Pharmageddon Chapter 3 

Istanbul Turkey 12:00 Sunday 2 January T+9hrs

Zvonimira Jelena was expecting Gipsy North’s story when it appeared on her monitor. The World Online’s content manager usually handled copy from the senior editors herself, leaving her team of moderators to deal with posts from tens of thousands of stringers.

Jelena was in her early 50s. Born in Croatia but raised in many countries thanks to her father's job installing steam turbines in power stations. She grew up speaking six languages like a native and had since acquired functional literacy in another five – one of the key requirements for her present job. 

She finished her schooling in Montreal, Canada, where she joined the Montreal Star as a junior sub-editor at a time when computerized newspaper editing and page makeup was in its infancy. She had been involved ever since in getting news ready for publication – first in newspapers, then television, and for most of the past decade, online.

The vast majority of TWO's content was sent in by stringers in the form of written copy, digital photos or video clips. Every submission was reviewed within minutes by one of Jelena's moderators – they would have been called 'copy tasters' in the old days – who classified each one on the basis of language, news-type, rank and risk. 

Hard-news stories – which were supposedly factual – were forwarded to one of a dozen companies around the world for editing, translation and sometimes legal opinion, before being sent back to TWO's page-making department on the second floor. 

Once posted, the position of stories changed according to their hit-rates and user-ratings, with the most popular and credible stories moving automatically to more prominent positions. Although stories were posted in the contributor's language, users could read them in any language they liked, thanks to the miracle of automatic translation. Processing thousands of stories a day, and keeping the average time from submission to publication below thirty minutes, was an extraordinary – and extraordinarily expensive – feat, but what truly energized TWO's citizen journalists was the fact that they were paid! 

Payment was not in cash but in 'stringettes', which sounded like a play on the term for part-time journalists, stringers, but actually came from a Monty Python sketch in which a manic ad-man named Adrian Wapcaplet – played by John Cleese – brainstormed ways to sell 122,000 miles of string that had been mistakenly cut into three-inch lengths. TWO's marketing team – whose meetings often descended into Wapcapletese – were inordinately proud that a use had finally been found for 'stringettes'.

TWO's stringers accumulated stringettes in much the same way that airline passengers collected frequent-flier miles, and they were entitled to exchange them for any of the goods or services sold by the site's advertisers – a process that gave accountants and tax collectors nightmares but was hugely popular among both stringers and advertisers. Regular contributors whose stories attracted higher ratings were promoted, getting more stringettes for each contribution.

Within seconds of receiving Gipsy North’s story from Shimla, Jelena forwarded a copy to the English-language sub-editing team in Seattle for proofing – even experienced journalists produced typos or wrote in British English when they were under pressure – while she extracted the first couple of paragraphs for TWO’s portal, or front page. She had barely finished when the body of the story reappeared in her queue. Intelligent software had linked many of the words in North’s article to other stories so users could find out more about AIDS, ARVs, Chandigarh, Maurya and Dr Gupta.

Nine minutes after Gipsy North’s copy first appeared in her in-box, Jelena posted the opening paragraphs to the English portal. A click on the headline or the ‘full story’ link would take users to the body of the story, making it instantly accessible to millions. Within another twenty minutes the story would be translated into all ten of TWO’s standard languages and posted to their respective portals, expanding the potential readership to more than a hundred million users.

As she watched, the hit-counter at the foot of her screen began to spool up.

Washington DC, 05:00 Sunday 2 January T+10hrs

‘Come in Vince.’ Delgado saw no reason to apologize for asking her senior adviser to spend the first night of the new year working when she was prepared to do the same. ‘What news from the trenches?’

‘The ambassadors are... not happy, madam secretary. I think they are genuinely worried about the safety of their embassies when word gets out that they’re safeguarding antiretroviral drugs.’

The secretary of state shook her head impatiently. ‘But... haven’t we been clear? It’s only for a day or two. They tell their host governments that we have intelligence reports that lead us to believe there’s a high risk their ARV reserves may be sabotaged, and that we’ll hand the drugs back as soon as it’s safe to do so.’

‘I’m sure the ambassadors understand, madam secretary. A couple of them have even told me they support the principle behind it...’

‘So what’s the problem? Is it difficult to get our hands on the drugs?’

‘No, that’s pretty easy. There’s always someone – from the CDC or one of the agencies – who is directly involved in the distribution of ARVs, and who effectively has carte blanche to move them around. I understand that most of the missions have already figured out their strategy. They’re just waiting on a green light from you. But they’re worried about what happens next.’

‘Meaning?’

‘They’re afraid the local military or police will shoot first and ask questions later. As you know, in many countries HIV prevalence is highest in the armed forces. They could easily see this as a threat to their survival, and not bother to check in with the politicians...’

‘I don’t know, Vince. It seems unlikely that they will move so quickly, especially if we play open cards with everyone from the beginning. Or at least, as soon as the ARVs are in our hands. Any word from the risk- assessment analysts?’

‘They’re still working on it, madam secretary. Their first take tends to support what the ambassadors are saying. Or what their deputies are saying.’

A ghost of a smile passed over the Delgado’s face, and then disappeared.

‘Okay. Well, I’m not happy about it myself, but I just got off the phone with the president and we’re going to stick our necks out on this one. He says it’s time to demonstrate that our military strength is not only there to protect Americans, but vulnerable people everywhere. It’s our time to take some risks. Diplomatic and physical.’

The adviser recognized the change in tone, and clicked his ballpoint pen in readiness to take instructions from his boss. She didn’t notice.

‘Tell the ambassadors to move on the acquisition of the drugs, and to put their marines on full alert immediately. But tell them not to do anything which they can’t defend later on the basis that it was a humanitarian imperative. Above all, don’t hurt anyone. Unless there’s a full-scale attack on their embassy, of course. Keep me in the loop, Vince. At least every hour.’

Before he could respond there was a brief rap on the door and Delgado’s personal assistant came in without waiting for an invitation. ‘Sorry madam secretary, but I thought you would want to see this immediately.’

‘What is it, Harry?’

He handed her a single sheet of paper. ‘It’s a story that has just been posted on The World Online, ma’am.’

Delgado took the page and read the first few lines, then looked up at her adviser. He wasn’t sure what her expression meant. It might have been relief.

‘Vince, ignore what I just said. The word is out on the ARVs.’ She swivelled her chair to stare for a moment at the collection of photographs above her bookshelf, as she usually did when she was thinking. Then she turned back.

‘Okay. Vince, set up a tele-conference with all the ambassadors in an hour. Harry, get the secretary of defense on the line – I need to see if he can join the conference. Oh, and Vince, tell the ambassadors to dust off their emergency evacuation plans.’

‘If they haven’t already done so,’ he murmured.

The secretary stared at him blankly for a moment, her mind still working down a checklist, visible only to her. Then she caught up with his comment and smiled grimly. ‘Yes, we’ve probably just skipped a step... Okay gentlemen, let’s get to it.’

London UK 12:00 Sunday 2 January T+11hrs

Ernest Wintermeyer looked suitably grave as he faced the cameras in the BBC World studio and followed the story on his teleprompter.

‘In our lead story this noon, the bombing of three commercial pharmaceutical laboratories in India early this morning has effectively crippled the global production of antiretroviral drugs, the mainstay of the fight against HIV/AIDS. The World Online quotes Indian pharmaceuticals manufacturer Shan Gupta, who owns one of the laboratories destroyed in the attacks, as saying the blasts were clearly intended to interrupt the supply of first-line generic antiretrovirals. Dr Gupta said the regions most likely to be affected are Africa, South East Asia, Latin America and the Caribbean.’

The camera angle changed, and Wintermeyer turned to look into the viewers’ eyes again. ‘And in the latest twist to this story, The World Online reported moments ago that a United Nations warehouse near Stockholm was extensively damaged by fire last night. The fire is believed to have begun at exactly the same time as the bombs went off in India. TWO health editor Gipsy North has claimed that the warehouse is used to store antiretrovirals which are destined for the same regions.’

Wintermeyer paused as instructed by his teleprompter and turned to his fellow anchor, Leslie Shaw, his face lined with concern. ‘This is terrible, Leslie. What do we know about the implications for AIDS patients, particularly in the third world?’

Shaw gave a grim smile, which offered reassurance and sympathy at the same time. ‘Ernie, this must be an extremely worrying time for everyone who depends on ARVs, and for the medical personnel who have dedicated themselves to fighting the AIDS pandemic.’

She turned to face the camera. ‘Although we have not managed to locate Dr Gupta since he first exposed the link between the sabotage and antiretroviral drugs, The World Online quotes him as saying it will take months to fully restore production, and doctors around the world need to adjust the way they prescribe ARVs to make their supplies last as long as possible.’

Shaw lifted a hand to her ear. ‘I’ve just been told our UN correspondent June Reddy is standing by in New York with the director of the United Nations Joint Secretariat for HIV and AIDS, Dr Ibrahim Mazzer. June?’

Reddy’s face appeared on the monitor behind Shaw and then filled the screen. ‘Thank you Leslie. As you said, I’m talking to the director of UNAIDS.’ She turned to the Egyptian who was standing next to her, bundled up against the cold and looking as though he would rather be in bed than standing on a freezing Manhattan sidewalk before dawn.

‘Dr Mazzer, can you confirm that your warehouse in Sweden has been damaged by fire?’

‘There has been an event of some kind at the UN storage facility, yes, but I have very few details as yet.’

‘And can you confirm these events in India and Sweden targeted the production and distribution of antiretrovirals?’

‘No, absolutely not. It is possible that the Indian plants produced some of the ingredients for antiretrovirals, and that ARVs were stored in our warehouse, but I’m sure you’ll find these factories and our warehouse have many other products in common, such as painkillers and antibiotics. There is a very real danger to jumping to conclusions, as I’m sure you are aware.’

Reddy was not easily put off. ‘Can you say to what extent the flow of ARVs may be affected?’

‘I don’t think that treatment for any disease will be affected at all. Remember these events happened...’ he glanced at his watch ‘not even twelve hours ago. It will take several days before we have all the data, and can make a proper determination.’

‘Dr Mazzer, do you have any idea who could be behind these blasts, or what their motives might be?’

‘We have no information on the explosions in India. As for our warehouse, it was more of a fire, so it could have been a malfunctioning gas cylinder, or some kind of spontaneous chemical reaction. Also we received no warning, and we cannot see what such an action could achieve. The conspiracy theory being promoted by The World Online makes no sense at all.’

‘What does this mean for the medical community, and for people who are receiving antiretrovirals?’

‘I don’t think anyone who is receiving chronic medication of any kind should be concerned, whether they are living with HIV, diabetes, hypertension, tuberculosis or anything else.’

Mazzer turned to look directly at the camera. ‘Remember the pharmaceutical industry is one of the largest in the world. Whatever happened in India... it has not affected the originators of these medications in Europe and the USA, nor the hundreds of generic-drug manufacturers all over the world.’

Reddy recognized a stonewall when she heard one, but she tried one more shot. ‘So you would not agree with the report from TWO which quotes Dr Gupta as saying the blasts have crippled global production of ARVs?’

Mazzer smiled thinly. ‘I fear that Dr Gupta may have been misquoted by The World Online, or perhaps has been influenced by the fact that he owns that publication.’

‘Are you saying that he deliberately exaggerated to encourage users to visit his website?’

‘I wouldn’t go that far, no. Maybe their reporter was throwing around some ideas with her employer, and his speculation was misinterpreted as fact.’

‘Thank you Dr Mazzer – we’ll have to leave it there. From the UNAIDS offices in New York this is June Reddy. Back to you in London, Leslie and Ernie.’

Istanbul Turkey 15:00 Sunday 2 January T+12hrs

‘Jim? Zvonimira.’

‘Hi Vonnie.’

‘I thought you might like to look at the hit-rate on Gipsy’s story, especially from countries with serious AIDS epidemics. I’ve put together a graphic showing the increase in the hit rate since the story broke, overlaid on a UNAIDS map.’

‘Just a sec... Okay, here it is. Wow, that’s impressive! Those are huge numbers! We’ve obviously stirred up something...’

‘Yes. And I noticed the hit-rate went up after the latest round of TV newscasts – the networks had no choice but to mention us. We’ve also recorded a record number of click-throughs from other news sites, so we’ll be generating good revenue from those.’

‘That’s great, Vonnie. Shan will be pleased.’ 

The content manager laughed. ‘Just as long as we’re right!’

‘Oh, I’m not worried about that. Shan knows what’s going on in the drug industry. And if he’s wrong... well, it’s his money.’

‘No, I wasn’t thinking of the accuracy of the story. I meant whether we were right to publish it...’ 

‘Oh?’

‘Yes, this increase in hit-rates... what if it’s a sign of panic among people who rely on ARVs?’ 

‘What makes you think that, Vonnie?’

‘You might want to look in on the forums...’ 

‘Are they also going crazy?’

‘Yes, but it’s not only the number of posts, it’s what they are saying. There are a lot of people who aren’t buying the line from the UN that there’s nothing to worry about. Some of the posters are doctors in organizations like MSF and the Red Cross who are saying they’ll run out of ARVs in a few days.’

‘Okay. Drop a line to Gip in case she hasn’t picked it up – she’s on a flight to Johannesburg.’ 

‘Johannesburg? She’s not coming back here?’

‘No she decided to go to South Africa. It’s the epicenter of the AIDS epidemic and the main consumer of ARVs. Lots of AIDS organizations have offices there.’

‘Okay, I’ll let her know.’

Pignon Haiti 09:00 Sunday 2 January T+14hrs

It was raining hard as the army truck scrabbled for grip on the slippery and deeply rutted road leading to the cluster of buildings on the brow of the hill. The man at the gate was not there to keep people out of the clinic but to direct them to the right place – the testing center for first-time visitors; the consulting rooms, dispensary and food bank for returning patients; and the hospice and morgue for those visiting terminally ill relatives, or collecting their remains.

The guard waved down the truck to ask their business but the driver ignored him and drove into the compound, sliding to a halt in front of the main building. Immediately a dozen men in dirty army fatigues jumped down from the canvas-covered back of the truck, rifles at their chests, and pushed their way through the crowded verandahs and into the various entrances. A moment later they emerged with half a dozen nurses and the single doctor on duty.

A man who appeared to be their leader although he wore no badges of rank, was leaning against the worn wooden parapet of the verandah waiting for them.

‘Who is in charge?’ he asked in French when the staff were assembled in front of him.

The doctor raised his hand a little, unsure of what was happening. Although unnerved by the rough entrance of the soldiers he did not fear for his life or those of the nurses. This humble clinic was literally a life-saver for thousands of families living in the surrounding highlands. In the fractured politics of Haiti, the doctors and nurses of Hands of Care were perhaps the only people respected by everyone.

‘Where is Legrande?’ asked the officer in a conversational tone.

‘He’s out of the country at the moment,’ the doctor replied. ‘I am Dr Ferry, his assistant. How can I help you?’

‘Bon. We are taking over the clinic.’ 

‘What? You can’t do that. We are here with the permission of the government. Who are you?’ 

‘Surely you know, doctor?’

Dr Ferry did, in fact, have a pretty good idea. Haiti’s recent history was essentially a record of the struggle between various elected governments and the remnants of a national army disbanded in 1995, which refused to lay down arms. This militia controlled large parts of the country outside of the capital, Port-au-Prince, and mostly lived in a state of uneasy peace with the legitimate authorities.

‘The FLRN – the Cannibal Army?’

‘Bravo!’

‘But Dr Legrande has met with your leaders, and they agreed we could operate here..’

‘Doctor – did I say anything about you not continuing your work? We are here to make sure you are not interrupted.’

‘But why do we need protection? Who would interrupt us? I don’t understand.’
‘Ah, I see you have not heard the news. There will be no more antiretroviral drugs for some time. It seems the companies that produce your tablets can no longer get the... essence... from India.’

The doctor’s first reaction was to laugh, but he realized this might be a mistake and choked it off. It sounded almost like a cry of surprise. ‘But surely... sir... that’s impossible. I mean there are a lot of ARVs, made by many different companies..’

‘Ah yes, but they all get this... principe actif... from India, and those factories were destroyed yesterday evening. Also the United Nations reserves in Sweden. Poof! It seems we will have to make do with what we have for some time to come.’

‘Well that won’t be very long – we usually keep about a week’s supply of ARVs. Our vehicle brings in supplies every Thursday from Port-au-Prince...’

‘And today is Sunday. I don’t think it’s very likely that your delivery will arrive this week, doctor.’

‘But... sir...’

‘You can call me major.’

‘Major, this is a catastrophe. We have many hundreds of people who depend on us, both here and in Port de Paix.’

‘Well, doctor, we may need to find ways of... how shall we say... stretching your supplies a little, until the situation is restored to normal.’

‘What do you mean, “stretch”?’

‘It’s quite simple. We’ll tell you who to treat, and who will be taking a little holiday from their medicines.’

‘Major, you can’t take a holiday from these medications. It just takes a week or two and... then the drugs don’t work any more. After that you need different formulations, which are very hard to find.’

‘What is your stock of those second-line drugs, doctor?’

The term ‘second-line’ was the giveaway. Ferry knew he had to stall, to protect his very small and precious supply of second-line ARVs.

‘Actually, major, we don’t have any – normally they come in on a Thursday and we dispense them to the patients who need them the following day...’

Without warning the officer stepped forward and slapped the doctor on the side of his face, hard. The sound was as shocking as the pain, and several nurses screamed.

‘Doctor, in my line of business we also dispense medicine. Most people find it distasteful but it... always... cures the problem. We are especially good at curing forgetfulness.’

He held up his right hand, palm upwards. ‘This... is the weakest of our medicines. Sometimes to cure a particularly bad case, we must use our medicine on someone else...’ He paused and glanced at the nurses. His meaning was lost on nobody.

‘Do not lie to me again,’ he said quietly.

New York 11:00 Sunday 2 January T+16hrs

If Maryam Kapur was tired after the long-haul flights from Karachi’s Quaid-E-Azam to London’s Heathrow and on to New York’s JFK, she didn’t show it. The secretary general was driven directly from the airport to her office at UN Plaza for the eleven o’clock briefing by UNAIDS executive director Ibrahim Mazzer, to prepare her for an emergency stakeholder meeting the following afternoon.

Mazzer began by briefing her on the arrangements for the next day’s meeting, then he responded to her request for an update on the epidemic by handing her a printed table of figures, which he explained in his accented but accurate English. The Egyptian wasn’t sure how much she would remember from previous briefings, so he took it from the top.

‘Five years ago there were roughly 33 million people living with HIV. Today that figure is approaching 36 million – an increase of a little over eight percent.’

Kapur was tracing the data on the table with her pen, and merely nodded to show she was listening.

‘But as you will see from the regional data, SG, that modest increase in global data masks a major shift in the locus of infection...’

The secretary general’s pen moved to another row, paused over a number, then flicked back and forth between two columns. ‘If I’m reading this correctly, Dr Mazzer, prevalence has actually fallen... quite substantially... everywhere except southern Africa?’

‘That’s correct.’

‘You told me previously that southern Africa was running against the trend, but... my god! I had no idea the situation had gone this far!’

‘These are the latest surveillance data, SG. We only finished compiling them last week, and I’m afraid the numbers were far worse than we expected. We were expecting... hoping that prevalence in southern Africa would have begun to decline, as it has in other regions, but instead it’s showing an accelerating trend.’

‘So southern Africa now accounts for, what, nearly 30 percent of all HIV infections?’

‘I’m afraid so. Up from 20 percent five years ago. From 6.6 million to 10.6...’

‘And the rest of Africa... there are so many figures here it’s hard to see the patterns.’

‘My apologies, SG. If you exclude the five countries of southern Africa, the pool of infection in the rest of sub-Saharan Africa has remained steady at a little over 15 million people.’

‘And the rest of the world? Is this a decrease from 11 million to 9.75 million people?’

‘It is. If you exclude sub-Saharan Africa, global prevalence has actually declined by more than 11 percent. But if you include everyone, it’s increased by 8.2 percent.’

Kapur put down her pen and stared at the UNAIDS head. ‘Dr Mazzer, the obvious question is... why? Why is it different in southern Africa? Are they not getting the same interventions as everyone else?’

‘They are, SG. In fact two of those five countries, Botswana and Namibia, have been an example to others. Everyone who needs antiretrovirals in those countries is getting them.’

‘And in South Africa?’

‘They came off a very low base of antiretroviral use, as you know. The number who are starting treatment is going up, but... the figures don’t tell the whole story.’

‘Go on.’

‘Well, SG, there are still many doubts and suspicions about antiretrovirals among their people. A lot of them buy into conspiracy theories – that antiretrovirals will make them sterile, or kill them. Many only take their medications when they are desperate, and stop taking them as soon as they feel better.’

Kapur shook her head in dismay. ‘Surely they’re told how important it is to take the drugs consistently?’

‘Of course, but there are so many people... such strong folklore... telling them their illness is not dangerous, but the medications are.’

‘Presumably if patients aren’t taking these drugs consistently, we will see an increase in drug-resistant strains of the virus?’

‘Well, yes and no. The drug-resistant strains will be there, but we won’t see them until the people who are carrying those viruses fail to respond to first-line therapies.’

‘Ah, of course. And that can be many years after they are infected.’

‘Just so. There are exceptions, of course, but it’s only when we have data from a large cohort of patients that we can draw conclusions about what happened seven or eight years ago.’

Kapur appeared lost in thought for a moment, then focused again on Mazzer. ‘I assume the South Africans have seen these figures? How did they react?’

‘Unfortunately not well, SG. They are saying a 60 percent increase in prevalence over the past five years - since they really started scaling up their ARV program - proves that antiretrovirals aren’t working... or that they are making the epidemic worse. ’

‘But how do you explain it, doctor? Why is their HIV prevalence rising, when it’s steady or falling everywhere else?’

‘There’s an interplay of factors at work, SG. When you give ARVs to everyone who needs them, prevalence tends to rise because people are no longer dying at the same rate...’

‘Yes, I understand this. If you reduce the number of deaths without reducing new infections, prevalence will go up. Are you saying the number of new infections is not declining in South Africa?’

‘I’m afraid not...’

‘But why? Why is the trend there so different to the rest of the continent? And the world?’

‘We don’t know, SG. We can only speculate that South Africans have been slower than others to... modify their behavior.’

‘I suppose it doesn’t help to have a president with multiple wives and mistresses...’

‘No indeed. Unfortunately they react quite badly to being told by foreigners that their culture poses a threat to their survival. This kind of message can come from their own leaders – which is... unlikely, under the circumstances.’

‘Would I be right in thinking that these figures mean that the rate of new infections has come down in the rest of the world... significantly?’

Kapur was surprised to see a fleeting smile on the Egyptian’s face.

‘If it were not for the latest figures from southern Africa, and now this threat to the supply of antiretrovirals, I would be asking you to announce that the end is in sight.’

‘What are you saying?’

‘It appears that in most countries, new HIV infections are now... quite rare.’

‘But... that’s wonderful news!’

‘Indeed it is, SG. For most of the world.’

Kapur read the conflicting emotions on her colleague’s face, and nodded slowly. ‘One road for Africa, another for the rest of the world. Again.’

Mazzer nodded too. ‘And now we have this... sabotage... to contend with.’

‘Yes. Tell me doctor, what are our prospects of restoring the supply of ARVs before present stocks are depleted?’

‘We simply don’t know as yet, SG. We know how much production capacity has been lost, but we have no idea how much spare capacity there is around the world. Needless to say Jean Folbert’s team and mine are working around the clock to find the answers...’

‘Very well. Let me ask you this – what will happen if we cannot restore supply before existing stocks are depleted?’

‘Then we are looking at a large-scale treatment interruption, SG. Once again we can’t predict exactly what that means, because it’s never happened, but we know that after a week or two without antiretrovirals, the amount of virus in a patient’s blood increases sharply, and drug-resistant strains emerge....’

‘Which means those patients will only respond to second-line medications?’

‘Most of them, yes...’

‘And there’s no way to separate those who can safely resume first-line medications from those who cannot?’

‘Not when we’re talking about hundreds of thousands of people, possibly millions. We would need to start everyone on second-line medications.’

‘So we need to know how soon each country will deplete their stocks of first-line ARVs, and whether we can restore production before then?’

Mazzer nodded. ‘And we need to know immediately. If we find that large-scale treatment interruptions are unavoidable, we need to focus on producing second-line drugs right now. Naturally this will have profound implications for... well, everyone.’

The two UN executives sat staring at each other, sharing a common thought. Finally Mazzer put it into words. ‘And we’ll need to ask ourselves who did this, and whether they will do it again.’ 

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