The Access To Drugs movement, in particular the focus on anti-HIV drugs, has achieved an unprecedented level of public awareness for a “Third World” or development issue. It has caught the attention not only of the general public and the mainstream media in Western countries, but even of audiences as congenitally unreceptive as the pharmaceutical industry and the Bush administration in the U.S. These encouraging developments could herald a major positive change in the global attitudes and international policies which have such an immense impact on the health of the world’s poor. But, if we limit our focus to drugs alone, we ignore the greater part of the continuum of health and social problems associated with poverty and inequality. More importantly, such a narrow emphasis may divert attention from the structural problems which underlie both the vast burden of preventable disease and the unequal access to treatment.
Recent events, such as the pharmaceutical industry’s well-publicized retreat in its battle over generic anti-HIV drugs in South Africa and the current debate over new Canadian drug patent laws, have fostered awareness of the global disparity in access to life-saving drugs. The deaths of millions of fellow human beings from HIV and other diseases for which effective treatments exist, have become much more real and immediate to people in the Western world, many of whom have experienced a healthy sense of outrage. Suddenly, it seems, almost anyone can see that these preventable deaths are illogical and unacceptable, as well as unjust. Alongside the life-and-death needs of real people, the predominance of “market principles” is seen in a new light.
This emerging perception contrasts starkly with our consistent track record of willingness to tolerate or ignore the lack of health care and basic human needs in poor countries. It certainly differs from the prevailing neoconservative position which considers these inequalities to be unavoidable, even desirable, and ultimately self-correcting effects of global market forces, with the implication that there is nothing we can or should do about them.
Part of the vision of the Access to Drugs movement is that it could open the door to wider awareness, broader knowledge, and deeper understanding of the causes and effects of global disparity, and lead to sustained support for constructive changes worldwide. An alternative outcome, perhaps more consistent with experience, is that the emphasis on medicines could tend to reinforce the medicalization of the issues, framing the problem as one of insufficient anti-HIV drugs and the solution as one of bigger, better charities to provide pharmaceutical products.
Addressing the issue of disparate access to treatment confronts us with some even more basic questions: Why is it that billions of people are so poor they can’t afford antiretroviral drugs, or even basic health care? Why are nearly 3 billion people forced to exist on less than two dollars a day? Why is per-capita spending on health hundreds of times greater in the richest countries than in the poorest? Why do more than a billion people lack access to clean water, some 2.4 billion to sanitation, and more than 100 million of the world’s children to primary education? How can life expectancy in some countries be as much as double that in others?
These questions place the obscene disparity in access to drugs squarely in the context of a much larger and more fundamental global injustice. This larger injustice remains the “elephant in the living room” that no one talks about. Whenever such political and economic questions manage to intrude into this treatment-focused discussion, the usual response is some variation on one of the following two fundamentally flawed assumptions:
1. The solution is just around the corner—all these problems are on the brink of resolution through the imminent benefits of globalization, another G-8 anti-poverty resolution, or the new Global Fund for AIDS, Tuberculosis and Malaria. Unfortunately, however, things are not getting better in much of the world. Globally, income inequality has been increasing steadily for over a century, and even more rapidly in the last decade. In spite of immense growth in global wealth, the number of people living on less than US$2.00 per day has increased over the last decade. Life expectancy is actually declining in many poor countries. The new Global Fund is gravely undersubscribed already. The international community has consistently failed to meet the commitments laid out in many previous resolutions on global poverty and is well on track for a dismal failure in reaching the recently proclaimed “Millennium Development Goals.” Hence it seems highly optimistic, if not delusional, to persist in the belief that the same old strategies are somehow about to start producing very different results.
2. Another widespread assumption is that poor people and poor countries are in their current predicament because of some factor beyond our control, such as “market forces” that are nearly as irresistible and immutable as gravitational forces. We seem to forget that markets and economies are wholly man-made entities—tools we developed to improve our lives and societies. Neither God nor Mother Nature, but people—mainly very wealthy people—make and change the rules that govern the global operation of the markets, according to their own beliefs. Therefore we (particularly those of us in the wealthy countries which benefit most from the global economy as currently structured) cannot avoid the lion’s share of responsibility for the negative effects of these market forces.
If we reject these two erroneous assumptions and accept that the broader scope of global inequity is as intolerable as the more specific disparity in access to drugs, we then find ourselves obligated to examine where the Access to Drugs movement is taking us—or, preferably, in which direction we should take it.
We must support access to life-saving medications for those in need. In responding to this need, however, we must not forget that the disparity in access to drugs is only one part of a much larger, longstanding disparity in health and wealth—an injustice which is at once intolerable, irrational, and, most importantly, correctable. Our challenge is to build on the gains achieved by the Access to Drugs movement and leverage them into fundamental global changes—debt cancellation, fair trade rules and international laws, for example—that address the underlying problem of disparity, including unequal access to treatment. We should start with the economic and trade policies of our own Canadian government.
(Stan Houston is Director of the Northern Alberta HIV Program. He previously worked for four years in several highly HIV-endemic countries in Africa.)