The High Stakes and Hard Choices at the U.N. AIDS Conference

Kofi Annan is speaking politely, and optimistically, about his global quest to fight AIDS. But in the end, he may be forced to shame the wealthy countries into doing more to fight a disease that has so far killed some 20 million people and has already selected its next 30 million victims. As the first-ever United Nations General Assembly session dedicated to a health issue got underway on Monday, the U.N. Secretary General told the gathering that "AIDS can no longer do its work in the dark, the world has started to wake up." Indeed, world leaders may be more aware than ever of the fact that more than 30 million people worldwide are currently living with AIDS, and that most of them — particularly among the 25 million who live in sub-Saharan Africa — are doomed to die from the disease. But that doesn't necessarily make them more inclined to take the steps necessary to stop the horror.

Although the AIDS crisis can't be solved by money alone, it certainly can't be solved without it. International experts agree that almost $10 billion a year is needed to stop the spread of HIV and to treat those already afflicted. That's small potatoes measured against national budgets in the industrialized nations, but it's prohibitive in the regions worst-hit by the disease. And the bad news is that Annan's drive to create a global war chest for fighting the disease has so far attracted pledges of only $528 million — a little over five percent of its projected target, and that's after donations from the world's richest country (the Bush administration pledged $200 million) and the world's richest man (the Bill and Melinda Gates Foundation promised $100 million).

Underfunded from the outset

No doubt this week's conference — and next month's confab of G8 leaders in Genoa — will see other nations stepping forward with new pledges, although many medical and development professionals fear that much of this money may simply be redirected from other aid programs supported by the wealthier countries. Despite the fundraising targets set by the U.N. on the basis of extensive research into the state of AIDS programs worldwide, few expect that it raise much more than 10 or 15 percent of those targets initially.

The control, operation and operating priorities of the fund proposed by Annan remain to be worked out in some fierce bureaucratic infighting at this conference and beyond. The U.N. Secretary General is proposing that the fund be managed outside of U.N. structures but with the U.N. participating alongside representatives of donor nations, afflicted nations and other interested parties — possibly including pharmaceutical corporations.

Letting them die?

But the most politically charged issue may be the allocation of resources between the competing priorities of stopping the spread of the disease and treating those already afflicted. Crunch the numbers of the projected budget shortfalls, and some chilling facts begin to emerge. U.N. experts believe that as much as $5 billion a year will be needed by 2005 simply to counter the spread of HIV through safe-sex education, the provision of condoms and relatively cheap drugs proven to stop mother-to-child transmission of the virus. Treating those already infected would require a further $4.5 billion a year. Plainly, the priority in the impoverished nations of sub-Saharan Africa is to stop the spread of a disease that threatens to drag the continent into anarchy. And where resources are already scarce, the unspoken choice may be to simply let the majority of those currently infected with HIV die. But that essentially implies a conscious choice by the world's wealthier nations to let some 30 million poor people die of a treatable disease rather than spend the money on keeping them alive. And that, presumably, is a choice with which the global citizenry won't feel entirely comfortable. At least not if Kofi Annan has anything to do with it.