TCS Daily


By James Pinkerton - July 14, 2004 12:00 AM

BANGKOK -- The international AIDS summit is boiling down to a battle between two three-letter phrases: ABC vs. CNN. No, this is not a battle of the networks. Instead, it's a battle of acronyms -- and of worldviews. But strange as it may seem, a vital four-letter world -- "cure" -- is being left out of the equation.

"ABC" is an acronym for "Abstinence, Be faithful, Condoms." That's the worldview best expressed by Uganda's President, Yoweri Museveni, one of the few heads of state who took the time to attend this conference. His first priority -- a life-saver, he emphasized -- was sexual restraint. And for his trouble, he got mostly grief from other attendees.

The alternative acronym, much more popular here, is "CNN," which stands for "Condoms, Needles, Negotiating Skills." One might be tempted to see some overlap here; after all, both ABC and CNN contain the "c" word -- condoms. But the CNN-ers strive mightily, albeit dishonestly, to minimize any such overlap.

The actor Rupert Everett is here in Bangkok; at a press conference on Monday, he was asked about ABC. His answer was that it was "kind of criminal" for anyone to argue that condoms don't work. Of course, the ABC-ers have said no such thing. But that didn't stop Rep. Barbara Lee (D-Calif.) from echoing Everett: "An abstinence-until-marriage program is not only irresponsible, it's really inhumane." But Museveni didn't say that, either.

What Museveni did say, however, is perilously close to what President George W. Bush and the Catholic Church have said: in an AIDS-ridden environment, abstinence is a good idea. Is that really so ridiculous? If the problem is smoking, what's the best solution: low-tar cigarettes, or quitting -- also known as "abstinence"?

Yet way beyond dilettantes such as Everett and Lee, most AIDS professionals seem equally dead-set against abstinence. Dr. Peter Piot, executive director of UN AIDS, one of the hosts of the Bangkok conference, declared, "No country has been successful in bringing down the prevalence of AIDS without a strong condom promotion component -- that's a fact." Then, warming to his topic -- and homing in on his true target -- he vented against the Vatican, which has raised various objections to condoms, including the blunt reality that they sometimes fail. "It is not acceptable to make statements like Cardinal Trujillo [Alfonso Cardinal Lopez Trujillo, President of the Pontifical Council for the Family], that condoms spread HIV, because it puts people's lives at risk. There is no competency in the church about the quality of materials, and effectiveness -- that's our job." Piot might just as easily have said, "Everyone is welcome to be part of the AIDS debate, except those heretics who disagree with us on matters of core doctrine!"

Without a doubt, condoms are at the core of the dominant AIDS belief system. Outside the convention center here is a "Victory Monument," a tower with a giant symbolic condom on it, courtesy of the Durex brand. And the closed-circuit TVs here feature a screen-saver-like test pattern that appears to be a bouquet of flowers. Except that when you get close, you see that the "flowers" are, in fact, brightly-colored condoms.

You get the idea. Use condoms, but don't diss condoms.

So there anything good to be said about the ABC approach? Only this: contra Everett, Lee, and Piot, abstinence -- backed up, as the acronym insists, by fidelity and, yes, condoms -- oftentimes works pretty well. In the words of Britain's Guardian newspaper -- hardly a stooge for Bush and the Religious Right -- Museveni's Uganda "provides a rare success story for sub-Saharan Africa." The paper notes that ABC took the country's infection rate from 30 percent to six percent in a decade. And the website of CNN -- the cable network, not commonly thought of as a haven for conservatives -- reports that "Uganda is one of the few African nations that have been successful in stemming AIDS."

So maybe Museveni and the abstinence-firsters deserve a more respectful hearing. Because surely, when millions of lives are at stake, we shouldn't be ideological; we should be empirical. If abstinence is proven to work, then let it be.

But even as we embrace the empirical, we should not lose sight of the technological. If the three letters, ABC, are great, the four letters -- "cure" -- are even better.

And yet it's the notion of a cure, and/or a vaccine, that's little talked about here. On CNN, I happened to see correspondent Dr. Sanjay Gupta, also here in Bangkok, asserting flatly, "A vaccine is not on the horizon." Continuing, he added, "'Vaccines' and 'cures' -- those aren't terms that we hear so much anymore." He then quoted an AIDS scientist, "We might not get there." Why? Explained Gupta, "The HIV virus mutates and changes itself. It's very sneaky." What's needed, he concluded, is bold new thinking and spending, to overcome the "different obstacles, financially and scientifically."

One might suppose that the upside of finding a cure/vaccine for AIDS is so enormous that profit-minded companies would be rushing into the breach. After all, nearly 40 million people around the world have HIV, and millions and billions more are at risk. Talk about a huge market -- right?

Or maybe wrong. Maybe the extreme politicization of AIDS makes profitability a long shot, or even a null set. On Monday, The Financial Times reported that John Kerry had pledged that if he were elected, his administration would back the purchase of generic drugs for AIDS, as opposed to patented drugs. Generics, of course, are the antithesis of huge R&D budgets. If there's no money to be made in the form of patent-protected premiums, there won't be much money put in for research.

And Kerry is hardly alone. After reading the candidate's comments, I went to a press conference conducted by officials from Médecins Sans Frontières (MSF), the prominent NGO. There's much to admire about the group, known in English as Doctors Without Borders. MSF won the Nobel Peace Prize in 1999; in June, five of its workers were killed by Taliban types in Afghanistan.

But as I listened to the MSFers talk, I realized that once again ideology might be blocking technology. That is, their preferred approach to treating AIDS might prevent a vaccine or cure from ever coming into existence. I heard over and over again from the panelists that the key to their anti-AIDS work, as they saw it, was reducing the price of medicine; Daniel Berman said that his group was seeking reductions of 98 percent or more. So I posed a question: "Is there any risk that if you force the drug companies to cut their prices by 98 percent or more, the companies will be less interested in researching a cure or a vaccine?"

The same Berman fielded the question. He did not look happy. His answer was long and circuitous, but his basic point was that even radical price reductions in the Third World would not disincentivize research, because Pharma companies could keep their prices high in the First World, thereby making plenty of money. "The profits that come from the wealthiest countries will keep incentives," he declared, even as "deep discounts" would be enjoyed by poorer countries. In other words, Berman's answer was "no," there would be no disincentive to R&D.

I beg to disagree. The innovation-limiting effect of price controls has been well-documented over the past 40 or so centuries. If I were a shareholder in the Pharma companies, and somebody -- the somebodies, in this case, being a possible next president and a leading activist in the field -- said that any breakthrough AIDS drug would be either genericized or price-controlled, or both, the investor part of my brain would want my company to steer clear of AIDS endeavors. And in fact, that seems to be happening, as Gupta reported.

Surely, I thought to myself, this is not what the AIDS activists want. Surely, if they understood economics and business better, they would be throwing carrots, not sticks, at the drug companies, encouraging them to eradicate this mass-killer.

But then I thought to myself, "Maybe these folks understand the economics of their business just fine. Maybe they have figured out that if AIDS keeps on killing, they will keep on making their livings. Maybe they see that if, on the other hand, AIDS becomes an ex-plague, they will have to seek a new line of work."

Nah, that's surely too cynical. There must be another explanation that tells us why the AIDS-ers seem more focused on coexisting with AIDS than on eliminating it. But I just don't know what that other explanation might be.


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