International Obligation and Human Health: Evolving Policy Responses to HIV/AIDS [Full Text]

Ethics & International Affairs, Volume 15.2 (Fall 2001)

The world is in the early stages of what will be the greatest health crisis since the advent of modern medical technologies. Millions of people -- particularly people in many of the world’s poor countries -- are infected with HIV. The vast majority of these people will go without modern medical intervention or substantial treatment, and will rapidly develop AIDS. The extent of this problem presents profound moral and ethical questions for the world’s wealthy people and countries, for it is they who are most able to assist the poor in managing and reversing this human tragedy.

Over the last century or more, there has been a gradual shift in global attitudes toward reducing suffering among the world’s poor. Governments have come to regard many forms of international assistance as the right thing to do (if not a legal obligation). For example, when famine strikes, governments and citizens of the developed countries generally recognize that they ought to respond because they have a surplus of food and the means to deliver it to those who are starving. Doing so is relatively easy and painless for those providing aid, yet it brings tremendous benefit to those in need. The degree to which assistance is provided varies, of course, but few would argue that the starving should be ignored. Similar feelings of duty in the developed world arise with regard to natural disasters and adverse environmental changes, among other issues, and governments of the rich countries (and indeed many of their private citizens and nongovernmental groups) respond accordingly with increasing frequency, robustness, and speed. HIV/AIDS presents the world with another problem requiring assistance from the world's wealthy.

Nevertheless, developed countries have been very slow to respond to the international dimensions of the HIV/AIDS problem. They have instead focused on the relatively few people within their own borders at risk for HIV or suffering from AIDS. The rhetoric has started to change -- the United States, for example, has pledged some funds in recent years, and it has become less vocal in its opposition to providing affordable drugs to the world’s poor suffering from the epidemic -- but the developed countries have not backed this rhetoric with substantial new funds to assist the poor countries in coping with and reversing the HIV/AIDS epidemic, and they continue to participate in activities that exacerbate the crisis and associated human suffering. This essay looks more closely at the global HIV/AIDS problem, especially in the developing world. We discuss what has been done and what can be done to stop the spread of HIV and reduce the suffering from AIDS. We identify some reasons why more has not been done, and we show why more ought to be done. Explicit in this discussion is the clear need for action from the world's wealthy countries to address the HIV/AIDS epidemic. Indeed, the developed world should view assisting the world’s poor in dealing with this problem as a moral obligation. We summarize the evolution of developed countries’ attitudes and actions toward aiding poor countries in several issue areas and demonstrate that the willingness to provide aid has increased over time. Finally, we argue that for reasons of morality (among others), this willingness to assist ought to be extended to the global HIV/AIDS crisis.

The Problem of Societal Devastation

It is hard to overstate the dimensions of the problem of HIV/AIDS in the developing world, particularly in sub-Saharan Africa. Worldwide, AIDS has already killed more than 22 million people and left more than 13 million children orphaned, according to the Joint United Nations Program on HIV/AIDS, more commonly referred to as UNAIDS.1 Approximately 36 million people are currently infected with HIV, and an average of 16,000 new infections is believed to occur daily.2

Studies of the demographics of HIV infection have correctly emphasized geography. Sub-Saharan Africa is a case in point. Although it has only about 10 percent of the world’s population, approximately 70 percent of the world’s HIV-positive adults and 80 percent of the world’s HIV-positive children live there, and the adult prevalence rate of HIV is eight times that of the rest of the world (8.8 percent compared to the 1.1 percent average worldwide). And the situation is not improving. Of the world’s estimated 5.3 million new infections in 2000, 3.8 million, or 71 percent, occurred in sub-Saharan Africa compared, for example, to the 45,000 new infections (less than 1 percent of the worldwide new infections) in North America.3 Other developing regions and the former communist countries of Europe also have huge numbers of infected individuals. As UN Secretary General Kofi Annan pointed out, India will soon have the highest number of HIV-positive people of any country in the world, and by 2005 China and India together are expected to have more than 10 million HIV-positive citizens.4

Although geography is a tremendously important way of viewing the world's AIDS pandemic, an equally important, and complementary, vantage is provided through the lens of poverty. Ninety-five percent of the world’s HIV-positive people live in low-income countries.5 In fact, poverty is currently the single most important factor in determining who among the world's people are most vulnerable to HIV.6 It is therefore not surprising that Africa, with its average GDP of $560 per person, compared to Asia's meager $730 and Latin America's $4,230, has suffered the most (although these numbers add urgency to the warnings that Asia is seriously at risk as well).7 The combination of poverty and HIV creates a terrible downward spiral in poor countries, with poverty providing many of the conditions that promote the spread of HIV. Poverty leads to poor health conditions generally, including the lack of treatment of conditions, such as sexually transmitted diseases, that make individuals more susceptible to HIV infection. Poverty also creates exploitative working conditions that have been shown to foster the spread of HIV infection. Lack of alternative economic opportunities and poverty force women into formal and informal prostitution. The few options open to poor men include trucking and mining -- both occupations that have been documented as facilitating the spread of HIV.8

As illness and death due to HIV infection spread through communities, poverty creates a situation in which every aspect of the disease -- from treatment of the ill to the creation of orphans through the death of parents and guardians to the challenges of implementing prevention programs -- creates strains on already overtaxed social systems. When people become sick, families are forced to spend precious resources on any treatment options they can find. Sickness in adult family members means they cannot earn an income, grow or provide food. The eventual death of adults leaves children with no one to care for them. They, and adult women survivors, may be forced into sex work to provide for themselves and their families, thereby multiplying not only their own suffering, but also the transmission of HIV.9

The destruction experienced within and among families is mirrored in the communities within which they live. In poor countries that already suffer from a lack of formally trained professionals in education, health care, the military, and the government bureaucracy, AIDS has been devastating. For instance, it has been estimated that a country with an HIV prevalence rate of 30 percent would lose between 3 percent and 7 percent of its health care workers annually to AIDS.10 The ranks of teachers are similarly being depleted. In Zambia in one year (1998), 1,300 teachers died -- two-thirds of the number trained annually.11 UNAIDS Director Peter Piot summed up the impact: “HIV does to society what it does to the human body. It undermines the very institutions that are meant to defend society -- its doctors, its teachers.”12

The future of these societies is seriously at issue. For example, the explosive growth in the orphan population should give the world cause for alarm. An estimated 12 million children have been orphaned by AIDS in sub-Saharan Africa, and absent significant intervention, that number is expected to grow to 40 million by 2010.13 Most of these children will reach adulthood without formal education, parental role modeling, or significant skills development. Lacking these abilities and attributes, they will be less able to take on the work and family responsibilities necessary for national stability. This is only one of many ways in which AIDS is undermining the economies and civil societies of African countries. What is more, in a forum sponsored by the Institute for Peace, international researchers and intelligence experts warned of a decrease in the GDP of sub-Saharan countries of as much as 20 percent over the next two decades, and the potential for extreme political instability and ethnic tension. Equally worrying, some of these problems could occur in India as well.14 As economies plunge and governments fail, the developed world will be forced to expend resources on peacekeeping and stabilization efforts for crises that could have been staved off with far fewer resources, and certainly much less human suffering, by the provision of assistance for the root problem of AIDS.

Further aggravating the poverty of the world's poorer countries is the staggering external debt they owe to wealthier countries and international financial institutions. Again, sub-Saharan Africa serves as a prominent, though by no means isolated, example. According to a report by the debt-relief nongovernmental organization Jubilee 2000, sub-Saharan Africa owes $231 billion to its creditors, which breaks down to $406 per African. Foreign aid cannot keep pace with the debt: for every dollar received in foreign aid in 1999, the region paid back $1.51 in debt. And the opportunity cost of this debt servicing is equally great. Sub-Saharan Africa spends twice as much on debt servicing as it does on health care.15 This debt, especially when combined with the adverse effect of HIV/AIDS on individuals, families and societies, leaves developing countries unable to cope without substantial assistance from the developed world.

The Developed World's Response to the HIV/AIDS Pandemic

By 2001, the rhetoric from developed countries about helping poorer countries cope with HIV/AIDS had started to change in favor of the sufferers, although actions to match those words were meager relative to the scale of the problem and the ability of the developed countries to provide assistance. When President Clinton signed the Global AIDS and Tuberculosis Relief Act on August 19, 2000, pledging more than $400 million to fight AIDS and other infectious diseases, it was hailed as a significant step in the sense that it was an important boost to previous spending levels. But that amount pales in comparison to the $7 billion to 10 billion that UN Secretary General Kofi Annan said would be necessary to establish a global fund to combat HIV/AIDS, malaria, and tuberculosis. Annan officially called for the establishment of the fund at the Organization of African Unity summit in Abuja, Nigeria, in April 2001, as a way to follow up on the commitments made by the leaders of developed countries at the Okinawa Group of Eight Summit in July 2000.16 President George W. Bush pledged $200 million to the UN global AIDS fund (the secretary general had requested $1 billion to 2 billion from the United States), and he called the global AIDS crisis “almost beyond comprehension.”17 During a tour of Africa a few weeks later, his secretary of state repeatedly cited the problem of AIDS, describing its extreme impact on human society,18 a theme he reiterated in June at the UN Special Assembly on HIV and AIDS. This certainly marked an important turnaround from the previously scant attention that the developed world had given to AIDS in Africa. But developed countries have remained reticent about making meaningful financial contributions to the problem, and they have actively blocked efforts by developing countries' governments and activists around the globe to provide affordable treatment options for people in low-income countries.

Blocking Access to Medicine

The relation of the developed world to the devastating poverty and circumstances aggravating AIDS in the developing world is of course complex. At the very least, the developed world has stood in the way of the developing world's efforts to solve AIDS and other health-related problems in the most cost-effective ways possible. The developed world has, for example, repeatedly taken positions that give patent protections priority over public health in developing countries (sometimes even stronger priority than prescribed by international treaties). Brazil, South Africa, and Thailand are among the countries that have been overtly pressured by the U. S. government not to take measures to bolster their abilities to obtain or produce cheaper generic drugs or even, in the case of Thailand, to monitor drug prices.19 Other leading countries have also publicly and privately shown their support for stronger patent regimes, regardless of the devastating effect they may have on people unable to afford the prices set by the branded (as opposed to generic) pharmaceutical industry. This was the case, for example, during and after the South African parliament's 1997 actions amending the country's Medicines and Related Substances Control Act with measures making it easier to purchase less expensive drugs. The amendment was opposed by the branded pharmaceutical industry, on whose behalf the United States government lobbies vigorously and European governments applied more subtle pressure.20

These positions stand in stark contrast to others being proposed by developing countries, humanitarian NGOs, and global networks around the world, which have suggested a variety of ways in which the countries that need them most could affordably gain access to medicines. Médecins Sans Frontières, Oxfam, and the Health GAP Coalition are among the most active NGOs calling for measures -- including compulsory licensing and parallel importing, tiered pricing, global bulk purchase at the lowest world prices, global pricing registries, and outright reform of world intellectual property law -- to help make medicines affordable. Although a full discussion of these practices is beyond the scope of this essay, a few words of explanation are in order. Briefly stated, compulsory licensing allows a country to issue a license to a third party (for example, a generic manufacturer) to make a patented product and then pay a small royalty to the owner of the patent (for example, a branded pharmaceutical company). Parallel importing allows a country to buy drugs that are being sold more cheaply in another country than domestically. Both are currently allowed within certain limitations by the World Trade Organization's TRIPS (Trade-Related Aspects of Intellectual Property Rights) agreement, although many developing countries have hesitated to exercise these options because of uncertainty about the law and pressures exerted on them by developed countries and the international pharmaceutical industry. Tiered pricing is a system of established differentiated prices based on a country's ability to pay, and is currently used for many vaccines administered globally. Global bulk purchase is an idea that would allow an international agent, such as a UN agency, to use money from the proposed global fund to purchase drugs in bulk from whatever producer offered them at the lowest bid. Finally, a global pricing registry, possibly to be managed by the World Health Organization, would offer a comparative database of manufacturer prices (which vary widely from country to country and from company to company) for the use of purchasers of essential medicines.

All of these proposals have been resisted by the international branded pharmaceutical industry, by the U.S. government, and, to a lesser degree, by other developed countries. Rejecting the idea of a drug pricing database while attending the May 2001 World Health Assembly, the head of the U.S. delegation, Secretary of Health and Human Services Tommy Thompson, enraged AIDS activists who had attended as observers. They objected not only to his position, but also to the openness of his sympathies in publicly saying to the International Federation of Pharmaceutical Manufacturers: "I want you to understand I'm fighting your fight for you."21 A month earlier U.S. Speaker of the House Dennis Hastert had declined entreaties to endorse government-sponsored drug price reduction plans while visiting an AIDS orphanage in Kenya, commenting: "The drug companies I've talked to are doing all they can to bring down drug prices."22 In June, the United States included Henry McKinnell, who serves as both the CEO of Pfizer and the chair of the Pharmaceutical Manufacturers and Manufacturers of America, on its official government delegation to the United Nations General Assembly Special Session (UNGASS) on HIV and AIDS. During the UNGASS meeting, the United States actively lobbied against both inclusion of language framing health care as a right and specific discussion of the strategies listed above for making AIDS treatment affordable.

Furthermore, in exchanges leading up to and during the 2001 Group of Eight Summit in Genoa, Italy, the United States informed the European Union that it would oppose the EU's tentative moves toward endorsing tiered pricing and a global database (arguably the least drastic of the proposals). In an April 2001 letter from Secretary of State Colin Powell to Christopher Patten, his EU counterpart, Powell argued: 'A formal government-driven tiered pricing plan is unnecessary."23 That letter was followed by a more specific one in late June sent by U.S. Trade Representative Robert Zoellick to his counterpart on the European Commission, Pascal Lamy. The letter stated specific opposition to any international regulation of drug prices as well as to the creation of a price database, a position that the United States actively continued to push during the G8 Summit.24

In the face of such evidence, it is difficult to argue that the developed countries do not bear some blame for blocking the means for developing countries to buy affordable medications. Some would argue that the culpability of the world's wealthy countries goes even further. According to this controversial line of argument, the neoliberal policies of the world's richest countries are partially responsible for the problems of the world's poorest countries. These policies, which place many developing countries at a disadvantage and thereby make it difficult for them to grow economically, include the purposeful retention of exploitative patterns set during colonial rule ('neocolonialism"): the liberalization of currency exchanges and financial markets, which has resulted in currency devaluations, market volatility, and uncontrollable movements of capital; and the imposition of frequently harmful structural adjustment programs that are disproportionately borne by the poorest in society.25 Together with the inequities inherent in economic globalization, some argue, these policies contribute to the inability of developing countries to solve their own economic and social problems -- including AIDS.

Despite this very difficult situation for developing countries, recently there have been promising developments. Brazil, Senegal, Thailand, and Uganda have successfully lowered or stabilized HIV transmission rates. And in April 2001, African leaders held a summit in Abuja, Nigeria, in which they pledged to spend a significant proportion of their national budgets on AIDS.26 Yet it is important to remember that these budgets themselves are tiny compared to those of developed countries. They are simply inadequate for the monumental task of successfully combating the AIDS epidemic. Even in Uganda, where infection rates have been cut in half over ten years -- an extremely impressive achievement -- HIV infections still remain almost ten times higher than the worldwide average prevalence rate.27 Political commitment by developing countries is clearly a necessary but not sufficient condition for ending the AIDS pandemic in the developing world. Solving this crisis requires assistance from the world's more affluent countries.

Denial of the Problem

Generally speaking, the dynamic of AIDS-related assistance from rich countries, and particularly the United States, has proceeded in several overlapping stages of policy development. First came a period of nonrecognition of the devastating impact of the AIDS pandemic -- in essence, the denial of the need for a response through the denial of a problem in the first place. Second, there was a phase of attempting to shift responsibility to the developing countries themselves, through a set of proposals that would place heavier financial responsibilities on the global South than on the global North. Finally, there has been a set of responses attempting to abrogate responsibility through various manifestations of an argument that the pandemic cannot be solved with aid from wealthy countries because of cultural barriers, lack of health care infrastructure, and the enormous (albeit highly inflated) costs of antiretroviral medications. Activists in the global North and South have vocally countered these responses, but the governments of developed countries have been slow to change their policies in response to these counterarguments.

Lack of Government Response

The United States was among those countries that, until very recently, denied the scale of the problem and the need for an international response. For example, officials of the CIA lobbied internally for three years, from 1987 to 1990, seeking permission to produce a report that was ultimately released in 1991. The classified document, entitled 'The Global AIDS Disaster," predicted 45 million HIV infections worldwide by 2000. However, there was no government response, even after portions of the report were declassified and released as a State Department white paper in 1992.28 During the mid-1990s, apathy continued among U.S. government bureaucracies like the Center for Disease Control (CDC) and Agency for International Development (USAID). Fear of creating unrealistic expectations and of losing budget autonomy, as well as the conviction that development money would be better spent on less expensive projects with proven results, contributed to the lack of activity. The governments of Western Europe were similarly unresponsive.29

ýhis denial was mirrored in two other sectors of society within and among developed countries -- domestic AIDS nongovernmental organizations and multinational corporations, specifically those within the pharmaceutical industry. In the latter case, the drug companies reached consensus in the early 1990s that price discounts in the developing world were a bad idea. They agreed that governments had the responsibility to worry about accessibility and distribution, that AIDS drug regimens were too complicated to be adapted to developing country conditions, and that other barriers to treatment existed in developing countries.30 For their part, AIDS NGOs spent much of the 1990s focusing on how to get combination drug therapies to their own clients. Until full accessibility existed at home, they believed, money sent to developing countries was money that deserved to be spent domestically. This type of reasoning has recently been replaced among most AIDS NGOs in developed countries by a position that sufficient resources exist to address AIDS both domestically and globally, as exemplified by the many statements and press releases made by AIDS NGOs during the recent UN Special Assembly on HIV and AIDS, which had an unprecedented level of accredited observers from civil society.

Shifting of Responsibility

As it became more and more difficult to deny the level of the AIDS catastrophe in developing countries, the developed world began to move away from denial of the problem to a position (sometimes explicit, sometimes implied) that it was up to the developing world to bear the responsibility for its emerging health crisis. This position has taken many forms, one of which emphasizes individual behavior. This approach had been seen during the early years of the struggle with AIDS, when governments of developed countries often maintained that it was the responsibility of individuals to stop engaging in high-risk behaviors. More recently, such governments have argued again that it is individual behavior or cultural norms (such as the poor treatment of vulnerable women in some developing countries) that result in the spread of AIDS, and that aid from developed countries would not affect these practices.

A second position emphasizes the role of national leaders. This line of argument has been applied to cases of both strong and weak national leadership on AIDS. Thus, when Ugandan President Yoweri Museveni forcefully addressed his country's AIDS crisis by openly speaking about the problem and advocating prevention measures, and Ugandan transmission levels subsequently plummeted, rich countries argued that their help was not needed -- a developing country could tackle AIDS on its own. But in the case of Zimbabwe under President Robert Mugabe or, as is more widely reported, South Africa under President Thabo Mbeki, the argument is that it is governments, not lack of outside aid, that prevent developing countries from coping with HIV/AIDS. Using this kind of thinking, the developed countries were able to rationalize turning a blind eye to great human suffering.

Finally, and most directly, 'solutions" have been offered at the international level that, while ostensibly aiding developing countries, actually place most of the costs squarely back upon them. This approach lies behind both World Bank and U.S. Export-Import Bank offers of loans to sub-Saharan African countries. When these countries responded negatively to the loan offers, the banks expressed dismay. Yet they failed to address, or even acknowledge, the reasons behind the negative reaction from developing countries. The developing countries turned down the loans for two reasons. First, the loans seemed an inappropriate vehicle for aid, given that these very countries were actively campaigning for debt relief and that AIDS was predicted to set back their economies even further in the years ahead. A second weakness of the loan scheme was that developing countries realized that they were not the only, or possibly even the primary, beneficiaries of the loans. Rather than enabling developing countries to buy drugs at steeply reduced prices, as many aspired to do, the loans were designed as a means to provide AIDS treatments at Western retail prices -- a policy that would have benefited multinational pharmaceutical companies but interfered with the goals of developing countries.

'Insolubility" of the Problem

We are currently experiencing the third phase of denial (although aspects of the first two linger). Generally speaking, the developed world no longer argues that the problem is insignificant, nor that developing countries could possibly solve it by themselves. Rather than an acknowledgment of the responsibilities of the First World, however, a third (again multifaceted) argument has been made -- that the problem is, in fact, insoluble. This argument is being voiced at a time when the context of the debate has changed quite rapidly. Owing in very large part to the strenuous efforts of AIDS activists and NGOs working in both the global North and South (in many cases in coordinated campaigns), AIDS-related demands by activists have achieved a high level of prominence in the mainstream media. The June 2000 Thirteenth International AIDS Conference held in Durban, South Africa, made more headlines as a forum for the demands of passionate and well-organized activists than as a showcase of international research. In April 2001, thirty-nine of the world's largest drug companies succumbed to international pressure and vocal activism, dropping their legal efforts to prevent the South African government from manufacturing cheap versions of patented AIDS drugs. The central theme of these demands was that future cases of HIV infection must be averted through prevention, and that at the same time current cases must be ameliorated through treatment.

This latter demand is no longer questioned as a vital strategy within developed countries, where sophisticated antiretroviral treatment has been the standard of care since the late 1990s. Yet it is widely seen as radical in the context of developing countries. The first and most obvious reason is cost. In the developed world, the combination of drugs -- called the 'cocktail" or anti-retrovirals (ARVs) -- used to directly attack HIV replication, as opposed to treating the opportunistic infections it causes, retails at around $10,000 to $12,000 per year. Aid agencies within the developed countries as well as the branded pharmaceutical industry have argued that such costs are utterly impractical for countries in the developing world, where per capita incomes are many times lower than these prices. Activists have countered that the retail cost of ARVs bears little resemblance to their actual manufacturing costs, which are many times lower. This assertion was given credibility when generic manufacturers, beginning with the Indian company Cipla, offered a version of the cocktail for $500 per year. Anticipating the competition of generic companies and the protests that were forthcoming in Durban, the five major branded manufacturers of ARVs announced in May 2000 that they would offer steep price cuts to the developing countries hardest hit by AIDS.31 Although these actions are insufficient in light of the scope of the problem, they have further encouraged activists to argue that the funding of treatment in developing countries, both for opportunistic infections and HIV, is possible and desirable.32

'Impossibility" of Treatment

At this point, when documented arguments had been widely distributed claiming that the largest obstacle to treatment is not actual cost but political will (both from governments who do not feel like offering aid and pharmaceutical firms that are worried about intellectual property rights), a new set of arguments on the impossibility of treatment was launched by both the pharmaceutical industry and the governments of the wealthy countries. This argument is that spending money on treatment would be futile. It is based on four premises. First, opponents claim that ARVs could not be distributed because developing countries lack the health care infrastructure (hospitals, clinics, trained personnel, and the like) to do so. Speaking during the UN Special Session, Pfizer CEO Henry McKinnell claimed the infrastructure problem was so serious that there was no point in pursuing the global fund at levels the secretary general had recommended. 'Trying to get that much money into the system would be like pushing onFa string," he said. 'We couldn't spend that much money if we had it."33 Second, they claim that the requirements for taking the drugs (rigorous dosing schedules, complex combinations of drugs, and so forth) would be too difficult for people in developing countries. A third and related claim is that people in developing countries would be unable to adhere to these requirements and that drug-resistant strains would consequently develop. And, finally, there is concern that treatment will be substituted for prevention, resulting in inefficient uses of resources and further spread of HIV. The comments of University of Pennsylvania bioethicist Arthur Kaplan are typical:

While drugs are an answer to the AIDS plague in North America and Western Europe, they are not the solution for Africa and many other extremely poor nations. The reasons are simple. Drugs designed for people in more developed countries do not work as well for people living in countries that have no hospitals, clinics, clean water, sewers, roads or doctors.34

Advocates of treatment provision argue that these claims are highly exaggerated. While no one disputes that health care infrastructure is seriously lacking in many developing countries, they suggest a number of counter points. First, NGOs such as Médicins Sans Frontières and Oxfam, which have outstanding credentials regarding delivery of health services in developing countries, have gone on record in high profile campaigns promoting treatment and claiming that there are many lives that could be saved immediately if drugs were available. They also argue that the experience of Brazil, where strong prevention and treatment programs have drastically reduced infection rates and suffering from AIDS, suggests that the provision of treatment fuels the development of an infrastructure to deliver it.

On the issues of pill burden and dosing requirements, they argue that opponents are working with outdated assumptions. For example, USAID head Andrew Natsios testified before Congress arguing that the drug cocktail wouldn't work because it would require taking dozens of pills per day, a fallacy denied by the current two or three pills twice a day being administered in pilot programs in developing countries.35 On the related issue of drug adherence, both the U.S. Treasury Department and USAID head Andrew Nastios have recently argued that Africans cannot be expected to take AIDS drugs because they do not have a Western view of time. These assertions are countered by the testimony of experts in treatment in resource-poor settings and with evidence of programs in the Ivory Coast, Brazil, and Haiti.36 While clients of these programs are not 100 percent compliant, neither are program participants in the developed countries. Furthermore, given that successfully administered ARVs decrease the amount of virus within individuals, they also decrease the opportunity for mutations within those individuals.

Finally, treatment advocates find the claims regarding the danger that treatment will be substituted for prevention to be perhaps the most specious of all. To the contrary, they argue, treatment complements prevention. Not only does treatment offer an incentive for people to undergo voluntary testing (an extremely important consideration given that the vast majority of the world's HIV-positive people are not aware of their status), but successful treatment lowers viral loads, making people less likely to pass the virus to their sexual partners and to their unborn and breast-fed children. Importantly, treatment advocates are arguing for medicines and services to address both the virus itself and associated communicable diseases, including tuberculosis and sexually transmitted diseases, that make individuals more vulnerable to becoming infected with HIV and progressing to AIDS. Finally, by prolonging the lives of adults, treatment prevents the creation of yet more orphans, an enormous consideration for countries already reeling under the burden of many thousands of children with no source of support or care.

Global Funds

A vast increase in assistance to developing countries to deal with their AIDS crises would go a long way toward providing treatment and prevention, and ameliorating some of the worst suffering from the crisis. The estimates of what would be required vary. UNAIDS Director Peter Piot originally suggested $3 billion annually as a minimal response to 'turn the tide of the epidemic."37 That estimate specifically excluded the possibility of anti-retroviral treatments, but some estimates include them in their numbers. Secretary General Kofi Annan has called for $7 billion to $10 billion for the global fund (to include treatment for malaria and tuberculosis), as noted above; the Harvard Consensus statement estimates a need for $1.4 billion initially, moving to $4.2 billion in five years; and the Global AIDS Alliance calls for $15 billion.38 These estimates usually assume that the United States should contribute about 25 percent of the total, with the rest coming from other developed countries and, in some cases, private corporations. Although all but the smallest of these estimates would require at least a tenfold increase in the level of assistance from developed countries, such an increase is easily affordable. In calling for the original $3 billion, for instance, UNAIDS Director Piot compared that figure to the $52 billion that U.S. citizens spend annually fighting obesity.39 Jeffrey Sachs of Harvard University often points out that for the United States to pay its portion of the Harvard estimates it would cost only $8 per person, or less than the cost of one movie with popcorn per year. More recently, Sachs has suggested that a global fund covering a number of lower-profile diseases besides AIDS could cost $20 billion per year -- about $20 per person among the 1 billion people living in high-income countries, as Sachs pointed out.40 Considering the degree of suffering that would be reduced, this seems an infinitesimal sacrifice for Americans.

In sum, the world -- particularly the developing world -- is facing an unprecedented health crisis in the forms of HIV and AIDS. This crisis is manifested by truly great human suffering, which is experienced most extensively by the world's poor. The developed countries of the world have, through action and inaction, exacerbated this suffering. They have actively blocked efforts to bring affordable medicines to people in the developing countries infected with HIV and suffering from AIDS, and they have resisted, at least until very recently, most calls for them to be much more forthcoming with the financial assistance and international economic flexibility that is crucial for attacking the epidemic and its underlying causes.

Ethics and International Assistance

Within the world's economically developed societies, assistance for the poor and sick has become established and institutionalized over the last century or more. Social welfare systems, which routinely redistribute resources from the more affluent in society to those who are poor, are now commonplace in almost all economically developed societies. In recent decades -- especially since the mid-twentieth century -- the desire to help those in need has extended to international affairs.41 The world's wealthy countries now give substantial amounts of money to the poorer countries, often for self-interested reasons, but also because it is now viewed as simply the right thing to do.

What justifies this international assistance? More specifically, why should the developed countries work much harder to ease -- and ideally, to end -- the tremendous global suffering from AIDS? Some answers can be found in ethical philosophy. That is, there are many moral justifications for further assistance from rich to poor countries -- and just as many moral arguments against continuing the current practice of most rich countries' providing very limited amounts of aid to the poor countries. Here we present two of the ethical arguments. We then turn to a discussion of how these ideas have taken shape in international affairs. Existing practices of international assistance in other areas of concern can serve as instigators for more action to combat HIV and reduce the suffering of those afflicted with AIDS around the world.

Utilitarianism and Responsibility for Harm

Among the ethical principles one could draw upon to justify much greater action by the world's more affluent countries to help poor countries and their people cope with HIV and AIDS are utilitarianism and considerations of responsibility for harm. Utilitarians generally argue that we should act in such a way as to achieve the greatest good ('happiness") -- or reduce the largest amount of suffering -- for the greatest number of individuals. One particularly relevant utilitarian strain of thinking is found in Peter Singer's seminal essay, 'Famine, Affluence, and Morality."42 Following Singer, we 'begin with the assumption that suffering and death from lack of food, shelter, and medical care are bad." Singer's fundamental assertion is this: 'If it is in our power to prevent something very bad from happening, without thereby sacrificing anything else morally significant, we ought, morally, to do it." Singer uses a now familiar story to illustrate his point: 'An application of the principle would be as follows: if I am walking past a shallow pond and see a child drowning in it, I ought to wade in and pull the child out. This will mean getting my clothing muddy, but this is insignificant, while the death of the child would presumably be a very bad thing."43 That is, we see great suffering, we are able to stop it, and doing so is relatively easy. Under these circumstances, we have a moral duty to act (and Singer would go further to say that we have a duty to act even if it is not easy to do so).

As Singer indicates, a moral point of view requires us to consider those living in other countries and on other continents. 'The fact that a person is physically near to us, so that we have personal contact with him, may make it more likely that we shall assist him, but this does not show that we ought to help him rather than another who happens to be further away. . . . We cannot discriminate against someone merely because he is far away from us (or we are far away)."44 What is more, we cannot easily claim that we need not act because we do not know of the suffering experienced by others. Modern communications technologies and the global media usually make us aware of most major problems eventually. Thus, the almost total emphasis by the rich countries of the world on HIV/AIDS among their own citizens, while commendable as far as it goes, does not go nearly far enough. The vast majority of suffering is in the world's poor countries; the utilitarian perspective would require that this suffering be addressed in a much more concerted fashion.

Thus, the way people in the affluent countries have reacted to the global AIDS crisis cannot be justified on moral grounds. 'Given the present conditions in many parts of the world, however, it does follow . . . that we ought, morally, to be working full time to relieve greater suffering of the world that occurs as a result of famine or other disasters."45 Full-time work may be far too much to ask of people today, but is it too much to ask for something well short of that, but which is presently not being provided? We think not. As Singer points out, most people are selfish and unlikely to do what they ought to do. But this is hardly evidence that we should not do what we ought, morally, to do. By taking really quite easy action that brings no great burden upon themselves or their citizens, governments of the world's wealthy countries can reduce incalculable human suffering experienced directly and indirectly from HIV/AIDS by literally millions of people in the Third World. This is crucial: Those suffering from HIV/AIDS are not asking for much at all. By Singer's measure, therefore, the developed countries ought, morally, to act in ways that aid those suffering from this epidemic.

This utilitarian perspective establishes a moral imperative to act. Doing so would, very simply, reduce great amounts of human suffering and thereby bring much 'happiness" (in the utilitarian conception, as well as the everyday one) to the world. But what if, as we have suggested, the developed world bears some culpability in the HIV/AIDS crisis? If that is indeed the case, the moral responsibility to act is even greater, thus suggesting that the response should be more substantial and faster. To be sure, the wealthy did not go out and purposely infect people. But by first ignoring the problem, by failing to support and sometimes fighting against international organizations trying to provide aid, and by using its power to help pharmaceutical makers keep prices high (and, some might add, by its hand in an exploitative international economic system that contributes to the poverty upon which HIV/AIDS feeds), the developed world is in fact complicit in the present state of affairs.

An ethical (and legal) perspective of responsibility for harm says, quite simply, that those responsible for causing harm are responsible for ending and ultimately righting that wrong. Henry Shue has clearly stated the fundamentals of this perspective: 'The obligation to restore those whom one has harmed is acknowledged even by those who reject any general obligation to help strangers. . . . This is because one ought even more fundamentally to do no harm in the first place."46 To be sure, acquiring HIV is sometimes the responsibility of those who have it (though often it is not), but even here the developed countries bear some responsibility. Developed countries are not doing enough to finance education campaigns and promote women's rights, for example, efforts that could reduce the spread of HIV. Their funding for treatment is minuscule relative to the scale of the problem and their ability to help. But these are acts of omission. What of acts of commission? Many of the developed countries, and indeed multinational corporations that have worked with governments to promote their objectives, have, as we have pointed out, actively worked to prevent the lowering of drug prices essential to widespread treatment and prolongation of life for AIDS sufferers. Thus, insofar as the developed countries are complicit in suffering experienced in the developing world, the obligation to act is much stronger. Hence, they are obliged to provide aid to mitigate and try to end suffering from AIDS.

Evolving Norms of International Assistance

Past and contemporary international experience provides us with examples of greater recognition by the world's wealthier countries that they ought to provide aid to the world's poorer countries. It also helps us understand why more has not been done in the case of HIV/AIDS. There has been a historical trend toward increased international transfers of aid and mutual cooperation to reduce human suffering beyond the borders of the wealthy countries. The logic is quite simple: Problems requiring action arise in which human beings are experiencing tremendous suffering. The problems are sufficiently immense that those affected cannot implement solutions or mitigation measures without help. Solutions to the problems or measures to mitigate the resulting human suffering exist, and those solutions and measures -- money, expertise, technology -- are readily available in countries with the ability to supply them (most often the world's wealthy countries). Moreover, doing so does not significantly harm those providing the aid (and may indeed benefit them materially in the long term, for example when those aided become trading partners). Therefore, those with the ability to provide the necessary aid ought to administer it even if they are not directly complicit in causing the problem -- but the obligation is much more profound if they are.

Here we look at three areas where international assistance between the world's rich and poor has grown.47 We believe this trend indicates what ought to happen in the case of HIV/AIDS. Indeed, there are some indications that movement in this direction has started. However, these precedents establish only a starting point. Assistance and action to limit suffering from AIDS should go even further.

Disaster Relief

Many of the world's people live in places that are prone to natural disasters ranging from hurricanes and cyclones to earthquakes and volcanic eruptions. These disasters can be severe, leading to many lost lives, extensive damage to infrastructure necessary for economic vitality, and widespread human suffering. Most of these events are very difficult to prepare for, especially in the case of countries experiencing poverty on a daily basis. Today, the developed countries recognize that they ought to help other countries when disaster strikes. Thus, when Turkey experiences a major earthquake, or when Honduras is hit by a hurricane, or when a volcano erupts in the Philippines, governments act by providing direct assistance or money necessary to cope with the resulting destruction and suffering. While reactions vary in magnitude and form, they are usually almost immediate.

Indeed, we might say that there is an international obligation for the wealthy to provide aid to the poor -- and often the not-so-poor -- in times of natural disaster. While this is not a requirement of international law, it is almost unassailable in the international norms of the modern world. What does this recognition that we ought to provide relief following natural disaster say about global HIV/AIDS? Some argue that HIV/AIDS is much like a natural disaster because it originated in nature, among the apes, and was transmitted to humans who lived among them. It was, according to this conception, nobody's fault. But, as the case of disaster relief shows, even if the wealthy countries are not at fault, the recognition that they ought to provide aid exists, and they routinely act upon this sentiment.

Famine Aid

Before the last century, when countries suffered from famine, people in the rich countries were no doubt saddened and perhaps prayed for the starving, but there was little they were willing to do (famine was sometimes not far from their own doorsteps) and even less they could do (by the time aid reached those in need by sailing ship, it would probably be too late). However, as the developed countries began to experience food surpluses, and as technologies improved for moving goods around the world, a new sense of how to respond emerged: Those countries with a food surplus ought to provide relief to those suffering from famine.48 The wealthier countries cannot now easily ignore famine and starvation; to do so would almost certainly lead to a chorus of condemnation from their own people.

Recognition by the developed countries that they ought to distribute food to those suffering from famine is visible today in airlifts of food and other famine relief. This sense that they ought to act is so great that governments of wealthy countries have felt obliged to act even when their national interests would clearly suffer from doing so. For example, during widespread famine in the Soviet Union in the early 1920s, the United States spent massive amounts of money and expended other aid to feed the starving millions there. This aid was sent despite extant hatred of the new Bolshevik regime, and even despite Lenin's acknowledgement that without aid, the revolution would fail. Robert McElroy has shown that U.S. justifications for providing famine reóief to Russia were not based on benefits for U.S. farmers or other self-interested reasons, but were instead grounded in the new belief, too strong to ignore, that those with a food surplus ought to provide aid to those suffering from famine.49

Similar arguments are being made today with regard to severe food shortages in North Korea. The largest amount of famine aid to North Korea -- headed by a regime that the United States hardly wishes to see remain in power -- comes from the United States. Indeed, it would not be farfetched to argue that the United States is largely responsible for keeping the country alive with its aid. There are of course practical reasons for providing the aid -- a sudden breakdown in North Korean society and government could spill over into conflict on the Korean peninsula -- but it is in any case extraordinarily difficult to argue that the people of North Korea should be allowed to starve to death as a means for bringing about political change there.50 Such arguments run up against the established international norm of famine relief. Similarly, in Afghanistan, where the Taliban is brutalizing the Afghan people, the United States and others have chosen to continue food aid. As to Iraq, even the powerful advocates of retaining sanctions are looking for new ways of punishing and containing the brutal Iraqi regime without causing suffering among its people.

To be sure, much famine and starvation is the consequence of government action (or intentional inaction), as demonstrated strongly by widespread famine from Mao's so-called Great Leap Forward and, more intentionally, Pol Pot's despicable policies toward the Cambodian people, or the policy of the current Sudanese government toward its rebellious South. And many famines are at least an indirect consequence of governments' failures to prepare for them. In the case of HIV/AIDS, many argue that it is the fault of governments. They are the ones to blame, so the rich need not feel an obligation to provide aid. But the case of famine relief shows that even where national governments are culpable, those with the means to reduce severe human suffering ought to do so.

Environmental Change

The world is experiencing many environmental problems, with the most acute effects being felt in the poorest countries. Indeed, environmental changes -- ranging from water pollution and shortages to desertification, air pollution, and climate change -- are placing increasing strain on developing economies and leading to substantial human suffering. In recent decades, and particularly in the last one, the world's governments have come to recognize their responsibilities toward the environment. To be sure, their actions have fallen short of what is required to protect the world's ecology, but they have started to act through the implementation of national environmental protection measures and, to a lesser degree, through international cooperation (for example, on the prevention of stratospheric ozone depletion and river pollution). More to the point, the developed countries have increasingly been willing to aid the poorer countries in their efforts to combat adverse environmental changes, and the wealthy of the world have started to acknowledge -- and act upon -- their responsibility for many of these problems.51

Global warming, and the resulting climatic changes, is a particularly salient case in point. Among the key principles of the 1992 UN Framework Convention on Climate Change (FCCC) was the notion of 'common but differentiated responsibility," whereby the economically developed countries would take the lead in addressing the problem of climate change, specifically excluding developing countries from binding limitations on emissions of the greenhouse gases that lead to global warming.52 In addition to the FCCC, this principle was implicit in the 1987 Montreal Protocol on Substances that Deplete the Ozone Layer, and it was recognized in other important international undertakings.53

All countries could suffer from climate change, although the poor countries of the world will suffer most due to their vulnerable geographies and economies.54 What is more, it is the economically developed countries of the global North that have generated the most greenhouse gases since the advent of the Industrial Revolution, and they have thereby benefited from using the global atmosphere as a sink for the harmful byproducts of their economic development.55 During the negotiations for the FCCC, developing countries were unified in emphasizing the historical responsibility of developed countries for climate change. They agreed to participate in the climate negotiations only on the condition that they not be required to accept any substantial commitments of their own.56 The United States and other developed-country parties to the FCCC accepted this standard (the new Bush administration's policies notwithstanding) because they knew developing countries would not -- and in many cases could not -- limit their greenhouse gas emissions and cope with climate change otherwise.57

True, the developed countries have so far not lived up to the spirit of the common but differentiated principle. But neither have they done nothing. They have given billions of dollars to developing countries through the Global Environment Facility and the Clean Development Mechanism. And the West Europeans in particular have gone from following the U.S. lead on this issue to challenging Americans to live up to their obligations under this principle. Most important, the codification of the common but differentiated principle in the 1992 climate change convention marks the recognition by the wealthy that they have special responsibilities not held by the poor.

To be sure, environmental cases differ from those of disaster and famine for many reasons, but they are particularly different because, in many instances, the wealthy countries clearly contribute to the problems and therefore share blame for them. This should increase the sense of obligation by the wealthy to give the poor the means to address adverse environmental changes and their consequences. The case for aid in many environmental issue areas is even stronger than that for disaster and famine relief. Common problems require common action, but those countries with the most responsibility for the problems and those with the greatest capacity to address them have an obligation to aid those less responsible and/or less able to act.

Conclusion

The historical emergence of a sense of obligation by the world's developed countries to provide assistance to the poorer countries when they are in dire need, and the frequent action on this sense of obligation, show that we have accepted that in a civilized world, the wealthy ought to help those in need. This argument gains strength as the responsibility for problems grows -- although, importantly, responsibility is clearly not a requirement for assistance to be provided. Thus a strong case for aid from the global rich to the global poor has a solid foundation not only in the corpus of ethical reasoning, but also in international practice and in new international instruments, as shown by, among other issues, the cases of disaster, famine, and environmental change.

Will the response of the world's wealthy countries toward HIV/AIDS in the developing world build upon the increasing recognition that the wealthy ought to aid the poor? There are indications that the response is moving in this direction, and there are ethical arguments for why it ought to, as we have tried to show. It appears to us that the publics of all countries, including those in the developed world, are nudging this historical trend forward. As UN Secretary General Kofi Annan has argued, global public opinion has pushed the developed country governments to start opening their wallets to assist those suffering from HIV/AIDS in the developing world: 'There has been a world-wide revolt of public opinion. People no longer accept that the sick and dying, simply because they are poor, should be denied drugs which have transformed the lives of others who are better off."58 It is becoming difficult for the wealthy countries to resist the tide of public opinion, because the arguments for resisting are seldom persuasive and run counter to so many good ethical arguments, and historical precedents, for helping those who are worst affected and least able to help themselves.

An immense crisis exists, and those suffering from it lack the means to deal with it to any satisfactory degree. Solutions to this crisis also exist, but many of them (for example, drugs for treating AIDS, money to acquire and administer treatment, resources for prevention programs) are possessed by the world's wealthier countries only. Those with the ability to help can do so without significant sacrifice. Hence, those countries with the means to provide solutions to the HIV/AIDS crisis, and give succor to those now suffering from it, have a moral obligation to act.



Endnotes

* The authors wish to thank the editors and anonymous readers for their very helpful comments, and the international joint research program of the Centre for Public Policy, Lingnan University, for facilitating research for this essay. [BACK]
1. UNAIDS, 'Report on the Global HIV/AIDS Epidemic," 2000. [BACK]
2. Individual Members of the Faculty of Harvard University, 'Consensus Statement on Antiretroviral Treatment for AIDS in Poor Countries," April 4, 2001, p. 3. [BACK]
3. UNAIDS, 'Report on the Global HIV/AIDS Epidemic." [BACK]
4. Kofi Annan, 'Remarks to the United States Chamber of Commerce," Washington, D.C., June 1, 2001. [BACK]
5. Individual Members of the Faculty of Harvard University, 'Consensus Statement," p. 3. [BACK]
6. Gerald Stine, AIDS Update 2000 (Upper Saddle River, N.J.: Prentice Hall, 2000), p. 11. [BACK]
7. These figures are taken from the Web page of USAID, 'USAID CP FY2000: AFR Regional Report." See Bates Gill and Sarah Palmer, 'The Coming AIDS Crisis in China," New York Times, July 16, 2001, p. A15. [BACK]
8. An excellent and more extensive discussion of these interactions of poverty and HIV can be found in Brook K. Baker, 'South African AIDS: Impacts of Globalization, Pharmaceutical Apartheid, and Legal Activism," April 3, 2001, pp. 4–7. [BACK]
9. An excellent snapshot of the tragic situations created by HIV in sub-Saharan Africa is provided in a Pulitzer prize-winning series by Mark Schoofs, 'AIDS: The Agony of Africa," Parts 1–8, Village Voice, November 9, 1999–January 4, 2000. [BACK]
10. World Bank, 'Difficult Health Policy Choices in a Severe AIDS Epidemic," in Confronting AIDS: Public Priorities in a Global Epidemicp(Washington D.C.: World Bank, 1997). [BACK]
11. Norimitsu Onishi, 'AIDS Cuts Swath Through Africa's Teachers," New York Times, August 14, 2000, p. A6. [BACK]
12. Peter Piot, UNAIDS Press Release, May 7, 2000. [BACK]
13. See John Donnelly, 'Suddenly a Plan to Treat AIDS in Africa," Boston Globe, February 13, 2001, p. A1. [BACK]
14 Reuters Health, 'Civil War Looms unless Poor Countries Get Relief from AIDS," May 8, 2001. [BACK]
15. All of these figures are taken from Jubilee 2000 Coalition, 'Eye of the Needle: African Debt Report," November 2000; available at http://www.jubileeresearch.org/analysis/reports/needle.htm. [BACK]
16. For basic information on the development of the fund see United Nations, 'Fact Sheet: A Global AIDS and Health Fund"; available at http://www.un.org/ga/aids/ungassfactsheets/html/fsfund_en.htm. [BACK]
17. Karen DeYoung, 'U.S. Gives AIDS Fund $200 Million Donation; Bush Vows More Money for Public-Private Project," Washington Post, May 12, 2001, p. A19. [BACK]
18. Karl Vick, 'Powell Talks of AIDS in Nairobi Slum," Washington Post, May 28, 2001, p. A19. [BACK]
19. See, for example, Tina Rosenberg, "Look at Brazil," New York Times Magazine, January 28, 2001. [BACK]
20. See European Union Ambassador Erwon Fouere's letter to Dr. O. Shisana, November 24, 1997. [BACK]
21. Health GAP Coalition, 'US at WHA Colludes with Drug Industry" (Press Release, May 17, 2001). [BACK]
22. Chris Tomlinson, 'U.S. Speaker of the House Dennis Hastert Hears Appeal from Priest Treating Children with HIV," Associated Press, April 12, 2001. [BACK]
23. U.S. Secretary of State Colin Powell, Letter to European Union Health Commissioner Patten, April 25, 2001. [BACK]
24. Donald G. McNeil Jr., 'U.S. at Odds with Europe over Rules on World Drug Pricing," New York Times, July 19, 2001, p. A8. [BACK]
25. These policies (and several more) are described in the context of the case of South Africa in Baker, 'South African AIDS." [BACK]
26. For one account of the Abuja summit see John Donnelly, 'Leaders Vow to Combat Africa AIDS Epidemic," Boston Globe, April 29, 2001, p. A22. [BACK]
27. For a description of Uganda's success, see Alex Duval Smith, 'Faith, Hope and Charity," The Independent (London), December 2, 2000, pp. 24, 25, 29, 30. [BACK]
28. Barton Gellman, 'Death Watch: The Global Response to AIDS in Africa: World Shunned Signs of the Coming Plague," Washington Post, July 5, 2000, p. A1. [BACK]
29. One indicator of this lack of responsiveness is the absolute numbers in foreign aid devoted to this problem by developed countries. An excellent analysis is provided by Amir Attaran and Jeffrey Sachs, 'Defining and Refining International Donor Support for Combating the AIDS Pandemic," Lancet 357, No. 9249 (January 6, 2001), pp. 57–61. [BACK]
30. Barton Gellman, 'An Unequal Calculus of Life and Death," Washington Post, December 27, 2000, p. A1. [BACK]
31. Michael Waldholdz, 'Makers of AIDS Drugs Agree to Slash Prices in the Third World," Wall Street Journal, May 11, 2000, p. A1. [BACK]
32. The estimates provided later in this essay on the cost of financial assistance are predicated on these new developments in decreased drug pricing. [BACK]
33. Theresa Agovino, 'Delegate: AIDS Goal Too Ambitious," Associated Press, June 25, 2001. [BACK]
34. Arthur Kaplan, 'Cheap Drugs Not Answer to African AIDS Crisis," MSNBC, April 4, 2001. [BACK]
35. Karen DeYoung, 'UN to Commit to Plan of Action on AIDS; Diversity of Players, Urgency of Crisis May Complicate Focus of N.Y. Gathering," Washington Post, June 24, 2001, p. A17. [BACK]
36. Paul Farmer et al., 'Community-Based Approaches to HIV Treatment in Resource-Poor Settings," Lancet 358, No. 9279 (August 4, 2001), pp. 404–409, and A. D. Harries et al., 'Preventing Antiretroviral Anarchy in Sub-Saharan Africa," Lancet 358, No. 9279 (August 4, 2001) pp. 410–14. [BACK]
37. UNAIDS Press Release, 'UNAIDS Calls on G8 for Massive Increase in Resources to Fight AIDS," July 20, 2000. [BACK]
38. For discussion of these estimates, see Eric Friedman and Paul Zeitz, 'Estimating the Costs for an Expanded and Comprehensive HIV/AIDS Response in Sub-Saharan Africa" (Discussion Memorandum, March 28, 2001), and Individual Members of the Faculty of Harvard University, 'Consensus Statement." [BACK]
39. Quoted in Joe Lauria, 'AIDS Study Cites Dire African Need, $3 B Remedy," Boston Globe, November 29, 2000. [BACK]
40. Jeffrey D. Sachs, 'A New Global Commitment to Disease Control in Africa," Nature Medicine 7, No. 5 (May 2001), pp. 521–23. [BACK]
41. See, for example, David H. Lumsdaine, Moral Vision in International Politics: The Foreign Aid Regime, 1949–1989 (Princeton: Princeton University Press, 1993); Alain Noel and Jean-Philippe Therien, 'From Domestic to International Justice: The Welfare State and Foreign Aid," International Organization 49, No. 3 (Summer 1995), pp. 523–53; and Louis-Marie Imbeau, Donor Aid -- The Determinants of Development Allocations to Third World Countries: A Comparative Analysis (New York: Peter Lang, 1989). [BACK]
42. Peter Singer, 'Famine, Affluence, and Morality," Philosophy and Public Affairs 1, No. 3 (Spring 1972), reprinted in William Aiken and Hugh LaFollette, eds., World Hunger and Morality, 2nd ed. (Upper Saddle River: Prentice Hall, 1996). [BACK]
43. Ibid., pp. 27, 31, 28. [BACK]
44. Ibid., p. 28. [BACK]
45. Ibid., p. 33. [BACK]
46. Henry Shue, 'Equity in an International Agreement on Climate Change," in Richard Samson Odingo et al., eds., Equity and Social Considerations Related to Climate Change (Nairobi: ICIPE Science Press, 1995), p. 386. [BACK]
47. These are some of the major examples. Others can be found, such as the obligation to provide humanitarian relief -- and at times to even intervene militarily -- in times of civic, ethnic, and interstate conflict. See, for example, Thomas G. Weiss and Cindy Collins, Humanitarian Challenges and Intervention (Boulder: Westview Press, 1996); and Michael J. Smith, 'Humanitarian Intervention: An Overview of the Ethical Issues," in Joel H. Rosenthal, ed., Ethics and International Affairs: A Reader, 2nd ed. (Washington, D.C.: Georgetown University Press, 1999). [BACK]
48. See, for example, Jovica Patrnogic, 'Some Reflections on Humanitarian Principles Applicable in Relief Actions," in Christopher Swinarski, ed., Studies and Essays on International Humanitarian Law (Geneva: Martinus Nijhoff Publications, 1984). [BACK]
49. Robert W. McElroy, Morality and American Foreign Policy (Princeton: Princeton University Press, 1992), pp. 57–87. See also Benjamin M. Weissman, Herbert Hoover and Famine Relief to Soviet Russia: 1921–1923 (Stanford: Hoover Institution Press, 1974). [BACK]
50. When asked why he thought the United States was providing food aid to North Korea, that country's consul-general to Hong Kong, Ri To Sop, told one of us on June 11, 2001, 'It's humanitarian," and 'Because we are human beings." This is a profound assessment, given his country's animosity toward the United States government. [BACK]
51. See Paul G. Harris, International Equity and Global Environmental Politics (Aldershot, UK: Ashgate, 2001). [BACK]
52. FCCC, Preamble, Articles 3 and 4. For a more detailed discussion of the common but differentiated responsibility principle, see Paul G. Harris, 'Common but Differentiated Responsibility: The Kyoto Protocol and United States Policy," Environmental Law Journal 7, No. 1 (1999), pp. 27–48; and Harris, International Equity and Global Environmental Politics. [BACK]
53. The principle of common but differentiated responsibility was acknowledged by, inter alia, the UN General Assembly (see GA Resolution 44/228 [1989]) and several climate-related meetings, including: the Second World Climate Conference, meetings of the Preparatory Committee of the United Nations Conference on Environment and Development, the Toronto Conference Statement, the Hague Declaration, and the Noordwijk Declaration. See Philippe Sands, 'The ‘Greening' of International Law: Emerging Principles and Rules," Global Legal Studies Journal 1, No. 2 (Spring 1994). [BACK]
54. Intergovernmental Panel on Climate Change, 'The Regional Impacts of Climate Change: An Assessment of Vulnerability," Summary for Policymakers (1997). [BACK]
55. Clive Ponting, A Green History of the World (New York: St. Martin's Press, 1991), especially pp. 387–92 and 405–406. [BACK]
56. Delphine Borione and Jean Ripert, 'Exercising Common but Differentiated Responsibility," in Irving M. Mintzer and J.A. Leonard, eds., Negotiating Climate Change (Cambridge: Cambridge University Press, 1994), pp. 83–84. [BACK]
57. Cf. Group of Seven Industrialized Countries (G-7) and Russia, 'Final Communiqué of the Denver Summit of the Eight," Denver, July 22, 1997, paras. 14–17. See Harris, 'Common but Differentiated Responsibility." [BACK]
58. Kofi Annan, 'Address to the African Summit on HIV/AIDS, Tuberculosis and Other Infectious Diseases," Abuja, April 26, 2001; available at http://www.un.org/News/ossg/sg/stories/statments_search_full.asp?statID=8. [BACK]

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