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Africa: AIDS & Financial Abstinence
Feb 11, 2004 (040211)
(Reposted from sources cited below)
"You might think that the industrial nations would compensate for
a decade of financial abstinence by embracing the Global Fund as
the obvious vehicle for resource-constrained countries. But that
hasn't been the case. At this moment in time, the Fund is several
hundred million dollars short for this year, and almost three
billion short for next."
Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa, went on to
note that the Bush administration has only asked for $200 million
for the Global Fund for 2005. This is $350 million less than the
sum approved by Congress for 2004 and a full billion dollars short
of what would be the fair contribution of the United States.
This issue of AfricaFocus Bulletin contains the text of Lewis's
February 8 speech in San Francisco to the 11th Conference on
Retroviruses and Opportunistic Infections. While targetting the
continued "financial abstinence" of the rich countries in the face
of millions of deaths, the outspoken envoy also denounced the
absence of any real change in women's lives despite the rhetoric of
Another AfricaFocus Bulletin today contains excerpts from reports
on progress on AIDS treatment in Botswana and new doubts about
political will to implement treatment plans in South Africa.
Many thanks to those of you who have already sent in your voluntary
subscription payment to support AfricaFocus Bulletin. If you have
not yet made such a payment and would like to do so, please visit
http://www.africafocus.org/support.php for details.
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
Keynote Lecture by Stephen Lewis at the 11th Conference on
Retroviruses and Opportunistic Infections
United Nations (New York)
February 8, 2004
San Francisco, CA
Mr. Chairperson, Ladies and Gentlemen: I want you all to know how
much I appreciate the invitation to speak to this auspicious
gathering, even though I stand before you with no scientific
Allow me to set the stage for my remarks in this fashion: last
Monday night, in London, I was privileged to attend a preview
showing for the United Kingdom of the film Angels in America.
Doubtless there are those in this audience who have seen it; it's
a brilliant piece of film-making. It deals, as you know, with the
early days of AIDS in America, and the dehumanizing process of
death of one of the male leads, mid-way through the movie, is as
harrowing and numbing an episode of horror as I've ever seen in the
cinema. The audience was laid waste. It was of course a faithful
rendering of the way death from AIDS used to be in this country,
and is no longer. But I must say that I sat in the theatre,
emotionally clobbered, and thought to myself "That's the way people
die in Africa, now, at this very moment, day upon day upon day".
How do we get the world to understand?
I've been in the UN Envoy role now for something more than two and
a half years. You will understand when I say that to visit Africa
repeatedly, and to observe the unraveling of so much of the
continent, is heartbreaking. There are simply no words, in the
lexicon of non-fiction, to describe the human carnage. I have
heard, from African leaders and social commentators alike, language
that startles and terrifies: 'holocaust', 'genocide',
'extermination', 'annihilation', and I want to say that on the
ground, at community level, watching the agony, the language is not
hyperbolic. And what makes it even worse is the tremendous
resilience and courage and effort and compassion with which the
entire population, especially the women, attempt to withstand the
The individual and collective work, therefore, of people attending
this conference, is truly invaluable. That's not a flippant or
gratuitous remark: it's important for everyone here to recognize
that you're part of the most significant battle against a disease
that has ever been waged in human history - and when you're
consumed in your laboratories, or wrestling with the esoterica of
science, at the end of that long exploratory road there lies the
whole fabric of the human family fighting for survival, searching,
desperately, for hope. The grieving villages, the funerals, the
hospital wards, the orphans, the women at the clinics; it's an
hallucinatory nightmare; it should never have come to this. Your
work can bring it to an end.
What I want to try to do in these remarks is to flag the signals of
hope as we enter 2004, and to look at some other related issues as
well. The items are six in number; I shall deal with some
elaborately, and others more briefly.
First, the single most dramatic development that has happened in
years around HIV/AIDS is the decision, by the World Health
Organization, in conjunction with UNAIDS, to achieve the goal of
three million people in treatment by the year 2005: '3 by 5' as
it's colloquially known. It has the potential to revolutionize the
struggle against the pandemic. Up until now, large numbers of
people have resisted testing for the obvious reason that
confirmation of a fatal disease, without any promise that the
information would improve or prolong life, made no sense, had no
appeal. Finding out that you were HIV positive simply intensified,
for many, the risk of depression and stigma. A prognosis of death,
without hope, is hardly an inducement to seek the prognosis. All of
that is about to change. Give people hope through treatment, and
with well-designed programmes, they will seek to get tested in ever
greater numbers. And if stigma proves so powerful as to limit the
uptake of testing, there is always the alternative of doing what
Botswana is now doing until testing becomes de rigeur: require
routine testing for HIV whenever someone presents at a medical
facility, with the option of course to opt out.
The new leadership of WHO, under Dr. J. W. Lee, is absolutely bound
and determined to pull off 3 by 5. It's amazing to see the depth of
commitment; it's as though WHO had undergone some religious
metamorphosis - they are collectively possessed. I almost expected
to see flashing iridescent lights and hear celestial thunder when
I visited WHO headquarters in Geneva ten days ago.
I'm not going to go into detail of '3 by 5' there are handbooks and
monographs available - but it is worth emphasizing that WHO sees
the entire initiative as "the antiretroviral treatment gap
emergency"; that emergency teams are already evaluating needs in
high prevalence countries; that WHO is working with multiple
partners, for example partnering with those doing the Prevention of
Mother to Child Transmission Plus, where the 'Plus' represents
treatment for the woman and her family; that the improvement of
health systems and human capacity is a sine qua non of the goal;
that the logistics of drug distribution and delivery are very much
a part of implementation; that the principle of equity of access
will be determinedly followed, women-men, rural-urban, rich and
poor; that a secure supply of medicines and diagnostics will be
pursued; and that this is just the beginning. In its publication on
3 by 5, titled "Making it Happen", WHO writes: "This Initiative
does not end in 2005. Antiretroviral therapy does not cure
infection and must be taken for life - withdrawing or ending
treatment will lead to the recurrences of illness and with it the
inevitability of premature death. Lifelong provision of therapy
must be guaranteed to everyone who has started antiretroviral
therapy. Thus, 3 by 5 is just the beginning of antiretroviral
therapy scale-up and strengthening of health systems".
And so it must surely be. On the continent of Africa, it is
estimated that 4.1 million people need treatment now - ie, their
CD4 counts are below 200 - and approximately 70,000 to 100,000 are
actually in treatment, or roughly two per cent. Quite frankly,
that's an abomination. The total number of people worldwide who
should be in treatment measures six million. In other words, even
if the target of 3 by 5 is reached, some three million people ---
fifty per cent of those eligible --- will continue to be in
desperate straits come 2005, with the numbers growing daily.What I
was reminded of today, at an earlier press conference, by Dr. Alex
Coutinho of Uganda, is that tens of millions more, who are now
infected, will inevitably require treatment at some point in the
future. When we talk of 3 by 5 then, it's the signal of what's to
come. It's also the symbol of the untold numbers of children, whose
parents will remain alive, and who will therefore not be
That's why the WHO initiative is of such enormous import. It has
unleashed huge expectations, great hope, and it's based on the
recognition that prevention is profoundly strengthened when
treatment takes hold. It cannot be allowed to fail. I repeat: it
cannot fail, or we will have given the pandemic a license of
unbridled human decimation greater even than that which presently
exists. To those sentiments should be added the lead words of the
handbook, under the heading "Guiding principles". They read:
"Immediate action is needed to avert millions of needless deaths".
There is, to be sure, a certain other-worldly, Ionesco quality to
all of this. We have all the will and money in the world to fight
the war against terrorism; what happened to the will and the money
to fight the war against AIDS? Why conflict and not compassion?
We're over twenty million dead, and counting.
With that in mind, there are four issues related to 3 by 5 which
I'd like to address.
1.The World Health Organization needs up to $200 million,
centrally, over and above its existing budget, to implement 3 by 5.
They need it for 2004 and 2005. They need it now. They need to
train 100,000 people at country level; they need to hire teams of
experts and dispatch them to the field, they need to put the whole
elaborate logistical mechanism of drugs, capacity and
infrastructure in place; they need to be the technical assistance
providers of first resort. They will not succeed without the money.
They don't have it. And though they have tried, they can't seem to
Frankly, I don't really care where the money comes from; it just
must come. The obvious and appropriate source would be individual
donor governments. There's just no way around it: rich countries
should provide the funds, and frankly, $200 million is a laughable
pittance when compared to what the world spends its money on these
days. If for perverse reasons, that doesn't prove possible, then
the Global Fund on AIDS, Tuberculosis and Malaria, becomes an
alternative conduit. It would differ from what the Global Fund has
done up till now, but it's clearly an integral part of everything
for which the Global Fund was created. But whatever the ultimate
nature of the bank account, if WHO does not get the resources, it
constitutes an unimaginable setback in the battle against AIDS.
2. What clearly makes the best sense, if 3 by 5 is to succeed, is
the WHO pre-qualified triple fixed-dose combination; one pill taken
twice a day, available only from generic manufacturers. It's
noteworthy that Medecins Sans Frontieres uses this drug with
several thousand clients, in twenty countries, with excellent
therapeutic results and excellent adherence rates. In order for us
to find the money to put huge numbers of people into treatment, and
scale up dramatically, this is the drug regimen of first-line
choice. It is surely of significance that the Clinton Foundation
has negotiated, in India, a reduction in the price of this fixed
dose combination to $132 per person per year. No one would have
thought that possible, even six months ago.
The international community, through the World Health Assembly, has
bestowed upon WHO the responsibility for approving, and providing
guidance in safety and efficacy for a vast array of medications.
They do so with consummate science, fidelity and integrity.
Fundamentally, evaluations carried out by the WHO pre-qualification
team provide assurance that international quality standards obtain.
One of the great strengths of multilateralism is that we have the
World Health Organization to do this work. There may be individual
countries who wish to pursue a different tack. But when WHO has
identified and pre-qualified generic drugs, at low cost, to prolong
millions of lives, that's the route the international community,
without caveats, should follow.
As a Canadian, I'm particularly sensitive to this reality. The
Government of Canada --- deserving of both recognition and plaudits
--- is about to amend patent legislation, in relation to AIDS and
other diseases, to permit the manufacture and export of generic
drugs, consistent with the WTO agreement reached August 30th, last.
The Government of Canada will undoubtedly accept the purview of the
World Health Organization.
3. If there's one thing we've learned about testing and treatment,
it's that the involvement of the community is decisive. If 3 by 5
is to make the intended impact, it must call on the community for
help, and jettison the lip-service to which so many are addicted.
And the key element of the community are the People Living With
HIV/AIDS, who are the real experts, and must be acknowledged as
such. They should be consulted on every aspect of the treatment
process, and they should be seen as helping to mobilize the
community to work, in an equal partnership, with the medical
facility dispensing the treatment. Wherever this formula has been
genuinely applied, testing increases exponentially, stigma and
discrimination drop significantly, and adherence rates are
generally higher --- I repeat, higher ---than they are in this city
of San Francisco.
4. Finally, you can't achieve equity in 3 by 5 without opening the
doors to women. I'll have more to say about that shortly, but at
this stage let me simply point out that the disproportionate
numbers of women infected in Africa, requires a similarly
disproportionate access to treatment. It is matter of bewildering
shame that even an insatiable pandemic, malevolently targeting
women, has failed to demonstrate, once and for all, the size of the
gender gap, and the deadly risk we run by failing to close it.
That brings me to my second omnibus point. Any discussion of
treatment necessarily focuses, in large measure, on funding, and
funding inevitably leads to the Global Fund on AIDS, Tuberculosis
and Malaria. So allow me to deal with it.
It's time for the world to embrace the Fund, without all the
carping to which it has been --- often mindlessly --- subject. No
one pretends the Fund is perfect, including its own Secretariat.
But it is emerging as one of the most inspired multilateral
financial instruments that the world has latterly fashioned. And I,
for one, am nonplussed by the refusal to fund the Fund at levels
which would save and prolong millions of lives. There's something
nuts about holding out a begging bowl for an organization dedicated
to confronting and subduing the AIDS pandemic. I am reminded of the
1980s, when members of the international community were reduced to
groveling on behalf of financing the United Nations, in order for
the world body to function in the interests of humankind. Where
would we be without it today --- you'll note that there seem to be
countries who suddenly need it --- if its capacity for intervention
had been eroded by the Scrooges of the planet?
The Global Fund is largely past the inevitable hiccups associated
with launching a new and complex international mechanism. It has
sophisticated and useful processes in place. The innovations of the
so-called CCM --- the country coordinating mechanism --- and the
Technical Review panels are working pretty effectively at country
level and at the centre. The Board, with its unique representative
nature, is functioning well, and the Fund is now disbursing money
rather more quickly than certain other international financial
institutions that have been around forever.
This isn't some blanket apologia. I myself have occasionally been
critical of the Global Fund and have raised with them some of the
frustrations felt by recipient countries. But let's keep
perspective here. In barely more than two years, we have an
entirely new international construct up and running, admirably
serving the interests for which it was intended, and getting money
to the grass-roots of AIDS-plagued countries where it is so
desperately needed. That's one of the most admirable things about
the Fund: because the proposals come from the bottom, the money can
get to the bottom.
The Fund was the brain-child of the Secretary-General of the United
Nations. It was an excellent cerebral birth. It can become the kind
of international coordinating body which we must have to defeat the
three communicable diseases that constitute its mandate. I have
nothing but regard for the work of the Clinton Foundation in the
four countries where it is most in evidence: Tanzania, Rwanda,
Mozambique and South Africa. And I'm delighted by the prospect of
President Bush's enterprise bringing hefty resources into twelve of
the countries of Africa. But what of the countries that are left
out of those initiatives? What of Swaziland and Lesotho and
Zimbabwe and Malawi, whose collective prevalence rates range from
fifteen to nearly forty per cent? It's the Global Fund that stands
ready to be called upon. With 3 by 5, the presence of a coherent
and rational funding body, for all regions of the world, is surely
It's been a heavy blow, then, to see how inadequately-funded the
Global Fund has been. In fact, I think I should stop pulling my
words: in my respectful submission the Global Fund has been
abysmally resourced. You might think that the industrial nations
would compensate for a decade of financial abstinence by embracing
the Global Fund as the obvious vehicle for resource-constrained
countries. But that hasn't been the case. At this moment in time,
the Fund is several hundred million dollars short for this year,
and almost three billion short for next. Nor are the omens
auspicious. The administration of the United States has asked for
only $200 million for the Fund for 2005, some $350 million less
than 2004, and a billion short of what many active observers feel
would be an equitable contribution. The rule of thumb, based on
gross world product, is one-third from the United States, one-third
from Europe and one-third from everyone else --- everyone else
comprising vast powers like Japan to sweetly diminutive states like
Canada. In 2005, the Fund will need a minimum of $3.6 billion -
hence $1.2 billion from the United States. This is not higher
calculus: the arithmetic is clear. And let me add a footnote: of
the $3.6 billion required for 2005, $1.6 billion represents money
needed to extend existing programmes - that is, those that were
approved in years one and two. If that money is not forthcoming,
the programmes cannot be extended, and people who have been put on
treatment with that money will have their regimen severed, posing
serious mortal risk.
On the other hand, it must be said that no country, my own
included, is paying an adequate share based on any reasonable
formula. And that, quite simply, is shocking. Worse, it deters
developing countries from asking for what they truly need because
they don't believe they can get it. People are dying at a rate of
three million a year, and we have the capacity to keep them alive,
and we can't summon sufficient resources. Overall, some $4.7
billion was spent in the global response to AIDS in 2003. UNAIDS
says a minimum of $10.5 billion is required by 2005, and $15.5
billion by 2007. Where will the dollars come from?
Third, this constant struggle for funding bedevils everything,
including the critical quest for a microbicide. But before I
address the question of microbicides, allow me to make a simple
point. The developed world has endorsed time and time again, at
conference after conference ad nauseam, the target of .7 per cent
of GNP --- seven-tenths of one per cent of GNP --- for foreign aid.
The only countries that have regularly reached or surpassed it are,
predictably, Norway, Denmark, Sweden and the Netherlands. Our
present annual official development assistance, from the OECD
countries, approximates $57 billion. According to Columbia
University's Dr.Jeffrey Sachs in his study on Macroeconomics and
Health, were we to reach an average of .7 of GNP, we would be at
$175 billion now, and $200 billion by 2007. The only figures I've
recently seen comparable to those are the cumulative expenditures
for Afghanistan and Iraq. Was there ever a double standard more
visible and egregious? People are dying in Malthusian numbers for
heaven's sake; people are dying.
And the majority of those people are now women. Hence the
scientific search for a microbicide. Women must somehow be given
control over a way to protect themselves from HIV, and that way is
As more and more research is done on the particular vulnerability
of women to infection, we're learning more about the situations in
which risk is paramount. And extraordinarily enough, according to
UNAIDS, the risk is particularly high in apparently monogamous
marriages and partnerships. Ironically, and lethally, in the age of
AIDS in Africa, marriage can be dangerous to women's health.
In the situation of intimate partners, condom use is very low. Nor
can it be demanded. In representative surveys of women in 14
African countries, it was found that only 7% reported condom use in
the last sex act with their regular partner. The prevailing
assumption is that commercial or casual sex is the primary way in
which women are infected. The assumption is wrong. There is a
growing body of evidence to show that a significant number of
infected women in Africa have been infected by their husbands or
intimate partners. There is virtually no defence against that
reality: the power imbalance in marriage is too great to permit or
to request the regular use of condoms.
Thus it is that the classic 'ABC' intervention doesn't work in the
one place where the risk for the woman may be greatest. Marriage
without sex is not realistic, nor is it desirable. Abstinence in
marriage is not possible; Being faithful is assumed; Condom use is
irregular at best.
A way must be found to allow the woman to protect herself,
independent of male hegemony. Female condoms are one possibility,
but they are very expensive, and they require partner consent. And
of course they act as barriers to conception. The most exciting
prospect that we have on the scientific and social horizon is a
I recognize that this is an audience of vast and copious knowledge,
but let me simply say, for exposition's sake, that a microbicide
can be formulated as a topical gel, film, sponge, lubricant,
time-released suppository, or intra-vaginal ring that could be used
for months at a time. It would restore to the woman the power to
protect herself from HIV in the absence of a condom. It would
reduce, geometrically, the incidence of infection.
Alas, we're still at least five years away from a first-generation
microbicide. But with government support and financing, there are
enough products in the testing pipeline now to achieve the
breakthrough in that timespan. The Rockefeller Foundation, deeply
committed to the development of a microbicide, estimates that the
cost required is in the vicinity of $775 million. At the end of
2002, research and development funding totaled $343 million. Thus
the shortfall is in the vicinity of $400 million. It may be higher.
In May of 2003, the Global HIV Prevention Working Group recommended
an additional $1 billion of public sector spending. But whether
it's three-quarters of a billion, or a billion, it's peanuts in the
vast panorama of international financial architecture.
Using mathematical models, researchers at the London School of
Hygiene and Tropical Medicine found that a microbicide, of even 60%
effectiveness, used by only 20% of women in contact with local
health services, could reduce the numbers of infections by
millions. Millions. It's breathtaking.
Some of the products under development are likely to be
contraceptive as well as microbicidal; others will be
non-contraceptive for disease prevention. As we meet, eleven
potential microbicides have advanced into human safety trials, and
some may well enter large-scale Phase II/III trials in 2004.
Obviously, there's a long way to go, but it's not without hope.
But we must have the money. The amount is so relatively modest ---
all the amounts related to HIV and tuberculosis and malaria are
relatively modest in the grand scheme of things --- that you have
to ask yourself what kind of warped dementia has crept into the
political process of assessing human priorities. Were we to pull
out all the stops, and get microbicides of various types, and
various levels of protection, to the market, we could give a
significant measure of sexual autonomy to the women of Africa and
prevent millions of HIV infections, and the millions of premature
deaths that follow, and the millions of orphans left behind.
Can anyone in this illustrious gathering explain to me why that
shouldn't be one of the greatest of political priorities?
Which brings me logically to the fourth item: is not the same true
for a vaccine? It's interesting to me how the search for an AIDS
vaccine is also struggling around issues of funding, and is often
eclipsed, in public debate, by the preoccupations of care and
prevention and treatment. Perhaps this is inevitable. It's tough
for the world to fix on a vaccine, when millions of people are
understandably clamouring for treatment. But just because a vaccine
is a long-term proposition, and obviously very tough science, it
cannot, it must not be depreciated.
These various aspects of the pandemic are not mutually exclusive.
There will be limitations to vaccines as there will be limitations
to microbicides, but a vaccine, as the ultimate answer to the
catastrophe, must be pursued with an almost supernatural fervour.
There should not be the slightest equivocation around funding. The
rule of thumb suggests that roughly ten per cent of the resources
allocated in the battle against AIDS should go to vaccines and
microbicides. That's not happening. Yet, the greater the number of
vaccine trials, assuming plausible candidates, the greater the
prospect of discovery. If ever a Nobel Prize lay in waiting, it's
for an AIDS vaccine.
Vaccines, of course, are part of a continuum of work, stretching
from the basic science and research done by so many in this room,
through to product development and moving the products forward. And
it must focus on the needs of the developing world, embracing
developing world scientists and sites, and planning determinedly,
in advance, how access for all will be secured when a vaccine is
finally found. It's important to note that there are more potential
vaccines in the pipeline than ever before, and that trials are
underway on six continents. Much of this is driven by IAVI, the
International AIDS Vaccine Initiative, artfully using
public-private partnerships. But we need more, much more, from NIH,
from big pharma --- only Merck is appreciably involved --- from
biotech companies and from IAVI.
I recall chatting with Seth Berkeley, the CEO of IAVI, not long
ago. He was making the point --- and, incidentally, regretting that
is was not widely understood --- that a vaccine is also a women's
issue. A fully effective vaccine, indeed, to some extent, even a
partially effective vaccine, would give to women the ultimate
protection from HIV infection without the male partner, intimate or
casual, having any involvement whatsoever. The best prospect of
course for women, is to have access to both a microbicide and
vaccine, the one complementing the other.
We're losing three million people a year. Treatment will slow, but
not eliminate the carnage. There are 14,000 new infections daily.
If we're five to ten years away from microbicides or vaccines,
there's a desperate human toll to be faced between now and then. At
least let the world rally to the prospect of bringing this
cataclysm to an end sooner than later. And that means working on
every front, on emergency footing simultaneously: care, prevention,
treatment, microbicides, vaccines. It was Colin Powell, the
American Secretary of State who said that HIV/AIDS poses the single
greatest threat to the world community. He's right. So where, I ask
you, is the world community?
And that brings me to the final two issues I want to raise, which
I shall not belabour, because I have dealt with them on innumerable
occasions. They flow organically from what has already been said.
They are rather more personal than analytic.
There is one factor more than any other that drives me crazy in
doing the Envoy job: it's the ferocious assault of the virus on
women. We're paying a dreadful and inconsolable price for the
refusal of the international community, every member of the
community without exception, to embrace gender equality. And in so
many parts of the world, gender inequality and AIDS is a
preordained equation of death.
There's nothing new in that. It's irrefutably documented in
encyclopedic profusion. The culture, the violence, the power, the
patriarchy, the male sexual behaviour - it's as though Darwin
himself had stirred this Hecate's brew into a potion of death for
Just last Monday, February 2nd, 2004, I attended the first meeting,
in London, of the newly-constituted Steering Committee of the
Global Coalition on Women and AIDS, a Steering committee, I might
add, of undisputed intelligence, influence and reach; a Steering
Committee, several of whose members are women living with HIV and
AIDS. The heading on the press release to stir media interest read:
"HIV Prevention and Protection Efforts are Failing Women and Girls
- More young women are becoming infected by husbands and long-tem
partners --- female-controlled HIV prevention methods urgently
needed". And then, during the presentations throughout the day, the
ritual ghastly litany of examples defining a
socio-economic-cultural gestalt that puts women at deadly risk.
Not in a million years would I challenge either the usefulness or
intent of the Global Coalition. My problem, entirely independent of
the Coalition, lies in the divide between the analysis and what's
happening on the ground. I read the superb studies produced by
Human Rights Watch, and I know that the gap between rhetoric and
reality can be tolerated no longer. In the last two and a half
years, traveling extensively on the African continent, I have seen
virtually no improvement in the status of women. Virtually none.
It's too painful for words. It makes me feel almost criminally
complicit. I have come to the personal conclusion --- and I admit
it's personal --- that it's time, truly and resoundingly, to take
off the gloves. It's time for the respected UN community, for
example, on the ground in countries, to join with the indigenous
allies and groups fighting for women's rights to demand the
visceral changes that are needed. It's time to abandon the fawning
diplomatic deference. It's time to swallow the insufferable jargon,
like 'mainstreaming gender' which serves to cement inequality by
pretending that a process somehow transforms the lives women lead.
It's not working. In Africa, of the ten million people living with
HIV/AIDS between the ages of 15 and 24, nearly two-thirds are women
and girls. Please explain to me what is working.
The time has come to confront Cabinet Ministers openly, and demand
that they promulgate or amend the laws on property rights and
inheritance rights. It's time to put people in jail, for a good
long chunk of life, for property-grabbing. If sexual violence leads
to HIV and death, then it's time to use the entire apparatus of the
state to enforce laws against rape; to stop putting the onus on the
woman to fight off predatory male sexual behaviour, and move in on
the oppressor with a vengeance. If male teachers molest young
girls, make a spectacle of them. If early marriage is a death
sentence, change the age of marriage and enforce it as though life
depends on it, because life depends on it.
It's time, in other words, country by country, to make the struggle
for gender equality the cause celebre of the land. Give no quarter.
Call press conferences, demand audiences with the political and
religious authorities, form coalitions, take a tactical lesson from
the Treatment Action Campaign in South Africa, demonstrate,
boycott, rail, risk the possibility of being declared persona non
grata by government, and if it happens, on this issue, wear it as
a badge of honour. And should it happen, the cause of women will
have been advanced.
It's all too much: too much sickness, too much sadness, too much
death. Women are the resilient force that sustains the continent,
and they are being eviscerated by a virus. And the world, there and
here, largely inert, is watching it happen. Shades of the genocide
You see, if we can make real gains in 3 by 5, and leverage the
money for the Global Fund, and raise the intensity of focus on
microbicides and vaccines, and understand that the pandemic has a
woman's face, then we can begin to break the back of this appalling
scourge. No one has to feel defeated. We just have to feel
resolved. Doubtless it will require superhuman intervention: so
much the better. It requires that level of magnitude to energize
But even all of that said --- and if it came to pass, it would be
incredibly exciting --- there remains one issue, growing
inexorably, that is thus far intractable: the issue of orphans. I
don't want to drive the nail through the wall; I've spoken a long
time and must wind my way to the end. But it is important to
understand that the millions of orphans are perhaps the most vexing
inheritance of the pandemic. There are several African countries
now, with more than a million orphans: it is without historical
precedent; no one quite knows how to handle it.
In the last few months, I've had the enviable opportunity to
accompany both Graca Machel and Oprah Winfrey on trips to Africa,
primarily to assess the situation of orphans and vulnerable
children. Graca Machel, who is seen by everyone as 'Mama Africa',
and has a formidable understanding of the continent was, I think it
fair to say, overwhelmed at times by the sheer numbers and
festering predicament of the orphans. Oprah, than whom it would be
hard to find someone of greater worldliness, was equally shaken to
her core. African communities are struggling valiantly to absorb
the orphans as the families fragment and die, but given the levels
of impoverishment, it's desperately, indescribably difficult.
And it's all becoming so strange. Now we have, pervasively, this
phenomenon which AIDS has brought, of grandparents burying their
children, and then living out their impoverished days looking after
the orphan grandchildren. I was in Alexandra Township in
Johannesburg in December, meeting with a large group of
grandmothers heroically networking through their anguish: they had
all lost almost all their children. It was a spirited if terribly
mournful conversation. There was one grandmother who refused to
speak until the end. And then, in a voice of wrenching and
unendurable pain, she told us how she had lost all of her adult
children, all five of her adult children, between the years 2001
and 2003. Five children in three years. She was left with four
grandchildren, all of whom I later learned, are HIV positive. Two
generations will disappear in an historical blink.
And where they don't disappear, these millions of orphans wander
the landscape of Africa. These lonely youngsters are bewildered,
angry, sad, frantically seeking nurture and affection, often
hungry, homeless, significant numbers living with grandmothers or
in child-headed households, countless numbers unable to go to
school, a school being the single most valuable and supportive
environment they could possibly have - unable to go to school
because they can't afford the school fees or the uniforms or the
books. And when you lose your parents, who then hands down the
knowledge and values from generation to generation? The orphan
crisis is a crisis without parallel.
Somewhere, somehow, someday, the world has to understand what AIDS
hath wrought. The understanding is not yet in evidence.
As I conclude these remarks, I beg you to enter the fray.
Admittedly, it's not in your collective terms of reference to mount
the barricades. You're trained as scientists or professionals of
other exotic disciplines; no one suggested a quotient of advocacy
added to everything else you do. But this is a powerful
constituency. You're knowledgeable; people listen. Somewhere in the
lives you lead, there has to be time carved out to shout from the
rooftops, and if my kind of stormy invective is unwholesome, then
shout in the muted tones of professional eloquence - but tell the
world and its governments, especially the governments of the west,
that an apocalypse has unfolded, and it has to be stopped in its
tracks before it engulfs us all. If morality is found wanting in
the actions of governments, let it be rediscovered in the advocacy
There's a true and acrid irony in all of this. We forever call for
behaviour change in Africa and so much of the rest of the
developing world. It's a valid call, no question. And because
nothing is more difficult to change than sexual behaviour, it comes
in painfully slow increments. But what about our change in
behaviour? It isn't sexual; it's financial, economic, technical,
psycho-social. And it progresses in increments even more
infinitesimal. How do we get away with it? What is it doing to our
collective humanity to deny life to millions?. With the money and
the will, we can bring the scourge of HIV/AIDS to an end, and
everyone here, in the depths of his or her soul, knows it.
I'm really not a Jeremiah. And I don't take Africa off the hook.
The silence, denial and palpable immobility of some African leaders
over the years, as the pandemic exploded, was entirely
unforgiveable. Would that they had mirrored the stirring public
voice of President Museveni. Some leaders may still be locked in a
nexus of unreality; it's hard to say. Most are now vocal, brutally
forthright about matters sexual and fully engaged. But even if all
of the leaders of Africa, were to move determinedly against the
virus, they just don't have the resources, the capacity or the
infrastructure. That's where we come in.
What in Heaven's name are we waiting for?
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