Zero Patience

May 2, 2011

Julio Montaner's decision to become a doctor came early and without debate-he declared his resolution at age five. This was the 1950s and this was Buenos Aires-a world of coups d'état, revolutionary dogma, and Eva Perón. Perhaps the fervour of that environment fused with the intellectualism of his parents: mom taught botany and dad was the prominent director of a hospital devoted to tuberculosis. But some alchemy made the boy a rebellious thinker early on-despite his intelligence, Montaner managed to do poorly at high school and never bothered learning how to type. The first of seven children, he still speaks with the authoritative voice of the elder brother. When questioned his answers are full-formed miniature essays.

Young Julio was routinely taken on house calls with his father, who also knew his own mind. One day, Montaner Sr. brought his son to a poor family's home where a woman was suffering from tuberculosis. "You know, Julio," he said, "tuberculosis is not really a medical problem."

Montaner, a teenager by then, said: "What the hell are you talking about, Dad? It's an infection."

His father shook his head. "No. Listen. When Argentina does well, rates of tuberculosis go down. When the country does poorly, rates go back up. We know how to prevent and cure tuberculosis, but the epidemic hasn't been controlled. And it won't be controlled until we address the socioeconomic needs of those affected."

Decades later, AIDS would become the ultimate illustration of that idea. And a series of accidental events would cause Julio Montaner's burgeoning career to swerve into a perfect storm where viral menace and political failure merge.

He entered medical school in Argentina at 18. "What for?" asked his father. "You'll only embarrass us like before." (The local priest had been called in when Montaner ignored his high school classes.) By 1986, Montaner was finishing his medical training, with a specialty in pulmonary medicine, at St. Paul's Hospital in Vancouver (the better to get out from under his father's influential shadow). At the time, someone was dying of AIDS every day in B.C., and since AIDS patients most often contract pneumonia early on, Montaner was treating them. His prowess was recognized early (he pioneered corticosteroid treatment for AIDS patients with pneumonia while still in his 20s) and he was made director of the hospital's AIDS Research Program at 30. "I'll take it on, as long as you transfer me back to respiratory in a year," Montaner told his boss. That was a quarter-century ago.

Today, still in Vancouver with his wife and four children, he has back-to-back meetings every hour (meticulously diarized in his iPhone). He greets visitors to his St. Paul's office with the well-worn grace of a diplomat, and one is ushered into simple surrounds: a computer; a Dictaphone (those abysmal typing skills); a plaque reading "Mutineers Will Walk The Plank"; and, covering the walls and shelves, 50 awards and recognitions.

He comes off as a supremely confident man, burdened with the vague impatience of the highly intelligent. He has greying good looks, wears good suits, and seems always to be unveiling things, starting declarations with phrases like "To be perfectly frank…" and ending them with permissions: "You can say I said so." He stands behind foot-tall stacks of paper and glowers at a screen of disappointing numbers.

But he admits to not knowing what he was doing back when he first took up the reins of the AIDS Research Program. A series of seemingly random career decisions had landed him at such a hospital, at such a time, with such an opportunity. He became the only person in Canada who had a commitment to clinical research in HIV. His department consisted of himself and half a secretary.

While AIDS seems, in hindsight, to be a defining condition of the 20th century, colleagues at the time told Montaner he was crazy. ("You're betting on a career with this, but you don't even know if HIV will be here tomorrow.") Meanwhile, St. Paul's was flooded with the patients other Vancouver hospitals were refusing to treat. Paranoia gripped medical professionals as well as private citizens. At dinner parties, HIV-positive guests were handed plastic utensils. Some mothers, in ignorance, refused to hug their gay sons.

By the early 1990s it was clear that treatments were only palliative. Conventional drug trials proved weak medicine, so Montaner called for bolder drug combinations. He wanted to treat patients with three drugs at once. Regulators said this would hurt people. Montaner replied, "We're hurting them by doing nothing."

And then came Nevirapine. It was an unlikely drug and had received poor reviews from American researchers. Maureen Myers, who was leading the development strategy for Nevirapine, brought her drug to Vancouver, to Montaner. "I was plan C," he recalls. "Or plan D."

Montaner, by then 39, led an international trial involving patients in Canada, the States, Italy, the Netherlands, and Australia. It was the first trial to combine three drugs (Nevirapine, AZT, and ddl). Blood samples from 151 patients were brought to a lab in Montreal, where a man named Mark Wainberg (now the senior HIV virologist in Canada) was observing how the HIV virus grew-if growth could be delayed, even by a month, that would count as a success. He called Montaner in December of 1995. "Julio, there's a problem."

"Don't tell me that."

"Well, there is. There's something wrong with the blood samples you took."

"No, Mark."

"Yes. I can't even grow the virus in some of them. You guys messed up the samples."

Weinberg was so desperately looking for some small success that he couldn't conceive that Montaner had delivered the closest thing to a cure that anyone had seen.

Montaner's father was visiting Toronto and called his son. "Julio, I'm looking at the Globe and Mail and it says you guys are flying by the seat of your pants."

"Dad, I'm doing my job. Let them criticize."

Suddenly, in the summer of 1996, AIDS patients in the five trial countries stopped dying. After more than a decade of decimation, a decade of daily funerals, Vancouver adopted Montaner's triple drug therapy. A year later, the death rate for AIDS patients in this city had dropped by more than 85 percent. It was the magic bullet the world had been waiting for. "And from that moment on," says Montaner, "it became clear to me that science was moving faster than implementation."

Like tuberculosis in Buenos Aires in the 1960s, AIDS had stopped being just a medical problem. Quietly, invisibly, it had morphed into a political and economic problem. Montaner began advocating for triple therapy immediately. But it took more than a decade for the World Health Organization to embrace it as standard treatment.

AIDS, at least in North America, has had its cultural and media moment; it galvanized us for a time but has since been replaced by other concerns. Globally, however, this inattention flies in the face of the facts. To begin with, 18 percent of people in South Africa are living with the virus. Currently, 5.7 million people in South Africa are HIV positive (about one million are in treatment). Two million South Africans were infected last year alone. "If we do nothing," Montaner says, "it's the collapse of their society by 2030."

Montaner's work is, increasingly, a global affair; a third of his life is now spent travelling. Last summer he flew to Vienna and stood before an assembly of the world's medical elite-his peers-and told them, "The G8 has, quite simply, failed us." The G8/G20 meetings that Stephen Harper hosted in Canada had recently concluded, and Montaner-then the president of the International AIDS Society-was appalled to discover that "Harper refused to put AIDS into the agenda." Five years earlier, the G8 had pledged to reach "universal access" by 2010-meaning universal access to the drugs that manage HIV. That kind of commitment requires substantial funding, and the funding had failed to materialize.

"They claim there is no money," Montaner says. "But when their friends on Wall Street needed money, or when there was an oil spill in the gulf, or when Greece went belly up, they found the money.

"In 2005, this country signed the Universal Access Pledge. The deadline is now, and we're at 30 percent of where we said we would be." Pouring coffee, Montaner drops one of the inflammatory remarks he's loved and hated for: "We've moved into an era where this country is only concerned with its own interests."

In this case (as in most cases), the facts bear out his anger. The United Nations recently released an assessment of national disbursements for AIDS, as a ratio of each country's GDP. For every $1 million of Canadian GDP, we give exactly $97.20 to AIDS efforts. Denmark, the Netherlands, and Sweden give six times more.

The fact that millions will die in Africa is, lamentably, not news. What's less well understood is that there are those-Montaner chief among them-who know exactly how to save AIDS patients, if the powers that be would only let them. The story of his troubled, persecuted, and triumphant career mirrors the larger matrix of politics and prejudices that has always surrounded HIV and AIDS.

If anyone has a better grasp than Montaner of Canada's half-hearted contribution to international AIDS efforts, it's Stephen Lewis. His leadership of Ontario's NDP (1970-78) has been dwarfed by his subsequent ambassadorship to the UN, his term as the UN's special envoy for HIV/AIDS, and his founding of the enormously influential Stephen Lewis Foundation. Lewis confirms Montaner's assertions, and matches his anger.

On the phone from Toronto, Lewis says, "Our contribution has been pretty paltry" in his carefully enunciated, impassioned way. "Now we've cut off funding to the international AIDS vaccine initiative at precisely the time when there's hope of a vaccine. Our government has had opportunities to make a difference and has failed to do so. They're also trying to kill CAMR." (The CAMR proposal would allow generic HIV drugs to be manufactured for Africa, where those who are dying have no hope of paying for the pharmaceutical cocktails that Canadians are afforded.) "Our government is deferring to pharmaceutical companies over people in Africa."

In the midst of this global pandemic, Montaner says, "the prime minister has shown no desire to engage in a discussion with anybody who is not prepared to praise him. He's not about to have a debate over anything. The current modus operandi of our federal leadership is ‘My way or the highway.' 

"I grew up around military governments," he adds, "and this is the way they operate. I have no sympathy for that mindset. It's not the Canada I embrace."

When Montaner was made president of the International AIDS Society in 2008, his first speech was on what he calls "the implementation gap." "Globally," he says, "we're implementing 10 percent of what we know."

And it isn't only because of neglect, a lack of funding. The Harper government has actively directed massive sums to thwart honest scientific conclusions. Montaner supported Insite (the Vancouver supervised-injection facility) on the grounds that its harm-reduction philosophy would lower HIV transmission and allow him to get more drug users on meds. Flawed reports were commissioned by the Conservatives to cast doubt on the peer-reviewed research Montaner had produced; and, in a fiasco exposed last year, after 18 months of work that generated a consensus that Insite was indeed the way forward, the deputy commissioner of the RCMP was ordered not to reveal his findings. "Our government," says Stephen Lewis, "has taken a bloody-minded and stupid approach to harm reduction."

In Canada, historically, AIDS has affected minority populations (homosexual men, intravenous drug users, sex workers) more than other groups, so each advance secured by the scientific method is embattled and stalled by bureaucratic machinery, minus the rage that might otherwise incite the voting majority. Such obstructions are various and far-reaching; the only happy news is that crusaders like Montaner tend to be vindicated after a painful amount of time has passed. But time means lives: from the moment you started this article to the moment you read this sentence, at least 10 people have died of AIDS.

Stephen Lewis says he doesn't get discouraged. "These are struggles for social justice-they require indefatigability. I feel anguished at times, but mostly I live in a rage. A rage toward the passivity of government and many UN agencies. It's a tremendous antidote, that rage. It sustains me."

Montaner's latest battle involves a radical and expensive approach called Treatment as Prevention. If you dramatically increase testing and treatment for HIV, new infections drop off. (Lower viral loads equal lower transmission rates.) This saves lives and money in the long run, Montaner argues, but requires tremendous resources now.

Not everyone favours Montaner's approach. In a Guardian op-ed piece, Elizabeth Pisani, the author of Wisdom of Whores, called Treatment as Prevention "a triumph of optimism over common sense." She argues that, since an HIV-positive person is most infectious in the months immediately following infection, even annual testing and buckets of expensive meds are usually too late. In a recent lecture she suggested that, because meds keep people alive (and therefore able to infect others), "we need to actually do more prevention the more treatment we have." Pisani and Montaner are both calling for policies based on scientific evidence, though their science has led them to separate conclusions.

Stephen Lewis points out that resistance to Montaner's work has always been Pavlovian, not founded in serious scientific thought. "There's an intense pathology," he says, "to the way agencies fight it. When Julio presented Treatment as Prevention, he was fought by UNAIDS and WHO. But he persuaded me a few years ago, and I now believe that literally millions will escape infection because of his work."

One of Montaner's final efforts as president of the International AIDS Society was his push, last year, for the Vienna Declaration. It was the battle cry of the year's conference; through it, 17,000 international experts (including Nobel laureates and heads of state) have called for the incorporation of clear scientific evidence into drug policy. More broadly, the Vienna Declaration makes painfully obvious just how unscientific (how disastrously gut-driven) most health policies are. Insite, on Montaner's home turf, may be the perfect example of science battling political stigma.

Last winter, a historic announcement was made: an HIV-positive man in Berlin was declared cured, thanks to stem-cell transplants. The procedure is dangerous in the extreme. (Many would die from it.) But it was a glimpse, a hope. "I have a profound conviction," says Montaner, "that any problem dealt with via scientific methodology can be solved. We're going to get a cure."

Before boarding his flight to Vienna, to the AIDS conference where he roundly condemned those who stand in the way of his works' deployment, Montaner and his team filed an article to the prestigious medical journal, Lancet. It was a report on whether intense treatment of injection drug users in B.C. had actually lowered incidences of new infections, as he'd predicted with his Treatment as Prevention talk. Over the last three years, it turned out, rates of infection dropped by 50 percent.

"Treatment as Prevention" became a mantra among the 20,000 participants at the Vienna Conference. Michel Sidibé, the executive director of UNAIDS, was in the audience when Montaner delivered his impassioned speech. Sidibé, a former critic, now says that Montaner's work is "a cornerstone of the global movement." Last winter Montaner received the "Albert Einstein" World Award of Science; several sources suggest that a Nobel Prize is imminent.

Even Stephen Lewis allows himself a brief reprieve from the rage that fuels him. "Julio's science is unassailable. Everyone who said he was wrong, they will change. One day-I believe this-the pendulum will swing."

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