By Steve Weinstein
By Devon Maloney
By Tessa Stuart
By Alison Flowers
By Albert Samaha
By Jesse Jarnow
By Eric Tsetsi
By Raillan Brooks
RIETPOORT FARM, STANDERTON DISTRICT, SOUTH AFRICAEvery time Christina Makhubu came home, it was like Christmas. Working as a housemaid in South Africas capital, Pretoria, she made more than anyone else in her family, including her brothers, who work as farmhands. So she would bring her mother dresses, her two sons books and once even a bicycle, school fees for her nephew, furniture for the house, and of course food for everyone. Her familythree generations gathered together in a room lit by a single candle, around the table where they would feast at her homecomingsremembers the last time Christina came home. She was so tired, and then the headaches began. She said she felt drunk and confused, and then she started seeing things that weren't theresnakes on the wall, and other animals that terrified her. The pain in her head just got worse, and when she began to fall down trying to walk, they took her to the hospital for the last time.
At some point, maybe years before, Christina had inhaled spores of the cryptococcus fungus. Healthy people control the infection, but HIV had ravaged Christina's immune system, so the fungus was able to pass into the blood, which carries it to the brain. There it sets up coloniespearly, glistening spheres along the blood vessels of the brain, most abundant on the wrinkled surface but also present deep in the brain's core. The fungus does not kill neural cells, but it makes them swell, squeezing the brain inside the skull and turning the gray matter into "a big bag of mush," explains John Bennett, who has studied the disease for 30 years at the National Institute of Allergy and Infectious Diseases in the United States. "When the skull is cut open at autopsy, the brain bulges out like toothpaste out of a tube."
This is cryptococcal meningitis, one of the most feared opportunistic illnesses that kill people with AIDS. It can be treated, but one of the key drugsfluconazole, which also works well against thrush, an extremely common ailment among HIV patientscosts the equivalent of about $7.50 for a standard dose, far too much for South Africa's struggling health care system. Pharmaceutical giant Pfizer holds the patent for fluconazole and sets the price in almost every country. But in Thailand, the government permits local companies to make a generic form of the drug; the price for the same dose is only about 70 cents.
Now, the Nobel Prize-winning organization Médecins Sans Frontières, ACT UP, and a South African AIDS activist group called Treatment Action Campaign are leading an effort to pressure Pfizer to match the Thai price, or to give TAC a license so that it can find a company to manufacture a generic version of the drug. Last Monday, the activists delivered letters to Pfizer offices in 18 different countries, giving the maker of Viagra and Zoloft one week to agree. But on Monday, the deadline passed and the company did not acquiesce, so both sides are preparing for a long siege.
This high-profile, high-stakes battle raises the possibility that the South African government might compel Pfizer to allow a generic version of fluconazole to be manufactured. Or the government could pull an end run by importing the Thai version of the drug. Either of these actions would force a showdown on international trade regulations, which the pharmaceutical industry insists support the right of companies to determine prices around the world. But humanitarian groupsas well as a swelling chorus of politicians, including Clinton, Gore, and many members of Congressbelieve those regulations should allow developing countries to obtain medicines that fight major epidemics, such as AIDS, at the lowest possible price.
This is the fight that will capture the attention of the international media. But here in South Africa, which is a blend of the First and Third Worlds, the push for this drug has laid bare some of the most daunting problems in treating AIDS. Insufficient money to purchase medicines is certainly the biggest obstacle, but there is also the government's frequent failure to deliver cheap drugs to hospitals, doctors' unfamiliarity with treatment possibilities, and a population that thinks of HIV as utterly hopeless and so gives in to despair. The fight over this one drugwhich does not even target HIV itself but rather some of the opportunistic illnesses the virus causesis therefore a microcosm of South Africa's battle to treat its 3.6 million citizens with HIV.
At Standerton Provincial Hospital, where Christina Makhubu died, senior medical superintendent Eckhart Oosterhuis desperately wants fluconazole, but he also wants a lot of other drugs. In 1998, the last year for which local figures are available, a shocking 51 percent of women attending public prenatal clinics in Standerton were infected with HIV. The hospital is supposed to stock 169 so-called essential drugs, but, producing a list, Oosterhuis says he is completely out of 38. "Our supplies are low for about another 50," he adds.
In AIDS, there are two conditions that are absolutely critical to treat: tuberculosis, because it probably kills more HIV-positive South Africans than any other opportunistic infection and because it imperils the general population; and sexually transmitted diseases, because people who have them are more likely to contract and transmit HIV. But despite being fairly cheap, drugs to treat these problems are often unavailable. For example, according to a report by the provincial government, TB drugs were out of stock between 15 and 30 percent of the time. As for STD drugs, Rensie Vellema, the Standerton district communicable disease coordinator, says that at least one is unavailable most of the time. "It's really a disgrace," she says. "If we send patients to a private pharmacy, they can't afford the drugs."