Interview with Professor Alan Whiteside, AIDS economist
Date: Tue, 30 Mar 2004 08:28:43 +0900
From: SAITO Ryoichiro
Subject: [viva_hiv_aids] 転送：AFRICA: Interview with Professor Alan Whiteside, AIDS economist
AFRICA: Interview with Professor Alan Whiteside, AIDS economist
MAPUTO, 29 March (PLUSNEWS) - Professor Alan Whiteside is a leading AIDS economist, based at the University of KwaZulu-Natal, South Africa. In 2003 he was appointed by Secretary-General Kofi Annan as one of 20 commissioners on the Commission for HIV/AIDS and Governance in Africa. He talked to PlusNews about the treatment challenges facing Africa.
QUESTION: What's the need for the Commission for HIV/AIDS and Governance in Africa?
ANSWER: We are dealing with an event we have no experience of. Human history gives us no experience of an epidemic that kills people in the numbers and the age groups that this one is doing. So the question is, how do you motivate people to think the unthinkable; to see what they cannot see. So, for me, one of the primary roles of this commission is around understanding this epidemic and what it might mean for Africa, and what we might do about it.
Q: So the commissioners are intermediaries between governments and civil society?
A: I can't speak for all the commissioners because, obviously, I have a particular view... But, for me, what I see ourselves doing is coming up with some solid data and influencing governments and donors. I don't necessarily think that we will have data on all the aspects: we can't, for example, have all the data on orphans - we can project it, but we can't have solid data. So we have a role in both collecting good solid information where we've got it, and making extrapolations where we haven't, and then influencing governments and donors and other key role players that are going to help us address this epidemic.
Q: So it's quite a strategic role?
A: Yes, and more than that. Let's just also mention that it's a commission on HIV/AIDS and governance. We've looked at the economic impact - however imperfectly; we've looked at orphaning; we've looked at the impact on the private sector, but what we haven't done at all is look at the impact of AIDS on governance.
Q: In terms of the capacity of governments or in terms of political leadership?
A: It has to be both Kyou can't have one with out the other. [The importance of] capacity is huge, but there are also issues around political leadership.
Q: Everything seems, now, to be about treatment and rolling it out, but we're still seeing only very small pilot projects. When is that going to change?
A: What I've found really interesting is that even the most optimistic projections of treatment [numbers] by governments are minute. If we talk about Mozambique - that by 2005 they will have 21,000 people on treatment - and you look at that in terms of WHO's [World Health Organisation] '3 by 5', I don't know where they are going to get three million [on treatment by 2005] from, because we've already had data from Uganda and a number of other countries, and the reality is that the numbers which people are talking about are minute. In South Africa the goal is to have 53,000 on treatment by June KI think we won't reach that.
So the question you ask is 'why is that the case?', and I think the answer is very simple: it's around capacity. I think the health systems cannot do more. The answer isn't necessarily money - although that's crucial - it's to find ways of capacitating health systems to provide the treatment.
Q: Even Botswana, the amount of people on treatment there is small ...
A: That's right, and in Botswana it's not that [treatment] is not available; it's not that they don't have the capacity - because they do, although they've brought it in from outside - the issue is stigma: people are just not prepared to go forward for treatment.
Q: So it's a dual problem in Africa: stigma among people themselves, and the capacity of governments and the health infrastructure?
A: Yes, and the capacity is around two things: it's around money, and its around [trained] staff
Q: And the political leadership?
A: I don't think, by and large, you've had the [necessary] political leadership. I'll be quite honest with you, I don't think, by and large, you've had African political leadership pushing for treatment, except in a very few cases. If you look at where the push for treatment is coming from, for the most part it's coming from international agencies, international NGOs and international activists. I would challenge anyone to produce the documents that show that African leadership has seized and pushed for treatment.
I'm open to correction on this, I think African leaderships would love treatment to be there, but they are very well aware of their creaking health systems, and the fact that, in Africa, you have to make choices between where you spend your money. Do you spend it on education or on health? And if you spend it on health, what do you spend it on - the disease that is killing most children, which is malaria - or on antiretroviral therapy?
I think we've also heard very clearly, in this commission, a couple of comments on the funding that is coming. First, we don't know how sustainable it will be. Secondly, that every source of funds comes with strings and reporting requirements which are putting an additional burden on our resources in Africa. I think there are two points Kthe first is that African governments would love for there to be treatment, but beware of Greeks bearing gifts.
Q: Are you worried, then, about ownership of the programmes; that governments might not, in a sense, be fully invested in the process?
A: Yes, that's absolutely correct. I think that is an issue, and that's not to denigrate the activities of Medecins Sans Frontieres or any of the NGOs that are coming in and saving lives. What they need to see themselves as is pilot projects, and that it's not just a case of treating people, it's also a case of giving local ownership, and that's what we need to see for a while. Now we're very lucky, as a commission, to have Paolo Teixeira [a former Brazilian health minister] as a commissioner. He said, in Brazil they said: 'okay it's not impossible to provide treatment', and they were pioneers - and there is room [in Africa] for that pioneering [spirit] that says, 'we will do it'.
Q: That argument: 'just start it and we'll figure it out as we go along', is that valid, or could it be problematic in terms of HIV/AIDS?
A: We have to remember that Brazil has 20 times the income of most African countries per capita, and about a twentieth, or less, in terms of HIV prevalence. It was possible to start it in Brazil because it had a bounded problem, and you - perhaps at a cost - could provide ARVs for all. In Africa I don't think we have the same range of policy options, but I do think we need to see some rolling-out of policy, and some courageous and innovative rolling-out of treatment - but it's not going to happen soon, and it's not going to happen for all that many people.
Q: How serious is the issue of drug resistance?
A: You have to distinguish between two sorts of resistance. If you or I are HIV-positive and we started taking the drugs, and we didn't take them properly and developed resistance, and eventually nothing could treat us - that's a catastrophe for the individual and it means they will die, and die quicker. But it's not a major issue for society in the sense that, in order for that resistance to become a societal problem, the individuals who are resistant have to pass on the mutated virus they have.
It's my considered opinion, and I may be wrong, that people who go on treatment are given the chance of life, and they will then act responsibly in terms of who they have sex with, and how they have sex. And I don't buy into the argument that HIV treatment will mean the epidemic will take off.
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