Aids is not just a health problem in sub-Saharan Africa. It is eating away at the economy of poor nations and destroying societies by eliminating farmers, parents, healthcare workers and teachers.
The war on Aids in Malawi is run not from the Health Ministry any more, but from the office of the vice president. Justin Malewezi, a 58-year-old Columbia University educated former headmaster, has the sort of vision and drive that UNAIDS says is essential to tackling the pandemic successfully. What he doesn't have is anything like enough money.
Malewezi and his team put together a proposal to get life-saving drug treatment to all the Malawians who urgently need it - thought to be around 300,000 out of the one million who are infected with HIV. They intended to submit it to the Global Fund to fight Aids, Tuberculosis and Malaria set up by UN Secretary General Kofi Annan to raise money from rich countries to subsidise treatment for the poor. It was ambitious, but they felt it was morally right and they believed they could do it. That plan has been whittled down, bit by bit, under pressure from the affluent half of the globe. Malawi has now been granted sufficient money to treat just 25,000.
"We had to cut it down. It was the demand of the donor group," says Malewezi. "Our justification is that there are people who need it and we must reach out to them. It is very difficult to decide which one is going to live, so our approach was from the ethical side. Of course the donors have to look at other issues and they told us that we don't have the capacity to implement such an ambitious programme. But at least we make the point that we need a very ambitious and large programme."
Malawi was originally asking for $1.62bn over seven years. Its officials argue that the figure was conservative, given the 15% infection rate in the country and the improvements needed if the healthcare system was to be able to respond. But a new reality intervened with the destruction of the twin towers on September 11, 2001, which switched the focus and the funds of the US and Europe away from Aids deaths towards fighting terror. On the advice of the World Health Organisation and the Liverpool School of Tropical Medicine, the plan was scaled back to $441m over five years to treat 100,000 people.
It was still too much. In the week before the March 2002 deadline for submitting Malawi's proposal, Malewezi's team was told by donors that the fund had an effective ceiling of $2 per capita and that proposals "over $300m would be thrown in the bin" - although the fund's executives vehemently deny there has ever been a limit.
Frantic rewriting went on over a weekend, and a bid to treat 40,000 went in, which the fund admitted was "comprehensive and technically sound". But it wanted less spending on healthcare staff and management. So more cuts were made. Finally $196m to treat 25,000 people over five years was approved - far less than was wanted but still the largest allocation from the fund to any one country.
The vice president thinks it's not just about money. "I think there is too much fear about antiretrovirals (ARVs) being introduced in a poor developing country and I think the fear is that we will not be able to manage these complex drugs and therefore will lead to resistant strains being developed in Africa, which will somehow find their way to the west. And therefore the best way to protect the west is not to allow these ARVs programmes in poor developing countries. But that is of course false. We have run in this country the best TB programme in the world. We have received awards for it. We have proved that you can have a directly observed therapy programme implemented in a poorly resourced country like Malawi. Now, what is so complex about ARVs? You take one tablet in the morning when the sun comes up. You take another tablet in the evening when the sun goes down. You don't even need a wristwatch."
Only around 2,000 people in Malawi are on treatment at the moment, and they pay the 2,500 kwacha ($28) themselves. The Global Fund money will allow hospitals to treat 25,000 more if the government buys patented drugs from companies like GlaxoSmith Kline, or 50,000 if they order, as they intend to, from generics companies - like Cipla in India - which make cheap copies of GSK's medicines.
But even buying the cheapest drugs around will not solve the dreadful decisions that have to be made over who will live and who will die. The original plan was to give free drugs to all. Now there has to be a rationing mechanism and it may have to be ability to pay at least something, not least because of the 2,000 private patients already on medication. "The danger is that if there is no system, all these 2,000 will move into the free programme and therefore limit or close the door for the others who would have come in," says the vice president.
The prices of the drugs Malawi badly needs have to come down, he says. "This is our campaign: that the pharmaceutical companies and governments of the industrial countries should work very hard to bring the price of these essential drugs down." Maybe the United States government, home to most of the drug companies, could pay them to produce medicines for the poor of Africa, he suggests. Then the multinationals would still pocket the income they argue is vital to pay for the research and development of new drugs.
The truth is that almost no price is affordable in a country where per capita income is around 50 cents a day. The Global Fund is still Malawi's best bet, but the vice president is not alone in his anxiety that it may not be able to deliver. "I understand there is only about $2.2bn in the kitty and that's going to be dispersed some time in April and we don't know what will happen to this fund after that. If we get into a programme like this, which is a long term programme, we cannot abandon it half way.
"So I would apppeal to the international community to allocate sufficient money for the Global Fund. We know that the money is there. Very soon there will be sufficient money for the Iraq programme. I understand it will be costing something like $1bn a month. Surely sufficient money can be saved to put into the fund to protect lives rather than destroy lives?"
There are other concerns. In the last few weeks they have been told that Malawi will get no more than $1.5m of the first year's allocation of $12m until it has shown things are going to plan. "It is almost childish," expostulates Matt Boxshall, administrator of the Lighthouse, Malawi's flagship Aids clinic. "My background is in the oil industry. The sort of numbers they are talking about are peanuts. How much does David Beckham earn in a year? How much does a bomber cost to bomb Iraq? My message to the Global Fund is just play honest. You have agreed to the thing - don't mess around. Just give us the money and we will get on and do something."