Times-Picayune
Sunday, December 29, 2002

Placing a value on human life might seem to be an issue for ethicists rather than corporate financial officers, but the AIDS crisis in sub-Saharan Africa is forcing multinational companies to consider the economics of keeping HIV-positive employees alive.

Many multinationals already have programs to educate their African workforces about AIDS, to provide free condoms and to prevent discrimination against afflicted workers. Now, these same companies are weighing the costs and benefits of providing the same medications in Africa that have made HIV manageable in the developed world.

"We've lost people across the board, from senior managers to middle managers to blue-collar workers," said Shuaib Manjra, BP's senior medical advisor for sub-Saharan Africa. Manjra put the company AIDS death count in Africa at 50.

Although the medicines, known as anti-retrovirals, are now provided to African workers at a handful of companies, including BP, DaimlerChrysler and Heineken, most multinationals are still reviewing the issue, said Ben Plumley, executive director of the Global Business Coalition on AIDS, a New York advocacy group. A November energy conference in New Orleans focused extensively on anti-retrovirals.

In recent years, medication costs have dropped from as much as $15,000 per person per year to as little as $300. Plumley hopes to see more companies cover the medications in the years ahead.

Business response to HIV

"We're still very much at the early stages of businesses responding to HIV," Plumley said. "We're saying, 'Here's how your peers are doing it. Here's how you can step up to the plate.' "

Like climate change and developing-world sweatshops, the corporate response to the African AIDS crisis has become a flashpoint in the evolving debates over globalization. In September, Coca-Cola expanded coverage to about 60,000 workers after lobbying by nongovernmental organizations. Advocates next plan to target the oil industry, which has flocked to Africa as an alternative to the Middle East.

Of course, not all companies agree that taking on a medical crisis is the proper role for a company. Some point out that there is no precedent for multinationals taking on such a crisis and providing medications that are otherwise unavailable in much of Africa.

Treating AIDS is not a "business core competency" for oil companies, said Steven Phillips, international medical director for ExxonMobil, adding that the company prefers working through existing providers to build local infrastructure. Companies that provide anti-retrovirals are getting into "uncharted territory," he said.

"Basically, there is not a clear template of what to do in Africa," Phillips said.

Absent medications

Like most U.S. health providers, Blue Cross and Blue Shield of Louisiana and Ochsner Health Plan, two companies that serve the oil industry and other major New Orleans employers, generally cover the medications. But the drugs are largely absent in the AIDS-plagued developing world.

No place has more need than sub-Saharan Africa, which is home to two-thirds of the world's total cases of HIV/AIDS. Of the 4 million to 6 million people on the continent who need anti-retrovirals, only 40,000 are getting the treatment, said Jeff Kemprecos, Merck public affairs director for Europe, Middle East and Africa.

There are numerous challenges in providing the medicine to workers. For one, it can be difficult for patients to adhere to the medical program, which can involve a "cocktail" of at least three drugs and 25 pills throughout the day. If patients don't follow the regimen, they can build up resistance to treatment, experts say.

The on-the-ground realities of providing anti-retrovirals also pose a challenge for oil companies. South Africa benefits from an extensive network of doctors and laboratories, much of the continent has only skeletal medical infrastructure. To overcome this problem, some companies send blood tests under strict temperature controls to South Africa more than 1,000 miles away.

'Definitely doable'

Despite the challenges, providing the drugs is "definitely doable with effort," Daimler human resource manager Mike Folan said. "There's a very intense program to ensure adherence is followed."

While Daimler's calculations show that anti-retroviral treatment is cheaper than treating full-blown AIDS, other research is less decisive.

A study for BP concluded that providing anti-retroviral medication would cost $6.6 million in 2010, $2.5 million more than not providing the medication. However, the estimates employed the cost of existing medications, said Stephen Kramer, manager of AIDS research for Metropolitan, a South African financial risk consultant that performed the study. If future technology matches the progress of recent years, it will be cost-effective to provide anti-retrovirals because of the cheaper outlays for death benefits, sick leave, recruitment and other AIDS-related costs, he said.

The report depicted the AIDS crisis as an opportunity for BP.

"The potential for BP to provide leadership in its response to AIDS cannot be overestimated," the report said. "It may well help persuade others to act in the same way, and ultimately help redirect the course of the epidemic in some countries by acting as a catalyst for change. It may also have an effect on treatment, as economies of scale are likely to develop, as treatment becomes more readily available."

Battling corruption

So far, about 20 BP employees in South Africa are getting the treatments, plus another few dozen in other parts of Africa, Manjra said. By guaranteeing the medications, BP has also provided an incentive for more employees to get tested as to their HIV status.

However, some question the impetus. Fadel Gheit, an oil analyst with Fahestock & Co., a New York investment bank, praised the coverage as "a very noble cause," but questioned whether multinationals should assume the duties of host governments, which recoup hundreds of millions of dollars from multinationals in drilling royalties. A recent International Monetary Fund report blamed corruption in Angola for the government's inability to account for $1 billion.

"The corruption is beyond description," said Gheit. "It is incredible."

Like BP, Shell plans to cover the medications for employees and their dependents. Starting in February, an industrial theater operation will travel to company sites across South Africa to enact lifelike HIV-related dramas to encourage workers to know their HIV status. The awareness campaign will be accompanied by the roll-out of Shell's anti-retroviral program, said Anna-Louise Olivier, a Shell employee care coordinator in Cape Town.

Doing 'the right thing'

Shell took action after learning that 200 retail employees died of AIDS over two years. "That sent out an alarm that we had to do something," Olivier said.

Philip Mshelbila, regional health advisor for Shell Oil Products in Nigeria, hopes to have the program up and running by the end of 2003.

"It's the right thing to do," he said of the program. Cost has become "almost a secondary issue."

The two leading U.S. oil multinationals, ChevronTexaco and ExxonMobil, are reviewing their policies.

As of now, ChevronTexaco offers the medications only to pregnant women with HIV. Stephen Simpson, the Angola-based regional medical director for ChevronTexaco, said the company will offer the medications more widely only if it can guarantee the supply and work through the logistical challenges.

"What we don't want to do is to start a program that's not going to continue or won't work," Simpson said. "It's not the cost, it's the feasibility."

'Medical apartheid'

Still, Simpson alluded to the oil industry's "slick" logistics at the November conference here. "We can make things happen," he said.

ExxonMobil views HIV/AIDS like any other illness, meaning that it prefers to work through community-based health options, Phillips said. In many parts of Africa, the quality of ExxonMobil health care is "vastly higher" than that otherwise available, he said.

At the November conference, Phillips referred to the sometimes strident tone of AIDS activists and the media, which sometimes underestimate the challenges associated with prescribing anti-retrovirals. If patients don't follow the regimen, the medications can potentially violate the medical dictum to first do no harm, he said.

Providing anti-retrovirals is a "subject of active internal review," Phillips said.

Previously AIDS advocacy groups have directed most of their ammunition at pharmaceutical companies. Now that medication costs have come down, these nongovernmental organizations are turning to companies with African operations and highly-visible retail products.

"We won with Coke, and now we're going after oil," said Sharonann Lynch, a spokeswoman for Health Gap, a U.S.-based non-profit that organized a global day of protest against the soda company. Providing the medications to employees in the West, but not in the developing world amounts to "medical apartheid," she said.

"It means they consider the lives of people of color in developing countries expendable," Lynch said. "Why should Africa be different?"