Vanity Fair
July 2007
Dedicated to providing lifesaving drugs to Africans with AIDS, through a partnership between the Global Fund and companies such as Apple, Armani, and Gap, (Product) Red could be a revolution in consumer-driven philanthropy. The author reports on both sides of the equation: the marketing of sunglasses, sneakers, and T-shirts, and the medicine's miraculous effects on dying patients in the poorest countries.
A Population on the Mend
I am not sure what I expected to find inside the AIDS ward at the Kinyinya Health Center, but it sure wasn't empty beds. This local government facility sits on a hilltop on the outskirts of Rwanda's capital, Kigali, where some 7 percent of the population is infected with H.I.V., the human retrovirus that causes AIDS. So what gives? Where are all the sick people? "All the beds used to be full," says Dr. Fred Mutabazi, who works at the center. "Now there are much fewer patients, because of the ARVs."
First introduced in 1987, anti-retroviral drugs - ARVs for short - block H.I.V.'s assault on the body's immune system. As the drugs have improved, becoming less toxic and easier to take, they have largely turned AIDS in the Western world from a death sentence into a manageable disease. But the drugs' high price - a year's supply can exceed $10,000 in the developed world - has kept them way out of reach for most Africans. In 2003, a coalition of activists led by former president Bill Clinton pulled off the heroic feat of persuading four manufacturers to make ARVs available to developing countries for $140 a year. They accomplished this not by appealing to the corporations' sense of compassion but by pointing out that, if you sell 1,000 times as many drugs at one-hundredth the price, you still increase your earnings tenfold. The drug companies were well aware that the African market for anti-retrovirals is huge and getting bigger all the time: roughly 28 million Africans are living with H.I.V., and roughly 15 percent of them are in dire need of ARV therapy.
But $140 for a year's worth of ARVs is still beyond the means of most H.I.V.-positive Africans. So the question then was: How can the medicine be made available to them for free? This time it was President George W. Bush who stepped up to the plate, pledging $15 billion through the President's Emergency Plan for AIDS Relief (pepfar). In addition, the Geneva-based Global Fund has raised $10.5 billion from 52 governments to distribute among 450 programs to combat AIDS, malaria, and tuberculosis. The results are impressive: in 2002, only 50,000 Africans - 1 percent of those who needed ARVs - had them. Today, 28 percent - or 1.34 million people - are getting the treatment. And the rate of increase is getting faster. Between December 2005 and December 2006, the number of Africans receiving AIDS drugs rose by 530,000 - or 1,450 per day.
Even so, 5,800 people who could be saved are dying of AIDS every day. In 2005 the consortium of rich nations known as the Group of Eight (G-8) promised "nearly universal access" to ARVs by 2010. That requires an annual increase of 655,000 treated patients in Africa alone.
"Judo Strategy"
There are only two patients in Kinyinya's eight-bed AIDS ward. Dr. Mutabazi introduces me to one of them, an emaciated man in his early 40s. "He was much thinner when he came in, three months ago, and so weak he was carried in by his brothers," the doctor says. "Now he can walk again. He is on the mend." Dr. Mutabazi explains that the man is a miller, "and women who bring grain to get milled sometimes slept with him to get served first. He doesn't know who infected him, but thinks there are three main possibilities, women he was sleeping with in 1995. He became sick in 2002. It started with some small disease."
One of the outpatients, a 35-year-old pregnant woman who is also on ARVs, is strong enough to lead us at a fast clip through banana and cassava shambas to her house, a few hundred yards from the health center. We sit on sisal mats in the front room. "She was infected by her husband, who died in 2004, leaving her with two children," Dr. Mutabazi says, translating as the woman tells her story. "She found out that she had H.I.V. during a routine pregnancy. She never suspected she had it. She is from Gikongoro [about 70 miles southwest of Kigali], but she came here for treatment, which is common: usually they come from far away, because they don't want the community to know. She made friends here and gets food from the center, so two years ago she moved here to be close to it. Later on, as you see, she became pregnant by a man, who also has H.I.V. He took off and is no longer in the picture. Her two children are with her mother, so there is social sharing of the burden. She has a support system, which many don't. Even if she dies, her brothers will take care of her children, but she doesn't think she will. Compared with the state she was in in 2004, she thinks she will survive. The ARVs have given her new life."
These two survivors are examples of what is being hailed as "the Lazarus effect." In the Gospel of John, Jesus raises a man named Lazarus from the dead, and in essence that's what these drugs are doing for people with AIDS. Antonin Kratochvil's photographs accompanying this article show the extraordinary transformation that can take place in critically ill patients after as little as 40 days of ARV treatment. While there is still no cure for AIDS, some patients have been restored to vibrant normalcy in just three months.
This medicinal miracle wouldn't be possible without the efforts of foundations such as the Global Fund, which began distributing free ARVs in Rwanda in 2004. The Global Fund gets most of its financing from world governments, but a growing proportion ($25 million by the end of 2006) comes from an altogether unlikely set of benefactors: Western retailers and the shoppers who can't resist them.
I admit to having been skeptical at first about the concept behind (Red). Buy a $170 pair of sunglasses and save the world? Give me a break. Not until I met Bono, the U2 singer, activist, and guest editor of this issue, did I understand what a fiendishly ingenious concept it is. "To change the world we need consumer power; idealists and activists alone will not get the job done," Bono told me. "(Red) is a gateway drug into a bigger movement."
The idea behind (Red) is simple: participating companies, which so far include American Express, Apple, Armani, Gap, Motorola, and Converse (a subsidiary of Nike), sell (Red)-branded products. Forty percent of the gross profits from those sales go to providing free ARVs to Africans with AIDS. As the Web site Joinred.com puts it in its bluntly worded manifesto:
(Red) is not a charity. It is simply a business model. You buy (Red) stuff. We get the money, buy the pills and distribute them. They take the pills, stay alive and continue to take care of their families and contribute socially and economically in their communities.
If they don't get the pills, they die. We don't want them to die. We want to give them the pills. And we can. And you can. And it's easy.
For the participating companies themselves, the appeal is strictly business. "What's in it for them is they get new customers, people who will buy your stuff if you do the following thing: give a percentage to the Global Fund," says Bobby Shriver, Bono's partner in (Red).
"It's judo strategy," adds Bono, "using the strength of your opponent to overthrow him." In this case the "opponent" is a criminally imbalanced world economy, where the residents of developed nations live in luxury while those of poor countries are lucky to scrape by. As Bono said at an N.A.A.C.P. event last year, "Where you live should not determine whether you live or die."
Shriver, a Los Angeles - based venture capitalist who happens to be a nephew of J.F.K. and the brother of California First Lady Maria Shriver, met Bono in 1987, when U2 contributed a song to the Special Olympics benefit album A Very Special Christmas. Shriver was a producer on the album (his mother, Eunice Kennedy Shriver, founded the Special Olympics in 1962), and it was probably inevitable that the Kennedy cousin and the socially conscious Irish rock star would hit it off.
As time went on, Bono began devoting more and more energy to the Jubilee 2000 movement to cancel debt for the world's poorest nations. (He says his music didn't suffer: "In fact, the opposite!") Jubilee was a coalition of religious, human-rights, and environmental groups, and its petition attracted millions of signatures in Europe but not nearly as many in the U.S. In 1998, Bono reached out to Shriver and asked him to help get America on board. "We thought we'd be at it for a few months, but it turned into seven, eight years," Shriver said. "The first thing that evolved was data, for Debt, AIDS, Trade, Africa, which lobbied Congress to increase its largesse. It also stands for Democracy, Accountability, Transparency - the things that the African countries have to do to make sure the money goes where it is supposed to. It was tough slogging. There were no votes in this one. We talked about having pig roasts, going to schools, and [appealing to] soccer moms. We started One: The Campaign to Make Poverty History, to get Americans to realize you could transform the future of the poorest people with only 1 percent more of the U.S. budget, directed at fair trade, debt relief, AIDS, education, clean water, care for orphans." Now comprising some 60 organizational members, One has recruited 2.5 million Americans to its campaign to fight AIDS and extreme poverty.
At the Gleneagles G-8 summit, in July 2005, Bono and Bob Geldof, another Irish rock star and activist, fronting a list of 31 million names from around the globe, persuaded the World Bank, the International Monetary Fund, and multilateral lenders including the African Development Bank to forgive $40 billion in debt owed by 18 of the world's poorest countries, all but 4 of which were African. The G-8 also promised to double their annual aid to Africa, from $25 to $50 billion, by 2015. "Getting the promises was one thing," Bono says. "Mobilizing public pressure to keep them was another."
One day in early 2004, Bono had a conversation with Robert Rubin, who had been secretary of the Treasury under Clinton, about the difficulty of engaging the American public on development issues. Rubin told him, "You'll never get this issue out there unless you market it like Nike." And with that, the idea was born for a new product line that would exploit the potential of a whole new sector of the U.S. economy.
Bono is the one who named it (Red), a color that brings to mind red alerts, the Red Cross, even the Red Army. The revolutionary undertone was appropriate, for this was a subversive new model in the staid world of cause marketing. By allowing partners to share in the profits, (Red) brought a whole new set of players into the aid game - and gave a scare to some in the nonprofit sector, who worried that "business … taking on the patina of philanthropy," as one academic put it, was going to cut into their action.
(Red) targeted the iconic brands: American Express was their first taker. Gap signed on for a (Red) line of clothing, Converse for (Red) sneakers, Motorola for (Red) cell phones, Apple for (Red) iPod Nanos, Armani for (Red) apparel, sunglasses, and wristwatches. "All of our relationships with these companies are with their marketing departments, not their public-relations, social-responsibility, or philanthropy divisions," says Shriver. "Good business is more sustainable than philanthropy, because next year there could be a tsunami and the support you were counting on could go there."
The companies agreed to divert tens of millions of dollars from their marketing budgets into a campaign publicizing (Red) and the African AIDS crisis. Christy Turlington, Steven Spielberg, and Chris Rock were photographed by Annie Leibovitz wearing (Red) clothes from the Gap, Gisele Bündchen posed with a Masai warrior and her (Red) AmEx card, and Kanye West and Penélope Cruz joined Bono on Oprah to unveil the line in time for Christmas 2006.
Some have criticized (Red) for spending more on marketing than the $25 million it has so far generated for the Global Fund. But, according to Shriver, this accusation is unfounded. In fact, he says, (Red) doesn't spend any money on advertising; the splashy campaigns are paid for with money diverted from its partners' existing marketing budgets. He also points out that $25 million is more than China, Australia, and Switzerland combined gave to the Global Fund last year.
So what do you call this?, I asked Bono when we met for dinner in Dublin this spring. Humanitarian self-indulgence? Bono borrowed my notebook and wrote the words "Fair Vanity." That's what he was hoping to talk V.F. editor Graydon Carter into letting him name this issue. (I told him not to get his hopes up. In 1997, I lobbied Graydon unsuccessfully on the idea of devoting a whole issue to global warming and calling it "Vanity Air." Guess I was a bit too far ahead of the curve on that one.)
Bono explained that unfair trade restrictions, enforced by the World Trade Organization, are giving African nations little chance of gaining economic traction. But the proliferation of fair-trade-certified products such as coffee, tea, chocolate, tropical fruit, rice, and sugar, which encourage sustainable farming methods and ensure that the farmers and workers receive fair compensation, proves that consumers can make a big difference simply by changing their buying habits. To quote the manifesto on Joinred.com, "As first-world consumers, we have tremendous power. What we collectively choose to buy, or not buy, can change the course of life and history on the planet."
"Post-Colonial Approach"
Most Westerners know Rwanda only as the site of the 1994 genocide, in which more than half a million Tutsi, together with thousands of insufficiently sectarian Hutu, were slaughtered in just a little more than three months. But much has happened in the past 13 years, and today Rwanda can claim a happier distinction, as one of Africa's leading success stories in the battle against AIDS.
Rwanda has managed to reduce the H.I.V.-positive proportion of its population from a high of 21 percent in the 1980s to around 3 percent today. Some of the decrease is actually attributable to the genocide, according to Dr. Étienne Karita, a virologist in Kigali, who has been tracking 500 H.I.V.-positive Rwandan women since 1986. Of those women, 200 were killed in the genocide and 200 have died of AIDS.
The bulk of the credit for Rwanda's decline in H.I.V. infection, however, goes to the post-genocide government of President Paul Kagame, which launched an ambitious campaign to educate the population on the ABCs of prevention, as they're called in neighboring Uganda: practice Abstinence, Be faithful, use a Condom. Thirty-nine percent of Rwandans are still illiterate, but, in the words of Dr. Innocent Nyaruhirira, Rwanda's minister of state in charge of H.I.V./AIDS and other epidemics, "We have a population that is responsive to guidance."
Of the 136 countries that receive aid from the Global Fund, Rwanda is one of the star performers. In 2004, it became one of the first countries to distribute ARVs with the Global Fund's help, and it launched another countrywide education campaign, urging people to come in and be tested. The Global Fund, which allocates the money raised by (Red), recommended Rwanda as the recipient of the campaign's first grant.
As in many African countries, there had been a terrible stigma attached to being H.I.V.-positive - especially for unmarried girls, since pre-marital sex is taboo for women. But by 2004 just about everyone in Rwanda had seen a family member succumb to AIDS. This destigmatized the disease, and the response to the new campaign was overwhelming. Since the program began, the 122 health facilities sponsored by the Global Fund have tested 635,300 people and provided 14,571 of them with free ARVs. (An additional 20,000 Rwandans receive the drugs from other foundations, including the Bill & Melinda Gates Foundation and pepfar.) The Global Fund soon launched a similar program in Zambia, where Antonin Kratochvil took the photographs to accompany this article.
"The programs are designed by the people in the country," says the Global Fund's outgoing executive director, Dr. Richard Feachem. "We treat our recipients as equals and grown-ups. This is not a patronizing relationship; it's the first truly post-neocolonial approach."
"There Is Hope"
Dr. Anita Asiimwe, the managing director of trac, the Rwandan Health Ministry's Treatment and Research AIDS Center, gives me a tour of its main clinic, in central Kigali. The waiting room - basically a roof providing shade and rain protection to benches filled with women and children - is divided into three areas: one for blood work, one for consultation, and one for dispensing the drugs. "Most of the people who come in for testing are presenting something chronic, like a cough and weaknesses, so they are questioning themselves why they are not feeling better," Asiimwe explains. "Others have had sexual behavior they think is risky, have lost a partner, or have been sent by doctors. If they are found positive, they are given counseling about their situation, and then a clinical exam to determine if they have any opportunistic diseases." Tuberculosis is the most prevalent and stubborn one, with new, multi-resistant strains arising all the time.
The doctors measure the AIDS virus's progress in attacking the immune system by testing each patient's level of CD4 immune cells. Patients with a count of more than 500 are released without further treatment. Those whose CD4 levels are between 500 and 350 are told to come back for more tests in three months. Those who score between 350 and 0 are eligible for ARVs.
The first-line regimen is usually a combination of three pills, taken twice a day. If side effects occur, the medication is adjusted. But if the virus is resistant to the first-line regimen, it is withdrawn and a completely different cocktail is prescribed. This second-line regimen is much more expensive, costing between $500 and $1,200 a year. The Clinton Foundation has just negotiated a deal with two India-based manufacturers of generic ARVs to provide the second-line regimen for a dollar a day to 1.5 million Africans by 2010.
I am introduced to a woman who developed lipodystrophy from taking her first trio of ARVs. A distortion of the body-fat distribution in the arms, legs, breasts, face, and buttocks, lipodystrophy is a common complication of stavudine, one of the medications that was in her first-line cocktail. When that was replaced with abacavir, the woman returned to normal. Still, she complains that the drugs are so strong she can't stand them without eating well, but since she isn't working, she can't afford food. The need for nutritional support was underforecast and underfunded, Asiimwe tells me. It will likely be written into the next grant proposals later this year.
Another patient, Angélique, 16, started on ARVs four years ago. "She used to be sickly, and now she can go on with her life," Asiimwe says. "She's a good student, fourth in a class of 40, and wants to be a doctor. Both her parents died - she doesn't know how - but she and her older sister were both probably infected perinatally by their mother when she was carrying them. Her neighbor, an old lady, became her guardian, but even the guardian died of AIDS. Her sister, who is also on ARVs, was taking care of her, but she now is in the hospital herself. We see many children with problems like this." I ask Angélique if she has anything to say to the Westerners who will be reading about her. Her message is "Thank you so much for these ARVs, because otherwise I'd be dead."
Among those in the waiting room are some of the 316,414 pregnant women who have volunteered for H.I.V. testing and counseling in Rwanda since 2004. There is a drug called nevirapine that helps prevent perinatal transmission, but a mother with the virus can still transmit it through her milk. A video about the danger of infecting your baby through breast-feeding is playing in the waiting room. Most women are unable to afford formula, and those who can afford it don't always have safe water to mix it with. The cheapest and most available alternative to infected breast milk is cow's milk, but the clinics don't have the money or infrastructure to distribute it. So here is another need that could be addressed with an influx of (Red) revenue.
"There is hope," says Florence Mukakabano, the principal nursing officer at the university hospital in Kigali. "The medicine is at least sustaining people." Mukakabano takes me through her hospital's pediatric ward, through the malnourishment room, the malaria room, the chest-problem room. "This cubicle is for very sick ones who need oxygen," she says, peering down at a tiny, nine-day-old girl with a mask strapped to her face. The girl is having difficulty breathing, for reasons not yet diagnosed.
As we enter the next room, a 13-year-old orphan named Toma appears from under a crumpled sheet. He is H.I.V.-positive, and very small for his age. "Toma has come in to be trained on how to take his ARVs," Mukakabano explains. "The drugs are very strong. He has to be taught how to eat. He has no family members. He came in very weak. Somebody brought him in. He does not know where he will go. When they are found to be positive, they are often abandoned by their families. He will go to an orphanage. We have many like this one." There are roughly 160,000 AIDS orphans in Rwanda.
"AIDS attacks Hutu, Tutsi, everybody, every background, and it will kill you unless you do A, B, C, and D," says Paul Kagame, the slender, austere 59-year-old Rwandan Patriotic Front leader who has been Rwanda's president since 2000. "We have no great reserves of minerals or timber, no oil. Our only asset is our people, so we are investing all of our resources in health and education. But our resources don't match our needs, so the fact that the private sector in the West is contributing to our well-being, to have thought of it and initiated it, is a wonderful thing. The brain behind that was brilliant."
Thanks to Kagame and foundations such as the Global Fund, ARVs have been distributed to a remarkable 67 percent of Rwandans who need them. Since 2004, the fund has disbursed $49 million in the country; of that amount, $14.3 million has come from (Red) since its launch last year. But, unlike government aid budgets, the private sector has the advantage of being a largely untapped resource. There is plenty of room for (Red) and programs like it to grow, and plenty of incentive to make them work.
"data members are walking the halls of Congress, One Campaigners are marching in the streets," says Bono. "And (Red) plays a key role in reaching parts that traditional activism cannot - raising more cash and adding mainstream appeal. It takes lobbyists, activists, and consumers to make a social movement of the kind we're trying to catalyze."
Back home in Montreal, I visit the Gap's flagship store, in the Eaton Mall. There, prominently displayed, is the full (Red) line: T-shirts, jeans, hoodies, raincoats, candles, journals, cosmetics. A stylish young African-Canadian saleswoman tells me they're selling pretty well. "The majority is bought by parents for their kids' Christmas or birthday presents," she says. "They figure, I'm giving my child a gift and also giving back. Clothes make you feel good. They make you stand tall, and these clothes make you feel great, because you know they're going to something."
Not all (Red) products are available universally, however. You need to be a U.K. resident to get the AmEx card, and Foot Locker - one of the largest shoe chains in the U.S. - won't carry (Red) Converse sneakers until this month. In the meantime, you can always buy them online or at the Gap. And with all the (Red) partners signed up for five years, and new ones expected to join this year, the plan is for (Red) to spread.
Naturally, the campaign still has its share of skeptics. I spoke to one woman from Montreal who works at Mother Teresa's orphanage in Kigali and is trying to set up housing for child-headed families orphaned by AIDS. "Isn't it pathetic," she reflected, "that to get money out of the rich you have to get them to buy something?" But then there's the view expressed by a Rwandan-exile friend of mine, who recently moved back to Kigali: "Whatever works."
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