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Falling For the Foe

By Milla Holt

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Nia Asaba glared at the clock above the receptionist’s desk. She could have sworn that its hands were moving backwards, but her phone and her watch agreed. It was still only 9:55.

She paced around the room, pausing next to the open window, grateful for the breeze that wafted past the curtains. It wasn’t yet midmorning but this was East Africa, and the heat was already threatening her hairdo and testing her antiperspirant.

She hated waiting. Especially when she didn’t know what she was waiting for. She had no idea why an official from Uganda’s Ministry of Health wanted to meet with her. She had a half-formed hope of what it could be about, but she didn’t want to jinx it by naming it, and that made the wait even more excruciating.
She looked at her phone, reading her email for what must have been the ten thousandth time.

Are you free for a meeting? Come to my office at 10:00am tomorrow. Henry.
“Henry” was Henry Lutale. He coordinated the HIV Outpatient Service on behalf of Uganda’s Ministry of Health. The HIV/AIDS activism community was a close-knit one, and in her work as a researcher and medicines access advocate, Nia had had many dealings with the HOS over the years. She had applied for a job here twice but didn’t get it. Three times, if she counted the time she had chickened out of mailing in her application. And now, this email. A faint hope rose again, and once more, she squelched it ruthlessly.

At last, a phone buzzed and the receptionist murmured into the receiver. She looked up at Nia. “Mr. Lutale will see you now. First door on your right.”
Nia restrained herself from running and pushed the door open.

Henry Lutale was sitting in front of a desk that looked like the scene of a controlled explosion. With his rotund form and grizzled hair and beard, he always made Nia think of a large bear.

“Nia. So glad you could make it,” his gruff voiced boomed.

Someone’s been eating my porridge, Nia thought, stifling a nervous giggle by clearing her throat. “Hello,” she said. “I got your email.”

“Yes. Please sit down.” Henry motioned toward one of the two chairs in front of his desk. He fixed his eyes on her for a moment. “I’ll cut to the chase, Miss Asaba. Can I call you Nia? You’re no stranger to us at HOS, of course.”

“No, I know all about you,” Nia said. “I really admire your approach to HIV outpatient care, especially since you’re the only ones who have rural clinics all over the country. I’ve always admired your work.” Her mouth was motoring on its own steam. Stop blabbering, she told herself.

“Indeed,” Henry said. “We have your information on file from a previous job application you submitted. And now it happens that we have a new position that we need to fill urgently.”

Henry paused for a moment, as though waiting for a reply. When Nia didn’t answer, he went on, “I know it’s an unusual request, but we need somebody with your skill set who can move quickly. The job involves some highly confidential information, so we’d need you to consent to a non-disclosure agreement before we can give you any details.”

Nia’s eyes widened. Her mind could just about process the fact that she was being offered a job, and she could barely marshal her wits to formulate a sensible question. “So, you need someone to do what, exactly?”

“Advocacy work, networking and negotiation. Media engagement. The things that you do.”

“For the HIV Outpatient Service?” Nia didn’t hesitate. “I’ll do it.” She could feel a wide grin stretching her face.

Henry’s eyebrows flew up. Even though he’d asked for a quick decision, Nia could tell that he wasn’t prepared for her instant acceptance.

“But I haven’t fully explained the role to you,” he said.

“I know enough about what you do,” Nia said. “Plus, I’m coming to the end of a research contract and it’s the perfect time for me to take on something new.”

Henry smiled. “Really? That’s great. Perfect! I’ll ask HR to move on the necessary processes.” He paused for a moment then said, “In the interests of full disclosure, Nia, although several of my colleagues feel you’re the right candidate for this role, there are some who have their doubts, given your history for, um, unorthodox tactics.”

He raised up his hand to stop Nia’s comment and went on, “But I’m happy enough to have you on board, based on the effectiveness of your work in the past. Now, let’s get down to business. Non-disclosure agreement.”

From the pile of papers and files on his desk, he selected a single sheet and handed it over to Nia. She scribbled her signature on it and passed it back to him.

He glanced at it, then said, “Good, good. Now, here’s what’s going on.” He handed her another sheet of paper. “We’ve recently evaluated our patients in all our clinics. As you can see, the numbers are very troubling.”

Nia glanced at the document. It was the executive summary of a report, marked highly confidential.

“Treatment failure,” Henry said. “One in ten of our adult patients are no longer responding to their anti-HIV medicines. Among the children, the numbers are even worse.”

Nia looked down at the paper again. She scanned the words, her eyes picking out the highlighted sections. As comprehension sank in, she felt as though the weight of a heavy stone was settling in her stomach. She knew what the numbers meant.

The HIV Outpatient Service provided free treatment to low-income clients. Through various strategies, it had secured cheap generics or lower-priced brand-name medicines for patients who would otherwise have been dead.

But now, according to this report, that treatment was failing one in ten patients. First-line treatments were relatively cheap. But when those medicines stopped working, patients had to move on to second-line therapies, which were twenty-five times more expensive.

Nia looked up at Henry. “Can you afford second-line treatment for ten percent of your clients?”

Henry’s answer was as blunt as it was bleak. “No. And there’s also the issue of the children. We have fewer child patients, but their statistics are worse. Almost half of those who are already on second-line treatment aren’t even responding to that anymore.”

He sighed. “It’s because those medicines are really hard to take. People have found it hard to stick to their therapy. You know that better than most; you worked with that medicine campaign last year.”

Nia nodded. She’d had a contract with UNAIDS to run a huge education drive among people living with HIV, trying to get them to learn how important it was to take their medication exactly as prescribed. The therapy was notoriously difficult to maintain. Patients had to make sure they took their dosage, sometimes a large number of pills, at the same time every day.

Many of the drugs caused severe nausea and other stomach problems, which made keeping the doses down difficult. Patients needed to have both a rigid self-discipline and schedule which they had to keep up indefinitely to suppress the virus and keep it from mutating into a drug-resistant form.

But now, this is exactly what had happened: one in ten of the HOS patients had developed resistant strains of the virus and were no longer responding to treatment.

Henry said, “This is why we need your help. We need to get new medicines, and we need them urgently. We’ll have to get the money somehow, or find some way of getting a big discount. Your main job will be to figure this out. Work out an arrangement with the pharma companies for us to get cheaper second-line medicines. Get together with other organizations and put pressure in the right places. You’ve done that sort of thing before.”

Nia nodded, remembering the years of lobbying Parliament, the street demonstrations and backroom wheeling and dealing it had taken to secure changes in the law and agreements which meant that thousands more Ugandans could get free HIV treatment.

She said, “You do know that my negotiation history is patchy, though, right? I’ve had results with quite a few companies, but I hit a wall with some others. To be honest, I’m not sure whether my name would do you any favors right now in some pharma circles.”

Henry said, “I know. That’s why I mentioned how your style has sometimes been a bit blunt. But you’re frankly the best at what you do. And it’s been a while since you last locked horns with anyone in the industry. I think enough time has gone by for you to negotiate with a clean slate.”

Nia’s eyes slid away from his. Henry had clearly not read her blog this week. She’d written a no-holds-barred post slamming pharma companies for putting profits before patients. And a couple of major international newspapers had called her yesterday, asking for her to elaborate on her comments. For reasons she couldn’t understand, her blog had a large following, particularly when she wrote anything controversial. But stories about Africa were usually buried deep inside the international papers and soon forgotten, Nia told herself. No need to mention it to Henry, she thought, rationalizing away a twinge of conscience.
She said out loud, “Okay, then. I’ll need details of who makes the medicines for your current second-line therapy so I can start thinking about who I need to approach.”

“No problem. I’ll send that to you as soon as possible,” Henry said. He pulled out another sheet of paper and gave it to Nia. “Also, we just heard that Acricaine is going to be approved. We would love to get access to it.”

Nia grabbed the paper and stared at it. It was a press release. “Already? I knew they were close, but not that close.”

Acricaine was a new HIV therapy that the world was hailing as a wonder drug. Instead of requiring a strict daily pill schedule, patients could take an injection once every two weeks. It had none of the side effects of current therapies and, best of all, promised to be more effective than any known treatment.

It was the perfect solution. Except for the fact that it cost over a thousand times more than the medicines most HOS patients were currently taking. And the fact that Nia had used her blog to condemn Nordic Wind Pharmaceuticals, the company that made Acricaine. She had used phrases that included “rampant greed” and “profiteering with death.” She hadn’t held back either when the journalists called to follow up. The thought of approaching Nordic Wind cap in hand was a bitter pill to swallow.

Acricaine could be exactly what the HIV Outpatient Service’s patients needed to stay alive. But surely those little interviews she had given would be buried on the inside pages of the papers, and she could quietly remove her blog post. Nordic Wind need never find out, she thought. Again, she felt that niggle of conscience, and she had a silent debate with God. Lord, I don’t really need to tell Henry about an interview that may never be published, and as soon as I leave here, I’ll take down my blog post.

Henry was looking at his papers again, but Nia knew he was waiting for an answer.

“Great!” she said. “I’ll make it a priority to approach them.”

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