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We All Have AIDS

The United Nations Secretariat Building is lit with a red ribbon to spotlight the General Assembly Special Session on HIV/AIDS.
United Nations Photo #206341C by Eskinder Debebe
Opinion
Donald M. Berwick, MD

(June 26, 2001) -- In many occupied nations during World War II, the Nazis ordered Jews to wear a yellow star, as prelude to their destruction. But not in Denmark. According to legend, the Danish king, Christian X, threatened that, if Danish Jews were to wear the star, he would, too. The story is almost certainly a myth, but its meaning is not: Despite the Nazi occupation, Denmark rescued the overwhelming majority of its Jews. "If some Danes are under siege," the story means to say, "then all Danes are under siege. So, for now, we are all Jews."

Now we all have AIDS. No other construction is any longer reasonable. The earth has AIDS; 36.1 million people at the end of the year 2000. In Botswana, 36 percent of adults are infected with HIV; in South Africa 20 percent. Three million humans died of AIDS in the year 2000, 2.4 million of them in sub-Saharan Africa. That is a Holocaust every two years; the entire population of Oregon, Iowa, Connecticut or Ireland dead last year, and next year, and next. More deaths since the AIDS epidemic began than in the Black Death of the Middle Ages. It is the most lethal epidemic in recorded history.

Prevention will be the most important way to attack AIDS everywhere, but treatment matters, too. We can treat AIDS effectively. We cannot cure its victims, but we can extend their healthy lives by years -- with luck, by decades. We can reduce its transmission from infected mother to unborn child by two-thirds or more. We are seeing the effects of advancing science plus enlightened public health policies in the United States, where the toll of AIDS began to fall in 1997.

Successful, life-prolonging management of HIV infection is not simple. Important dimensions include education, social support and life-style interventions that are extremely difficult to achieve in the developed nations, and many times more so in impoverished nations. But it is a mistake to ignore the role of medications. In New York, San Francisco or Nairobi, no matter how different the cultural challenges, the correct mainstay of lifesaving care for the unborn child or the infected adult is medicine, given in a timely, scientifically accurate and reliable way.

Most people on earth with HIV and AIDS do not get those medicines. The barriers are partly social and logistical, but the overwhelming barrier is cost. At current prices, one year of triple drug therapy for an HIV-positive person costs $15,000. Recent, welcome changes by a few progressive pharmaceutical companies, such as Merck & Co., promise to reduce that cost by thousands of dollars per year.

But keep in mind that no legend claims King Christian talked of putting on only half a yellow star.

Here is what the world needs: free anti-AIDS medicines. The devastated nations of the world need AIDS medicines at no cost at all, or, at a bare minimum, medicines available at exactly their marginal costs of manufacture, not loaded at all with indirect costs or amortized costs of development. No hand-waving or accounting maneuvers -- for all practical purposes, free.

Here is how it could happen: The board chairs and executives of the world's leading drug companies decide to do it, period. To the anxious corporate lawyers, the incredulous stockholders, the cynical regulators and the suspicious public, they say, together, the same thing:

"The earth has AIDS, and therefore we all, for now, have AIDS. Therefore, we are taking one simple action that will save millions and millions of lives. We choose to do it, together, and we will use the intelligence of our own forces to figure out how to make it possible, while preserving the futures of our companies."

No one could stop them; none would dare try. For the small profit they would lose, they would gain the trust and gratitude of the entire world. They would have created a story to be told for a millennium, and those who depend on the prudence of these leaders -- on their "fiduciary responsibility" -- might choose then not to blame them but to join them in celebration, as fiduciaries of humankind.

The names of the people who can say this, together, include these: Raymond Gilmartin (chairman and CEO of Merck & Co.); Sir Richard Sykes and Jean-Pierre Garnier (respectively chairman and CEO of GlaxoSmithKline); Charles A. Heimbold Jr. and Peter Dolan (respectively, chairman/CEO and president of Bristol-Myers Squibb); Dr. Franz B. Humer (chairman and CEO of Roche). There are others; they know who they are. These few souls, with this act, would ultimately save the lives of more human beings than died in the Holocaust -- perhaps two or three times over.

If a Nobel Prize followed, it would be redundant. The memory of the deed would likely outlive even the story of the Danish king who joined his people in their need.

Donald Berwick is the President and CEO of the Institute for Healthcare Improvement, and Professor of Pediatrics and Health Care Policy at Harvard Medical School.

This article first appeared in The Washington Post.

The views expressed by individuals on this website do not necessarily reflect the views of Harvard University, and the selection of linked websites does not necessarily reflect Harvard's endorsement of those sites or of their content.

©2001 Harvard School of Public Health
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