hurt treatment in other lands.

But there are other drugs where compliance is easier (taking a single pill at dawn and dusk). Hence, Natsios, statement that Africans can't comply with drug regimes because they "don't know what Western time is" was not only rather cruel, but has probably become an embarrassment to him.

The result is that USAID will continue to promote "abstinence, faithfulness and the use of condoms" as the essence and corner stone of HIV prevention. And it has its work cut out doing this because some African politicians, such as several ministers I met from Nigeria last year, incorrectly believe that condoms don't prevent transmission of HIV.

Still, making tough choices is Natsios' responsibility, and there are probably numerous better ways that hundreds of millions of dollars at his disposal could be spent than for AIDS treatment or prevention. For example, controlling malaria would be a start. After all, it afflicts many more people than AIDS and is easily preventable and curable at low cost, compared with other diseases.

Another area where expenditure would be useful is in actually establishing decent health infrastructures in the poorest developing countries. Ironically, it is appalling health care services that prevents so many African women from receiving the freely donated drug Nevirapine, which reduces mother to child transmission of HIV. But infrastructure investment is an unfashionable method of spending money, with few obvious political beneficiaries within USAID or the developing countries themselves.

Natsios was right to reject AIDS drug treatment not because it doesn't work, but because he could spend the money on things like malaria control that would work. But in doing so he managed to incur the wrath of AIDS activists and experts in Western medical practice.

And unfortunately, Natsios stance was not to last. He could not indefinitely challenge U.S. political orthodoxy that puts rhetoric above lives in the developing world. Discussing such trade-offs in health is normal in medical practice, but it apparently it is heresy in politics. The result is that he, and his ultimate boss George W. Bush, caved in and pledged money for AIDS treatment at the recent Monterrey, Mexico aid conference.

For the thousands that will be helped, and whose lives will be prolonged, this aid is indeed a blessing, but for the millions who will die and could be cured of other diseases, the opportunity cost of such politically directed aid is unbelievably cruel.

Natsios is still hated by the militant left AIDS activists. He is now upsetting conservative development experts and health workers in the developing world for his recent U-turn.

Dr. Roger Bate is director of the International Policy Network in Washington D.C.

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