Refilwe is a spectral figure, so thin that the light from the huge hospital window at her back seems to pass through her. She sits as straight as a knife, all bone, white robe, and huge eyes gazing at nothing, breathing shallowly through an open mouth. She is 30 and has a son of seven. She has tuberculosis and her mouth is covered with the telltale white spots of a common infection she cannot fight off, because HIV is destroying her body's resistance.
Ask her how she is and she slowly turns her entire body towards you. "I'm feeling better," she whispers. It is a fiction maintained by the plump and jolly nurses at the Natalspruit hospital outside Johannesburg who have dozens more like her on drips in wards 13 and 16, where anybody with any strength resists going because if you have HIV, you have no future.
Refilwe, impossibly, gets to her feet and makes her way with pitiful steps and the arm of a nurse to the door, a walking wraith. She is going to the TB clinic. They will sort out the TB but then they will send her home to die. She is fatally weakened and there are no antiretroviral drugs to take on HIV here.
Nokuthula, 23, is also under a death sentence, for all that she appears robust with health. So is her 18-month-old son Sipho, whose name means a gift. The young mother has put herself and her child in the care of the traditional healer in the township outside Natalspruit hospital who gives them herb and bark infusions to make them strong. But traditional medicine could not save Nokuthula's husband, who died of Aids last September.
At an age when women in the west are embarking on families and careers, Refilwe and Nokuthula have begun the business of dying. They live in the East Rand suburbs of Johannesburg, South Africa, where one in five is estimated to be harbouring the virus that will kill them.
Across Africa and the developing world millions more will die of diseases that are treatable in the west, such as diarrhoea, meningitis, malaria, TB and Aids. The hospitals do what they can, but their best efforts are a sticking plaster on a haemorrhage. The western drugs they need are unaffordable. Life is priced too high.
Thirty-five miles away in Pretoria, a legal battle critical to the fate of many more women like Refilwe and Nokuthula, their men and their children, is about to begin. Case number 4183/98 in the South African high court is an action brought by 42 pharmaceutical companies, including the British giant GlaxoSmithKline, against the South African government.
The case is an attempt to block South Africa from importing cheap medicines. The drug companies have spent three years and millions of pounds preparing the case.
They have retained virtually every patent lawyer in South Africa. On March 5 their barristers will try to stop the South African government from buying the medicines its people so badly need from countries where the prices are lowest, on the grounds that it is infringing world trade agreements.
The rest of Africa will be closely watching the outcome of the trial. So will developing countries on other continents. With the death toll from infectious diseases inexorably rising, especially in Africa, a tide of outrage is swelling among local activists and international aid organisations who see medicines denied to the sick in the name of commerce.
More than 2.5m people die every year from Aids-related illnesses. More than 13m children have lost one or both parents to the condition. There are more than 32m men, women and children infected by HIV in developing countries. AZT and 3TC, the basic antiretroviral drugs in the west, would keep them alive and well, but the price tag is $10,000 (£7,000) to $15,000 per patient a year. The majority of employed people in South Africa, with whole families to support, earn less than $3,000 a year, and by comparison with most of the rest of the continent, they are rich.
But there are now alternatives - cheap copies of life-saving medicines called generics, made mainly in Brazil, India and Thailand whose national laws allow them to ignore drug patents in cases of dire human need. Thailand believes it could reduce the cost to $200 a year per patient. It is a price the South African government might be able to pay for the life of Refilwe and Nokuthula, but the drug companies, in Case 4183/98, afraid of the potential worldwide consequences if their prices start to be undercut, say no.
Today in Cape Town at least 5,000 supporters of the successful grassroots Treatment Action Campaign will march on parliament to demand the medicines. At the same time in London, Oxfam is launching an international campaign demanding help for developing countries who want to use legitimate measures to buy or make their own cheap drugs, but who are bullied into submission by the lawyers working for drug companies and by the western governments who support them.
The pharmaceutical companies argue that they need 20 years of patent protection to recoup the vast sum it costs to research and develop drugs. They say it takes $1bn and at least 12 years to get a new medicine to market.
But, their accusers say, 90% of those new medicines are designed for 10% of the world's population in rich countries who can pay for them. The companies argue they already sell to developing countries at prices lower than in the west and that, with the approval of UNAids, the joint UN programme on HIV/Aids, five major companies have offered 85% discounts on drugs that are badly needed.
That could bring antiretrovirals down to $1,500 a patient, low enough for poor countries to hand them out to a chosen few but, say critics, millions would still have to die.
The Pharmaceutical Manufacturers Association of South Africa, which is bringing the case with the international companies, says it supports any country's right to buy supplies of drugs that are cheaper abroad "in exceptional circumstances". But it argues that section 15c of the Medicines Act, passed by the South African government in 1997 to allow it to import cheap copies of western medicines, would give the health minister "unfettered discretion to override patent rights for medicines in this country". And it was appalled when the South African delegation told a World Health Organisation meeting in January 1999 that the new legislation was a model which the rest of Africa should follow.
It is not just Africa that worries the big pharmaceuticals. On behalf of the industry the US government is taking the offensive to Brazil, which has had dramatic success in manufacturing its own cheap copies of patented drugs and now exports generics. Its price for an AZT equivalent is down from $15,000 a year to $4,000. There are now 60,000 people with HIV in Brazil who get free treatment.
At the heart of the growing legal battles directed against South Africa, Brazil and several other developing countries lies a little known international agreement called Trips - trade related intellectual property rights. It was agreed within the World Trade Organisation in order to ensure patent rights were respected around the world. The poorest countries have until 2006 to comply with Trips by passing their own patent laws. Under Trips, signatory states can pass clauses, as South Africa has tried to do, to bypass patents and make or buy cheaper drugs in cases of "dire emergency", and few could argue Aids is less than that.
But the west's sharp legal minds, backed by vast drug company wealth, are willing and able to mount expensive challenges in the courts to uphold their patent rights - and thus the price of their drugs - as is about to happen in Pretoria.
For the first time, there is also about to be a challenge in the WTO itself. Last month the new US administration, which accepted substantial election funding from the pharmaceutical industry, asked for a WTO disputes hearing where it will claim Brazil is in breach of Trips. Oxfam and others fear the offensive against Brazil and South Africa marks a new determination by the drugs companies to resist the flouting of their patents by poor countries.
GlaxoSmithKline has recently threatened legal action against the Indian generics company Cipla, blocking its plans to bring a cheap version of Combivir - AZT and 3TC in one pill - into Uganda and Ghana. "The implementation of WTO patent rules is taking place against the backdrop of a sustained campaign led by the pharmaceutical industry which may well erode the public health protection provided by safeguard provisions," says an Oxfam report published today.
In Khayelitsha, a shanty town that sprawls over a vast plain near Cape Town's airport, the Nobel prize-winning volunteer doctors are raising the stakes. They pioneered the use of nevirapine, a drug that stops pregnant women transmitting HIV to their babies. Now the government is rolling out the programme to the entire country.
After the period of apostasy, when President Thabo Mbeki upset the medical world by doubting that HIV caused Aids, the government seems willing to seek out and use cheap drugs if it is allowed to.
Last year it opened an infectious diseases clinic - code for HIV - where people are offered counselling and treatment for the "opportunistic infections" that can kill. They use fluconazole, a strong antibiotic most hospitals lack because of its price, to treat cryptococcal meningitis and thrush.
In May, they will take the most radical step of all and start 150 adults and 30 children who are at death's door on antiretrovirals - the very medication that keeps people in the west with HIV alive. Dr Eric Goemaere, head of the South African mission of Medécins sans Frontières, sees it as a marker for the future. "We are here on the frontline to show that it is possible and it will change attitudes totally," he says.
South Africa could by now be in the relatively advantageous position of Brazil, he believes, making its own cheap drugs and importing others. Perhaps Nokuthula's husband need not have died and Refilwe might be strong. There was a political willingness to use generics in 1997, but Case 4183/98 put a stop to all that. "I have no hesitation in saying that I'm totally convinced that's exactly where it is," Dr Goemaere said. "The pharmaceutical companies blocked South Africa becoming like Brazil."
South Africa's director general of health, Ayunda Ntsaluba, says something similar. "Three years down the road, access to medicines would have been completely different. We would be providing certainly for opportunistic infections, although it would be disingenuous to say we would have been providing triple therapy," he said.
It is hard to be a doctor in Africa. Herman Reuter, a young South African of German extraction who works for MSF in Khayelitsha, has more medicines at his disposal than most, but he is clearly under strain. Doctors go into the profession to cure the sick, not temporarily staunch their wounds before they die.
"We have our worse days and our better days," he says. "I saw one woman last Friday with a CD4 count of two [very low resistance to infection]. I said we hope to give antiretrovirals by May. She said, 'yes, but doctor, what happens until May?' I see many people die."
A very sick woman of about 41 had been brought to his clinic that morning by her 18-year-old daughter. She had cryptococcal meningitis. A week earlier, she had been to a government hospital and was turned away. There was nothing they could do for her, they said. They did not have the right medicine. But they mentioned the MSF clinic.
Dr Reuter was able to give her fluconazole, which costs around $4 for a 200mg capsule that will, for the moment, save her life. His last resort is to send the very sick to Somerset hospital in Cape Town, where pharmaceutical companies are running trials of drug combinations for HIV.
There is a bitter irony in it. The trials cannot be run in Britain or the US where the drugs will eventually be sold because everyone who needs antiretrovirals is on them. Refilwe and Nokuthula have no hope of a trial. Their best chance is to eat well, if they can afford to, to build up their strength and hang on.
Refilwe, like the rest of the patients in wards 13 and 16, refuses to accept she has HIV. What is the point when there is no treatment? "I don't know why I'm sick," she says, barely audibly.
Nokuthula places all her hope in the traditional healer, David Ngalana, even though he acknowledges he can give her only limited help. A large poster on the wall declares: "Traditional medicine can cure almost all sicknesses but currently we cannot cure HIV/Aids."
Nokuthula knows nothing about Aids drugs. There are no antiretrovirals for the people of her township, so they may as well not exist. She will drink her treebark infusions and convince herself they failed to save her husband only because he did not take them properly. In that way, maybe, hope can triumph for a while over despair.
© Guardian Newspapers Limited 2001