The most important day in Dr. Brian Brink's medical career came last August 1, more than 15 years after he put down his stethoscope and started climbing the ladder at Anglo American, the mining conglomerate that is the most powerful company in South Africa. It had taken Brink years of meetings and memos to get Anglo to that day. He had had moments of optimism and months of discouragement as three earlier plans were each announced, only to be sidelined. Then, quickly, in a morning meeting, it was decided. CEO Tony Trahar said simply, "Let's do it."
That Thursday, Brink got approval from Trahar and Anglo's executive committee to buy anti-AIDS medicine for any of Anglo's 130,000 employees in South Africa who needed it. Between 25% and 30% of the company's employees are HIV positive; the decision to provide the drugs made Anglo one of the largest customers for AIDS medicine in the world. It may also be the pivot of a terrible 10 years for South Africa.
Tall and slight, with a lean face and alert eyes, Brink seems unlikely to have the muscle to reset the course of a company with 177,000 employees in 61 countries. A South African, he speaks with an amused drawl that sounds cultivated and charming to an American ear. At 50, he has the confidence of an experienced doctor. He is soft-spoken, even when insistent.
That Thursday in August, after the decision was made, Brink went back to his desk and dialed the office of South Africa's minister of health. He was calling with good news. But the phone call was a reminder that the war wasn't yet won, by any stretch. "I need to speak with the minister rather urgently," Brink said. "I'd like an appointment."
"The minister is out," her assistant said, "and the soonest you could expect an appointment is October."
"I was actually thinking about Monday," Brink replied. He eventually wrangled the cell-phone number of the director general of health. "I called," says Brink. "I got his voice mail."
That Monday, Anglo officials faxed details of its AIDS treatment plan to the minister of health and to the office of the president of South Africa, along with private numbers for a range of Anglo officials, including CEO Trahar. No response. "What were we going to do?" says Brink. "Wait and ask for permission? I said, Let's just do it."
On Tuesday, August 6, Anglo announced that it would be providing its miners with the same "triple cocktail" antiretrovirals that have helped arrest AIDS in the developed world. The decision was front-page news in South Africa. It also made the front page of the Financial Times in London and the New York Times. But the South African government was silent for a week. The minister of health, Dr. Manto Tshabalala-Msimang, is known in the country as "Dr. No" for her refusal to provide antiretroviral therapy (ART) to government clinics in a nation that has more AIDS cases than any country in the world. The ministry had to be sued last year to force it to provide poor pregnant women with the antiretroviral drugs, which dramatically cut the rate of transmission of HIV to fetuses.
More than a week after Anglo's announcement, Tshabalala-Msimang did have something to say. She denounced Anglo for providing the drugs, failing to consult her in advance, and putting the government in the awkward position of refusing to provide medicine that a mining company would be giving away. In a meeting with Brink, she was scorching. "Oh, she was pissed off. She said, 'You're squeezing me.' For that," says Brink, a twinkle in his eyes, "I don't apologize."
A Nation Lost: A Thousand Dead per Day
How bad is AIDS in South Africa? Average life expectancy around the world is now 66.5 years. In the United States, it's 77 years. In South Africa, it's 48 years — down from 54 in 1997, largely as a result of AIDS. Life expectancy hasn't been 48 years in the United States since 1901.
Here's how debilitating an HIV infection rate of 30% is. Earlier this year, I went to a managers' safety meeting at Anglo's Mponeng gold mine, an hour west of Johannesburg. This group of 150 fresh-scrubbed men and women in khakis and golf shirts manage a mine that produced 29,125 pounds of gold last year. How do you run a mine while planning for the possibility that 40 of your 150 frontline managers will die from a single disease before 2010? The mine employs 5,616 people in all. Imagine losing 1,400 of them.
In the United States, providing medicine in this situation would seem obvious. But South Africa is such a complicated place that it took Anglo years to talk itself into providing ART. CEO Trahar says that his thinking changed "180 degrees" on whether Anglo should provide AIDS drugs. "I was pretty opposed when we first started considering this," says Trahar. "I really thought, Treatment is a problem for other organizations. Now I think it's absolutely the right thing for us to do."
Brink was the one who persuaded him. "Has he been a relentless pest?" says Trahar, laughing. "Yes. But I like relentless pests. You have to have them — especially relentless pests who are normally right."
The decision was about money — but it was about much more too. When Anglo first started talking about providing anti-AIDS drugs, a year's medicine cost twice the annual salary of a miner. Eighty percent of Anglo's employees in Africa aren't enrolled in conventional health-insurance plans — mines are in such remote areas that Anglo and its subsidiaries have long owned and operated their own clinics and hospitals on-site. The nurses and doctors are Anglo employees, just like the miners. (Brink, now senior vice president for medical services at Anglo American, got his start as a doctor at an Anglo-owned hospital.) So Anglo would not only be paying for the medicine, but it would also have to develop a system to dispense it and to monitor treatment. For now, AIDS drugs need to be taken twice a day, every day, forever. Meanwhile, the government was openly hostile to the medicines. President Thabo Mbeki not only publicly questioned the effectiveness of the antiviral drugs, but he also warned that they were toxic.
And so last summer, when Anglo announced that it was finally putting its full resources up against AIDS, South Africans were witness to this odd situation: The 86-year-old gold- and diamond-mining colossus, which had long benefited from a century-old migrant-labor system that separates black men from their families, was standing up for its workers' right to medicine, and life. And the country's black liberation government, just eight years old, was standing by stubbornly while a thousand South Africans a day died of AIDS.
Reality Check: "Treatment Changes the Whole Thing"
Brink is standing in a ward of the Anglo-Coal Highveld Hospital, talking to the nurse in charge, Sister Wright. (Nurses in South Africa are all addressed as "Sister.") This Anglo-Coal hospital, 90 kilometers east of Johannesburg, is clean and bright. It is, says Brink as he prowls the halls with an air of familiarity, "a standard of care not generally available to most South Africans. This isn't what the public hospitals are like."
Sister Wright is a veteran of the nearby public hospital, in Witbank. "They are so overwhelmed," she says, "you have to bring your own sheets." Brink shakes his head at the image. After a moment, he says, "I've heard that, but I don't have any idea whether or not it's true." He gets directions from Sister Wright. "Let's go see if there are sheets on the beds."
It's a classic Brian Brink moment. Be patient enough to find the truth and impatient enough to look for it. It's dark by the time his minivan finds the parking lot of Witbank's hospital. He leads the way in, muttering, "Look at this place." The information desk has been abandoned, the paint is peeling, and the smell is not the kind you want in a hospital.
The nurse in charge of the pediatric medical ward tells Brink, "Ninety-nine percent of the children we see have AIDS." The hospital has neither resources nor permission to provide ART. "It is depressing work," says the nurse. "With each child, we know the end of the story at the beginning." Bad as the place is, Brink deflates one myth: On every ward, every bed has clean linens. "The hospitals still have sheets," says Brink under his breath, "even if they don't have medicines."
Before the fight to get AIDS drugs, Brink led the effort to halt the spread of AIDS inside Anglo, deploying education, counseling, testing, treatment for the diseases AIDS allowed in, and, of course, condoms. At Greenside Colliery, a coal mine outside of Witbank that is part of Anglo Coal, manager John Standish-White has a kind of lunatic energy toward AIDS awareness. He's got anti-AIDS hats and T-shirts, Oprah-style town meetings, and a map titled "Let's Talk About Sex!!!" that shows the mine's 12 condom-distribution points. "If one of our miners gets lucky, they should be able to get a condom within 60 seconds of needing it," says Standish-White, beaming.
Standish-White is the very model of the AIDS-impassioned Anglo manager. His staff puts out a daily bulletin about the 550-employee mine that, along with production statistics, injury reports, and safety tips, includes a list of every employee who works in Highveld Hospital, a daily AIDS-prevention tip, and, once a week, a report of the number of condoms used by miners (average: 350 a week). Standish-White regularly meets with the local prostitutes. At his most recent sit-down, he asked one woman if she requires condoms. Her response: "No condom, no fuck!"
Standish-White was so thrilled, he had his picture taken with the woman, and he includes the picture, along with her response, in his PowerPoint presentation.
And yet, for all of his efforts, Standish-White says, "I don't think we've been completely successful. We may have had an HIV rate of 27% in 2000. And we have one of 27% now. Great." Actually, he doesn't know the rate of infection, because the main labor union has blocked anonymous testing to determine prevalence. Confidentiality — self-consciousness about being infected, and having other people know — remains a huge issue. Indeed, although perhaps 140 of his employees are HIV positive, Standish-White says that only one has ever admitted to having AIDS, and that just weeks before he died of it.
The arrival of ART at the mine may already be having an impact. At a December meeting where details of the drug program were discussed, 250 people showed up, including some wives and children. "Normally," says Standish-White, "you have to pull the first questions out. But at that meeting, the questions were free-flowing. You could tell something had blown in. It was the same company. It was the same people. But there was some good news about AIDS. That's why treatment is so important. Because treatment changes the whole thing."
The Stakes: "It's Not Business As Usual"
The per-capita income in South Africa is $2,900 a year — six times what it is in the rest of sub-Saharan Africa. And the average miner makes $6,500 a year. Roughly 80% of Anglo's African miners are living away from home. Until the mid-1990s, the South African attitude about sexually transmitted diseases was so mired in embarrassment and traditional beliefs that even modern medical-insurance plans excluded coverage for treatment of STDs.
This set of circumstances — the economic power of mining jobs, thousands of men living away from their families, and a dangerous lack of education about sex and disease — provided the perfect environment for AIDS to explode.
It made for an explosive challenge for Anglo. Brink remembers, in the mid-1980s, sitting in the office of microbiologist Ruben Sher, talking about AIDS. Back then, almost no one in South Africa was infected. "At that time, a 4% [infection rate] was thought to be a disaster," Brink recalls. "We thought, What if this was to happen? How would we cope?"
Within 10 years — by 1995 — the infection rate inside Anglo was roaring past 15%. AIDS accelerated as apartheid was being dismantled. The first liberation government in South Africa — Nelson Mandela's — took office in 1994. It wasn't hostile to AIDS treatment; it was busy, distracted, perhaps indifferent. And so Anglo, and its home country, drifted into crisis. In 1999, Brink wrote a blunt paper to Anglo's top executives. If 25% to 30% of the productive adults in the country are on track to sicken and die, the implications are staggering, Brink wrote. Labor supply. Productivity. Markets to which to sell. Crippled families. Orphans. Health-care costs. Despondency.
"If you look at the socioeconomic impact of that, you start recognizing this as a disaster," says Brink. "It's not business as usual. You can't stand back and watch. You have to lead."
In late 1999 and early 2000, ART was showing powerful results in clinical trials. Brink's wake-up call worked. In late 2000, Anglo's executive committee approved, in principle, treating AIDS with ART. A pilot study, preparatory to full rollout, was announced in May 2001. Gradually, however, a new reality dawned. Treating AIDS wasn't like treating high blood pressure, or diabetes, or TB. To say that it was expensive hardly covered it: If the average American earns $35,000 a year, how long would an American employer think before offering a permanent yearly benefit that cost $70,000?
Cost was just a small piece of the complexity. What do you do about infected dependents? The government doesn't provide ART. Even if you could find a way to pay for ART for spouses, who would deliver it, in small villages, in other countries? But morally, how could you justify providing the medicine to a husband and not to his wife? What if the husband skims off some pills to send home — resulting not in treatment, but in drug-resistant HIV at the mine and at the village? How do you persuade people to take medicine at the same time, two times a day, when they work deep in a mine — and don't want any of their buddies to see them taking pills?
By fall 2001, the challenges looked insurmountable. A "pilot" study means putting people on medicine — committing to treating those people permanently. Anglo got cold feet. The pilot study became a "feasibility study." Then Anglo halted the feasibility study. The executive committee asked Brink to partner with South Africa's Chamber of Mines, an industry group. "I remember that meeting well," says Brink. "I was not happy. They just said, this is too high-risk for one company."
At some level, Brink understood. "The complexity and enormity of the problem — it was out of our experience." He pauses. "And there was a sense of, This isn't our problem. Why do we need to solve AIDS when no one else is doing anything?"
The Patients: "One Day, I'm Going to Die"
Anglo's Mponeng gold mine is the second-deepest mine in the world. The elevator shafts go down 11,880 feet. The ride to the bottom of this 2-mile-deep hole takes about 8 minutes, in a low-roofed, wire-mesh cage, in the dark. Just getting from the surface to the working face takes 45 minutes; a healthy person arrives drenched in sweat, without having done the hard work of digging ore out of the ground and sending it topside. It's a demanding place to work under the best of circumstances. It must seem nearly impossible if you have AIDS.
A miner we'll call Mr. Dlamini (not his real name) has been going down into Mponeng for over 20 years. An underground supervisor, he helps plan a day's digging for a group of 10 miners. He's a Zulu who comes from Swaziland, and he is robust — he looks strong — a handsome, plainspoken man. He has a complicated life. Through a translator, he says, "I have two wives, and I have children with both of them. They live a few hours away by bus. I visit every couple of months."
He is also sick. "Since 1999, I've been suspicious that there is something in my body. Because I've been getting weaker. I didn't relate that to HIV. But I have gotten sicker and sicker." In 2001, he had TB; in 2002, he had pneumonia. "I have had exposure to information about AIDS from the company. I'm able to recognize the symptoms." He shrugs. "I just thought, This is not my thing."
Dlamini got sick again last Christmas, and he agreed to the test that showed he was HIV positive. He's probably been infected at least since his first bout of TB in 2001. He has counseled many of his fellow miners, but privately, he's scared. "When I'm alone, I think, One day, I'm going to die."
A month after learning his status, Dlamini has not yet told his wives. He is still absorbing the information, learning about ART, which could push off AIDS for a decade or more. "I'm positive about the medicine; I'm willing to take it." He laughs. "I'm surprised they are offering it. I've heard about all the politics of the drugs."
Dlamini says that the medical staff at the Anglo Gold hospital that serves Mponeng has provided supportive counseling, including advice on how to talk to his wives. "It's difficult," he says, "because there are two. At the end of the day, I have to go and tell them. What my guilty conscience is telling me is — what I'm thinking about — I'm worried they might be infected too. If we all test positive, what is the next step for them?"
The Pledge: "We Will Find a Way"
One of Brink's most powerful qualities — it is really a well-honed skill — is his ability to be patient and impatient at the same time. He knows that in the corporate world, when you are trying to get something brand-new accomplished, the short game and the long game are quite different. He knows that, regardless of the urgency of the problem, you almost never win if all you do is push. People can't take it. Giving everyone a chance to regroup, a chance to think, is not surrender — so long as you keep your own goal in mind.
Last spring was a period when things looked grim, but patience was rewarded. ART prices had fallen dramatically, mostly because of international pressure on drug companies, some brought quietly in negotiations by Brink himself. What in 2000 would have cost $12,000 a year for a single patient was by mid-2002 down to $1,200 a year. Meanwhile, Anglo — which, since the end of apartheid, has moved its global headquarters to London — was feeling increasing pressure about the AIDS problem. Anglo executives were getting questions from financial analysts about how AIDS would affect South African operations. And at the international AIDS conference in Barcelona, Spain in July last year, only two multinational companies were targeted for protest because of their refusal to confront AIDS: Coca-Cola and Anglo American.
For Brink and colleagues who went to Barcelona, medical progress reported at the conference provided a burst of energy and optimism. Brink reported back to Trahar on July 22 and urged action. Like Brink, Trahar has spent his whole career at Anglo. The company's relationship to its mother country is hard to overstate. At one point, Anglo's sales were the equivalent of 25% of South Africa's GDP, and sales today are the equivalent of more than 10%. Standing still at Anglo sends as powerful a message as taking action.
At that late-July meeting, Trahar changed his mind. Providing medicine couldn't wait for someone else. "This crisis is not going away," Trahar says now. "If there is a lead to be taken, Anglo American will take it. It's a leap of faith. I think our decision has made the government sit up and think about what they've been doing and saying. I think they will come to the party." Trahar's decision was ratified on August 1.
One way that the stalemate was broken: Brink suggested putting aside the question of treating dependents. "If we just keep sitting and deliberating, keep saying we can't start until we can do everything, then we never start. We have to start where we can start. Once we start, it's unstoppable."
Anglo's decision to provide ART only to its employees dramatically highlights the AIDS treatment gap in South Africa, and it has begun to put pressure on the national government. Brink is now offering Anglo's expertise to local communities and to aid organizations that want to partner to provide ART through the public health system. It's possible, in fact, that Anglo's provision of medicine only to its employees will get medicine to everyone more quickly than if Anglo had found a way to include dependents. "We will get ART for [Dlamini's] wives," says Brink. "We will find a way. That's what I'm going to spend almost all my time on this year."
Anglo's decision has won more than praise. It has sent a palpable wave of relief, optimism, and hope throughout southern Africa. Other companies either have announced their own programs or are preparing to. Ben Plumley, a staffer at the United Nations who now runs the New York - based Global Business Coalition on HIV/AIDS, says, "Brian Brink has not let the pressure up on Anglo at any stage. He has been persuasive and persistent. In an ironic way, he is perhaps one of South Africa's most effective anti-AIDS activists."
The antiviral medicines are complicated. The protocols and forms that Anglo has developed for helping doctors decide who needs the medicine and for tracking how it works fill a three-ring binder. ART requires commitment from patients and a sound bureaucracy from the health-care system. Anglo hopes to have 3,000 employees on ART within a year, but nine months after the announcement, just 250 had been enrolled.
Brink doesn't muddle his roles as executive and doctor, though, and he doesn't ever lose sight of the fact that for those with AIDS, too much patience is lethal. Two days after last summer's announcement, Brink got a call from one of Anglo's doctors. "He said to me, 'I've got patients dying of AIDS. You've decided to give them the drugs. So what do I do now?' I said, 'Don't wait. You treat them now.' "
Charles Fishman (email@example.com) is a Fast Company senior editor. Contact Brian Brink by email (firstname.lastname@example.org).