Global Policy Forum

By Stephen Lewis

These are notes Stephen Lewis, the UN Secretary-General's Special Envoy for HIV/AIDS in Africa, prepared for a press briefing in New York.

Last month, I spent two weeks touring four countries in Southern Africa: Lesotho, Zimbabwe, Malawi and Zambia. The primary purpose was to view the link between hunger and AIDS. I want to look back at that visit, because little will have changed between then and now (except, perhaps, that things will have deteriorated further), and then look forward to the prospects for addressing the pandemic in 2003.

At the outset, however, let me express, yet again, the fundamental conviction I have every time I visit Africa: there is no question that the pandemic can be defeated. No matter how terrible the scourge of AIDS, no matter how limited the capacity to respond, no matter how devastating the human toll, it is absolutely certain that the pandemic can be turned around with a joint and herculean effort between the African countries themselves and the international community.

I am weary to the point of exasperated impatience at the endless expressions of doubt about Africa's resolve and Africa's intentions and Africa's capacities. The truth is that all over the continent, even in the most extreme of circumstances, such as those which prevail today in the four nations I visited, Africans are engaged in endless numbers of initiatives and projects and programmes and models which, if taken to scale, if generalized throughout the country, would halt the pandemic, and prolong and save millions of lives.

What is required is a combination of political will and resources. The political will is increasingly there; the money is not. A major newspaper in the United States, reflecting on the paucity of resources, used the startling phrase "murder by complacency". I differ in only one particular: it's mass murder by complacency.

You will forgive me for the strong language. But as we enter the year 2003, the time for polite, even agitated entreaties is over. This pandemic cannot be allowed to continue, and those who watch it unfold with a kind of pathological equanimity must be held to account. There may yet come a day when we have peacetime tribunals to deal with this particular version of crimes against humanity.

As bad as things are in Southern Africa --- and they are terrible --- every country I visited exhibited particular strengths and hopes.

The little country of Lesotho has a most impressive political leadership, but is absolutely impoverished. If it had some significant additional resources, with which to build capacity, it could begin to rescue countless lives. I vividly remember the Prime Minister of Lesotho saying to me "We're told repeatedly by donors that we don't have capacity. I know we have no capacity; give us some help and we'll build the capacity". It's worth remembering that Lesotho has a population greater than that of Namibia and Botswana, but it has nowhere near the same pockets of wealth. It has, however, one of the highest prevalence rates for HIV on the continent ... higher than Namibia; almost as high as Botswana ... and is fatally compromised in its response by the lack of resources.

Zimbabwe, whatever the levels of political turbulence, has created a sturdy municipal infrastructure for the purpose of dealing with AIDS. You will know that for the last couple of years, Zimbabwe has had a 3% surtax on corporate and personal income, devoted to work on AIDS. A good part of that money has been channelled down to district and village level, through a complex array of committees and structures which actually get the money to the grassroots. It's visible in the work of youth peer educators, outreach workers and home care through community-based and faith-based organizations. In other words, for all the convulsions to which Zimbabwe is subject, there remains an elaborate capacity to implement programmes, if only there were more programmes to implement.

In Malawi, we may be about to see the most interesting of experiments in the provision of anti-retroviral treatment in the public sector. The Government of Malawi had originally intended to treat 25,000 people based on receipt of monies from the Global Fund. They then realized that the calculation of 25,000 was based on the purchase of patent drugs, but now that it is possible to purchase generic drugs, the numbers eligible for treatment could rise to 50,000. There has been, predictably, a great deal of skepticism in the donor and other communities. However, while we were in Malawi, the country was visited by a WHO team which carefully examined the capacity and delivery issues, and came to the conclusion that treating 50,000 people, phased in of course, was entirely possible. This is an exciting prospect: the treatments are meant to be free of charge, and delivered through the public health sector.

Zambia, whatever the difficulties --- and they are overwhelming --- is emerging from the bleak and dark ages of denial into the light of recognition. The bitter truth is that in the regime of the previous President, nothing was done. He spent his time disavowing the reality of AIDS, and hurling obstacles in the way of those who were desperate to confront the pandemic. I can recall personally attending an annual OAU Summit on behalf of UNICEF, and sitting down with the then President Chiluba, and asking him what he intended to do about AIDS, and he simply wouldn't talk to me about it. Well there's a new President in Zambia. And although he's been in place for only one year, everyone agrees that there's a dramatic change in the voice of political leadership around the subject of AIDS.

The fact is that in every country, even under the most appalling of human circumstance, there are signs of determination and hope. Whether they can be harnessed in the name of social change will be known in the year 2003. God knows, there are incredible hurdles to leap.

If I am to extract from my trip those aspects that made the greatest impression on me, they are six in number.

First, there is absolutely no doubt that hunger and AIDS have come together in a Hecate's brew of horror. We saw it everywhere. How could it be otherwise? In Malawi, for example, analysis of the data shows that 50% of poor households are affected by chronic illness due to HIV/AIDS. You can't till the soil, grow the crops, feed the family, when disease stalks the land. Add to that the reality of erratic rainfall and drought, and WFP and the broader UN family have a hugely daunting job.

I think the nadir was reached for me in the paediatric ward of the University Teaching Hospital in Lusaka. The infants were clustered, stick-thin, three and four to a bed, most so weakened by hunger and ravaged by AIDS (a prevalence rate in the nutrition section of the ward of 56% ... in the respiratory section of the ward, 72%), that they really had no chance. We were there for forty-five minutes. Every fifteen minutes, another child died, awkwardly covered with a sheet, then removed by a nurse, while the ward was filled with the anguished weeping of the mothers. A scene from hell.

Second, I couldn't help but feel, on occasion, that we were witnessing the grinding down of a society. We've all imagined the catastrophe, but no one wanted to believe that it could happen. The fact that the agricultural sector is beginning to decay could simply be a harbinger of worse to come. My own sense is that education is on the brink. In all of the countries, teachers were dead, teachers were dying, teachers were ill and away from school, children, especially girls, were being taken out of school to tend to sick and dying parents, children who had lost their parents to AIDS weren't in school because they couldn't afford the school fees. It felt, in every instance, as though the education sector was under siege. In Zambia, they lost 1,967 teachers in 2001, over two thousand teachers in 2002; the Teacher's Colleges are graduating fewer than one thousand a year. In parts of Malawi, HIV-positive teachers are estimated at over thirty percent. How can education be sustained?

Or maybe the collapse of agriculture and education are happening simultaneously, and we fasten on agriculture simply because the human damage is visible and immediate. If you don't eat for five days, the consequence is far more dramatic than being out of school for five days. In Malawi they've done an analysis of the impact of AIDS on four different Ministries, and the erosion in each, in human terms, to a lesser or greater degree, is inescapable. It's necessary to recognize that even at a prevalence rate of fifteen or twenty percent, let alone thirty or thirty-five percent as in Botswana, Lesotho, Zimbabwe and Swaziland, the incessant, irreversible, cumulative death of so many productive members of society means, ultimately, that things fall apart. When Chinua Achebe wrote his novel of that title several decades ago, little did he know that it would be the mantra of whole societies. I wouldn't discount the possibility, ten or fifteen years down the road, of failed states.

Third, one of the saddest manifestations of a society coming apart at the seams, is the growing rate of sexual abuse of children and adolescents. I was frankly jolted by what we were told. Whether it was the plight of orphans in the mountains of Lesotho, or outreach workers telling gruesome stories, sotto voce, as we traveled in Zimbabwe, or the evidence we absorbed in Zambia, there seems little doubt that sexual assaults on children have reached shocking proportions. It's so bad in Zambia that a trio of women parliamentarians are actually introducing a private member's bill to counter "child defilement". The Director of the YWCA in Zambia told us that cases of sexual violation of children, reported to the Lusaka YWCA clinic, numbered 23 in 1998; 77 in 1999; 88 in 2000; 110 in 2001; 152 in the first ten months of 2002. And that's just in one of eleven clinics, and only the reported cases. Towards the end of this month, Human Rights Watch will release a powerful, heartbreaking monograph on the sexual abuse of girls in Zambia, and the link with HIV. There's something deeply, deeply wrong when children are the frequent victims of adult sexual violence.

It appears to happen to orphans especially. As they are moved from place to place, more and more distant from their origins, they become increasingly vulnerable to sexual abuse. Ironically, and bitterly, they also therefore become ever more vulnerable to HIV transmission.

Fourth, I've never before felt the impact of orphans so strongly. It struck me again that we have obvious ways of dealing with most other aspects of the pandemic, but dealing with the astronomic number of orphans is a new phenomenon for which the world has no evident solution. Public health has confronted and subdued terrible contagions of communicable disease at other moments in human history. One day, the same will be true for AIDS. But we've never before confronted the selective destruction of parents that leaves such a mass of orphans behind.

And it's necessary, I think, to recognize that the extended family, and the willing community, can never fully cope with the numbers. The result is the present and escalating reality of orphan street children, of orphan gangs, of orphan delinquency, as hordes of kids, torn from their familial roots, wander the continent, bewildered, lonely, disenfranchised from reality, angry, acting out, unable to relate to normal life. Some have already reached adulthood; they've had no love, no nurturing ... how do they bring up their own children? And in the meantime, they can be a high risk group, posing a collective threat to social stability.

Fifth, if women are at the center of the pandemic, as they are, acutely vulnerable to infection on the one hand, doing all the care-giving for the sick and the orphans on the other, we saw precious little evidence of efforts at women's empowerment, sexual autonomy or gender equality. And there was certainly no effort whatsoever to relieve their unfair share of the burden. In fact, male hegemony was ubiquitous. On my return trip later this month, I intend to focus on what is being done to imbed the human rights of women in each country, such that they can save their lives.

Finally, the issue of antiretroviral treatment came up constantly and everywhere. Every single group of People Living With HIV/AIDS pounded the demand home in unrelenting fashion. There is a crescendo of rage and desperation which governments will ignore at their peril. In Malawi, the prospect of 50,000 people eligible for treatment in the foreseeable future brings a strong quotient of hope. But in Zambia, the amorphous prospect of perhaps ten thousand people entering into treatment, over time, the eligibility criteria not yet known, prompts nothing but anger. And in Zimbabwe and Lesotho, where treatment is at the earliest stage of discussion, there is a festering despair among those who need it now.

What has changed is the maturity, vehemence and confidence of the organizations of People Living With HIV/AIDS. Time and again we met activists who know everything there is to know about CD4 counts and viral loads; they know the cost of generic drugs; they know about the treatment regimens; they know that WHO has undertaken to have three million people in treatment by 2005; they know that the rich members of society vault down to South Africa for treatment, while the poor remain helplessly behind; they know about Doha and intellectual property rights and the WTO; they know, from bitter experience, about all the false political promises. Increasingly, we're dealing with sophistication and determination in equal measure.

When I met with the group of People Living With HIV/AIDS in Lusaka, they presented me with a powerful and encyclopedic brief, a small part of which read as follows: "...for each day that passes without people accessing treatment we attend funerals. People die. We hear a hundred reasons for not providing people with treatment. For each reason given, lives are lost. The government must realize that it has a responsibility to provide health care for its people. Any government that fails to put in place measures to ensure the health of its citizens is not a government worth its name. Such governments should resign. If it does not do so, then people are justified to remove it by any means necessary. The right to life and dignity should not be a preserve of the rich and powerful.

"What we are seeing in Zambia is a microcosm of what is happening globally. The HIV/AIDS crisis is not a crisis of lack of resources. It is a crisis of lack of conscience. It is the obscene gap between the haves and the have-nots that is driving this holocaust ..."

That issue of the obscene gap brings me to the end of these notes, and to the beginning of 2003.

The crucial new component that emerged from the trip to Southern Africa was the role of the Global Fund. It is impossible to overstate how strongly people feel --- from Cabinet Ministers to People Living With HIV/AIDS --- that the Global Fund is the best vehicle we have to finance the struggle against the pandemic. Every country yielded the same questions: When will the money come? Does the Global Fund have enough money? Why don't governments contribute to it? What happens if it goes bankrupt?

The questions are germane. As I understand it, the Global Fund has enough resources to get through the next round of proposals at the end of this month, but then it faces the moment of truth. The Global Fund, after January, can be said to be in crisis.

It's legitimate to ask: what's wrong with this world? What's wrong with the rich countries? Why are they willing to jeopardize the integrity of the most hopeful financial instrument we have to combat the cruelest disease the world has ever seen?

But it gets worse. I want to say what we're all saying privately to each other. If, as some suggest, there is a war in Iraq come February, then the war will eclipse every other international human priority, HIV/AIDS included. In other words, if the United States, and the other members of the G7 don't augment their contributions to the Global Fund in the immediate future, we will be in desperate trouble. Wars divert attention, wars consume resources, wars ride roughshod over external calamities.

People living with HIV/AIDS are in a race against time. What they never imagined was that over and above the virus itself, there would be a new adversary, and that adversary would be a war.

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