TCS Daily

The Meaning of "Whorigami"

By James Pinkerton - July 19, 2004 12:00 AM

BANGKOK -- If you try to solve every problem, you end up solving no problem. That's the lesson of the XV Global Aids Conference, just concluded here.

The slogan for this conference was "Access for All." I now think it should have been "Everything for Everybody" -- which translates into "consciousness gets raised, but nothing else gets done."

Which is exactly what Randall Tobias, the US Global AIDS Coordinator, has been warning against. In an interview conducted before he left for the conference, Tobias told me of his determination to keep his focus on three, and only three, concerns: "treatment, prevention, and care."

Tobias is so focused on focus that he even wrote a book in which the "f-word" is a major theme. In his fascinating and enlightening business memoir, Put the Moose on the Table: Lessons in Leadership From a CEO's Journey Through Business and Life, Tobias, the former head of Eli Lilly & Co. who came out of retirement and into public service in response to President George W. Bush's request, argues that the essential question for any organization is, "What business are we really in?" And sometimes, asking this question yields provocative answers. For example, when Tobias took over Lilly in 1993, he found that the company, best known for pharmaceuticals, was also in the medical equipment business. That second line was a distraction from the core function, he concluded, and so the medical equipment division was spun off. "We needed to avoid being an inch deep," Tobias recalled. He had no regrets about the spinning-off: Guidant became a successful stand-alone medical equipment maker, boasting annual sales of $3.6 billion; Lilly's stock price sextupled during the remaining five years of his tenure.

But now that he is in the public sector, Tobias clings to the same basic wisdom: "structure must follow strategy." That is, know your knitting, and stick to it. And such determination has dominated his effort to keep his new governmental organization's focus on those big three issues: treatment, prevention, and care.

Yet Tobias and his trinity of focus is up against a big problem: the rest of the world wants a multiplicity of focus -- which, as it ends up, is no focus at all. I should hasten to point out that "rest of the world" should be defined as "the noisiest elements in the rest of the world"; it's hard to know what the Silent Planetary Majority might want.

But the Not-So-Silent Minority of activists and NGOs is always to be heard from -- and often heeded. This Loud Minority wants it all, and it wants it all now. We might start by recalling the words of Irene Zubaida Khan, secretary general of Amnesty International, who said in 2002, "Social exclusion, economic deprivation and discrimination are integrally linked to HIV/AIDS." What social ill, one might wonder, isn't covered in that litany? More to the point, according to that AIDS-linkage, what right-thinking, high-minded NGO can't claim to be fighting AIDS by doing exactly what it's always done?

No wonder that so many NGOs converged on Bangkok; they could all claim to be part of "the solution." Yes, AIDS was much-discussed, but so was everything else. The Correspondent, a free newspaper distributed here at the conference, featured an "Asian People's Charter on HIV/AIDS." Included in this Charter was a call for civil society to "draw attention to the links between the spread of HIV/AIDS and underlying social determinants, such as poverty, war, and displacement." And of course, then came a loud avowal to "participate in efforts to address these injustices."

The Foundation for Human Rights put up a huge poster in the lobby of the convention center, declaring, "The respect, protection and fulfillment of human rights is central to the AIDS agenda, and equally AIDS needs to be at the centre of the global human rights agenda." And what were some of the specifics to be respected and protected? Here's a partial list: "Freedom of opinion and expression, the right to freely receive and impart information ... Equal access to education, an adequate standard of living, Social Security assistance and welfare." In other words, nothing was left out.

Much of the mindshare at Bangkok was devoted to feminist causes that were, at best, tangential to AIDS. These might be meritorious on their own, but breakout sessions such as "Women's Networking: Our Life, Our Decisions" and "The Community Sector: Assuming Leadership" were surely marginal to the targeting of the Human Immunodeficiency Virus, which infects some 38 million people worldwide.

Indeed, a strange kind of in-your-face feminism infected the conference. Also in the lobby, right in front of the media center was a show put on by the Australian-based "Debby Project," which celebrated the life of "sex workers," aka, prostitutes. The tagline was "Debby doesn't do it for free"; visitors were told, "It is not necessarily degrading to have intimacy with strangers. In fact, it is one of the most liberating things you can experience." Some of the art included a display of "whorigami" -- get it? -- and a painting entitled, "The C__ of Many Colors." It's worth pointing out once again that this display wasn't hidden away somewhere, wrapped inside a metaphorical brown paper wrapper. Nope, Debby and her Doings were large, in charge, and highly visible. One has to wonder how the celebration of sex workers might contribute to preventing or healing AIDS.

But strange as it may seem, celebrating sex seemed to be more important to many conferees than eradicating a sexually transmitted disease. Gregg Gonsalves, of the Gay Men's Health Crisis, a Manhattan-based activist group, walked around with a tee-shirt declaring that he was HIV positive. To my mind, that's unfortunate, but to Gonsalves, his medical situation seemed to be almost an asset, because it gave him a platform from which to unleash his own far-reaching social-activist agenda.

Gonsalves appeared on a panel discussion alongside Mark Dybul, a deputy to Randall Tobias, which he, Gonsalves, used as an opportunity to blast the Bush administration for "defunding reproductive health programs that offer a full range of health programs to women." In political parlance, "full range" is code for state-subsidized abortion; the US funding of which the Bush administration has labored to stop. Now whether pro-choice or not, one can still acknowledge that abortion is a different issue from AIDS. Moreover, one might assume that anyone who is totally focused on AIDS -- using the Tobias Trinity of treatment, prevention, and care -- would understand that wandering into the abortion issue is a politically risky detour.

But Gonsalves didn't see it that way. He seemed to believe that mobilizing activists was more important than mobilizing scientists; the more activists and activisms, the merrier.

The key to fighting AIDS, he lectured, is "greater involvement of people living with AIDS." Continuing in that agitprop-y vein, he maintained that only by "documenting the work of the community, tapping into the community, acknowledging the work of communities" would the "professions" -- a word that he practically spat out of his mouth -- be forced to accept the "power" of "community organizations." In so doing, the people would "reveal the missing lessons of history." By "professions," incidentally, he meant doctors and scientists.

That's a mouthful, and much is revealed therein. For much of the last century, the Left put "class-conscious will" ahead of "bourgeois" science; the idea was the moral force of the masses -- guided, of course, by their vanguard leaders -- would sweep aside the encumbering confines of scientific reality, as well as economic reality. Such magical Marxism was a way of explaining the proletarian past -- hence Gonsalves' comment about revealing "the missing lessons of history" -- but even more crucially, it was a guide to policy for the present and for the future. Such Marx-mindedness, to be sure, once inspired both the anti-tech Trofim Lysenko in the old Soviet Union. There's catch: mobilizing the masses doesn't have much to do with either feeding them or curing what ails them.

But it wasn't just white Westerners who spouted anti-medical mumbo jumbo; Asians, too, provided their own Luddite lyricism. An op-ed by Sanitsuda Ekachai, columnist for The Bangkok Post, was revealingly headlined, "Living with HIV and a sick society." Got that? It's not people with HIV/AIDS who are sick, but rather society. This was standard stuff in the US in the 60s, but today it's getting another reworking in the Third World. Sanitsuda quoted an HIV positive activist asserting, "The problem is not the virus. It's social rejection, condemnation, discrimination." Gee, and all this time I had thought the problem was the virus. Yet to the Thai activist, HIV was a vehicle; AIDS "offers the world a chance . . . to confront life's impermanence and the roots of discrimination."

If one is fighting to "reveal the missing lessons of history," and to "confront life's impermanence and the roots of discrimination," then the mere curing of AIDS must seem like a pitifully small goal. And in fact, action against AIDS has been sacrificed to the larger political dramaturgy, in which the US government and big drug multinational companies are the devil figures in a planetary passion play. The heroes of this show are activists, armed with condoms, clean needles, and community empowerment.

So facts and logic be damned. The July 13 edition of The Bangkok Post offered this headline: "US blasted for 'doing too little.'" The article noted that the Uncle Sam has announced plans to donate $15 billion over the next five years. But, the Post continued, "It was not enough for the activists who even praised Thailand as having done more than the US in helping the fund. Thailand has decided to give $1 million for five years to the fund." Now let's see here: the US is giving $15 billion over five years, while Thailand is giving $5 million over five years. Even adjusting for population and GDP, the US is making 134 times the effort. And yet the activists "praised Thailand as having done more." Welcome to the bizarro world of AIDS conferences.

In fact, it gets even weirder, and more counterproductive. As I have written previously, the AIDS activists don't just want our money; they want our pharmaceuticals and our intellectual property, in the form of generic drugs, all for free. And they have many media figures on their side, too. Typical is NPR's Richard Knox, who praised a Thai woman for pirating Western patents and intellectual property. In Knox's telling, she bravely "stood up to multinational drug companies."

To be sure, some more realistic counter-voices did emerge. One such was Anu Bhardawaj, who chose caustic words for his op-ed in The Bangkok Post: "Instead of responding to this crisis," he remarked, "the Thai government has tried to ingratiate itself to the HIV community by promising to produce generic versions of anti-retrovirals for all infected people in Thailand." He continued, "Such words may appeal to Western activists who have come to Thailand to attack the pharmaceutical companies that keep them alive -- for a price -- but the proposal would do little if anything to improve the conditions of Thais with the disease."

In fact, proposals that undermine drug R&D do everything to dis-improve the conditions of anyone with AIDS, anywhere. The disease, which infected an additional five million people last year, shows signs of mutating toward more deadly incarnations. That was the upshot of a piece in the July 8 New York Times, headlined, "AIDS Drugs' Fast Rise in Asia Risks Resistant Strains."

And so to the mega-issue for all of us. Darwin's evolutionary "ism" still lives, which means that more people will get sick and die if pharmacology stays static. And it's not only AIDS that we have to worry about; it's just about every other disease, too. Time magazine reports this month on the comeback of polio; the crippling malady, once thought to be consigned to medical history, is making a horrible comeback. Polio bottomed out in Africa three years ago, when just 82 cases were reported; last year, 447 African cases were found.

In the same vein, what are the future prospects for SARS -- or for a breakout of, say, avian flu into the human population? We don't know. But we should know that slogans such as "access for all" are not the same as a cure for all, or a vaccine for all.

Randall Tobias doesn't want to worry about polio, or SARS, or anything else bad that might be in the offing. He wants to focus on AIDS. But in fact, politics has already pushed him to include malaria and tuberculosis, too, in his portfolio. And it's entirely possible that additional political pressure will force even more diffusion of his focus. He complained in Bangkok that "there are some people here who have the objective of the US being the global whipping boy." But such pressure works, more often than not, at uncorking more money for more causes.

What activist pressure cannot do, of course, is uncork a cure. Americans are a naturally optimistic bunch, and their own history-including their history of technologizing their way out of problems -- gives them more reasons for optimism than for pessimism. And for his part, Tobias always kept a stiff upper lip in Bangkok, if not always quite a cheerful smile. But no American has ever confronted such a steady chorus of criticism, combined with a systematic effort -- through the manufacturing of generics and the mulcting of intellectual property -- to undermine the fundamentals of both pharmaceutical advancement and American prosperity.

Yes, the past has gone well for Americans. But some of the leading political indicators for the future are ominous. As Tobias wrote in his book, "Life has many twists and turns, not all with happy endings." One shudders to think that the US AIDS coordinator might prove to have a gift for politico-medical prophecy, as well as for corporate leadership.


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