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AIDS crisis needs more than money

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WASHINGTON — Even if you've never watched a good friend waste away and die from AIDS, you have to be alarmed by the damage this still-cureless disease is wreaking across the world. Even if you've never seen an AIDS-diagnosed acquaintance, responding to the newest antiviral "cocktail," pull back from the brink of death, you have to hope the treatments will become cheaper, more widespread and more effective. The alternative is just too ghastly to contemplate.

Fortunately, the world seems to be coming to grips with this pandemic — at least in terms of cash and commitment. "Over the past 18 months there has been a change of sentiment about the shared, global responsibility for a situation of this kind," Gro Harlem Brundtland, the top health official of the United Nations said the other day. "I cannot be sure we will see all the money ($7 billion to $10 billion in international contributions proposed by U.N. Secretary-General

Kofi Annan), but I think we will see billions."

The money is flowing already — from governments, from private businesses, from international agencies. Microsoft's Bill Gates has pledged $100 million from his foundation.

The pharmaceutical houses also are kicking into gear, writing down the cost of their medications in an effort to strike a balance between doing good for the world and doing well by their stockholders.

It's all good news. But it isn't enough.

It isn't enough, to begin with, because no one has yet figured out the smartest way to spend the money as it becomes available. Do you make the newest medications as broadly available as possible, even though some parts of the AIDS-stricken world lack the medical technicians, the sanitary facilities, even the clean water necessary to make the drugs most effective for the estimated 36 million people already infected with HIV (the virus that causes AIDS)? Or do you devote a considerable chunk of the new resources toward halting the spread of the disease?

In natural-disaster terms, how much of your limited resources do you expend pulling half-drowned villagers out of the flood, and how much relocating the village to higher ground?

But AIDS is not quite a natural disaster, which is the other reason the billions that international health officials hope to raise won't be enough.

The bubonic plague that devastated Europe in the 14th century, like the tuberculosis, smallpox and polio epidemics of more recent times, were natural disasters in the sense that they just seemed to happen — and that there was nothing anyone could really do to be safe from them. Some of my grade-school classmates wore little bags filled with foul-smelling asafetida to ward off infantile paralysis, as polio was then called. It was all that their frightened parents knew to do against the menace.

But most of the world knows how AIDS is spread. And too many people go right on spreading it. Not just in South Africa, where 4 million of the world's HIV-infected people live, or in east Africa or Asia or the Caribbean. There is a resurgence of AIDS among American gay men generally — and an infection rate three times as high among gay black men. This is not because these men are newly ignorant about how one gets AIDS. It is because they are newly careless about their behavior — in part, no doubt, because they now believe medical science can rescue them from the consequences of their carelessness.

Am I suggesting that the world shouldn't spend the money it takes to treat the millions already afflicted with AIDS? Of course not. Beyond the economic, health, social, cultural and geopolitical consequences of such shortsightedness, it is simply obscene even to contemplate letting people die when they might be saved.

But it does seem clear to me that our spending won't be nearly as effective as it might be unless the leaders of the most devastated countries also undertake to change the behavior that spreads HIV/AIDS.

Money is necessary, but it isn't everything. In the long term, with a behavior-spawned plague like AIDS, it may not even be the most important thing.

William Raspberry's e-mail address is willrasp@washpost.com .