Thousands of people living with HIV/AIDS in southern Africa go without even the most basic medicines. Jonathan Dimbleby calls for urgent action.

When I first met Manda Mwila, he seemed a happy and confident man. I was at once struck by his broad smile and assured manner. However, I soon discovered that this successful and apparently optimistic Zambian broadcaster and entrepreneur was HIV-positive.

In Manda’s home city of Lusaka, appearances are everywhere belied by reality. Unscathed by civil strife, war or famine, Zambia’s capital city seems as serene as any on the continent. Yet with one in three of its population HIV-positive, fighting AIDS is proving to be a conflict far more devastating to this beautiful country than all of Africa’s wars and famines put together.

The disease, which disproportionately affects men and women of working age, is in the process of wiping out an entire generation. As a result, the number of children living on the streets of Lusaka has soared to 30,000 – many of them orphaned by AIDS and often infected by HIV themselves.

I had come to visit the ‘eye of the storm’ as president of VSO. I was only in Zambia for a week, but it was quite enough to get a sense of the devastation caused by HIV and its associated diseases. I discovered a tragedy, a scandal and, mercifully, a reason for hope.

The tragedy is personified in Manda, who discovered he was HIV-positive when he lost his wife to AIDS in 1994. He also lost his job, and was left with no income and a son to support. As he told me his story, he added as an aside that were it not for his friends he “would be gone by now”. This was no idle turn of phrase. Last year Manda came down with TB. No surprise there. TB is the most common infection associated with AIDS. It accounts for 15 per cent of AIDS-related deaths worldwide, and it kills somebody every 15 seconds. It is a chronic, insidious disease, usually affecting the lungs. TB and other AIDS-related infections such as shingles, pneumonia and meningitis are the biggest threats facing Manda.

In Zambia, people rarely live long enough to die of full-blown AIDS; the so-called ‘opportunistic’ diseases carry them away first. The scandal is that when Manda fell ill last year, he visited his local clinic only to be told there were no drugs available for him. Simple as that. Fortunately, a good friend paid for him to get the drugs privately at great expense. His bout of TB has since cleared up.

But Manda Mwila is not at peace with himself; he cannot escape the feeling that his friend has been punished financially for his own misfortune. He told me that if the TB were to recur he could not bring himself to depend on her charity for a second time. His only recourse is to try the Zambian health service again. “And if the drugs are still not available?” I asked him. “Well… goodbye. I’ll die – that’s the reality,” he replied.

It is estimated that if somebody with TB is left untreated they will typically infect between 10 and 15 people in a year. AIDS-related TB claims over 50,000 lives per year in Zambia alone. Any health service that would leave somebody in Manda’s position untreated, rather than invest in a six-month course of antibiotics, is practising a crazy form of economics.

To be fair to the authorities, the Ministry officials are juggling scant resources. They claim that they can often only supply 70-80 per cent of the medicines needed by local clinics. As a result the health professionals administering these drugs find themselves sending home a dying man with an aspirin. It is a violation of their calling – and they know it. But they must make decisions like this every day.

Zambia’s health spending per capita has plummeted in the last decade while the country’s population has risen. At the same time AIDS has now reached epidemic proportions. The Zambian Government now has less than $2 per head to spend on healthcare. The country is paying off three times this amount in debt relief. The odds are not in Zambia’s favour.

Elvis Simamvwa is the Medical Director of the Chikankata Salvation Army Hospital to the north of Lusaka. He holds a privileged position, in that he is running one of the better resourced hospitals in the country. But he says his government funding has declined by 62 per cent in the past year. And this hospital, which serves a predominantly poor rural population, has seen the prevalence of HIV go through the roof in under a decade. When we were there, 85 per cent of the women on Chikankata Hospital’s wards were HIV-positive.

In addition, even this hospital had run out of morphine, supplies of oral rehydration solution had dried up, and stocks of Septrin (Co-trimoxazole) – a treatment for pneumonia – were worryingly low. Mr Simamvwa told me that there were so few blood bags available nationwide, he’d had to source them through the black market. Even then his precious 30 units worth could only be used for life or death situations.

Hope for the future

My hope – which is widely shared – lies in the spirit of the Zambian people and, in particular, the way in which so many of them are working for themselves, and closely with agencies like VSO, to tackle the biggest crisis facing southern Africa. But more must be done for those living with HIV and with little hope of treatment. In the words of Kennedy Phiri, former Programme Officer with VSO in Zambia: “The saddest thing is when you see someone die, and you know they could have been treated with simple drugs but they couldn’t afford them.”

When AIDS treatment has hit the international agenda, the debate has focused only on the sophisticated cocktails of drugs, the anti-retrovirals. These are way beyond the means of most Africans, and demand complex treatment regimes that make them unfeasible for those who are lucky to get by on one meal a day. In the meantime, the basic drugs that could make a difference now are neglected. Drugs that we in the West take for granted.

Inspired by its workers on the ground who have been pressing for action, VSO has launched its Treatment for Life campaign to begin addressing some of these problems. The aim is to ensure that those living with HIV/AIDS in developing countries have a decent chance at living and working longer. The UK Government can and should take a leadership role in making this happen. The pharmaceutical industry too can do much more to reduce the prices of basic but vital drugs which mean the difference between life and death.

The problems of access to treatment are complex, but the recent VSO report Drug Deals: Medicines, Development & HIV/AIDS looks at some of the possible ways forward. It takes Fluconazole, a drug for treating AIDS-related meningitis, as an example. Costing on average $900 for a course of this drug in Africa, this is equivalent to two years’ salary for an ordinary worker. The report shows how in some countries prices for certain drugs remain high due to patent laws, while in others cheap copy versions can be sold at a fraction of the cost. But the availability of these cheaper generic versions is threatened by new World Trade Organisation rules.

To my mind, these examples show that far more has to be done to make a priority of the treatments that would make a huge difference to the immediate needs of people – like Manda – who are living with HIV/AIDS.

But is anyone listening?

In October the Zambian Government was moved to join other southern African countries in rejecting its part of the World Bank’s offer of a $3.8 billion anti-AIDS loan. The reason for this decision? The loan came with pre-conditions that the money be spent on AIDS research and consultancy, and not on healthcare.

David Mpamba, Zambia’s health minister, says that he would not be diverted from what he sees as his nation’s priority: to secure cheaper drugs. At the same time his government cannot afford to get further into debt, when – as a result of, in part, endemic mismanagement – it is already struggling to service its existing debts.

In his matter-of-fact way, Manda Mwila had been intent that I should understand his position and the position of many others like him in Zambia. “I am living by the grace of God, let me be frank about it,” he emphasised. “Each time one wakes up you are never sure if the system will provide. I’m just stating a fact – God plays a big hand in our survival.”

Manda believes that only God can save him and his nation in the fight against AIDS. Given the failure of western governments, pharmaceutical companies and financial institutions like the World Bank to meet the challenge of the crisis, his attitude is hardly surprising. But for us, such fatalism would be an outrage.

There have been repeated calls over the last decade for an international response that is equal to the gravity of the AIDS crisis. Despite this we are not much further forward. How long do we allow this scandal to persist? How long before international public opinion demands action? It is impossible to say. Every day that is wasted means more death, disease and destruction, where there could so easily be better health, longer life and justifiable hope.

Jonathan Dimbleby is a journalist, author and broadcaster, and is president of VSO.

Drug Deals: Medicines, Development & HIV/AIDS is available at: www.vso.org.uk. The new White Paper on globalisation also addresses the issue of HIV/AIDS.