Perspective on the XIII International AIDS Conference in Durban, South Africa

An Interview with Michael Sinclair, Ph.D., Senior Vice President of the Kaiser Family Foundation’s South Africa Program

Michael Sinclair provides highlights from the AIDS 2000 conference and shares his views on the role of the South African government in access to treatment and care, U.S. government and private sector support efforts, and the future of the AIDS epidemic.


Q: The big question is what came out of this conference? What was good about it, what might be — what consequences might be good, and how far does it take us, that sort of thing.

MR. SINCLAIR: I think what was different about this conference from the 12 that have preceded it was, first, that obviously it was in a developing country for the first time in its history, which is of major significance.

But secondly, I think it was the first conference that really served as a global platform for bringing to the attention of the world the scale of this epidemic, the fact that its growth is exponential in the developing world in particular, and also that the issues relating to controlling the epidemic and preventing its further spread are inordinately complex, and they relate to the politics and the economics of health and the distribution of drugs, in particular, but they also relate to the scientific facts of the virus and the difficulties in trying to find a vaccine and a cure, and the inordinate amount of effort, scientific and otherwise, that has gone in that direction for very little result, in fact, over the past 15, nearly 20 years now, and that that is of inordinate frustration to the scientific community and to the political leadership.

And I think that one is seeing some of that frustration play itself out now in this tension between President Mbeki and — which is supported by many leaders in the third world — of questioning just how effective and how dedicated the search for a cure or a vaccine has been, and whether that search has in fact been directed in a way which is in the best interests to the developing world. Obviously many in the developing world say no, and their frustration is particularly centered on the fact that the available therapies are basically unaffordable outside of the Western world.

So I think what has come out of this conference is a real focus on the fact that the seat of this epidemic is now in the developing world, that as long as this epidemic is raging on the scale that it is, the rest of the world is clearly threatened. So it is of global concern. And that suddenly, I think forces from across huge spectrum of sectors has been brought to bear on the issue, and we have a real chance of meaningful alliances being formed to address the problem. I don’t think there’s any magic bullet out there any time soon, but I think we have an array of forces and resources like never before.

Q: You mentioned a couple of things. You mentioned a lot of things, actually, and one of them is that the — the new impetus, the new aid. What are some of the highlights of that? I know the Congress sort of actually reversed itself on the aid question to deal with AIDS. Is that significant?

MR. SINCLAIR: It was significant, clearly. And we saw during the week of the conference a number of announcements, ranging from the World Bank, saying it was $500 million or something of that sort, a loan package; the U.S., what is it, Federal Loan Administration making its announcement, I think it was a billion-dollar loan package; promises from Congress of substantially additional funding; promises from various private-sector groups of substantial funding. All of that, obviously, is terribly meaningful; however, it’s not the whole answer.

For example, most of the countries that are most affected by the epidemic are also heavily indebted to these same institutions that are now promising to loan them more money. They’re not in a position to borrow more money to do anything, let alone to fight a disease that is killing people and that is probably going to kill those self-same people for whom they are borrowing the money anyway. That’s going to be their calculation, believe me.

And secondly, that the money doesn’t buy the systems that are required to enable governments to provide decent health services to the people most affected by this epidemic. And at the end of the day, that’s what it comes down to. And a decent responsive health service in turn requires a government that is responsive to the needs of its population — i.e., a basically democratic system of governance. And in many of these countries, that is not in place either. So where you have greater priorities being given to the enforcement of rule and order, for example — i.e., the political status quo, the fighting of border wars or inter-regional conflict and so on, as is the case in many of these countries — health systems development is not high on the agenda. Despite the fact that you have an epidemic that is now demanding the attention of political leadership, the commitment to the development of the broader infrastructure is not there. The systems are not in place to be able to deliver sophisticated treatment, let alone basic prevention programs.

Q: One of the things, I think, that the foundation is doing in South Africa is trying to create or help support clinics. Now, with your knowledge of that attempt, how far are some of the other countries from being able to even get to the point where South Africa is?

MR. SINCLAIR: Well, as you point out, South Africa really is, certainly in the African context, at a considerable advantage because it has had historically a very sophisticated Western-style medical system, which previously has been largely there for the use of the white, advantaged population. But in the past six years, since the new government has come to power, they have spent a great deal of money and effort in developing their primary health care infrastructure, including building a lot of clinics and so on. So the infrastructure has been considerably extended. But even in South Africa, even given in that commitment, the difficulties of providing these sort of therapies is very considerable and the expense involved would be very considerable. The know-how is not there, the management system is not there, even though the physical infrastructure is there. So that’s at the positive end of the equation.

And then you can look across Africa and you can see gradations of that type of situation, in other words, until we can imagine the worst-case scenario, where there is no infrastructure. A country like Mozambique, for example, devastated by civil war over the past 10 years, just pulling itself together, now devastated by floods. They don’t have enough health infrastructure. They are not even in a position to count how many people they have, let alone how many AIDS cases they have. So the opportunities for other African countries, I think, are inordinately limited. And clearly there is — from a country like Tanzania, which is relatively ordered and well-organized, to countries like the Congo, for example, Zaire, the Democratic Republic of the Congo, Nigeria, which has been hugely mismanaged for many decades now, originally had a very sophisticated health system. What the capacity of that health system is now, I don’t know. Countries in the Eastern Horn of Africa, which have been at war with each other for many years — there is no health infrastructure there to talk of. So it’s — I think their opportunities are very limited.

I think that South Africa has done a valiant job of taking on the pharmaceutical companies and pricking the conscience of the world on this issue. But they’re — in some ways, they’re shooting themselves in the foot, because they’re also arguing that South Africa won’t take it until other countries can take it as well.

And we’re hearing, I think with some degree of legitimacy, from the pharmaceutical companies and others, who will give their drugs for free, that they won’t give them for free unless they can be assured that the systems are there. And part of the reason for that is that if they give them out willy-nilly, we all know that the reaction to uncontrolled distribution of expensive drugs could be disastrous.

Q: So we need to have the health care system in place before really the drugs can be entirely effective, and we can’t have the drugs until that happens.

So in terms of what — I mean, we’re talking billions of dollars have been promised recently. How far does that take us, and how much, to actually address the issues?

MR. SINCLAIR: Well, I think it takes us quantum leaps further than we were as recently as a year ago. And the reason for that is that suddenly people are beginning to realize the scale of the issue and that these are the sort of resources that are needed in order to address this problem.

And I’m not saying that nothing can be done. Clearly, even with minimally functional health infrastructures, there are centers where the health infrastructure is operational or can be made operational, and so it can be done locally. I think doing it nationally and doing it with the hope of stopping an epidemic is a little far-fetched at this point. So I don’t think it brings us any closer to stopping the epidemic. I think it brings us closer to being able to reach out to more people than certainly was the case a year or so ago. But that requires political commitment.

And South Africa, where this could be done very easily, very quickly, has hesitated about that political commitment, because they argue that the current South Africa, as democratic as it is, is founded on the principle of equity. In other words, you don’t provide health care with government resources to one set of the population if you can’t provide it to another. And so this concept of localized implementation of sophisticated AIDS therapy is being delayed because of political reasons. And we have to see where that argument goes.

Q: Let me just ask you specifically about the conference. Were there any major highlights? Obviously, one was Mbeki’s speech at the beginning, and then Mandela’s speech at the end. Is that one of the major things that we should have focused on while the conference was going on, or are there other things that perhaps were more significant at the conference itself?

MR. SINCLAIR: I think, in the context of time, what President Mbeki and former President Mandela had to say would be remembered with interest, but of little consequence, frankly.

I think that what is clearly more important is the attention of the scientific and broader community involved in the issues related to HIV-AIDS. And yes, there is inordinately broad-based work going on, but it’s amazing to me how broad the partnerships and connections are. It’s not just a medical thing; I think the issue — as it was for many years — it’s very much now an economic issue. The economics of HIV-AIDS are really taking center stage. And I think that these types of conferences provide an opportunity for all of the individuals and organizations working in the field in their different ways to suddenly recognize each other and to develop networks that otherwise don’t happen. So, as is often the case with these events, I think the most important developments are what happened outside of the formal events. There obviously were important scientific findings, some negative, some positive, that were presented. There were no magic bullets, there were no major, you know, bolts of lightening from the blue. Incremental findings here and there. And that’s in the nature of the beast. But I think, as I said earlier, that the main importance was in the breadth of the coalitions that were represented and, I’m sure, were consolidated.

Q: All right. Give me some sense, Michael, of how you see things going down the road.

MR. SINCLAIR: Well, I think it’s going to be a lot more of the same. I think that this conference has given the whole movement, if you like, a far broader perspective on the epidemic; substantial momentum. I think a lot of that momentum will only be maintained if there is a commensurate level of — and sustained commensurate level of political leadership.

And, if — you know, it’s doubtful, for a whole variety of reasons, and I think the conference focused the attention of a lot of world leaders at one time. The conference is now gone. How are we going to continue to sustain that interest in an epidemic which is going to be enduring for a very, very long time, and which is easily forgotten, particularly by the western world, because, you know, it’s Africa. They shrug their shoulders and say, “It’s out there. People have been dying there for decades, and so what’s new?” and sadly and tragically, that is exactly true. I mean, that’s what frustrates the likes of President Mbeki and others.

And I think that, as we’ve just seen with the G-8 summit, President Mbeki and the president of Nigeria were mandated by developing countries to represent them and their interests to the G-8, but their interests didn’t focus specifically on AIDS. It focused on distribution of resources internationally, and I think that that’s probably where AIDS is going to find its seat in the future.

I’m not sure that that is the best strategy, because I think there are too many other vested interests on the part of the industrialized world to be able to give on the issue of AIDS within the context of a broader development framework. So I’m not all that optimistic that a whole lot is going to change in the short term.

Q: In terms of the industrialized nations, the one thing that occurs to me is that you were just talking about how it’s Africa and, therefore, perhaps a lot of people don’t pay full attention to it until it reaches a crisis point. What — what should Americans or Europeans or the Japanese, these developed nations, why should they be concerned about what’s happening in Africa with AIDS?

MR. SINCLAIR: Well, it’s a good question, and probably they should be concerned with what’s been happening in Africa historically. Clearly, Africa has been significantly disadvantaged over time, for a variety of historical reasons. That’s not to say that the western world necessarily owes it to Africa per se, although many African leaders would argue that.

But I think the potential is enormous. This here is the last, great untapped continent of the world, and South Africa probably is the stellar example of that creativity, the energy, that exists within southern Africa as a broader region, with South Africa, obviously, spearheading that. It’s extraordinary. The richness of those parts of the world, both in terms of natural resources and in human resources, is virtually untapped. So if you were to be looking at the future globalization opportunities, the two great opportunities are China and Africa. China is one country, and so in some ways it’s easier, and more difficult — (chuckles) — to deal with. Africa is more than 50 different countries, which makes it horrendously difficult to deal with. But the opportunities are certainly there. That’s the upside.

The downside, obviously, is that as long as disease and war and poverty rage in Africa, there are going to be significant consequences for the industrialized world. We’re seeing huge numbers of refugees pouring into Europe, for example. It’s suddenly become a big issue. They’re being pushed out of Africa. They’re leaving Africa for all the reasons I just described. We’re seeing Western Nile Disease in Manhattan. That’s coming out of Africa, out of neglect of the health infrastructure.

So these are the types of issues. And we have seen here in the United States that AIDS has been declared a national security crisis, and I would argue it’s a global security crisis. And it’s not just a function of AIDS. Clearly, AIDS is the symptom of a much bigger and much more deep-seated set of problems.

Q: So I guess you would say that there is a moral imperative, a creative imperative and also a security imperative.

MR. SINCLAIR: And self-interest. At the end of the day, it’s self-interest. And that self-interest is security, certainly, i.e., health security, general security of one’s and the Western World’s state of being, quality of life for the citizens of the Western World. But also, economic interests, self-interest, almost, dictates that one take an interest in what is happening in this continent. And companies will not do that. Companies are not the forerunners of major interventions. That requires political — or companies will follow in the train of the political leadership. And that was the sort of hope that was generated by President Clinton’s visit to South Africa and Africa in 1998. But of course, he became embroiled in his issues almost immediately after that, and that came to nothing, which I think was a great sadness. And so that’s where things stand.

Q: Thank you, Michael.

MR. SINCLAIR: You’re welcome.



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