Doctors Without Borders: Humanitarian Quests, Impossible Dreams of Médecins Sans Frontières

7. Struggling with HIV/AIDS

CHAPTER SEVEN Struggling with HIV/AIDS HIV/AIDS is the greatest health crisis the world faces today. In two decades, the pandemic has claimed nearly 30 million lives. An estimated 40 million people are now living with HIV/AIDS, 93% of them in developing countries, and 14,000 new infections occur daily. . . . There is currently no cure for HIV infection . . . yet the development of life-saving anti-retroviral drugs has brought new hope. . . . Of the 6 million people who currently urgently need anti-retroviral therapy in developing countries, fewer than 8% are receiving it. Without rapid access to properly managed treatment, these millions of women, children and men will die. WORLD HEALTH ORGANIZATION, TREATING 1 MILLION BY 2005 Who would have predicted that the end of the last millennium would see the emergence of new pathogens and epidemics, when the medical world thought it had it all under control . . . ? PETER PIOT, NO TIME TO LOSE A pestilence isn’t a thing made to man’s measure; therefore we tell ourselves that pestilence is a mere bogy of the mind, a bad dream that will pass away. But it doesn’t pass away and, from one bad dream to another, it is men who pass away. . . . Dr. Rieux knew . . . that the plague bacillus never dies or disappears for good . . . [H]e knew that the tale he had to tell could not be one of a final victory. It could only be the record of what had to be done, and what assuredly would have to be once again in the never ending fight . . . by all who, while unable to be saints, but refusing to bow down to pestilences, strive their utmost to be healers. ALBERT CAMUS, THE PLAGUE 122 In South Africa In 2000–2001, MSF began to integrate the treatment of HIV/AIDS with antiretroviral drugs into its programs and to engage in intensive witnessing and advocacy to promote access, at affordable prices, to these medications, which are essential for treating the disease. The decision to do this was not arrived at quickly or easily. It was reached incrementally, movement-wide—preceded and accompanied by great hesitancy, strong resistance, and intense debate about the capacity of MSF to deal with an epidemic of this magnitude, which would entail undertaking the lifelong, intricate care of multitudes afflicted with a complex, chronic, and incurable disease, which was ultimately fatal, and about the feasibility of doing so in the characteristically resource-poor, economically and socially disadvantaged settings in which the disease was especially rampant. The history of MSF has been coterminous with the global emergence of many new infectious diseases, and the reemergence of numerous old ones.1 None, however, compared with the HIV/AIDS pandemic, which the medical scientist and public-health expert Helen Epstein has judged “the most serious health crisis of our time, and perhaps in all human history.”2 Moreover, MSF was not accustomed to dealing with long-term illnesses. It specialized in what one member called “a medicine of emergency” focused on “rescuing victims of conflict and the wounded of war,” whose symbolic and substantive quintessence was epitomized by “the surgical act”: Historically, MSF was not ready to battle head-on with AIDS when it occurred during the 1980s. It rapidly set into motion measures to counter the transmissible aspects of the epidemic. But its conception of humanitarian medicine remained rigid, and aspects of prevention and of public health, and therefore of access to care more generally were not yet integrated into it.3 It took a number of converging factors for MSF to break through what it described as its “ideological and sociological impermeability to any form of activism concerning HIV/AIDS,” or even to recognize the potentially revolutionary implications of antiretroviral drugs for its treatment.4 One of these factors was the initiative taken by Paul Cawthorne, a nurse, and David Wilson, a physician, working for MSF in Thailand, which had one of the highest rates of HIV/AIDS in Southeast Asia during the 1990s. Partly because the early cases of HIV/AIDS there occurred primarily among men who had sexual relations with men, and partly because they were a gay couple, Cawthorne and Wilson became involved with the plight of homosexuals af- Struggling with HIV/AIDS 123 flicted with AIDS. They went on to create a program of home-based care for AIDS patients that emphasized psychological and social support. Then, in collaboration...