| Emails in response to the article, "Comments on Problems in the First Draft World Health Organization (WHO) Antiretroviral Treatment Guidelines for Resource Limited Settings" | ||
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Subj: Re: Mark Harrington on "ARV Treatment Guidelines" Wouldn't it be great if the WHO and UNAIDS had leadership and a commitment to do the things that Richard Stern is talking about [below]? They have utterly failed to advocate for the resources necessary to do the job, and they have utterly failed to develop a forceful, pro-active strategy which both help leverage and help focus resources. Instead, they provide lame, last-minute assistance to the Secretary General when he decides to make an intervention at Abuja or at UNGASS. The reality is that the entire public health bureaucracy, of which WHO is a venerable and UNAIDS a more recent incarnation, were more or less horrified by the idea of a serious effort to provide antiretroviral therapy in developing countries. The very creation of UNAIDS was an implicit indictment of the inability of the existing UN agencies to respond to AIDS in a meaningful, coordinated way. The very creation of the GFATM is an implicit indictment of the inability of UNAIDS to develop and implement the strategies which the magnitude of the pandemic call for. With virtually no staff at either agency with focused expertise in AIDS research and treatment, and with those staff busy in a two year long transition from UNAIDS to WHO in an utterly untransparent and bureaucratically opaque manner, the agencies have been simply unable to cope with the magnitude of the needs they are facing, so they try and evade their responsibility by at least implicitly and sometimes explicitly murmuring the nostrums of public health ideology that prevention is cheaper and more cost-effective (and in any case the only thing we can afford) than treatment. With the exception of Bernard Schwartlander's brilliant piece in last June's SCIENCE,* neither WHO nor UNAIDS have produced a credible strategy document for scaling up treatment programs on the scale and with the diversity necesssary to make a difference. Thus, without an unlikely-looking renaissance of leadership or a vision transplant, it is hard to imagine these cash-strapped, politically compromised agencies, so often distracted by the complex internecine political and personnel struggles of multinational UN agencies, ever coming up with a coherent strategic plan without a significantly more aggressive and articulate global pressure campaign from grassroots agencies and NGOs around the world. Just look at how successful MSF has been at pressuring WHO to finally address patent issues, intellectual property, quality control of generics, and drugs for neglected diseases. The initiative for these changes (which are still incomplete) did not come from WHO, it came from MSF. Similarly, treatment activists must mobilize more effectively and present the WHO and UNAIDS leadership with a coordinated demand for a better strategy and a way to get there. TAG has advocated for a doubling of the UNAIDS budget for years. Every time I ask Peter Piot to ask his sponsor countries for more support, he does nothing. Instead, the responsibility and staff for AIDS treatment have migrated, by dead of bureaucratic night, from UNAIDS to WHO, where they are now simply overwhelmed by the magnitude of the tasks they face and completely unable to leverage the resources and staff necessary to do a better job. But money alone will not solve the problem; what's needed is stronger leadership, a clearer commitment to an ambitious treatment scale -up program, and quantifiable goals. Mark Harrington * Originally published in Science Express as 10.1126/science.1062876 on June 21, 2001; Science, Vol. 292, Issue 5526, 2434-2436, June 29, 2001; AIDS: Resource Needs for HIV/AIDS. B. Schwartländer, J. Stover, N. Walker, L. Bollinger, J. P. Gutierrez, W. McGreevey, M. Opuni, S. Forsythe, L. Kumaranayake, C. Watts, S. Bertozzi Subj: re: Mark Harrington on "ARV Treatment Guidlines" It was a breath of fresh air to read Mark's piece. I have been saying for a long time that a big piece of this puzzle is the failure of UNAIDS/WHO/(PAHO in Latin America) to provide an effective and coherent response to issues relating to access to treatment, but I have felt that this was an issue that others didn't pay too much attention to. Although it sounds paradoxical I would rather see the Global Fund give $50 million to WHO/UNAIDS so they can scale up to provide an international infrastructure, than to to give the money to Country programs that will find a way to waste it.(With the exception of funds that go directly to the purchase of ARV's that will be delivered directly to people, under adequate medical supervision). Of course providing additional funding for WHO/UNAIDS implies holding them accountable for quality outcome in terms of their reports, programs, and interventions. Mark has made many good recommendations. Ironically in most countries in Latin America, that I have knowledge about, the global fund application process was supported by UNAIDS/WHO staffers who had the technical ability to help a Country Coordinating Mechanism write an intelligent application. Who is going to help the country carry out programs once they are approved. Understaffed National AIDS program staff are used to working with budgets number in four figures (like $8000 a year)? How are they suddenly going to "Scale Up" intelligently to to carry out a program that provides a million dollars or more? The UNAIDS "accelerated access" program which can be effective where it has been carried out, muddles along like a lost turtle. Latin America has infrastructure and some economic resources to take advantage of this program but only in Trinidad, Chile and now Honduras has the program been carried out. The much praised Peter Piot has not asked for the resources he needs to do a good job with UNAIDS. By now, its apparent that his well intended rhetoric is not getting the job done, but he is strangely silent on the treatment access issue and providing recommendations as to what it takes to create a really meaningful response. UNGASS in most parts of the world is just lip service...the life of the average person affected by AIDS has not changed at all. Those who are alive in 2002 are not going to benefit from UNGASS's (unenforceable) target dates of 2005 or 2010. The Global Fund remains an open question...as far as funding for treatment access and purchase of generics is concerned. Basic issues such as getting accurate price information to health ministries, getting generic products registered, (plus all the other issues that Mark raises) and getting an adequate assessment of who needs what kind of care in what country, could be addressed by international Agencies who could provide quality level consultation to governments.... On a small scale MSF has put together all the ingredients that it takes to deliver ARV medications in resource poor settings...with of course, very small numbers of patients in selected programs. If MSF staff could just replace WHO staff, we would already be light years ahead.... I would challenge this list-serv to devote some attention to trying to figure out if there are effective advocacy actions that could be taken in support of the issues that Mark is raising. This is a tricky issue, but a few demonstrations outside of WHO offices in Washington might not be a bad idea... Richard Stern Originally posted to the HealthGAP list (hgapallies@critpath.org) |
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