[afro-nets] Stephen Lewis on women and HIV/AIDS

[Claudio Schuftan <claudio@hcmc.netnam.vn>]

Stephen Lewis on women and HIV/AIDS
-----------------------------------

Can't miss this one!

Claudio Schuftan
mailto:claudio@hcmc.netnam.vn

*********************************

Text of a speech by Stephen Lewis, UN Special Envoy for HIV/AIDS
in Africa, delivered at the University of Pennsylvania's Summit
on Global Issues in Women's Health, Philadelphia, April 26,
2005.

I well realize that this is a conference on women's global
health, and everything I'm about to say will apply to that ge-
neric definition. But the more I thought of the subject matter,
the more I want to use HIV/AIDS in Africa as a surrogate for
every international issue of women's health, partly because it's
what I know best; partly because it's an accurate reflection of
reality.

I've been in the Envoy role for four years. Things are changing
in an incremental, if painfully glacial way. It's now possible
to feel merely catastrophic rather than apocalyptic. Initiatives
on treatment, resources, training, capacity, infrastructure and
prevention are underway. But one factor is largely impervious to
change: the situation of women. On the ground, where it counts,
where the wily words confront reality, the lives of women are as
mercilessly desperate as they have always been in the last
twenty plus years of the pandemic.

Just a few weeks ago, I was in Zambia, visiting a district well
outside of Lusaka. We were taken to a rural village to see an
"income generating project" run by a group of Women Living With
AIDS. They were gathered under a large banner proclaiming their
identity, some fifteen or twenty women, all living with the vi-
rus, all looking after orphans. They were standing proudly be-
side the income generating project . a bountiful cabbage patch.
After they had spoken volubly and eloquently about their needs
and the needs of their children (as always, hunger led the lit-
any), I asked about the cabbages.. I assumed it supplemented
their diet? Yes, they chorused. And you sell the surplus at mar-
ket? An energetic nodding of heads. And I take it you make a
profit? Yes again. What do you do with the profit? And this time
there was an almost quizzical response as if to say what kind of
ridiculous question is that .. surely you knew the answer before
you asked: "We buy coffins of course; we never have enough cof-
fins".

It's at moments like that when I feel the world has gone mad.
That's no existential spasm on my part. I simply don't know how
otherwise to characterize what we're doing to half of humankind.

I want to remind you that it took until the Bangkok AIDS confer-
ence in 2004 --- more than twenty years into the pandemic ---
before the definitive report from UNAIDS disaggregated the sta-
tistics and commented, extensively, upon the devastating vulner-
ability of women. The phrase "AIDS has a woman's face" actually
gained currency at the AIDS conference in Barcelona two years
earlier, in 2002, and even then it was years late. Perhaps we
should stop using it now as though it has a revelatory dimen-
sion. The women of Africa have always known whose face it is
that's withered and aching from the virus.

I want to remind you that when the Millennium Development Goals
were launched, there was no goal on sexual and reproductive
health. How was that possible? Everyone is now scrambling to
find a way to make sexual and reproductive health fit comforta-
bly into HIV/AIDS or women's empowerment or maternal mortality.
But it surely should have had a category, a goal, of its own.
Interestingly, the primacy of women is rescued (albeit there's
still no goal) in the Millennium Project document, authored by
Jeffrey Sachs.

And while mentioning maternal mortality, allow me to point out
that this issue has been haunting the lives of women for genera-
tions. I can remember back in the late 90s, when I was oversee-
ing the publication of State of the World's Children for UNICEF,
and we did a major piece on maternal mortality and realized that
the same number of annual deaths --- between 500 and 600 hundred
thousand --- had not changed for twenty years. And now it's
thirty years. You can bet that if there was something called pa-
ternal mortality, the numbers wouldn't be frozen in time for
three decades.

I want to remind you that within the UN system, there's some-
thing called the Task Force on Women and AIDS in Southern Af-
rica. Permit me to tell you how it came about, and where it ap-
pears to be headed and I beg you to see this as descriptive
rather than self-indulgent.

In January of 2003, I traveled with the Executive Director of
the World Food Programme, James Morris, to four African coun-
tries beset by a combination of famine and AIDS: Zimbabwe, Zam-
bia, Malawi and Lesotho. We had surmised, at the outset, that we
would be dealing primarily with drought and erratic rainfall,
but in the field it became apparent that to a devastating ex-
tent, agricultural productivity and household food security were
being clobbered by AIDS. We were shocked by the human toll, the
numbers of orphans, and the pervasive death amongst the female
population. In fact, so distressed were we about the decimation
of women, that we appealed to the Secretary-General of the
United Nations to personally intervene.

And he did. He summoned a high level meeting on the 38th floor
of the UN Secretariat, with TV conferencing outreach to James
Morris in Rome and to the various UN agencies in Geneva, and af-
ter several agitated interventions, the Secretary-General struck
a Task Force on Gender and AIDS in Southern Africa, to be
chaired by Carol Bellamy of UNICEF.

If memory serves me, Carol Bellamy determined to focus on seven
of the highest prevalence rate countries: studies were done,
recommendations were made, costs of implementation were esti-
mated, monographs were published.. And here's what festers in
the craw: the funding for implementation is not yet available.
The needs and rights of women never command singular urgency..

There's an odd footnote to this. Within the last two months, a
number of senior students at the University of Toronto Law
School, compiled papers dealing with potential legal interven-
tions on a number of issues related to HIV/AIDS in Africa. One
of the issues was, predictably, gender. Not a single student,
over the course of several weeks, whether on the internet or
wider personal reading, came across the Secretary-General's Task
Force (although one student said that she had a vague recollec-
tion that such a thing existed). The Task Force findings are
clearly not something the UN promotes with messianic fervour.

I want to remind you that as recently as March, there was ta-
bled, internationally, the Commission on Africa, chaired by
Prime Minister Tony Blair, indeed established by Tony Blair. It
has received nothing but accolades, particularly for the analy-
sis and recommendations on Official Development Assistance, on
trade and on debt. The tributes are deserved.. The document goes
further down a progressive road than any other contemporary in-
ternational compilation.

With one exception. I want it to be known --- because it's not
known --- that the one aspect of this prestigious report which
fails, lamentably, is the way in which it deals with women.
There is the occasional obligatory paragraph which signals that
the Commission recognizes that there are two sexes in the world,
but by and large, given that women are absolutely central to the
very integrity and survival of the African continent, they are
dealt with as they are always dealt with in these auspicious
studies: at the margins, in passing, pro forma. And it's not
just HIV/AIDS; it's everything, from trade to agriculture to
conflict to peace-building.

Maybe we should have guessed what was coming when there were
only three women appointed out of seventeen commissioners. They
had the whole world to choose from, and they could find only
three women . it doesn't even begin to meet the Beijing minimum
target of thirty percent. We're not just climbing uphill; we
might as well be facing the Himalayas.

I want to remind you, finally, of the arrangements we've made
within the United Nations itself. HIV/AIDS is the worst plague
this world is facing; it wrecks havoc on women and girls, and
within the multilateral system, best-placed to confront the pan-
demic, we have absolutely no agency of power to promote women's
development, to offer advice and technical assistance to govern-
ments on their behalf, and to oversee programmes, as well as
representing the rights of women. We have no agency of authority
to intervene on behalf of half the human race. Despite the man-
tra of 'Women's Rights are Human Rights', intoned at the Inter-
national Conference on Human Rights in Vienna in 1993; despite
the pugnacious assertion of the rights of women advanced at the
Cairo International conference in 1994; despite the Beijing Con-
ference on women in 1995; despite the existence of the Conven-
tion on the Elimination of Discrimination against Women, now
ratified by over 150 countries; we have only UNIFEM, the UN De-
velopment Fund for Women, with an annual core budget in the vi-
cinity of $20 million dollars, to represent the women of the
world. There are several UNICEF offices in individual developing
countries where the annual budget is greater than that of
UNIFEM.

More, UNIFEM isn't even a free-standing entity. It's a depart-
ment of the UNDP (the United Nations Development Programme). Its
Executive Director ranks lower in grade than over a dozen of her
colleagues within UNDP, and lower in rank than the vast majority
of the Secretary-General's Special Representatives.

More still, because UNIFEM is so marginalized, there's nobody to
represent women adequately on the group of co-sponsors convened
by UNAIDS. You see, UNAIDS is a coordinating body: it coordi-
nates the AIDS activities of UNICEF, UNDP, the World Bank,
UNESCO, UNFPA, WHO, UNDCP (the Drug Agency), ILO and WFP. UNIFEM
asked to be a co-sponsor, but it was denied that privilege.

So who, I ask, speaks for women at the heart of the pandemic?
Well, UNFPA in part. And UNICEF, in part (a smaller part). And
ostensibly UNDP (although from my observations in the field,
"ostensible" is the operative word).

Let me be clear: what we have here is the most ferocious assault
ever made by a communicable disease on women's health, and there
is just no concerted coalition of forces to go to the barricades
on women's behalf. We do have the Global Coalition on Women and
AIDS, launched almost by way of desperation, by some interna-
tional women leaders . like Mary Robinson, like Geeta Rao Gupta,
but they're struggling for significant sustainable funding, and
their presence on the ground is inevitably peripheral.

I was listening to the presentations at the dinner last night,
and thinking to myself, when in heaven's name does it end? Ob-
stetric fistula causes such awful misery, and isn't it sympto-
matic that one of the largest --- perhaps the largest --- con-
tributions to addressing this appalling condition has come not
from a government but from Oprah Winfrey?

I was noting, just in the last 48 hours, that Save the Children
in the UK has released a report pointing out that fully half of
the three hundred thousand child soldiers in the world are
girls. And if that isn't a maiming of health --- in this case
emotional and psychological health --- then I don't know what
is. And perhaps you notice the rancid irony: women have achieved
parity on the receiving end of conflict and AIDS, but nowhere
else.

Female genital mutilation, the contagion of violence against
women, sexual violence in particular, rape as a weapon of war --
- Rwanda, Darfur, Northern Uganda, Eastern Congo --- marital
rape, child defilement, as it is called in Zambia, sexual traf-
ficking, maternal mortality, early marriage . I pause to point
out that studies now show that in parts of Africa, the preva-
lence rates of HIV in marriage are often higher than they are
for sexually active single women in the surrounding community;
who would have thought that possible? .

The overall subject matters you're tackling at this conference
strike to the heart of the human condition. All my adult life I
have accepted the feminist analysis of male power and authority.
But perhaps because of an acute naiveté, I never imagined that
the analysis would be overwhelmed by the objective historical
realities. Of course the women's movement has had great suc-
cesses, but the contemporary global struggle to secure women's
health seems to me to be a challenge of almost insuperable di-
mension.

And because I believe that, and because I see the evidence month
after month, week after week, day after day, in the unremitting
carnage of women and AIDS --- God it tears the heart from the
body. I just don't know how to convey it. These young women, who
crave so desperately to live, who suddenly face a pox, a scourge
which tears their life from them before they have a life. Who
can't even get treatment because the men are first in line, or
the treatment rolls out at such a paralytic snail's pace. Who
are part of the 90% of pregnant women who have no access to the
prevention of Mother to Child Transmission and so their infants
are born positive. Who carry the entire burden of care even
while they're sick, tending to the family, carrying the water,
tilling the fields, looking after the orphans. The women who
lose their property, and have no inheritance rights, and no le-
gal or jurisprudential infrastructure which will guarantee those
rights. No criminal code which will stop the violence. Because I
have observed all of that, and have observed it for four years,
and am driven to distraction by the recognition that it will
continue, I want a kind of revolution in the world's response,
not another stab at institutional reform, but a virtual revolu-
tion.

Let me, therefore, put before the conference, two quite prag-
matic responses which will make a world of difference to women,
and then a much more fundamental proposal.

Many at the conference will not know this, but the Kingdom of
Swaziland recently made history when it received from the Global
Fund on AIDS, Tuberculosis and Malaria, money to pay a stipend -
-- modest of course, but of huge impact --- to ten thousand
caregivers, looking after orphans, the vast majority being
women. The Swaziland National AIDS Commission (that may not be
the precise name), reeling from the exploding orphan population,
made the proposal for payment to the Global Fund, and it swept
through the review process with nary a word. The amount is
roughly $30/month, or a dollar a day . not a lot to be sure, but
clearly enough to make a great difference.

My recommendation is that this conference orchestrate the writ-
ing of a letter, to be signed by people like Mary Robinson,
Geeta Rao Gupta, and prominent women from academia, and have
that letter sent to every African Head of State and Minister of
Health, urging them to ask for compensation for caregivers, us-
ing the Swaziland precedent.

And the second pragmatic proposal? I would recommend, with every
fibre of persuasion at my command, that the conference collabo-
rate directly with the International Partnership on Microbi-
cides, whose remarkably effective Executive Director, Dr. Zeda
Rosenberg, will be here on campus on Thursday. She will tell you
what she needs and how to go about getting it. The prospect of a
microbicide, in the form of a gel or cream or ring, which will
prevent infection, while permitting conception --- the partner
need not even know of its presence --- can save the lives of
millions of women. The head of UNAIDS, Dr. Peter Piot, who will
be known to many of you, recently suggested that the discovery
of a microbicide may be only three to four years off. That's al-
most miraculous: short of a vaccine --- and we must never stop
the indefatigable hunt for a vaccine --- a microbicide can
transform the lives of women, and dramatically reduce their dis-
proportionate vulnerability. What's needed is science and money.
You can help with both.

On the more fundamental front, I want to suggest that the proc-
ess of UN reform, now urgently underway, be confronted with ar-
guments that spare no impatience.

I have heard the President of Botswana use the word extermina-
tion when he described what the country is battling. I have
heard the Prime Minister of Lesotho use the word annihilation
when he described what the country is battling. I sat with the
President of Zambia and members of his cabinet not long ago,
when he used the word holocaust to describe what the country is
battling.

The words are true; there's no hyperbole. The words apply, over-
whelmingly, to women. That being the case, there has to be a
proportionate response. It seems to me that the response should
proceed on two simultaneous fronts.

First, let me say that I was thrilled by the suggestion from
Mary Robinson, and others, that Penn State act as a kind of co-
ordinator for the surprising numbers of initiatives, unrelated
one to the other, occurring under the auspices of many universi-
ties. The practice of twinning, the practice of using various
Faculties as training centres, the practice of American and Ca-
nadian universities bridging the gap in capacity until the de-
veloping country can take over. All of that is to the good, and
it needs coordination. But there's more, I would submit, for you
to do. Within multilateralism, that is within the UN system,
wherein lies the best hope for leadership, there must be a
change in the representation of women. There must emerge, for
Women's Global Health, and certainly for HIV/AIDS, an agency, an
organization, a powerful Think Tank, whatever the entity --- it
can start on the outside, and then claim equal presence amongst
the co-sponsors of UNAIDS, and thrust its advocacy upon the Se-
cretariat, the Agencies, the member states, in unprecedented
volume and urgency. Nor does this entity confine itself solely
to women's global health, although that is the entry point. It
insists on the 50% rule. Just start your evidence-gathering by
identifying the numbers of senior women, agency by agency, se-
cretariat department by secretariat department, diplomatic mis-
sion by diplomatic mission, and when you've recovered from the
shock of learning that the multilateral citadel knows nothing of
affirmative action, then begin your unrelenting advocacy. This
must become a movement for social change. It needs leadership.
Why not this University, why not this conference? And let me em-
phasize; there's nothing limiting about this concept. We're
looking towards the day when governments are finally made to un-
derstand that women constitute half of everything that affects
humankind, and must therefore be engaged in absolutely every-
thing. Why would it not be possible to build a movement, commit-
ted to the rights of women, in the first instance amongst nurs-
ing and medical faculties across the world, and take the world
by storm? You have resources, knowledge and influence available
to no others. The terrible problem is that you've never mar-
shalled your collective capacities.

Second, a similar movement must be directed, I would submit, to
Africa itself. I'm hesitant here, because there are enough neo-
colonial impulses around without my being presumptuous in making
recommendations for Africa, and indeed for women. But I must
bring myself to say what I know to be true: the African leader-
ship, at the highest level, is not engaged when it comes to
women's health. There's so much lip service; there's so much pa-
tronizing gobble-de-gook. The political leadership of Africa has
to be lobbied with an almost maniacal intensity on the issues of
this conference, or nothing will change for women.

That, too, will take a monumental effort. In my fantasies, I see
a group of African women, moving country to country, President
to President, identifying violations of women's health specific
to that country, and demanding a change so profound that it
shakes to the root the gender relationships of the society. I
know that African women leaders like Wangari Matthai and Gracia
Machel and many prominent cabinet ministers, committed activists
and professionals think in those terms; what is needed is a mas-
sive outpouring of international support from their sisters and
brothers on the planet.

I'm 67 years old. I'm a man. I've spent time in politics, diplo-
macy and multilateralism. I know a little of how this man's
world works, but I still find much of it inexplicable. I don't
really care anymore about whom I might offend or what line I
cross: that's what's useful about inching into one's dotage.

I know only that this world is off its rocker when it comes to
women. I must admit that I live in such a state of perpetual
rage at what I see happening to women in the pandemic, that I
would like to throttle those responsible, those who've waited so
unendurably long to act, those who can find infinite resources
for war but never sufficient resources to ameliorate the human
condition.

I'm excited of course about the Millennium Development Goals,
and I'm equally excited that with the leadership of the British,
this next G8 Summit in the summer might just possibly spawn a
breakthrough. And there are countless numbers of people working
to that end.

But I have to say that I can't get the images of women I've met,
unbearably ill, out of my mind. And I don't have it in me either
to forgive or to forget. I have it in me only to join with all
of you in the greatest liberation struggle there is: the strug-
gle on behalf of the women of the world.