Pharmageddon Chapter 11

Johannesburg Wednesday 12 January

My red-headed ‘husband’ strongly advised me not to hang around for the funeral, and so did my gray-headed executive editor. As usual the answer-to-everything from the nuns’ at my convent-school – to ask Jesus – didn’t-answer-anything, but Em was emphatic. ‘Get out of there, lover. Come home.’ Three votes against, and two abstentions.

Waiting for my flight at O R Tambo International I had to keep busy, had to unscramble the egg somehow, so I phoned Shan, and tried to sound businesslike.

‘I’ve been trying to get the results of the analysis of those contaminated ARVs from NguniMed. They’re playing hard to get, but I thought you may know something.’

‘We haven’t heard anything from them yet. But we got hold of a sample from the same batch of medications and we did our own analysis. I’m sure all their suppliers have done the same, but we all pretend we’re waiting for the results of the official assay.’

‘And?’

‘Actually, we didn’t find anything at all.’ 

‘Oh. What does that tell you?’

‘Well, the most important thing from our perspective is that none of the basic ingredients - including our API - were at fault. It can only mean that individual packs of capsules were tampered with. I imagine that NguniMed have analyzed doses from those packs by now...’

‘Did you hear anything more about the patients who received those drugs?’

‘Yes, we heard they recovered fully. It was just diarrhea and nausea.’

‘So it looks like the bad guys went out of their way to avoid killing anyone... again.’

Shan was looking at me – or at least my image on his phone – like a proud brother. ‘Yes. The same thought occurred to me. What do you suppose it means?’

‘I don’t know. It’s like someone is playing chess, but with real people. Trying not to kill anyone, but not caring about the long-term consequence. Speaking of which... how is your project going, Shan? Converting your research lab to production?’

‘My people are still working on the process design. It’s a complex process.’ 

‘When will you know for sure?’

‘Sometime next week, I believe.’

‘And if the answer is no?’

‘Then we’re back to the Chinese. Hoping they can make enough NRTIs for everyone – first and second-line drugs. Dr Kershaw from UNAIDS is still here, and she thinks they can do it, but it’s going to be close.’

‘We’re assuming the South African government will dispense the second-line drugs, when they get them.’ 

‘Yes, that’s the big unknown.’

‘And if they don’t?’

‘Dr Kershaw says the only way forward in that case would be some kind of UN intervention. But it would have to be on a massive scale. She’s not very optimistic, after reading about your interview with Minister Makeba and hearing about Dr Shabangu’s death.’

Hearing Bettina’s name was like being punched in the stomach, and Shan must have read it in my face.

‘Oh Gipsy, I’m sorry. I’d forgotten that she was your friend. It’s an absolute tragedy – especially for South Africa. She did so much to build their treatment program. I’ll miss her greatly. And I know Dr Kershaw is very upset.’

I mumbled something, but I’d lost the thread of our discussion so I found an excuse to ring off, and headed for the free bar in the first class lounge.

Istanbul Thursday 13 January

Istanbul looked different somehow, although I couldn’t pin down the reason. What hadn’t changed was the traffic – unfortunately 8am is the busiest time and it took me the best part of two hours to get from Ataturk to Fenerbahçe. But finally the white garage door swung up and I drove into our sanctuary.

Irem the night nurse had left already, but Kenan the day nurse, Helen the cook and Arda the factotum fussed around with my hand-luggage and offers of refreshment. Then I walked through to the day room and into the warmth of Emily’s eyes, and at last I was home.

‘G’day, mate.’ Hugging isn’t easy when you’re in a wheelchair, even a state-of-the-art electric buggy, but it’s never stopped us. And it’s hard to fake an Ozzie accent when you can barely make sounds, but somehow Em managed that, too.

She used to speak so beautifully with a wild Irish accent and a crazy laugh, but speech control was the first to go as her immune system attacked her central nervous system, and her balance went next. If it was me sitting on that battery pack with wheels I’d spend my life worrying about which pony in my paddock was next for the knackers, but Em just made the most of what she had. And she had more than enough – so much, in fact, that she was always giving it away. People were drawn to Emily like a moths to a storm lantern.

‘Why are you up so early?’ It was my standard joke. She was always showered and dressed by the time Kenan arrived for the day shift, even though I kept telling her that she should enjoy being waited on. She was wearing a finely embroidered Indian kurta and salwaaz – tunic and pants – with a contrasting shawl.

Her eyes were filled with mischief. ‘I thought Jamie and I’d go for a run along the beach.’ 

‘Jamie?’

Suddenly I heard what sounded like a handful of gravel being thrown at a window and a yellow whirlwind appeared from the direction of the kitchen. Em’s beloved companion dog always came when he heard his name, but now he was scrabbling for grip on the unfamiliar wooden floors. He was way too well mannered to jump on me, but he managed to convey that he really really would if he were allowed, by burying his head between my knees and wagging his tail furiously.

‘Jamie! When did you arrive?’

‘I got here yesterday, daddy.’ Emily spoke for him. Irish ventriloquism. ‘The nice people at quarantine said I was special, so I didn’t need to stay any longer.’

‘That’s great! Welcome home, big boy!’ I could see the staff grinning from the kitchen door. ‘How did he react when he saw you?’

‘He said – why did you take me away from that holiday camp, you Irish bitch? Oh, hang on a sec. This is rather nice. Lots of people to feed me and tickle me. Hmm, and lots of space on the bed. Oh, OK, this’ll do.’

I roared, and Jamie took this as an invitation to roll on his back so I could inspect his undercarriage and do some tickling. I caught Em’s eyes on me.

‘You must be exhausted, lover. Can Helen make you something?’

I’d had breakfast on the short leg from Rome so I declined and went to stand in the shower. By the time I turned off the tap I was practically asleep, and I don’t really remember getting into bed. When I finally opened my eyes it was dark outside, and dead quiet. I turned over and found Em propped on one elbow, looking at me and smiling.

‘How long...’

‘About fourteen hours..’

‘No, how long have you been staring at me?’

‘About fourteen hours.’

I reached for her under the bedclothes and found she was naked. ‘Uh oh!’ She smiled. ‘Uh oh.’

Even though Emily had practically no sense of balance, she was anything but disabled in bed. She said it was like fucking underwater, except you can breathe! And she kept in shape with daily exercises in our small but state-of-the-art gym, under the barbarian’s supervision.

I threw off the duvet so I could get a look at her, starting with her naughty green eyes, pert nose and full mouth, down her beautifully formed neck and shoulders to her small breasts and rose colored nipples, now hard and puckered. I saw the gooseflesh form on her pale but perfect skin as I ran my hands down her stomach to the golden triangle and the soft, sweet hiding place beyond. I felt her quads tighten as she pulled her legs up and apart, to let me in.

In a second I was out of my t-shirt and knickers and she was exploring me, too. In a few minutes we were both grunting and groaning, and in another few – with some battery-powered assistance – we were wailing like banshees. When at last I felt her shudder and convulse, that was all I needed to send me over the top.

A little later I was lying behind her, my chin on her shoulder, her bum firm against my hips, my hands cradling her breasts.

‘I missed you.’

‘I know,’ she said. ‘You’re supposed to.’

‘Oh fuck – I can’t imagine what Irem thought of us.’

I felt Em trembling with laughter. ‘I gave her the night off. Said you’d look after me tonight. And you have! She put me to bed though. Without my jarmies.’

‘Hmm. The end of innocence. Did you eat?’

‘Mmmm. Pussy delight.’

‘No calories in that. I’m starving. You?’

Turned out she hadn’t eaten since lunch so I boiled up some pasta and we sat in the day room with a good Bordeaux and the lights dimmed so we could enjoy the bright jewels of light from the yachts moored offshore, and the Princess Islands beyond, while I told her about the people I’d met and the strange things I’d seen. Just like always.

While they were happening, the events of the past ten days felt like scenes from a movie but now, as I recounted them, they became shockingly real. It was a discordant chant of horror, dread, confusion and disbelief, reaching a crescendo of sheer panic as I escaped from Colin Makeba’s office.

But when I got to the moment when I realized Makeba would assume I got my information from Bettina, and that I had probably killed one of my closest friends, my vision dimmed and I felt light headed and nauseous. I scrambled for the bathroom but only succeeded in plastering the passageway with a mulch of pasta, tomato sauce and red wine. The remains of Bettina and her beautiful family.

It’s not quite true to say the next thing I remember was waking up in hospital, but it’s close enough. Memories aren’t always useful. I lay there, drugged to the eyeballs, for a couple of days, but it could have been a few months for all I knew or cared. All I remember is a succession of tedious nightmares, separated by bad food and bed-baths. Actually I didn’t mind the bed-baths. And Emily, sitting in her buggy by the bed. She didn’t look too worried, just... there. That look you give someone which says: ‘Hey, this is something, isn’t it?’

Istanbul Monday 17 January

Finally I was back home, again, clutching a bag full of medications that I had no intention of swallowing. Our staff looked pleased, again, and Emily looked amused. At least Jamie had the grace to look worried, although I suspected it might be because he’d sampled my artwork in the passageway and found it fell short of his usual culinary standards.

Em asked me to finish my story, and I did. We were both blubbering like schoolgirls as I passed on what I’d managed to drag out of the security guys, who talked to the paramedics who scraped the Shabangus out of their Audi.

Afterwards, as I lay on the couch with my head on Em’s lap, staring into Jamie’s bronze eyes, I was surprised and a little embarrassed to find that I felt okay. Also, it felt... real. I could feel Em’s soft woolen trousers under my cheek, see specks of dust on the coffee table, and smell Jamie’s dog-breath over the strange perfume of Istanbul. It wasn’t a dream. I was there, in Fenerbahçe, in Istanbul. Safe. I sat up.

‘I feel like I’m awake.’ 

‘Good morning!’

‘No, really. It’s weird, but somehow the whole thing – going to Shimla, Jo’burg – at the time it all seemed so... unreal. It started off crazy and just went south from there. Off the scale.’

I looked into Em’s green eyes and was surprised to find concern, for the first time. Then I understood.

‘Don’t worry, babe. I know Bettina has gone, and her country is in deep shit. I’m not... hiding from it. But I feel better. Really.’

A little later Jim arrived, unannounced and clutching a bottle of Cuban rum and a bag of limes and mint leaves. We supplied the sugar, ice and club soda, and spent the evening working on the perfect mojito. Eventually our learning curves and blood-alcohol levels converged, and Jim got to the point.

‘Gipsy girl, I don’t want to see you at the office for a while. You haven’t taken any leave since we started this thing, and I want you to take a couple of weeks now.’

I caught Em’s eye, and recognized the look of a conspirator. Then I surprised myself. ‘Okay.’

‘Okay?’

‘Yeah, boss. I can’t fight the three of you.’

Jamie didn’t open his eyes, but flapped his tail to confirm his part in the evil plot. Jim looked unsettled by my easy capitulation, but I knew I needed to stand back for a while. To get some perspective.

‘Okay then. I’ll check in, to make sure you’re not abusing my friends here.’ He flicked his eyes at Emily and Jamie, but I saw the flash of angst as he realized his words could be taken as a reference to Bettina.

‘But I have three conditions, Jimboy...’ 

‘Ah, that’s more like it. So give.’

‘One, you promise not to pussyfoot around me. I cocked up, and Bettina and her family are dead. I’m not going to kill anyone else, and I’ll be fine in a few days.’

I sensed a movement at my feet and found that Jamie had lifted his head to stare at me. That made three sets of round eyes, and a lot of stillness.

‘Two, you don’t argue if I stay on top of things from here. I won’t scare the kids at work, but I want to monitor things online. And to write op-eds, if I feel so inclined.’

Jim didn’t like that, and neither did Em, but they didn’t say anything.

‘And three, next time bring coconut cream and pineapple juice. I think we’ve nailed mojitos, so we may as well practice our piña coladas.’

Jim was smiling now. ‘Anything else?’

‘Damn right. We’ll need another bottle of rum.’ 

++++

Monitoring the unfolding drama in southern Africa was like watching a vast Hollywood epic being filmed, scenes shot out of sequence, meaningless to anyone without a script. I spent hours – days – sitting at my computer watching the flood of posts flowing by. And even though each video, audio and text added a pixel of light to the picture, its final form refused to take shape in my mind.

In South Africa I’d vacillated between confusion, elation, fear and anger, but it was all theater-emotion. Vicarious. Safe. Now, in Istanbul, I understood things much better but, after my meltdown last week, I felt... empty. No, that’s not right – I felt dumbfounded. Stunned. The way I felt when I watched the re-election of George W Bush, after Michael Moore showed so clearly that the emperor had no clothes. How can so many people ignore the obvious? Could it be that knowing the truth and behaving rationally don’t necessarily go together?

The clips, bytes and tweets weren’t all from South Africa, of course. Politicians, priests, public health specialists, economists, apologists, critics, Uncle Tom Cobley and all had something to say, regardless of where they were or how much they knew. But it was all words. Talking heads. Reaction, without action. At first.

A lot of the information emerged from the black grapevine, the rumor-mill that developed over centuries of colonialism as an alternative to the often indifferent and sometimes xenophobic white media. For a long time the two channels of information, black and white, informal and commercial, remained quite separate, but all that changed when Shan Gupta started paying people for news. Today our stringers were listening, and every whisper found its way onto our electronic pages, and from there onto the cellphones of the masses.

At first the buzz was that ARVs had been ‘withdrawn’ from public hospitals because they were no good, and the epidemic was getting worse. But the good news was that government had arranged for ‘better’ ARVs, which would save the day. Hang in there, folks!

It was a good rumor because it tallied with what people saw, and it allayed their fears while requiring no action. It also tied in nicely with my story that Maurya were fast-tracking the production of active ingredients for second-line ARVs. If PI-based drugs were rolled out to government hospitals within the next couple of months, the blip in South Africa’s AIDS deaths would be barely visible – especially after a little statistical massage.

For me the only dead pixel in this otherwise crystal picture was – why use the rumor mill? Why didn’t the government just say openly that they were planning to introduce second-line medications? The best I could come up with was that they were trying to save face. Or to buy time, while they chopped off a few heads following the secret stockpile fiasco.

Except that they weren’t chopping off heads. The honorable minister of health denied everything, as did their ambassador to the UN, and – incredibly – the government closed ranks behind them. For their part, NguniMed issued a public statement saying that, as an unlisted company, they were not required to reveal the identity of their shareholders, but minister Colin Makeba was not among them. Well, I knew that already – Bettina told me his equity was held by a proxy.

As for Bettina herself, the official line was that the death of the director general and her family was a tragic accident, but the buzz was that it was retribution by the west for her brave stand against their evil drugs. Never let the facts get in the way of a good story!

Meanwhile, according to Bettina’s replacement at the department of health, AIDS patients were simply going about their business, confident that international fears for their survival were misplaced. AIDS clinics around the country were deserted, but our stringers had no difficulty in finding ARVs for sale on the street, or in confirming there was a big demand for the looted drugs – even at extortionate black-market prices. The fact that many cops were ordering new cars, or buying bigger houses, also didn’t go unnoticed or unreported.

And of course the legend of the Xhosa-nostra was endlessly chewed over on our conspiracy pages. It was fascinating to watch the debate evolve from one-line declarations of support or opposition, to carefully researched historical and political treatises, either for or against. What they all had in common was a lack of hard evidence.

It didn’t matter. Whether or not people believed in a secret cabal of tribal elders united against the Zulu, they certainly bought into the ‘demographic adjustment’ theory, and South African society slowly began to separate into its ethnic parts.

It began with small things, all carefully documented on our forums – birds of a tribal feather flocking together during tea-breaks, or in work-groups or committees. Then there were reports – isolated at first – of people relocating from one residential township or suburb to another, or between farms, mines or companies, so they could be with their kin. As the days passed people began to talk openly about this place being Zulu and that one being Xhosa.

The term ‘Xhosa’ also morphed from a clear tribal designation into an omnibus term meaning ‘non-Zulu’. Disclaimers from the chiefs of other tribes such as the Sotho, Ndebele and Tswana made absolutely no difference. People believed what they wanted to believe, and used words to mean whatever they wanted them to mean.

I sat in my study, studying this river of news, trying to see where it was heading. I tried out some of my ideas in op-eds, as did Georghe and the rest of the guys, while Enoch provided exquisite insight into the confusion and conflict of being South African. It made compelling copy, and Jim muttered that we were starting to carry way too much advertising, and that our marketing and finance people were becoming insufferably smug.

We were just adjusting to the Balkanization of southern Africa when another rumor bobbed to the surface in our pharmageddon forum, suggesting that the ‘better’ ARVs would be distributed only to the Xhosa areas of the country, leaving the Zulus to die! The geographic separation of the tribes, so the buzz went, was playing right into the Xhosa-nostra’s hands, making it easy to control who would be treated and who would be fatally neglected.

The post struck a chord among the hundreds of thousands of South Africans who were now following every word of the unfolding story, and within a few days a group of Zulu students at a university in Johannesburg staged a march to protest their anger at being ‘targeted for destruction’. After a couple of them vandalized cars and buildings, the student representative council sent a delegation to ‘allay their fears’ but it turned into a brawl, and the riot police intervened. One of the leaders of the Zulu protest march was stabbed during the fracas, and died later in hospital.

That night, in a predominantly Zulu township to the west of Johannesburg, five men accused of being Xhosa informers were lynched by a street committee who placed burning automobile tires around their necks in the barbaric practice known as necklacing. Gangs of youths took their cue from the lynching and burned down twenty ‘Xhosa shacks’ in the same township. In one of them a woman, a small boy and a baby had been locked in by her boyfriend while he went drinking. In another, an invalid was unable to get out in time.

By the next morning the township was cleansed of non-Zulus, with several hundred taking refuge in the local police station and a thousand more simply disappearing into the night. When names were put to the dead it turned out that only one – the invalid – was actually Xhosa, the others being drawn from many tribes, including one Zulu.

That night president Josias Shezi finally broke his silence and addressed the nation. ‘We saw the same thing happen in 2008, and we cannot allow it to happen again.’ The police would be deployed in full force to potential flashpoints, he said, and the army placed on alert.

Shezi also took the opportunity to confirm rumors that ‘better’ ARVs were indeed on the way for those who needed them, and to announce that the first province to receive them would be KwaZulu-Natal – the home of his own people, the Zulus.

Nobody was sure whether it was the carrot of the ARVs, or the stick of armed intervention, but the next few nights were quiet. Our stringers described how the calm was used by hundreds of thousands to pack up their homes and move to townships or provinces populated by their own kind. Within days, rumor had achieved what fifty years of apartheid failed to do – separate the nation into its tribal components.

The relocation of a large part of its population played havoc with the biggest economy in Africa, particularly the economic heartland around Johannesburg which had always been an ethnic melting pot. Absenteeism brought industrial production almost to a halt, while the withdrawal of patronage from stores, and money from banks, had a similar effect on commerce. Agriculture fared a little better because many commercial farmers had long preferred to stick to ethnically homogenous workforces.

Then came another post to the pharmageddon forum, saying that the plan all along had been to give the ‘better’ ARVs to the Zulu – but that ‘better’ actually meant ‘toxic’! The new drugs, according to the post, were not designed to cure, but to kill!

The poster said the announcement by the Zulu president that his own people would get the toxic drugs was a masterstroke by the shadowy cabal who fed him their propaganda, and that the Xhosa-nostra’s secret stash of API would sustain their tribe while the culling of the Zulu proceeded. And, for good measure, the poster added that the late Bettina Shabangu – herself of Zulu stock – had become aware of this plot and had been killed to prevent her from foiling it!

This latest rumor drew a blizzard of denial, with countless posts pointing out there was absolutely no evidence – or rational argument – to support such a bizarre theory. But it made no difference. All that a conspiracy theory needs in order to fly is that enough people want to believe it, and cannot be persuaded otherwise. Then fiction turns into fact.

Naturally there was an instant denial by the deputy minister of health, reinforced by the president himself, but overnight five AIDS clinics in KwaZulu were firebombed, sending an unmistakable message that the president was no longer trusted in his own province.

In Durban, campus demonstrations morphed into street riots, soon joined by Zulu tribesmen wearing traditional animal-skins and carrying sticks and spears. Buoyed by the collective bravado and more than a little alcoholic courage, one rabble marched on the local offices of the ruling African National Congress, where they chanted and stamped their feet in a terrifying display. 

A handgun fired into the air was enough to spook the frightened and outnumbered police assigned to monitor the march, who responded with a volley of shotgun fire. Unfortunately their weapons were loaded with buckshot, not the rubber bullets intended for riot control, and forty people were injured and two killed outright in what was instantly dubbed the Magagula Massacre, after the street where the ‘massacre’ took place.

Before the night was over, several police stations and the homes of a number of senior police officers were raided by armed gangs looking for – and finding – stashes of ARVs, then burning those buildings in retaliation for police brutality and ‘disloyalty to the people’.

The following day emergency meetings were brokered between the police, students, traditional leaders and politicians by a group of church leaders. The discussions were never made public but they appeared to be successful because there were no further riots. What happened instead is that senior police, prisons and justice officials who were not Zulu quietly left the province, and were replaced by Zulus.

As the situation in South Africa careened toward the precipice, desperate diplomacy by the UN with their larger neighbors – Namibia, Botswana, Zimbabwe and Mozambique – persuaded them to declare they would maintain universal ARV treatment at all costs, and would look to the UN to re-supply their hospitals. However the tiny fetal nations of Swaziland and Lesotho could not be induced to leave the South African womb...

New York Wednesday 2 February

UN secretary general Maryam Kapur was famously efficient as a chairperson – especially for internal meetings such as this – and less than a minute after calling the meeting to order she turned to Ibrahim Mazzer and asked for an update on ARV procurement.

Mazzer knew the heads of all UN agencies had been invited to the meeting but was not surprised to see a few had declined, and others had sent deputies in their stead. Nevertheless, alongside the more obvious agencies dealing with humanitarian and human-rights issues, he recognized delegates from tourism, intellectual property, civil aviation, drugs and crime, food and agriculture, labor, trade, industrial development, the World Bank and the International Monetary Fund, pointing to the breadth and gravity of the issue.

‘Thank you SG. Much of this information has already found its way into the public domain, so I will be brief. Four weeks ago, immediately after you convened the emergency meeting, we placed substantial orders with a range of Chinese companies for active pharmaceutical ingredients – API – for both first- and second- line antiretrovirals. If all of them had made good on those orders, we would by now have been in... aah... an interesting over-supply situation.’

Mazzer looked around to see if anyone would smile. Nobody did. The Egyptian picked up his spectacles in one hand, and a sheet of paper with the other. ‘The first shipments began arriving at our depot in Bangkok within ten days of order, and every batch was quality-tested by two independent laboratories. To date, about one third of the API which was scheduled for delivery has been received and of that, about fifteen percent is of acceptable quality.’

A rumble of voices greeted this news. Mazzer put down his notes and spectacles and continued. ‘In addition, I am sure you all read that Dr Gupta was hoping to convert a large research laboratory at Maurya’s headquarters to API production? I am sorry to inform you now that he was unsuccessful in this. My head of procurement...’ he swiveled to gesture to Nikki Kershaw, who was sitting behind him, ‘has been monitoring the situation, and she reports that the reactors he hoped to re-commission turned out to be unsuitable.’

Mazzer ignored the continuing rumble of disappointment and ploughed on. ‘Of course our original recovery plan was developed before this offer came up, and we have been keeping the pressure on the Chinese and other API manufacturers, and today our best estimates are as follows.’

Once more the spectacles were parked on his nose and the paper lifted from the table. ‘Within one month from today – that is, two months from the sabotage – we expect to have sufficient API to satisfy about two thirds of the pre-existing demand for first-line combinations, and most of the existing demand for PI-based drugs... second-line medications. After another 30 days we expect to reach 100 percent of first-line demand, and 120 percent for second-line drugs.’

Again he put down the paper, followed by the glasses. ‘To explain what this means in terms of treatment on the ground, I would like to hand over to Jean.’ Mazzer glanced at Kapur to indicate he was done.

‘Thank you Dr Mazzer. Ladies and gentlemen, please hold your questions until we’ve heard from Dr Folbert.’ She nodded toward the director general of the WHO.

Folbert stood as Mazzer sat down. ‘Merci madame. Like Ibrahim I will be brief. Following our meeting on the third of January, all countries supplied us with inventories of their ARV reserves. Our rough calculations at the last meeting proved to be almost correct – we found the global reserve of first-line ARVs was equal to 65 days. And of course we are now halfway through that period. Unfortunately three countries have not met the agreed protocol for re- supply – South Africa has refused to allow physical verification of their reserves and, together with Swaziland and Lesotho, they are not maintaining universal treatment.’

Folbert glared around the room to make sure he had everyone’s attention. ‘These three countries are home to nearly two million of the 7.5 million people who were receiving first-line ARVs. They are now committed to a large-scale treatment interruption, which means we have no option but to restore universal treatment using second-line drugs.’

The Frenchman hesitated a second before continuing. ‘I take no joy in pointing out that the unintended consequence of South Africa’s... difficulty... is that the number of people who are actually receiving first-line treatment in other countries today is 5.5 million, and that the global reserve is sufficient to satisfy their needs until new stocks arrive, even allowing some margin for error.’

This time the ripple which ran through the group sounded like a sigh of relief. But Folbert held up his hand. ‘At this point our major concern is for those two million in Southern Africa. In the past month we have had three independent teams working full-time to model the possible outcomes of a large scale involuntary treatment interruption, such as we are now witnessing there.’

Folbert nodded to an assistant and the lights dimmed, and a large screen at the furthest end of the table glowed with a brightly colored graph. ‘The research teams broadly agree on what they call the biomedical model – that is, what is most likely to happen until ARV treatment is restored, if you ignore any non-medical factors. As you can see they anticipate a half-bell curve in mortality, starting very gradually within three weeks of the treatment interruption, then rising more rapidly after three months, and reaching a peak somewhere between 12 and 18 months.’

Folbert pressed a button on a remote and a second line appeared, branching off from the first. ‘However, restoring universal treatment – with second-line medications – at any point will result in a leveling off in mortality within a week, and a decline within three weeks. Based on Ibrahim’s projections, we expect to have sufficient second-line drugs available to reintroduce universal treatment sometime in April. By mid-year we would expect daily AIDS deaths to be back within five percent of the pre-January figures. In the absence of other factors.

Once again he pressed a button, and the graph on the screen changed. ‘The second graph reflects what our research teams called the economic model, which takes into account the effects of declining health on productivity and earnings. Sick people can’t work, and this line shows mortality among AIDS patients, if you take into account malnutrition and other compounding factors as their savings are used up.’

Folbert pressed a button and a second line appeared on the graph, rising above the first. ‘This second line shows collateral mortality – the death rate among people who do not have AIDS, but who depend financially on people who do, such as children and the elderly. We must remember that more than 90 percent of people with AIDS are aged between 20 and 50. They are typically family breadwinners, so their illness affects everyone in the household.’

He pointed a laser device and a bright red dot appeared on the screen. ‘As you can see the rate of collateral mortality remains lower than AIDS deaths for a while. This is the period during which families use up their savings and sell their assets. Some children and old people will go hungry, of course, but we expect they will only start dying after about two months. Then the line begins to rise steeply, crossing the death rate for infected people at four months, and by twelve months we expect collateral mortality to be at least three times higher than deaths from AIDS.’

He glanced around the room. ‘Not that we expect to go that long before treatment is restored, of course. It is simply... unthinkable.’

As Folbert spoke the lights in the room brightened, and the image on the screen disappeared. He continued. ‘Then our teams looked at a third model, the socio-political model. As the name implies this considers the impact of various social and political phenomena such as civil unrest, sexual incontinence and ethnic cleansing. Frankly, this is where the teams started... to go a little crazy!’

His audience were as still and silent as a photograph. ‘The worst-case scenarios are... very bad, I’m afraid, and our monitoring of the current situation in South Africa has led our teams to be... somewhat pessimistic in their predictions. In particular they were very alarmed by the ethnic separation of the country. Their fear is that this could trigger widespread civil unrest, which will make it difficult to restore ARV treatment, even if the government is supportive and the drugs are available.’

Folbert looked like he wanted to expand on that theme, but changed his mind. ‘Of course such a scenario moves out of the public health domain and into matters of national and international security. We have prepared a report along these lines which has already been given to the secretary general. Copies will be distributed at the end of this meeting. Essentially we have recommended a peacekeeping force to stabilize the region politically and militarily and to supervise the reintroduction of ARV treatment.’

Folbert sat down, and for a long moment the room was silent. Most of those present were staring at their hands, or blankly ahead. Maryam Kapur broke the silence. ‘Thank you, gentlemen, for your huge effort over the past month. I believe the world is in your debt. Do we have any questions for either Dr Mazzer or Dr Folbert, before we move on?’

There were no questions, but a spirited debate erupted over the wisdom of an armed intervention to ‘save South Africa from itself’ as one agency head put it. Kapur indulged the group for ten minutes before raising her hand. ‘I’m sorry, colleagues, but a decision on a political intervention does not rest with us. Our role is to support the security council so they can make an informed decision, and I have already briefed the president of the security council and given Dr Folbert’s report to him. He has taken the decision to call an emergency meeting tomorrow to discuss this issue.’

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