PHA-Exchange> Peter Piot's speech to President of World Bank

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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 dying, 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 inside the
institution.

It is therefore profoundly significant for me and a great honour, 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 unprecedented 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 globalisation 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 between 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 labour, 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 enormous
demographic shifts are having on the fabric of societies. Consider
those left behind when adults die from AIDS: the millions 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 childheaded
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 instability. 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 entering 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 Caribbean - 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 leadership is priceless and requires the courage and
vision for governments 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, including 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 developing 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 innovative Multi- Country HIV/AIDS Programme has
pioneered new mechanisms 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 cosponsors.
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 billion, 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 effective
strategies against AIDS. 

Some developing nations have shown real successes in the response 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, Senegal, 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
comprehensive approaches on prevention, care, treatment and impact
mitigation. A commitment by all states in the world to accelerate 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 leaders.

Fourth, breaking down stigma and discrimination. Stigma and
discrimination 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
costeffective.

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 antiretroviral 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 investments. 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 mortality 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 compensate for
formal skills gaps. This does not require specialists. 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
development. Aren't we paying the price now for decades of development
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 single agency, so no
one should feel at liberty to shirk their share of the burden.

The second overriding challenge is harmonization and joint
accountability. 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 duplicative 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 national
leadership. I call this the "three ones." One national AIDS strategy
that drives alignment of all partners; one national 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" project succeeded in a country
where the national program simultaneously 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 remarkable 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
improving our modalities of support, as this year's World Development
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 reputation 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 exceptionalism
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 accelerate
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 susceptible 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 demands exceptional actions.
As Abraham Lincoln once remarked, "The dogmas of the quiet past will
not work in the turbulent future. 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 expenditure 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 development aid.
And this is the one institution--along with your sister across the
street--that can show a new way on issues 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, prostitution, 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 exceptional 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 challenge 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 uncertainty 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, unemployment,
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 Development 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. Gender equality creates
security and opportunity for women, reducing the number who must resort
to commercial sex work for survival. 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 addresses
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 international 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.