Published: May 9, 2010
Her disease is probably quite advanced: her kidneys are failing and she is so weak she can barely walk. Leaving her young daughter with family, she rode a bus four hours to the hospital where her cousin Allen Bamurekye, born infected, both works and gets the drugs that keep her alive.
But there are no drugs for Ms. Kamukama. As is happening in other clinics in Kampala, all new patients go on a waiting list. A slot opens when a patient dies.
“So many people are being supported by America,” Ms. Kamukama, 28, says mournfully. “Can they not help me as well?”
The answer increasingly is no. Uganda is the first and most obvious example of how the war on global AIDS is falling apart.
The last decade has been what some doctors call a “golden window” for treatment. Drugs that once cost $12,000 a year fell to less than $100, and the world was willing to pay.
In Uganda, where fewer than 10,000 were on drugs a decade ago, nearly 200,000 now are, largely as a result of American generosity. But the golden window is closing.
Uganda is the first country where major clinics routinely turn people away, but it will not be the last. In Kenya next door, grants to keep 200,000 on drugs will expire soon. An American-run program in Mozambique has been told to stop opening clinics. There have been drug shortages in Nigeria and Swaziland. Tanzania and Botswana are trimming treatment slots, according to a report by the medical charity Doctors Without Borders.
The collapse was set off by the global recession’s effect on donors, and by a growing sense that more lives would be saved by fighting other, cheaper diseases. Even as the number of people infected by AIDS grows by a million a year, money for treatment has stopped growing.
Other forces made failure almost inevitable.
Science has produced no magic bullet — no cure, no vaccine, no widely accepted female condom. Every proposal for controlling the epidemic with current tools — like circumcising every man in the third world, giving a daily prophylactic pill to everyone contemplating sex or testing billions of people and treating all the estimated 33 million who would test positive — is wildly impractical.
And, most devastating of all, old-fashioned prevention has flopped. Too few people, particularly in Africa, are using the “ABC” approach pioneered here in Uganda: abstain, be faithful, use condoms.
For every 100 people put on treatment, 250 are newly infected, according to the United Nations’ AIDS-fighting agency, Unaids.
That makes prospects for the future grim. Worldwide, even though two million people with the disease die each year, the total keeps growing because nearly three million adults and children become infected.
Even now, the fight is falling short. Of the 33 million people infected, 14 million are immuno-compromised enough to need drugs now, under the latest World Health Organization guidelines. (W.H.O. guidelines are conservative; if all 33 million were Americans, most clinicians would treat them at once.)
Instead, despite a superhuman effort by donors, fewer than four million are on treatment. Just to meet the minimal W.H.O. guidelines, donations would have to treble instead of going flat.
Uganda is a microcosm of that: 500,000 need treatment, 200,000 are getting it, but each year, an additional 110,000 are infected.
“You cannot mop the floor when the tap is still running on it,” said Dr. David Kihumuro Apuuli, director-general of the Uganda AIDS Commission.
Some battles will still be won. Middle-income countries with limited epidemics, like India, Brazil and Russia, can probably treat all their patients without outside help. China almost certainly can. South Africa might; it has a raging epidemic but is rich by African standards.
But for most of Africa and scattered other countries like Haiti, Guyana and Cambodia, it seems inevitable that the 1990s will return: walking skeletons in the villages, stacks of bodies in morgues, mountains of newly turned earth in cemeteries.
As he tours world capitals seeking donations, Dr. Michel D. Kazatchkine, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, said he had become “hugely frustrated.”
“The consistent answer I hear is: ‘We love you, we hear you, we acknowledge the fund’s good results, but our budget is tight, our budget is cut, it’s the economic crisis.’ ”
No commander in the global fight openly concedes that the war is over, but all admit to deep pessimism.
“I’m worried we’ll be in a ‘Kampala situation’ in other countries soon,” said Ambassador Eric Goosby, the Obama administration’s new global AIDS coordinator.
“What I see is making me very scared,” agreed Michel Sidibé, executive director of Unaids. Without a change of heart among donors, Mr. Sidibé said, “the whole hope I’ve had for the last 10 years will disappear.”
Donors give about $10 billion a year, while controlling the epidemic would cost $27 billion a year, he estimated.
His predecessor, Dr. Peter Piot, said he had seen optimism soar and then fade.
Hopes rose from 2001 to 2003 when cheap generic antiretroviral drugs became available, Secretary General Kofi Annan of the United Nations formed the Global Fund and President George W. Bush initiated the President’s Emergency Plan for AIDS Relief, or Pepfar.
“Then, we were at a tipping point in the right direction,” Dr. Piot said. “Now I’m afraid we’re at a tipping point in the wrong direction.”
AIDS2031, a panel he convened to look ahead to the epidemic’s 50th anniversary, issued a pessimistic report in November that concluded: “Without a change in approach, a major epidemic will still be with us in 2031.” Because of population growth, it said, there may still be two million new infections a year even then.
According to the Uganda AIDS Commission, the lifetime bill for treating one Ugandan AIDS patient, counting drugs, tests and medical salaries, is $11,500.
Donors have decided that is too much, that more lives can be saved by concentrating on child-killers like stillbirth, pneumonia, diarrhea, malaria, measles and tetanus. Cures for those killers, like antibiotics, mosquito nets, rehydration salts, water filters, shots and deworming pills, cost $1 to $10.
Under its new Global Health Initiative, the Obama administration has announced plans to shift its focus to mother-and-child health. The AIDS budget was increased by only 2 percent.
“The political winds have changed,” said Sharonann Lynch, chief author of the Doctors Without Borders report. “And I don’t believe for a minute it’s just the economic downturn. I think world leaders feel the heat is off and they’re fatigued.”
American taxpayers have been particularly generous to Uganda, paying for 88 percent of its drugs; Ugandans know it.
Karen Morgan, an American who runs a laboratory at the hospital where Ms. Kamukama was turned away, said: “Just today, a patient came up to me in the parking lot and said, ‘Thank you, American.’ I said, ‘For what?’ He said ‘For my medicine. You care if I live or die.’ ”
Nearby, in a tent on the hospital lawn, Moses Nsubuga, a D.J. known as Supercharger, rehearsed his troupe, the Stigmaless Band, composed entirely of teenagers on AIDS drugs.
One of their songs is “America, Thank You So Much.”
The loss of donor interest “makes me frantic with worry,” Dr. Mugyenyi said. “Once word spreads that there is no treatment, people do what they did in the past: go to the witch doctors and buy fake treatments.”
He offers copies of e-mail messages he exchanged with American aid officials. One reminds him that he has been instructed to stop enrolling new patients and asks for an explanation of reports that he is treating 37,000 when only 32,000 are authorized. Another asks him not to announce publicly that his funds have been frozen.
He admits slipping pregnant women and young mothers like Ms. Kamukama into treatment slots “contrary to instructions.”
“Morally, I can’t turn them away,” he said.
He has another reason. Family members like Ms. Kamukama and her cousin will often share one set of pills, an act of love that leads to disaster. Incomplete treatment means both will probably die, but may first develop drug-resistant AIDS and pass it on.
American officials who spoke on the condition of anonymity confirmed the financing freeze.
“The decision was made late in the Bush administration to cap Uganda at $280 million,” one said. “That’s an industrial amount of money.”
United States Embassy officials debated adding $38 million, he said, but cabinet-level Ugandan ministers had been caught stealing from other donors and, though forced to repay the money, were not jailed. The government “hasn’t shown the leadership or commitment to transparency to earn additional funds,” the official added.
Also, he said, Uganda contributes too little. Oil was recently discovered near Lake Albert and the government promised to spend the royalties on roads and electricity, but did not mention AIDS.
“And now the paper says they’re buying Russian jets,” another official added with obvious disgust. Uganda is negotiating for a $300 million squadron of Sukhoi fighter-bombers.
For doctors on the front line, the frustration is palpable.
Dr. Natasha Astill is a British AIDS specialist working at a hospital on the edges of the Bwindi Impenetrable Forest, in a mountain valley with pygmy settlements close by fancy gorilla-tourist lodges. It is so remote that the drugs that reached Kampala in 2003 did not get here until 2007.
After a long day in which she and a nurse saw 118 patients, many huddling together in the examining room to avoid the storm pounding on the tin roof, she broke down in tears. All day she told subsistence farmers she could not, for example, treat the white fungal thrush filling their mouths unless they could pay $1 a day — more than they earn.
She can still give free antiretrovirals to a few; while her hospital’s American funds are frozen, it still gets some drugs from the Ugandan Ministry of Health and cash gifts from wildlife tourists and the singer Elton John. But soon this hospital, too, will make a waiting list.
“It makes me angry,” she says. “It feels horrible. Sometimes you wonder if you’re doing people favors. You start them on drugs, you give them hope, and then you’re not sure you can keep it up. We all knew these drugs are for life.”