TCS Daily

WHO's Latest Initiative: Blame Avoidance

By Roger Bate - May 10, 2005 12:00 AM

Policies pursued by South Africa on HIV-AIDS have been spectacularly flaky. Even now, while state facilities are treating 42,367 patients with life-prolonging antiretroviral medicines (ARVs) , the health minister, Manto Tshabalala-Msimang warns that patients should be aware of their side-effects and perversely continues to advocate dietary supplements which have been shown to actually reduce CD4 counts (measurements of the immune system). So the health minister's complaint yesterday that South Africa was facing undue pressure from the World Health Organization to treat hundreds of thousands more people is likely to be heavily discounted by the world's media. This is a pity, because Mrs. Tshabalala-Msimang is right to be alarmed by the WHO's pressure. She is fighting back because she knows that South Africa is about to be made the scapegoat for another failed WHO target. "It's not about chasing numbers, it's about the quality of health care we provide for our people", she said.

WHO's target of treating three million HIV patients in developing countries with ARVs by the end of this year ("3 by 5") is unlikely to be met due to a lack of political will in South Africa, Nigeria and India, said an editorial in last week's The Lancet, the premier UK medical journal. The 3 by 5 target, set in December 2003, represented 50% of the estimated number of people needing drugs in the developing world. But by last December, according to The Lancet, only 720,000 people were on treatment in the developing world (including the 42,367 in South Africa); roughly 8% of the 4-million Africans needing anti-HIV therapy were getting it.

I've recently been looking at the problems of HIV treatment in Africa in a paper and agree with The Lancet's assessment that, "Without SA on board, with its ... leadership position within Africa, 3 by 5 is but a pipe dream," and that only SA has the necessary infrastructure to speed up provision of AIDS drugs.

But before journalists get the knives out, once again, for South Africa, the reason for failure is because the WHO's target was ludicrous from the beginning. There simply isn't the infrastructure in place in most of Africa to treat that many people and won't be for years, perhaps not even until 2010. Furthermore, WHO cannot afford to provide South Africa with the funds to treat the number it set as its target (approximately 800,000), so it has no right to feel aggrieved that South Africa fails to hit it.

For a wider appreciation of WHO's folly, take the example of Lesotho, South Africa's incredibly poor neighbor. I was there in March and it has 2,000 people on ARV treatment. The WHO target for this year is 28,000. That is madness. Of the 2,000 people, perhaps 800 are on sustainable treatment, the rest on a far from ideal mix of single or dual therapy with frequent forced changes in drug regimens due to supply shortages (caused largely by poor local management rather than major procurement concerns), and staff shortages. It takes specifically-trained staff to deliver ARVs and, as in most of sub-Saharan Africa, they are thin on the ground in Lesotho. Those I spoke with in the capital Maseru, were shocked at the target. They thought that, if they had to treat patients with whatever drugs were in supply, and they were pressed by their government, maybe 5,000 could be treated by the end of the year.

Lesotho's experience is probably typical of the WHO "approach" which shows no evidence of logical assessment of what is actually deliverable. I can only imagine that the process went like this at WHO HQ in Geneva: What is theoretically possible if the price of drugs were a bit lower, if competence were a bit higher, if there were more staff (perhaps courtesy of WHO grants), if we piggy-back on existing successful programs, and then we double that figure for luck? Only such a process can have produced Lesotho's target.

Nigeria is the corruption capital of Africa. Recall that it allowed copy-cat, untested Indian drugs to expire, unused back in 2002, while only 800 of a targeted 15,000 people were treated. Its current treatment levels are woeful (the number under sustainable treatment is probably in the low thousands -- but no one seems to really know), and its ability to ramp up treatment is severely limited by capacity. Again, WHO targets of many tens of thousands are a fantasy. But there are other reasons, which I highlight in my paper, why the target of 3 by 5 won't be hit.

First, there were not 720,000 people on sustainable treatment at the end of 2004 as claimed by The Lancet (incidentally the WHO claimed figure was 700,000, but this also inaccurate). It is a matter of public record that this number is inflated by around 10%. Two agencies, UNAIDS and PEPFAR, both honestly, openly and correctly claimed the same 630,000 people, given that both agencies funded some of the same treatment facilities, and so both counted these in their independent assessments. But despite the agencies making this information public -- I found out about it at the Davos World Economic Forum this February -- WHO went ahead and added their total figures. That WHO is so ready to spin such widely-available information surely undermines the integrity of its claim.

Second, it now seems likely that some generic drugs approved by WHO and distributed to treatment programs have been sub-standard. They have been found not to be bioequivalent to the fully-tested branded drugs they emulate. The least-bad outcome of this failure is that the drugs won't work; the worst is that they have killed patients and bred resistance, making treatment extremely difficult and expensive.

Third, drug prices of the copycat versions WHO has embraced are far higher than WHO is assuming. The Clinton Foundation claims drug prices as low as $140 per person per year for ARVs. The reality is well above $210 (and that is for generics of dubious quality); there simply is not enough money in the budgets to buy all these drugs, even if they were being produced, which they're not.

Fourth, and most importantly, re-allocating medical staff away from immunization, anti-malaria, child health and other programs to treat HIV patients would be a misallocation. Compared with other life-saving public health measures available, HIV treatment has a high cost and a poor relative outcome -- and the Departments of Health in many poor countries would be justified in not allowing the switch.

The WHO is preparing its blame avoidance techniques for a target it knew would never be hit. South Africa deserves opprobrium for its poor roll-out of ARVs, but the failure to hit 3 by 5 is all of WHO's own making -- it was a disgraceful showboating target to garner more funds, which has already backfired on the very people it was supposed to be helping.


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