The Real Price of Fighting AIDS

By JOSHUA COOPER RAMO

Almost as soon as the United Nations announced that it had developed a figure for the cost of the fight against AIDS in Africa earlier this spring, Washington started to fret. The number, the Administration said, was just too big. Other donor nations were also concerned that the figure was unrealistic. The sum would be hard to raise. Moreover, a U.N. official explained, Washington was concerned that the U.S. contribution would "look like a drop in the bucket."

But this wasn't a number that could be fiddled. Much as donor nations might have liked to round the overall number down, the costs of AIDS defy even the fuzziest bureaucratic math. So the U.N. stuck with an estimate of $7 billion to $10 billion a year, a number reinforced by Secretary-General Kofi Annan last week, and the Bush Administration stuck with its plan to contribute $200 million to a global fund to fight HIV/AIDS, a fifth of what the U.N. had hoped for. To a problem that will kill more than 2 million Africans this year, many of them children, the U.S. contributed the annual budget of a Midwestern community hospital. Speaking to the U.N. AIDS conference last week, Secretary of State Colin Powell said the initial U.S. pledge is just a down payment, and, indeed, Congress is considering a donation of $750 million to a global HIV/AIDS fund next year. Powell's speech was passionate, but there is still no comprehensive U.S. strategy for delivering more leadership for HIV/AIDS.

One U.N. official who helped push for and keep that $7 billion to $10 billion estimate is Mark Malloch Brown, head of the U.N. Development Program. His agency has a unique mandate inside the U.N. system: it is charged with helping emerging economies get on their feet. In the past few years, Malloch Brown has seen that it is impossible to promote economic development without providing massive social support. In Africa he has come to the conclusion that tackling AIDS is essential to development. "This war will consume Africa's energies," he says. "Other development will be in the backseat."

The latest numbers on the cost of that war are breathtaking. The UNDP estimates that the per capita cost of annual treatment for infected Africans is likely to be $1,100. That includes $600 for antiretroviral drugs and an additional $500 in other medical costs. The $600 drug figure won't be reduced much, even if, as is hoped, drug companies forfeit their patents on these medications. Though that would save precious dollars on royalties, the cost of producing the drugs will remain high. It's like Nestle giving away the recipe for Toll House chocolate-chip cookies: someone still has to pay for the ingredients.

Similarly, the $500 cost is tough to reduce. In a typical African country fighting the epidemic, the government's annual spending per capita on health care is far less than $20. That means a huge health infrastructure will have to be built and maintained. So even if you could freeze Africa's infected populations today, at 25 million people, the annual cost of care would be close to $27.5 billion, roughly triple the most commonly discussed numbers. And then there are Asia and Eastern Europe, where the disease is rapidly taking hold.

For the next few years, it will probably be possible to make do with $5 billion or so a year. That's because we still need to identify infected populations and get them on medications, a task so difficult that even if the U.N. had $7 billion to spend on antiretrovirals this year, it could not distribute all the drugs or provide adequate care. "Like World War II," says Malloch Brown, "it will require a huge initial push of resources, a massive pulse to get us forward." After seven or eight years, he hopes, the demand will begin to abate. That huge initial push needs to happen soon. It is easy to understand why donors want a lower, "more realistic" number for AIDS spending. It would probably be more realistic for them to raise less money. But with 73,000 Africans infected every week, a truly realistic number may be much higher than we've yet imagined.