United Nations (New York)

Africa: The Strength to Fight HIV/Aids in Africa is at the Grassroots

document

New York — Speech by Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa at Centre for Strategic and International Studies in Washington, DC.

Allow me to begin with three observations, faintly heretical perhaps, but observations I'd like to make. First, I'm frankly bemused by the way in which the question of security, even if never fully defined, suddenly confers on the pandemic a new level of significance. All you have to say is that a study was produced by the National Intelligence Council, and everything is immediately elevated to riveting import. I'm reminded of the fact that the HIV/AIDS pandemic couldn't even get traction within the multilateral system, until it was considered to be a matter of international peace and security, worthy of debate in the Security Council itself.

No one diminishes the question of security. God knows, in this day and age it's a consuming obsession. But it does say something about the way we respond to the human condition, doesn't it? It's not enough to engage the world simply by having an incomparable human catastrophe; it has to have security implications to make it come alive.

Second, the new figures from the 'Next Wave' document are hallucinatory. They're simply more than the mind can absorb. And from only five countries, however large. I note that the authors are at pains to point out that the estimates are by consensus rather than by science, and that they're rough, and there's a healthy margin of error. But the contemplation of more than a hundred million infections, when you take in all countries, by the year 2010, is like the contents of Pandora's box gone mad.

To be sure, some of the news coverage tells us that there are people who are skeptical, that there are those who challenge the basis for the figures, those who think the figures are inflated. But some of the very experts who express concern are among those who informed us, ahead of Barcelona, that 68 to 70 million people, in the 45-most affected countries, would likely die by 2020. I make the point, not to challenge epidemiology, but simply to say that the numbers, from whatever source, have now reached levels where life imitates science fiction. Except that there's nothing fictional about it.

Third, the Next Wave study is a relentlessly disturbing document. What I found so depressing was the way in which the analysis of every country leads to a coda of despair. Let me remind you: Nigeria, quote: "...the Obasanjo administration is beset by such other pressing problems as an approaching election and rising ethnic and religious tensions. Moreover, Nigeria's government institutions have deteriorated so badly over the last decade that Obasanjo has few functioning public sector assets left to mobilize even if he chose to engage fully on the issue". Ethiopia, quote: "... we expect 7 to 10 million Ethiopians probably will be infected by 2010 because of the current rate of adult prevalence, widespread poverty, low educational levels, and the government's limited capacity to respond ...".

Russia, quote: "Driven by widespread drug use, inadequate infrastructure, and the government's limited capability to respond, the number of HIV positive people probably will rise to 5 to 8 million by 2010". India, quote: "The current trajectory of the disease, limited public awareness, and the lack of resources for a major anti-AIDS programme will continue to drive the spread of the disease". China, quote: "Despite growing concern over the disease among senior leaders, China's sheer size, resource constraints, widespread ignorance of AIDS, cultural taboos about discussing sex, and coordination problems between levels of government will make it difficult to check the spread of the disease".

It is unrelieved, punctuated only by trifling glimpses of hope. Indeed, there are even omnibus, gloomy comments covering all five countries, quote: "It will be difficult for any of the five countries to check their epidemics by 2010 without dramatic shifts in priorities. The disease has built up significant momentum, health services are inadequate, and the cost of education and treatment programmes will be overwhelming" And later, quote: "Even if effective programmes could be implemented in the coming years, such practical concerns as cost, scale, and experience in health service delivery probably will result in the omission of services to a large number of infected individuals, and the burden of disease will continue to rise".

This is actually a quite excellent, dispassionate, if bracing report. No pretensions, no embroidery, no dissembling. But it leaves you raw and aching.

So allow me at this point to provide a disclaimer. My role is confined to Africa. I don't pretend to know more than what I've read and heard about China and India and Russia, and I'm much relieved that there are so many experts in this room. I have, however, spent some considerable time examining the pandemic in Nigeria and Ethiopia , and I can speak more confidently about those countries. That's not to deny that there'll soon be more infections in Asia than anywhere in the world; it is simply to say that the lessons learned in Africa probably have a significant --- albeit not universal --- application to most other countries.

I'm no optimist about the virus. But I simply don't believe, on the basis of personal observation, that we have to face Armageddon. In fact it enrages me the way in which we pile despair upon catastrophe, over and over again, rendering everyone paralyzed. You don't have to be some pathetic bleeding heart to see the potential strength in these societies at the grass roots, and know that if we could galvanize the governments, indigenous and external, and equip civil society, and address capacity and infrastructure with external resources, then we could defeat this pandemic. It is not beyond our competence.

I met not long ago with a thousand high school students in Addis Ababa, for a question and answer session that lasted an entire afternoon, and the intelligence and understanding and sophistication of those kids gives nothing but hope; I've met with the WFP truck drivers in Nazareth, south of Addis, as they tell their stories of the training they receive, and how they now always carry condoms on their routes; I've met at length with his Holiness, the Patriarch of the Ethiopian Orthodox church as we discussed how the UN family could set in process training for his 350 thousand priests so that they, in turn, could address their parishioners; I've sat over coffee with village women miles and miles from the Ethiopian capital, while neighbours gather to talk about how the virus is transmitted and how to protect themselves. They laugh self-consciously in the presence of a stranger, but they don't mince words.

I've attended the two day sensitivity sessions in Abuja, Nigeria, for the establishment of mother-to-child-transmission clinics ... a tremendously impressive undertaking; I've sat with the doctors and nurses in a leading hospital in Benue state as they decide how they'll choose those who should receive anti-retroviral treatment when it begins, and how to handle the counselling; I've met with groups of People Living with Aids out in the Eastern region, near Onitsha, as the mothers talk about the kids they'll leave behind, and then make their eloquent, moving, unanswerable plea for treatment. I've sat, as many others here have sat, with President Obasanjo, as he, on the one hand, expresses something akin to fear at the spread of the pandemic, and on the other, his absolute determination to subdue it no matter what it takes. There is no doubt in my mind, that when he heard about these new estimates of prevalence, he would have summoned a council of war.

I'm not kidding myself. I know the task is Herculean. But I also know that the words of the study are right: the only way to check the next wave is through a dramatic shift in priorities.

There are four things I want to say about that shift in priorities, drawing on themes that I believe to be germane to all the countries under examination.

First, and most compelling, is the question of gender. At the UN Special Session on AIDS last year, the Declaration of Commitment contained the toughest articles on the rights and protection of women that had yet appeared anywhere. It was truly memorable. Why then do I put it in the past tense? Because before the ink was dry, the words shrivelled on the page. There is very little evidence, in the aftermath of the Special Session, of governments taking seriously the commitment to women. It was one thing to recognize, rhetorically, that women were overwhelmingly at risk, it was quite another to act on the rhetoric. And it would appear, that yet again, as ever, with indifference aforethought, the women are betrayed. The women are always betrayed..

Just look at the figures that emerged from Barcelona. Of the 28 million people in sub-Saharan Africa living with AIDS, ages 15 to 49, 15 million are women. That's 58%. Of the 8 million, six hundred thousand, in the age group 15 to 24, 67% are young women and girls. How is that possible? We're just beginning to understand that where AIDS is concerned, gender inequality is lethal. It requires a campaign, across the continent and the world, to enshrine gender equality in the family, in the laws, in the institutions, and in the apparatus of the state. We've never faced anything like this. There's a passing comment in the Next Wave study, pointing out that in a country like China --- but China is merely an example --- "...as AIDS moves more into the general population, past experiences in other countries suggests it will exacerbate an already existing gender imbalance because of the practice of female infanticide". What is happening is a kind of Darwinian nightmare, where the survival of the fittest results in the annihilation of women. There will be, down the road, in many communities, in many countries, a demographic skewing of gender, such that the voices of women will no longer be heard in the land.

The world has to be made to understand that AIDS has brought into brutal relief the predatory sexual behaviour of adult males, and the terrible consequences of intergenerational sex, and the equally terrible vulnerability of women who have neither sexual power nor sexual autonomy. More, we are just beginning to understand that the levels of sexual violence, the levels of rape, inexorably transmit the virus. Whether it's the violence of conflict, or the violence of a domestic household, women are the targets. It's a part of the human condition that cries out for study and desperate, immediate response.

All my adult life I've believed that gender is the toughest issue to deal with. Tougher even than race. And I don't really know how we cope with what is happening except to reverse the pattern through a massive, international, single-minded initiative.

Second, for more than a decade now, those who have chronicled the sweep of the pandemic, have warned about the excruciating consequences of societies falling apart. Now, more than ever, we have groups coming together to fashion scenarios of what will happen in the future. The Next Wave study repeats in several places , quote: "The rise of HIV/AIDS in the next wave countries is likely to have significant economic, social, political and military implications". That seems to me to be unarguable.

But if the present teaches anything about the future, then just draw back and look at what is happening in Southern Africa. It has been established that 14.4 million people are at risk of starvation in six countries: Zimbabwe, Zambia, Lesotho, Swaziland, Malawi and Mozambique. Now allow me to be personal for a moment. Last week, I met with Mr. James Morris, head of the World Food Programme, who had just returned from a mission, as Special Envoy, to the six beleaguered countries. He was a man physically and emotionally reeling from what he'd seen. He had instantly recognized that food was only part of the problem; the heart of the problem was AIDS.

That should ring one of the most piercing alarm bells that we've yet heard during the course of the pandemic. If you read the Mission report, it's like a revelation, quote: "What the mission team found was shocking. There is a dramatic and complex crisis unfolding in Southern Africa. Erratic rainfall and drought can be identified as contributing factors to acute vulnerability, but in many cases the causes of the crisis can be linked to other sources ... Worst of all, Southern Africa is being devastated by the HIV/AIDS pandemic. HIV/AIDS is a fundamental, underlying cause of vulnerability in the region, and represents the single largest threat to its people and societies".

And then, over and over again, in country after country, the report chronicles the way in which AIDS exacerbates the crisis. The language is startling ... allow me to quote one other section: "The relationship between the HIV/AIDS pandemic and the reduced capacity of the people and governments of Southern Africa to cope with the current crisis is striking. In every country of the region, HIV/AIDS is causing agricultural productivity to decline, forcing children to drop out of school, and placing an extraordinary burden on families and health systems".

I've read the report carefully. I've talked to numerous colleagues. I've discussed the matter with three people who were on the UN mission. I've consulted a notable academic who is the pre-eminent scholar on AIDS in Southern Africa. Let me tell you what I think --- I obviously cannot prove --- but what I think has happened. I think it is reasonable to argue that AIDS has caused the famine; that what we all feared one day would happen, is happening. So many people, particularly women, have died, or are desperately ill, or whose immune systems are like shrinking parchment, that there simply aren't enough farmers left to plant the seeds, till the soil, harvest the crops, provide the food. We may be witness to one of those appalling, traumatic societal upheavals where the world shifts on its axis.

We've been predicting that you can't ravage the 15 to 49 year-old productive age group forever, without reaping the whirlwind. The whirlwind is in Southern Africa. And surely that has huge implications for the next wave. If you watch while your educational systems are shattered, your health infrastructure is frayed, your agriculturalists are dying, your militaries and police have astronomic levels of infection, your private sector is atrophying, then it becomes impossible to escape the economic and social and political and military consequences. For the so-called next wave countries, there is no time left to contemplate. There is only time left to act. Southern Africa is the canary in the pandemic.

Third, and to be dealt with briskly, is the question of orphans. As always, there are the hyperactive arithmetic calculations; fourteen million orphans now, twenty-five million by 2010. But whatever the numbers, we have very few solutions. If there really will be, at the outer limits, fifteen million AIDS cases in China by 2010, and twenty-five million in India, and eight million in Russia, then I ask you to reflect on the orphan problem down the road. We now rely primarily on grandmothers, and when they die, we're often faced with what are now called "sibling families". Communities, and foster parents, move heaven and earth to embrace these youngsters, but they all live in such extreme poverty, that another mouth to feed can push everyone over the edge.

We've been stymied by orphans, and now we're overwhelmed by orphans. Just last month, at a small gathering in Johannesburg, hosted by UNICEF with Carol Bellamy present throughout, attended by both Nelson Mandela and Graca Machel, plus activists and experts from within and outside Africa, an urgent effort was made, over the course of a day and an evening, to articulate policies which could confront the orphan dilemma and take successful models to scale. It's interesting that many of the recommendations focussed on Parliamentarians, religious leaders, national conclaves, and above all, the determination to launch a campaign to "Put Every Child in School".

I cannot emphasize strongly enough that education was raised by practically everyone. All of the Next Wave countries, indeed, all of the countries in the world, save two, have ratified the Convention on the Rights of the Child, and the Convention says, unequivocally, that primary education shall be free and universal. The same objective is embraced by the Education For All initiative, launched in Jomtien, Thailand in 1990, and reaffirmed in 2000 in Dakar, Senegal. The idea of the school as the centrepiece of the child's' life ... the anchor which gives a child the greatest sense of hope, confidence and self-worth ... is now firmly entrenched in our international norms and our everyday dialectic. And yet, AIDS is playing havoc with the fundamental right of the child, especially the girl child --- gender again --- to education, and it's as though, seized by some perverse, passive compliance, we watch the havoc unfold and stand inert. It's unbearable, and it's indefensible.

I think and feel that progress was made at our meeting; I'm not sure how much progress. But of one thing I am certain: the next wave countries had better be concentrating now on how to address, nurture, embrace the orphan population. If the vast numbers get out of hand, the best clairvoyant on the planet won't be able to predict the consequences.

Finally, I want to re-emphasize my conviction that this pandemic, in all its multivarious forms in the countries with which we're dealing, can be turned around. There is tremendous knowledge and selflessness at the grass-roots; it just has to be given a chance. We --- and it's the royal, generic 'we' ---know a great deal, if only we can apply it. We know how to go about Voluntary Counselling and Testing; we know ways in which to reduce, dramatically, vertical (mother-to-child) transmission; we know how to administer anti-retroviral treatment; we know of excellent preventive interventions; we know the world of care at community level, provided by the women, and rooted in faith-based and community-based organizations; we know the knowledge and expertise that can be brought to bear by People Living with AIDS. We know, as well, the huge challenges of mobilizing the political leadership, galvanizing the religious leadership, fighting the curse of stigma and strengthening advocacy on all fronts.

What we don't have is the means to do it with. We don't have the dollars. I've knocked this particular nail through the wall so many times that even I feel a certain ad nauseam quality merely to mention it; in fact, I feel like a minor clone of Jeffrey Sachs. But the truth is that what's literally killing the women and men and children of Africa is the lack of resources.

Just two weeks ago, I was meeting in Arusha, Tanzania, with a group of women living with AIDS. I asked them, as I always do, to tell me what they most needed and wanted, and as always the same replies came back: food, because everyone is hungry, especially the children; money for school fees, and some kind of guarantee to keep their kids in school, because when they die they want their children to be assured of an education. And drugs. Anti-retroviral drugs to prolong life ... so as not to leave their children so prematurely-orphaned. To be quite honest, I never know what to say in such a situation. I'm strangled by the double standard between developed and developing countries. I'm haunted by the monies available for the war on terrorism, and doubtless to be available for the war on Iraq, but somehow never available for the human imperative.

I believe that all the things those women asked for could be provided, or at least provided in large measure, if we had the money. Next weekend, the Global Fund will pronounce on its financial needs. There will then ensue a tenacious, indefatigable effort to round up the dollars. I have no idea what to expect.

I know only that if the Next Wave is to escape the wretched fate of the last wave, then the world and its governments will have to come to their senses.

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