Moving Mountains: The Race to Treat Global AIDS
http://www.100md.com
《新英格兰医药杂志》
The term "paradigm shift" became something of a cliché in the late 20th century, but there are few who would argue with its use to describe the revolution in global thinking that occurred less than five years ago, when the world community decided that it was actually not all right for people to die from a treatable disease just because they could not afford the drugs they needed. In reality, few people probably ever thought that it was acceptable, but the world seemed to be constructed in a way that said it was. That was the paradigm. If you had diabetes, cancer, hypertension, the human immunodeficiency virus (HIV), or AIDS and happened to be a poor person in a poor country, you simply could not expect that most of the known effective treatments were going to be made available to you.
Although the world community had previously united against epidemic diseases and their causes, with the smallpox campaign held up as the greatest victory, there was always a sense that any health strategies being considered for global implementation had to wait until there was a realistic (read, "cheap") solution at hand. With AIDS treatment, many people seemed to take a different view. Once antiretroviral drugs were seen as having the potential to transform HIV infection from a disease of guaranteed lethality into a manageable chronic infection, the call, led by an informal coalition of nongovernmental advocates, academics, and others, went out to make these drugs available to the 90 percent or more of people with HIV infection who live in poor countries.
The precise moment of this paradigm shift is often considered to have been in 2000 at the International AIDS Conference, which for the first time was staged not only in a developing country (in Durban, South Africa) but right in the heart of one of the most affected areas in the world. From that time on, it became a matter of when, rather than whether, poor people would have access to antiretroviral drugs. Since then, "when" has become "how many," since a mutually reinforcing cascade of initiatives — including large-scale private donations, the distribution of low-cost copies of antiretroviral drugs, and massive public-sector programs, such as the Global Fund — have combined to send the message that effective treatment is essentially a basic human right.
In Moving Mountains, journalist d'Adesky tells the story of this revolution in global thinking. Using a series of case studies from various countries, she covers a vast territory, both geographic and conceptual, and reports on her engagement with many of the key people and organizations that have been at the forefront of HIV treatment. D'Adesky clearly knows her way around this world, and she provides convincing testimony about the social and political challenges that this epidemic has exposed so starkly in many countries, including the overwhelming discrimination experienced by people with HIV infection, the risk that women face when they are not in a position to negotiate their sexual safety, and the thinly stretched fabric of infrastructure for primary health care that must now become the front line for HIV treatment.
The author's country-by-country approach provides the reader with vivid images of local circumstances, but it also leads to a degree of fragmentation in the thematic aspects of her story. She sometimes reports an aspect of an issue as if it were unique to the place from which she is reporting, such as the fact that people in Mexico with HIV infection present late in the course of disease, whereas late presentation is common in most developing countries. On the other hand, the approach also produces some repetition that can serve to emphasize the power of her message.
Despite containing a wealth of valuable detail (including eight appendixes and more than 75 pages of footnotes), the book could have benefited from some further technical editing. Protease inhibitors were not widely available in the early 1990s, Uganda is part of sub-Saharan Africa, it is the World Trade Organization (not the World Health Organization) that would have been the recipient of the U.S. government's complaint against Brazil in February 2001, and Bill Clinton was no longer in charge at that point.
These quibbles about structural and editorial matters are secondary to the main problem with d'Adesky's book, which is that it is ultimately an extended polemic that divides the world into heroes and villains, whose roles are determined as much by their affiliation as by their actions: Pharma (Big) vs. Farmer (Paul), to extend the caricature. D'Adesky's account fails to acknowledge that the new global thinking about HIV treatment not only represents a paradigm shift for the AIDS epidemic but also challenges many of the comfortable and long-held assumptions on which the world economic and political order is based. Toward the end of the book, d'Adesky allows that the revolution in HIV treatment could well have implications for the funding and distribution of other drugs, but she does not make the links beyond health initiatives that can be put into small bottles and does not try to understand what it was about the AIDS epidemic that forced the world to respond in a way that it never had before.
It is hard to resist the almost missionary fervor that d'Adesky conveys so well in her book, but the world remains a complicated place. Drug companies will still expect to protect their investments and intellectual property, international agencies will still have too few resources and too many demands to meet, and donors will still be driven by geopolitical imperatives and self-interest as much as by altruism. To be sure, some sobering lessons have come from the early chapters of the AIDS epidemic, when the international community spoke of confronting the epidemic with a change in behavior. Treatments have indeed made remarkable progress during the past decade, and we must keep extending their availability in every corner of the world, but it is important to remember that they do not provide anything approaching a cure, and there is not even a hint on the horizon that they will be capable of doing so. So although the situation for patients with HIV in poor countries may start to look more like that of patients in rich countries, we are still on a very long journey — with many more mountains to cross, go around, or even move — toward the control of the global pandemic, whether it is achieved through prevention or treatment.
John M. Kaldor, Ph.D.
National Centre in HIV Epidemiology and Clinical Research
Darlinghurst, NSW 2010, Australia
jkaldor@nchecr.unsw.edu.au(Anne-christine d'Adesky. )
Although the world community had previously united against epidemic diseases and their causes, with the smallpox campaign held up as the greatest victory, there was always a sense that any health strategies being considered for global implementation had to wait until there was a realistic (read, "cheap") solution at hand. With AIDS treatment, many people seemed to take a different view. Once antiretroviral drugs were seen as having the potential to transform HIV infection from a disease of guaranteed lethality into a manageable chronic infection, the call, led by an informal coalition of nongovernmental advocates, academics, and others, went out to make these drugs available to the 90 percent or more of people with HIV infection who live in poor countries.
The precise moment of this paradigm shift is often considered to have been in 2000 at the International AIDS Conference, which for the first time was staged not only in a developing country (in Durban, South Africa) but right in the heart of one of the most affected areas in the world. From that time on, it became a matter of when, rather than whether, poor people would have access to antiretroviral drugs. Since then, "when" has become "how many," since a mutually reinforcing cascade of initiatives — including large-scale private donations, the distribution of low-cost copies of antiretroviral drugs, and massive public-sector programs, such as the Global Fund — have combined to send the message that effective treatment is essentially a basic human right.
In Moving Mountains, journalist d'Adesky tells the story of this revolution in global thinking. Using a series of case studies from various countries, she covers a vast territory, both geographic and conceptual, and reports on her engagement with many of the key people and organizations that have been at the forefront of HIV treatment. D'Adesky clearly knows her way around this world, and she provides convincing testimony about the social and political challenges that this epidemic has exposed so starkly in many countries, including the overwhelming discrimination experienced by people with HIV infection, the risk that women face when they are not in a position to negotiate their sexual safety, and the thinly stretched fabric of infrastructure for primary health care that must now become the front line for HIV treatment.
The author's country-by-country approach provides the reader with vivid images of local circumstances, but it also leads to a degree of fragmentation in the thematic aspects of her story. She sometimes reports an aspect of an issue as if it were unique to the place from which she is reporting, such as the fact that people in Mexico with HIV infection present late in the course of disease, whereas late presentation is common in most developing countries. On the other hand, the approach also produces some repetition that can serve to emphasize the power of her message.
Despite containing a wealth of valuable detail (including eight appendixes and more than 75 pages of footnotes), the book could have benefited from some further technical editing. Protease inhibitors were not widely available in the early 1990s, Uganda is part of sub-Saharan Africa, it is the World Trade Organization (not the World Health Organization) that would have been the recipient of the U.S. government's complaint against Brazil in February 2001, and Bill Clinton was no longer in charge at that point.
These quibbles about structural and editorial matters are secondary to the main problem with d'Adesky's book, which is that it is ultimately an extended polemic that divides the world into heroes and villains, whose roles are determined as much by their affiliation as by their actions: Pharma (Big) vs. Farmer (Paul), to extend the caricature. D'Adesky's account fails to acknowledge that the new global thinking about HIV treatment not only represents a paradigm shift for the AIDS epidemic but also challenges many of the comfortable and long-held assumptions on which the world economic and political order is based. Toward the end of the book, d'Adesky allows that the revolution in HIV treatment could well have implications for the funding and distribution of other drugs, but she does not make the links beyond health initiatives that can be put into small bottles and does not try to understand what it was about the AIDS epidemic that forced the world to respond in a way that it never had before.
It is hard to resist the almost missionary fervor that d'Adesky conveys so well in her book, but the world remains a complicated place. Drug companies will still expect to protect their investments and intellectual property, international agencies will still have too few resources and too many demands to meet, and donors will still be driven by geopolitical imperatives and self-interest as much as by altruism. To be sure, some sobering lessons have come from the early chapters of the AIDS epidemic, when the international community spoke of confronting the epidemic with a change in behavior. Treatments have indeed made remarkable progress during the past decade, and we must keep extending their availability in every corner of the world, but it is important to remember that they do not provide anything approaching a cure, and there is not even a hint on the horizon that they will be capable of doing so. So although the situation for patients with HIV in poor countries may start to look more like that of patients in rich countries, we are still on a very long journey — with many more mountains to cross, go around, or even move — toward the control of the global pandemic, whether it is achieved through prevention or treatment.
John M. Kaldor, Ph.D.
National Centre in HIV Epidemiology and Clinical Research
Darlinghurst, NSW 2010, Australia
jkaldor@nchecr.unsw.edu.au(Anne-christine d'Adesky. )