hen I was asked to consider becoming dean of the Harvard School of Public Health, one of the more compelling arguments offered was that the dean has a unique platform from which to capture the attention of leaders and the public. Perhaps I can convey a sense of that privilege with a recent story.

It begins last January when, thanks in large part to Ambassador Richard Holbrooke and UN Secretary General Kofi Annan, the Security Council of the UN held its first special session on a health-related issue and declared that HIV/AIDS was a global security problem. A special session of the General Assembly was then scheduled for May to engage all nations in a discussion of the worldwide impact of HIV/AIDS and to mobilize them--after 20 years of inaction--to address this scourge with resources on a scale commensurate to this global threat.

A few weeks prior to the General Assembly meeting, the School received an influential visitor who asked to meet with some of our AIDS researchers and experts. The visitor was Bernard Kouchner, the health minister of France, who formerly served as special representative of the UN Secretary General for Kosovo and was the founder of Médecins Sans Frontières and Médecins du Monde, the humanitarian disaster groups that observe no boundaries. Dr. Kouchner was deeply concerned about the impact of AIDS on developing countries and, together with Countess Albina du Boisrouvray who created our François-Xavier Bagnoud Center for Health and Human Rights, asked whether we could formulate some ideas that might be useful to Secretary General Annan as he led the UN special session. We arranged a meeting on short notice with about a dozen of our faculty who work on AIDS or have relevant experience in developing countries.

The meeting was electric--with questions and ideas flying, among them some creative suggestions that we hoped might be of practical value. What we drafted was not a plan--there were already many plans on the table for the special session--but some "points for consideration" that we thought could help Kouchner mobilize support for and clarify use of a Global AIDS and Health Fund. Such a fund was proposed by Kofi Annan at the most recent meeting of African Heads of State in Abuja, Nigeria, in which several of us were privileged to participate. Our letter emphasized some general points, particularly the need to balance prevention, treatment, care, and support, and the recognition of the synergy between treatment and prevention. There was also a new idea, which we found very exciting: we called it "A Global HIV/AIDS DrugStore." Let me set the context.

HIV/AIDS represents the greatest infectious disease threat to humanity since the Black Death ravaged Europe in 1348. In the two decades of the epidemic, 22 million people have died, 75 percent of them in Africa alone. Some 6.1 million people are infected with the virus, and there are 13 million AIDS orphans. While the introduction of antiretroviral drugs has changed the whole pattern of disease in rich countries, the drugs are too expensive for most developing countries to afford. Clearly, from a public health perspective, the most important thing in an epidemic is prevention to stop transmission. Still, more than 90 percent of people infected with HIV do not know it, and many would not be willing to be voluntarily tested and counseled if the only outcome were stigmatization and ostracization. The only way to reverse this reluctance to be tested is if those infected are provided with some hope and expectation of treatment. That treatment should include antiretroviral drugs, antibiotics for sexually transmitted diseases, and therapies for opportunistic infections including tuberculosis, which is a primary threat to people with AIDS.

Since the discovery of their effectiveness, antiretroviral drugs have been out of the reach of poorer nations. But this year the world changed--there was a paradigm shift, and the pharmaceutical industry, industrial countries, and the UN are now creating partnerships to make drugs to save the lives of those already infected more affordable, while we at the School, and many in other labs, work to develop a vaccine to prevent the disease. It is becoming clear that we must move on both the prevention and treatment fronts in the HIV/AIDS assault because the two efforts are linked and can potentially strengthen one another. Treatment would allow babies to be born free of the virus, mothers to survive to serve as meaningful parents, and workers to continue to be productive and provide for their families. Prevention solidifies the gains of treatment and protects the future health of people and nations.

Making this link is where the Global Drugstore concept comes in. At least 45 developing countries have a major need for drugs to treat AIDS, tuberculosis, and sexually transmitted diseases. There are now 14 companies that manufacture antiretroviral drugs alone, plus more companies that make drugs for related opportunistic infections. Soon many more companies will be in the market. Does each country have to negotiate with each company for each drug? And how can it be guaranteed that the right combinations of drugs are appropriately used? We know from the case of tuberculosis, where effective, safe, and inexpensive drugs exist, that if their use is not properly supervised--if people are able to buy them for one day, one week, or one month and take the red one today, the green one tomorrow--resistance results. For the multidrug resistant TB we see in Russian prisons and increasingly in many developing countries, we have few available effective drugs. And strains that resist treatments have a Darwinian survival advantage.

The Global Drugstore concept was conceived by the group convened hurriedly for Kouchner's visit in January. The hope was to suggest a mechanism to both make treatments for HIV/AIDS, TB, and STDs accessible and inextricably link them so as to strengthen, rather than compete against, prevention activities. To flesh out some of the key issues around the provision of drugs for AIDS, Michael Reich, director of our Center for Population and Development Studies, Jim Kim of Harvard Medical School, and I convened a brainstorming meeting in August involving 30 people, many with technical knowledge about drug provision to developing countries for other diseases. They came to Boston from WHO, The World Bank, UNICEF, Médecins sans Frontières, and AmFar. Also joining us were scientists from major pharmaceutical companies, who were involved in international activities, and people knowledgeable about government--including Ambassador Holbrooke, now head of the Business Council for AIDS; Eric Chevallier, chief of staff to the health minister of France; and Jeffrey Sachs from Harvard's Kennedy School of Government--who helped us think about how to relate technical issues to real-world politics. The opportunity to save millions of lives with appropriate treatment is compelling. But the risks we face over the misuse of the drugs and the possible emergence of multidrug resistant HIV are daunting; the logistics of how to get the drugs to the patients responsibly are challenging. And most important, it is crucial that we learn how to link the drug treatment effort to strengthening prevention.

From the varied perspectives of industry, intergovernmental organizations, academics, and people on the ground, a set of general ideas emerged. They were informed profoundly by lessons from the experience of several programs already providing developing countries with drugs for treating and preventing other diseases, such as river blindness, tuberculosis, and trachoma. We sought to develop some general principles for resource allocations from the Global AIDS and Health Fund, through which countries or NGOs would assess treatment needs and request drugs from a number of purchasing agents who could provide appropriate drug combinations with high quality assurance. Those proposals that could best assure the drugs' responsible use and present creative ideas for linking treatment to prevention efforts would be the first funded by independent review. Those proposals not initially funded would receive help and advice to develop effective infrastructures to do so. None of us knows yet how to use antiretroviral drugs most effectively in resource-poor countries, and a key element of any program will be to learn what works and what doesn't from the initial experiences. This effort will require the thoughtful analysis of results and the creation of an information system through which these experiences can shared by all.

In a summary of our deliberations from the August meeting, we are conveying our thoughts to Secretary General Kofi Annan in hopes that they will be helpful to his Transition Team charged with organizing the Global AIDS and Health Fund. The degree to which these ideas will have a useful impact remains unclear. But the fact that so many busy people with such extraordinary expertise agreed to come on short notice to the School of Public Health to think about one of the world's great problems exemplifies the power of the platform. I hope we can use it wisely to fulfill our mission--to change the world and learn how to improve the health of people everywhere.

Barry R. Bloom