AFRO-NETS> Peter Piot's speech to President of World Bank

[Claudio Schuftan <aviva@netnam.vn>]

Peter Piot's speech to President of World Bank
----------------------------------------------
 
AIDS: The Need for an Exceptional Response to an Unprecendented 
Crisis 
 
A Presidential Fellows Lecture
 
Speech by Peter Piot,
Executive Director of UNAIDS and Under Secretary-General of the 
United Nations
 
20 November 2003
Preston Auditorium, World Bank
 
Mr President,
 
Thank you for inviting me to deliver this lecture, but above 
all, thank you for your leadership on AIDS - it goes back to a 
time when working on AIDS was certainly not part of the global 
agenda as it is today.
 
At the outset, I would also like to pay tribute to Debrework 
Zewdie and all her colleagues of the Global HIV/AIDS Programme 
of the World Bank Group and the Multi-Country HIV/AIDS Programme 
(MAP) for their groundbreaking work on AIDS in the Bank, and for 
ensuring that the collaboration between the UNAIDS Secretariat 
and our Cosponsor the World Bank is a mutually beneficial one.
 
It is exactly 20 years ago that I started investigating AIDS in 
Kinshasa, Zaire. I can recall the exact moment I realized what 
we were up against. When I saw all these young men and women dy-
ing, emaciated in Mama Yemo Hospital, I became convinced that 
this disease would be predominantly heterosexually transmitted, 
that therefore it would become an epidemic, that Africa and the 
world were in trouble, and that it would change my life.
 
A few years later, in 1987, my relationship with the Bank 
started. I was determined to convince the Bank to confront AIDS, 
because it had become clear to me that without your financial 
and intellectual muscle, African countries could not confront 
AIDS.
 
It was a total failure - I used both the wrong vocabulary and 
the wrong arguments, and did not know how to push an agenda in-
side the institution.
 
It is therefore profoundly significant for me and a great hon-
our, that today, I can address you in this Presidential lecture.
 
Where are we? I am not here today to inundate you with numbers 
on AIDS we will release some new global estimates on HIV next 
week for World AIDS Day. I am here today to alert you of an un-
precedented crisis. This crisis is not about numbers, it is 
about human suffering and the failings of development.
 
Let me describe the situation: 
 
HIV infection is not levelling off:
New infections continue to grow as prevention efforts remain 
small scale and millions of people need treatment. Rapid global-
isation of the epidemic is also evident. The fastest growing 
epidemic is in Eastern Europe. Particularly worrisome is the 
AIDS situation in Russia. The Caribbean is still experiencing 
high levels of infection. There is potential for the epidemic to 
explode in China, India and Indonesia. Even in western Africa 
where infection rates were relatively low, there is now a sharp 
increase, such as in Burkina Faso, Cameroon and Nigeria.
 
Increased feminisation of the epidemic:
Every year we see an increase in the number of women infected 
with HIV. Globally, more than half of all persons infected be-
tween the ages of 15 to 49 are women. In Africa, the proportion 
is reaching 60%. Because of gender inequality, women living with 
HIV/AIDS often experience more stigma and discrimination. And 
since women are the main care givers and source of household la-
bour, their illness means the collapse of family community care 
systems and household production. At the same time, society 
needs to increase its efforts in preventing infection among 
women, which would then also prevent mothers from being infected 
and eventually prevent children from being orphaned.
 
AIDS has created vast secondary impacts:
We are already beginning to see the profound impacts these enor-
mous demographic shifts are having on the fabric of societies. 
Consider those left behind when adults die from AIDS: the mil-
lions of orphans - they will be 15% of all children in the worst 
affected countries by 2010, adding to the growing number of 
street children and child headed households.
 
Most worrisome is the impact of AIDS on the capacity of the 
state and private sector to deliver services because of illness 
and death among service providers. This in turn contributes to 
failings of development. AIDS creates economic insecurity which 
could also cause growing local, national and international in-
stability. This includes an increasing threat to the services 
provided by police and military forces. This is why it was so 
appropriate that the UN Security Council in January 2000 took 
the unprecedented step in debating AIDS - on Monday I addressed 
the Council again on HIV in peacekeeping operations.
 
A time of great opportunity
 
Ladies and Gentlemen,
 
There are three clear signs the global response to AIDS is en-
tering a new phase - a time of great opportunity to defeat this 
epidemic.
 
First, there is growing political momentum to respond to AIDS - 
never before seen at such a high level for a health problem, and 
indeed rarely for any international development issue. 
 
Today, when global leaders meet, AIDS is on their agenda. As a 
matter of fact, this afternoon in London, President George W. 
Bush and Prime Minister Tony Blair announced they will greatly 
intensify their collaboration on AIDS. But let's face it: many 
countries, particularly outside sub-Saharan Africa and the Car-
ibbean - and many international institutions - still do not take 
AIDS as seriously as they should. There remains a marked deficit 
in leadership which goes beyond politically correct speeches - 
if words would do it, AIDS would be gone by now! Yet real lead-
ership is priceless and requires the courage and vision for gov-
ernments to go against the stream of public opinion if that is 
what is needed in this epidemic associated with sex, drug use 
and stigma and shame.
 
Second, there is a discernable momentum of evidence. The hope 
that we can bring the epidemic under control is being bolstered 
by growing evidence it is feasible. We are seeing more and more 
instances of prevention success on all continents. And with the 
fall in prices of antiretroviral medicines, the scaling up of 
effective HIV treatment is now a real possibility, driving a 
number of national and international initiatives forward, in-
cluding the 3 by 5 campaign to provide 3 million people with 
antiretroviral treatment by 2005. We must not underestimate the 
extent to which these efforts are bringing hope amid the despair 
AIDS has caused.
 
Third, there is a real momentum in greatly increased resources 
going to AIDS from both donors and from the governments of de-
veloping countries. The World Bank has shown the way, together 
with several of the major donor countries. The Bank has played a 
leading role in the financing of AIDS programmes and in advocacy 
on AIDS as a development issue. In addition, the Bank's innova-
tive Multi- Country HIV/AIDS Programme has pioneered new mecha-
nisms to support local authorities and NGOs in Africa and the 
Caribbean. I saw it with my own eyes this year in Kenya and 
Ethiopia. It may surprise even you to learn that there are more 
than a thousand community groups in Kenya and 5000 villages in 
Ethiopia receiving World Bank support. The Bank has developed 
the disbursement and accountability mechanisms through existing 
national structures that make this possible.
 
Mr President,
 
UNAIDS is proud to have the World Bank as one of its nine co-
sponsors. Together, we are spearheading UN reform and together 
are responsible to deliver 5 key functions: 
* Provide leadership and advocate for effective action
* Provide strategic information required to guide the efforts of
  partners
* Track, monitor and evaluate the epidemic and the response
* Engage civil society and businesses
* Mobilize financial, technical and political resources
 
This week's decision by the US Congress to allocate 2.4 billion 
US dollars to international AIDS activities in the coming budget 
year follows the commitment of President Bush in his 2003 State 
of the Union address to provide 15 billion dollars over the next 
five years. South Africa, the country with the largest number of 
people living with HIV/AIDS in the world has not only tripled 
its budget for AIDS, yesterday it has also accepted the plan to 
roll out universal access to treatment.
 
However, we are still falling short of the minimum $10 billion 
needed annually to mount an effective, comprehensive response in 
low and middle income countries. But let's also recall that when 
UNAIDS started in 1996, barely $200 million was being spent on 
global AIDS efforts. This year, we estimate it will be $4.7 bil-
lion, including resources from the Global Fund to fight AIDS, TB 
and Malaria and the World Bank.
 
What we have learned from the response so far?
 
AIDS is undoubtedly a major problem, but it is a problem with a 
solution. Worldwide experience in responding to AIDS has been 
accumulated over the last 20 years, resulting in a body of ef-
fective strategies against AIDS. 
 
Some developing nations have shown real successes in the re-
sponse to AIDS - particularly when it comes to preventing new 
HIV infections among adolescents and young adults, less so in 
offering antiretroviral therapy. Most notable are Uganda, Sene-
gal, Brazil, Cambodia, Thailand, and a growing number of cities 
in East Africa, such as Kigali and Addis Ababa. However, these 
few successes need to be sustained.
 
Let me highlight 5 key elements, which I believe can be found in 
every effective response to date and which should underpin our 
efforts going forward.
 
First, leadership. No money can replace courageous leadership at 
all levels and the response to AIDS needs to be led from the 
highest level in the state.
 
Second, comprehensiveness. Success comes from sustained and com-
prehensive approaches on prevention, care, treatment and impact 
mitigation. A commitment by all states in the world to acceler-
ate and scale up implementation of a comprehensive response was 
reached at the UN General Assembly Special Session on AIDS in 
June 2001. This led to the new UN initiative led by WHO and 
UNAIDS to get 3 million people on treatment by 2005.
 
Third, multisectorality and inclusiveness. This epidemic cannot 
be brought under control by the health sector alone - we need 
the broad engagement of all sectors and people of all walks of 
life including people living with HIV/AIDS and religious lead-
ers.
 
Fourth, breaking down stigma and discrimination. Stigma and dis-
crimination are major obstacles in encouraging people to take 
advantage of prevention and care services. As Mary Robinson put 
it so forcefully in her Presidential lecture two years ago, AIDS 
clearly demonstrates that promoting human rights in development 
is cost effective.
 
Finally, act now, or pay later. Africa has learned this lesson 
the hard way. Denial and ignorance do not reverse this epidemic. 
It is a lesson that the countries of Asia and Eastern Europe 
have got to take to heart now.
 
We still have much to learn on the ever changing challenges in 
AIDS: we are also aware that we still need to understand how to 
respond to the ramifications of enormous numbers of orphans, how 
to reverse AIDS-induced food insecurity, how to implement anti-
retroviral therapy programs on a very large scale, how massive 
foreign aid will affect macroeconomic and fiscal policies, and 
how we can reverse the crippling effect of AIDS on countries' 
abilities to govern themselves effectively.
 
What are the key challenges?
 
But you know as well as I that money alone will solve little. If 
we are to succeed, we must come to grips with three overriding 
challenges. 
 
The first is capacity. One way in which the epidemic drives a 
vicious circle is by striking hardest at those countries with 
the weakest capacity for implementation. In many nations, AIDS 
is now depleting capacity faster than it can be replenished--a 
macabre mirror of what it does to the immune system. Already we 
face an unparalleled crisis in human resources, and it is only 
going to get worse. We cannot possibly keep pace by relying on 
traditional tools. Many private firms have figured this out, and 
are taking unprecedented steps to safeguard their human invest-
ments. We need to do the same. We need to broaden our vision of 
how we approach capacity, combining vital short-term measures 
with long-term capacity development.
 
How can we do this?
 
We can begin by preserving existing capacity. In other words, 
keep people alive. This is why providing HIV treatment is so 
critical. In the hard-hit countries, nothing else--nothing--will 
so directly or quickly arrest the plunge in public capacity as 
this single measure. Antiretroviral therapy has reduced mortal-
ity by 80% in Brazil--what other capacity-building measure can 
show such a return?
 
We must then call in reinforcements. In many countries, there 
are vast cadres of trained specialists who are sitting idle in 
the struggle against HIV/AIDS. Kenya, for instance, is said to 
have four thousand nurses who are no longer practicing. Can 
there be any higher priority for the nation than to lure these 
front-line workers back into service?
 
We can also expand our concept of capacity. In times of crisis, 
many countries have developed non-conventional capacity to com-
pensate for formal skills gaps. This does not require special-
ists. The simple knowledge and services they can provide have 
helped countries make far faster gains in health and education 
than they would have by waiting for formal capacity to develop. 
In HIV/AIDS, so much of what makes for good practice requires 
little or no technical knowledge. Enlisting and empowering a 
wider range of talents and untapped resources in the community - 
particularly people living with HIV/AIDS - would both swell our 
numbers and help break the silence on AIDS.
 
And over the long term, of course, we must help countries build 
strong foundations to sustain capacity. That is a long-standing 
challenge of development, but it has taken on new urgency in the 
age of AIDS. I must tell you that we in the donor community bear 
much of the blame for this. Weak capacity is one of the most 
crippling legacies of the past 20 years of AIDS efforts, most of 
which paid little mind to building true national institutions. 
We cannot repeat that mistake. In high-prevalence countries, 
AIDS calls for a complete rethinking of how skills will be 
built, retained, and sustained. In low-prevalence countries, it 
underlines the importance of aggressive prevention efforts, to 
preserve the vast investments in human and institutional devel-
opment. Aren't we paying the price now for decades of develop-
ment donor practice?
 
In my view, any donor AIDS program that neglects the capacity 
dimension should be rejected. It is no answer to fly in experts 
from rich countries, or to focus only on hardware and thereby 
undermining capacity even more. This job is bigger than any sin-
gle agency, so no one should feel at liberty to shirk their 
share of the burden.
 
The second overriding challenge is harmonization and joint ac-
countability. This, too, is fast becoming a development cliché, 
but it is no less true for that. In AIDS as elsewhere, program 
managers are often little more than data processors for donors, 
spending obscene amounts of time trying to satisfy dozens of du-
plicative reporting requirements, and hosting repetitive review 
missions month after month. Donor driven agendas are raising 
transaction costs and reducing program effectiveness. It is a 
bit rich for donors to complain of absorptive capacity when they 
are the ones absorbing much of it.
 
It is time for donors of all types -- multilateral, bilateral, 
philanthropic -- to formally agree to work together under na-
tional leadership. I call this the "three ones." One national 
AIDS strategy that drives alignment of all partners; one na-
tional AIDS authority to coordinate it, and one nationally-owned 
monitoring and evaluation system to serve the needs of all. Here 
we are making progress. Kenya now hosts regular joint program 
reviews, in which all donors take part. In Malawi, eight donors 
are supporting the national AIDS program in a unified way, and 
four of them are even pooling their funds -- including the World 
Bank. We need to make such common cause in every country so the 
officials entrusted with AIDS can spend their time contending 
with the pandemic, not paperwork.
 
This is not just important for practical reasons. It is also a 
means of acknowledging and enforcing the joint accountability 
that all of us share for what happens on our watch. What on 
earth can donors be thinking when they report that "their" pro-
ject succeeded in a country where the national program simulta-
neously fell apart? Where a country fails, all of us have 
failed. This means we must stop planting flags and set aside 
childish hopes of instant gratification, such as producing re-
markable results by the end of the next fiscal quarter. This is 
a generation-long struggle, not an invitation to a quick fix. We 
must instead take on the politically difficult challenge of im-
proving our modalities of support, as this year's World Develop-
ment Report so persuasively shows. Let us think programmes, not 
projects. Let us act as seamlessly as possible. And let us take 
the long view.
 
If we succeed, there will be plenty of credit to go around. In 
the river blindness control programme, dozens of organizations 
joined forces, and all of them today deservedly share the glory 
of having saved millions.
 
If we fail -- especially by tripping over ourselves -- we and 
our institutions will all be held accountable, and history will 
rightly consign us to disgrace. And what happens to our reputa-
tion will pale beside what will happen to tens of millions of 
people around the globe.
 
The third great challenge -- and the most daunting -- is the ex-
ceptionalism of AIDS. I don't normally use such words, but 
"exceptional" is the only word that fits. AIDS stands almost 
alone in human experience. Many diseases and natural disasters 
create their own brutal equilibrium, a self-regulating mechanism 
that eventually enables society to cope, if not to overcome. 
AIDS, thus far, seems different.
 
Virtually all its impacts serve to weaken our defenses and ac-
celerate its spread, not to limit it. By selectively killing 
young adults, AIDS removes the keystone of developing societies. 
The surviving children are less likely to be in school, well 
nourished, or properly socialized. This makes them more suscep-
tible to the very situations that enable HIV to spread, and so 
the circle turns. Moreover, because it preys on the most private 
human behavior and stays invisible for years, it has silenced us 
from acting. In short, AIDS has rewritten the rules.
 
After long reflection, I have concluded that to prevail, we, 
too, must rewrite the rules. I once believed that it would be 
enough for us simply to do more, or do it better. I now believe 
we have to act differently as well. An exceptional threat de-
mands exceptional actions. As Abraham Lincoln once remarked, 
"The dogmas of the quiet past will not work in the turbulent fu-
ture. As our cause is new, so we must think and act anew."
 
I believe the time has come to take exceptional action in the 
way we finance the response to HIV/AIDS. For example, when I 
hear that countries are choosing to comply with medium-term ex-
penditure ceilings at the expense of adequately funding AIDS 
programs, it strikes me that someone isn't looking hard enough 
for sound alternatives. I recognize that such principles are in 
place for good reason, and by no means am I urging countries to 
act in ways that would merely deepen their economic woes. But 
surely there must be means of accommodating vast new inflows 
without stirring economic demons. The Bank must agree, since you 
have been arguing so eloquently for a dramatic increase in de-
velopment aid. And this is the one institution -- along with 
your sister across the street -- that can show a new way on is-
sues such as this. For countries emerging from conflict, the 
Bank has pioneered a careful program of exceptions, running a 
calculated risk on the grounds that inaction would be riskier 
still. Let us now do something similar for AIDS, a risk far 
greater than conflict for many countries.
 
Above all, every community and every country needs to rewrite 
the rules of how it deals with those sensitive issues at the 
heart of the epidemic -- sex, adultery, homosexuality, prostitu-
tion, drug use, blood sales, rape, stigma, gender, inequality. 
Each community needs to find its own language for addressing 
these painful truths. This is already happening in many places 
around the world, with encouraging results. But what is now ex-
ceptional needs to become commonplace. Nothing spreads HIV 
faster than silence.
 
Where do we go from here?
 
So how can we get our minds around the greatest natural chal-
lenge ever to confront humanity? I would propose that we look to 
the future. Twenty years from now, what can we expect from the 
epidemic, and what should we expect from ourselves?
 
>From AIDS, I can only say that we should expect the unexpected. 
Frankly, the virus has made fools of us at every turn. Ten years 
ago, the World Development Report forecast a worst-case scenario 
for Africa of two million new HIV infections per year by 2000. 
But by 1999, it had already hit four million. Globally, this 
year the number of new infections will be greater than the total 
number of HIV/AIDS cases there were worldwide in 1987, the year 
of the first World AIDS Day. Almost no predictions have proven 
too pessimistic in practice. What the epidemic will do next is 
beyond our power to say.
 
What lies entirely within our power is how we respond. At first 
glance, AIDS seems to create a dilemma of managing under uncer-
tainty for the vast part of the developing world where it is 
only getting started. If you don't know how much risk you face, 
it's hard to know how much to invest in guarding against it.
 
But I would argue the opposite. This is not a dilemma -- it's an 
opportunity. For AIDS is, more than anything else, an invitation 
to redouble our efforts in development. Poverty, ignorance, un-
employment, and inequality are the handmaidens of the epidemic. 
They help spread HIV, and AIDS, in turn, undermines development. 
Already in Africa, hopes of reaching most of the Millennium De-
velopment Goals have been dashed because of AIDS.
 
By the same token, however, most of what is good for development 
is good for defeating HIV/AIDS, and vice-versa. Children who 
stay in school are at lower risk of becoming infected. A vibrant 
rural sector creates local jobs that keep families intact. Gen-
der equality creates security and opportunity for women, reduc-
ing the number who must resort to commercial sex work for sur-
vival. Twenty years on, if we have helped the developing world 
to achieve these goals, I can assure you that AIDS will be in 
retreat. Indeed, the epidemic has created an opening for us to 
do more in development. In Africa, AIDS inspired a commitment by 
leaders two years ago to devote 15% of their national budgets to 
health--a far greater portion than most had ever spent before. 
Globally, AIDS has given rise to a new Global Fund which ad-
dresses other mass killers as well. And the outcomes of AIDS 
programs are serving the development cause more broadly.
 
For instance, community-driven AIDS efforts have helped nourish 
social capital that is now having beneficial effects in areas 
far beyond the epidemic.
 
This great institution, and the larger UN family which we serve, 
are living reminders of the vision of those who resolved half a 
century ago to prevent another world war by eradicating the 
causes that would give rise to it. They recognized the interna-
tional system was irrevocably broken, and proceeded to rewrite 
the rules of trade, of aid, and of collective security forever.
 
Today, with more people already infected than died in both world 
wars, and no end in sight, it should be clear to all that the 
challenge confronting us is no less compelling. As a virus, HIV 
is likely to be with us for a very long time. But how far it 
spreads and how much damage it does are entirely up to us. We 
should always ask the question: do we in the organization and 
does our action pass the AIDS test?
 
Let us recognize the root causes of this tragedy, let us treat 
those already afflicted, let us prevent new infections, and let 
us remake what is no longer valid in the global system of our 
own era. Twenty years from now, let it be said of us that we not 
only saved a second generation from this scourge, but that we 
planted the seeds for a world where nothing like AIDS could ever 
run rampant again.
 
Let me conclude, Mr President, by quoting from your speech in 
Dubai: "It's time to take a cold, hard look at the future."
 
That future will look much bleaker certainly in Africa and the 
Caribbean, but also in countries in Asia and Eastern Europe if 
we don't take exceptional actions immediately.
 
The stakes are high,
 
The agenda is clear,
 
AIDS forces us to do business differently - this is not only 
about personal behaviour change, but also about institutional 
behaviour change.
 
AIDS is one of the great moral causes of our time. We can save 
lives and reduce suffering. Effectively rising to the challenge 
will be a key test for the international system, including the 
World Bank.
 
Thank you.

--
To send a message to AFRO-NETS, write to: afro-nets@healthnet.org
To subscribe or unsubscribe, write to: majordomo@healthnet.org
in the body of the message type: subscribe afro-nets OR unsubscribe afro-nets
To contact a person, send a message to: afro-nets-help@healthnet.org
Information and archives: http://www.afronets.org