by Piot, Peter
Mike was by now embroiled in discussions with the UN Development Programme (UNDP), the World Bank, UNICEF, UNESCO, and UNFPA (the world population agency), along with a group of representatives from major donor countries and nongovernmental organizations, about how to transform the Global Programme on AIDS. This task force, set up in April 1992 by the GPA board, was frustrated by the lack of coordination of international work on AIDS. The positive news was the that the big agencies of the UN system had begun to set up AIDS programs when AIDS started to affect their areas of activity, but as is typical of the international development system, they were doing this separately, almost in competition.
There were some strong personalities in charge of this process: Jim Sherry at UNICEF, Elizabeth Reid at UNDP. They had their own views on what to do and frankly they worked at loggerheads, laying down different policy recommendations, sometimes accusing Mike Merson of not understanding the epidemic. And all the agencies were going to the same donors and saying give the money to my agency, not to his. The donor countries, meanwhile, could see that WHO’s political and administrative modes of doing business were creating enormous inefficiencies, because routing everything through regional offices meant that a lot of money was stuck there. There was no question of corruption but often sloppy management and entrenchment: “If I’m not running this project, it won’t happen.” At the same time, major development agencies such as USAID and the UK’s Department for International Development were setting up their own AIDS programs and were reluctant to channel their money through the multilateral system over which they had less control and which did not directly benefit their own international development organizations.
There was a lot of disenchantment with WHO, which was under attack for its weak management, although Nakajima was reelected as director in 1993 in controversial circumstances. This coincided with a move by many Nordic countries and others to reform the whole UN system, and re-creating a new world AIDS program became a big part of that. In addition, a number of developing countries, especially Uganda, felt that not enough money was coming into Africa to deal with AIDS: again, the bottom line was that AIDS needed a higher profile international organization. However, the other UN organizations wanted only a weak secretariat-type coordination: they wanted to continue to run their own shows. It was an unpleasant and conflicted process. But I was not involved in this gestation. I didn’t feel emotionally or intellectually interested in it: I thought of it as Intra-UN equivocation. All I knew was Mike would disappear for a few days for some traumatic meeting with an interagency task force that was shaping the skeleton of a new UN program on AIDS, with a lot of drama and accusations of double-dealing and personal ego.
It was Hans Moerkerk who first approached me to become head of the UN’s new, reformed AIDS entity. (“Entity” was the word employed, since even the word “agency” was the subject of bitter conflict.) Hans was the chair of GPA’s board, since the Netherlands was the number one donor to AIDS. (The Dutch have a big development-aid budget, and they target it strategically: they don’t just sprinkle it uniformly, they target a handful of issues and deliver a big packet.) Hans was a “nuchter”—as we say in Dutch—no-nonsense and stubborn Dutchman, who was in charge of AIDS at the Ministry of Foreign Affairs and had been at the forefront of the gay rights movement in his country. We had become friends over the years, when he negotiated more money for AIDS, sought resolutions against blocking people with HIV from entering countries such as the United States and China, and demanded stronger accountability for international assistance. He is a smart diplomat and activist all rolled into one. But I said no. This was not for me: I was not interested in becoming a UN bureaucrat.
Then Jean-Louis Lamboray, a Belgian public health doctor who had worked for the Belgian medical cooperation in Zaire, came to town. He and I had worked on setting up outposts of Projet SIDA in Kinshasa, where we could recruit people for our research projects, add a nurse or two, train them, beef up the lab, set up a functioning freezer. Jean-Louis had joined the Africa division of the World Bank, and he was probably the first World Bank person to be interested in the impact of AIDS on African economies. In fact in the late 1980s he organized a presentation for me at the bank in Washington. In my simplistic view of the world from Kinshasa, where I had seen the influence of the World Bank in Africa, and the failures of WHO, I felt that the bank was the international institution to get on board for the fight against AIDS. So I went to Washington to make the case. It was a complete failure. I was urging the bank to invest massively in AIDS control, but the audience was mostly economists and they blew me out of the water with arguments about cost effectiveness and return on investment. I had not come with a plan, with bullet points that said each specific action will save this many lives and thus produce this positive impact on the economy. I hadn’t considered the hardnosed arguments you need to influence policy—a mistake I tried not to make again.
In any case, Jean-Louis represented the World Bank in this interagency task force preparing this new UN entity on AIDS. One day when we met for lunch he said, “We’re going nowhere because there’s no leadership and all the players are trying to undermine each other. We need a leader. What about you?” Again, I said, “You must be joking.” Director of a UN agency? I thought this meant someone with great political clout, someone charismatic, who could move politicians to make decisions and mobilize donors. I didn’t think these were my strengths.
But when I heard who the main candidates were, I thought, Why not? It was a mix of UN officials and politicians, such as Dr. Jesus Kumate Rodriguez, the then minister of health of Mexico, who was a friend of both Dr. Nakajima’s and of James Grant’s, the UNICEF director (who, incidentally, in 1990 objected to include a reference to AIDS in the Declaration of the Rights of the Child). Dr. Kumate was already seventy years old and quite conservative in his views on issues such as condom promotion. There was also Elizabeth Reid from UNDP, who was very committed to the AIDS cause, and other internal UN candidates.
I had real practical familiarity with AIDS on the ground. I knew quite a lot about a range of AIDS issues: epidemiology, microbiology, vaccines, policy, clinical, lab. I had a whole network of contacts and experts to fall back on, I was connected with activists, and I was fast acquiring experience at how to function within the UN. On the downside I lacked political experience and was not familiar with the ins and outs of the United Nations system—but that could also be perceived as a plus. So, I didn’t one day wake up with the illumination that I wanted to direct a UN agency.
At the time in 1993/1994 I was going to Tokyo almost every month. I had made it a condition of my employment at WHO that I could continue to function—without pay—as president of the International AIDS Society, to prepare the first of the annual international AIDS conferences to take place outside Europe and North America. In those days these conferences influenced the AIDS agenda in a big way, and the work of structuring them meant you could spotlight specific aspects of the epidemic and key figures of the AIDS movement because that is what it had become: a movement. My agenda was to bring in more of a developing-country perspective to these conferences, as that had not been the case until now, and to bring in networks of people with HIV and community organizations because I felt strongly that this could not be just a conference of doctors and scientists: the people affected and the NGOs definitely had a major role to play in the AIDS response, and were often the driving force to obtain budgets and get things done. I also promoted caucuses, one on women because they were marginalized at these conferences, not only as presenters in plenary sessions but also in terms of women’s issues. People were missing a whole dimension of the epidemic—not only heterosexual transmission, aspects of coerced sex, and risks in stable couples, but also how to ensure that HIV prevention programs would not perpetuate macho behavior.
Setting up the 1994 Yokohama conference was a huge headache, but it made me appreciate and like Japanese society, food, and culture. Japan bans prostitutes an
d drug users from the country, and nearly all Asian and East European countries even ban methadone—a form of substitution treatment for heroin addiction. We anticipated activists with big placards reading “I’m a junkie,” possibly derailing all media attention from the substance of the conference to the protests. We needed to be sure everyone would be allowed entry into the country to participate in the conference and we needed to train police and staff in hotels and restaurants that you can’t get HIV infection from serving someone at a table and so on. It was a huge opportunity to raise awareness about AIDS in Japan, where the AIDS agenda had been dominated by a scandal around contaminated blood substitutes for patients with hemophilia, and where traditionally the voice of marginalized communities has been very weak or even suppressed. I was the middleman between the official deciders and the international activist community, represented by the Canadians Richard Bruczynski and Don de Gagné, and a nascent Japanese NGO community, which included activist civil servant Naoko Yamamoto and my good friend Masayoshi Tarui, a professor of philosophy and expert on Immanuel Kant at Keio University. We convened every night at Daigo’s, a bar—actually just a tiny counter for six customers—near Shinbashi train station. Since that time, whenever I am in Tokyo, I go to pay my respects to Master Daigo and drink a few glasses of his sake with the Japanese who used to work with me in UNAIDS, such as Hiro Endo, Tammy Umeda, Chieko Ikeda, and Aikichi Iwamoto.
Decision making was painfully slow. Then one day I was invited to a shadow committee. It turns out, decision making for the conference occurred in circles. You have a big circle, where nothing is ever really decided, but ideas and opinions are gathered. Within that is a smaller circle, the first shadow committee, where fewer people are seated but have more power. I got to a second shadow committee eventually, and I still don’t know whether there was another, third, core group.
The conference was opened in great pomp by Crown Prince Naruhito and his wife Crown Princess Masako in August 1994, in Yokohama—after Nagasaki, the first port in Japan opened up to the world in the nineteenth century. It went very smoothly, although there were no scientific breakthroughs announced. These were the terrible years of HIV’s continued, apparently unstoppable expansion—years of despair among scientists because of the lack of progress in research. During the conference I began talking to friends from all over the world (some of whom I hadn’t seen for a while) to discuss whether it would be a good idea if I became a candidate to direct the new UNAIDS program—and if I were a candidate, whether I had any chance of winning. I found it was particularly my African colleagues who encouraged me, even pushed me. People like Ibrahim Ndoye, the head of Senegal’s national AIDS program, Ugandans Noerine Kaleeba from the AIDS Support Organization TASO and Sam Okware from the Ministry of Health, and Winston Zulu, a Zambian activist living with HIV. They trusted that I would speak up for them.
I had a very strong bond with the NGO community and with “Positive People,” as they were called, and they were also encouraging. Then I met with Franz Bindert, a German official whose main concern was that a European direct the new program. He said that if I were candidate, Germany would support me; moreover, because Germany held the rotating presidency of the European Union that semester, they would try to rally all EU member states behind me. I wasn’t as familiar then as I am now with the backstage power calculations of international politics, but even so, I knew that this was big news. I also spoke with other possible candidates for the job, such as my old friend Helene Gayle, who was then head of AIDS at USAID, and is now president of Care International, one of the largest private aid agencies in the world. Helene had extensive public health and AIDS experience and was popular with AIDS community groups in Africa. We agreed we would stay in touch, whatever happened, even if, as she predicted, “it would be dirty.”
After the conference ended I took a week off in the Alps with my family and thought about the prospect seriously. I thought about how the new UN agency might work. I weighed the kind of impact it might have. Then I called Hans Moerkerk to tell him I would be a candidate to direct the new body. I added that I wanted to win.
CHAPTER 16
Sharks in the Water
GENEVA IS A small town, and the UN is a big industry there. By mid-September the air was full of rumors about who would be nominated as director of the new AIDS program. Various AIDS constituencies and governments were becoming exasperated by the lack of progress by the cosponsoring agencies, and a consensus had emerged that the process wouldn’t be able to move forward until a leader for this new entity had been identified. Most countries were looking for a political hot shot: a well-known figure, a bankable name.
The selection of this director started accelerating at various levels. The Netherlands and Germany formally announced that I was their candidate, soon followed by Denmark and then my own country. (In other words, I certainly was not promoted by my own country first, as is so often the case with candidates for top UN jobs.) As president of the European Union for the second half of 2004, Germany rallied the European Union behind me. Soon thereafter, and to many people’s surprise my friend Ibrahim Ndoye from Senegal told me his government had officially decided to back me.
Ibrahim also told me that a marabout—a holy man—had slaughtered a bull for my success, just to be sure. And he sent me a special amulet by DHL, a wad of nonwoven cloth, tied up with thread. There’s something inside it, though I have no idea what. As a scientist I’m kind of embarrassed to say this, but I have carried that thing beside a photo of my children in my wallet ever since; it has done a good job so far.
Slowly, but surely, support for my candidacy grew, including from nongovernmental organizations, which had become very vocal in the process. By now, every day brought new rumors about candidates. They destabilized me a little in the beginning, but I decided to keep my head cool and continue with my work at WHO, while quietly lobbying for the new position. I had nothing to lose: deep down I was still hoping that a more competent person than I could be found for what increasingly looked like it was going to be a brutal job. I also still had a job waiting for me back in Antwerp, as the new dean of the Institute of Tropical Medicine. On three occasions I was approached to renounce my candidacy and become the deputy of someone else—as, in the words of one official, they “would need someone to do the work.” I thanked them politely and said that if they wanted me to do the work, I could just as well be the actual boss. At no stage did I feel it worth compromising, just to have a well-paid, prestigious job.
Quite a lot was at stake. It was by no means clear whether the new AIDS program would be a weak secretariat—basically a powerless coordinating administration—or a strong body that would, in effect, lead the whole UN system’s effort against AIDS, with money and political clout. The task force of UN agencies was still paralyzed, still calling it an “entity,” and there continued to be a high degree of animosity about the process. On October 6, a director from UNDP told me that if I were appointed, “UNDP and UNICEF would do everything they could to sabotage me.” I suppose they saw me as a puppet of WHO, a technical guy from the medical establishment. Even if I hardly knew them, mid-level UNDP and UNICEF staff treated me with hostility. I’m still puzzled by their behavior, in which mediocrity was often matched by arrogance.
I began to actively campaign. In October I went to New York, to a meeting of the Economic and Social Committee, ECOSOC, a broad and often weak UN body that oversees economics and social affairs. I had never even heard of ECOSOC before, but it was the body with the mandate to formally establish the new agency. I also went to Washington, to visit the World Bank and see policy makers at the US departments of State and of Health and Human Services. In the eyes of the UN system Washington is kind of a lion’s den because it is the powerhouse of the world and the largest contributor to UN programs, given the size of its economy. Even though some were implying that US support for the AIDS agency would depend on having an American as its director, I knew after my trip to Washington that I could
work with the United States and vice versa.
Then, in a surprising turnaround, Dr. Nakajima and his regional directors at WHO said they would nominate me, together with Dr. Kumate from Mexico. Many Ministries of Health, which had been waiting for WHO’s guidance, followed suit. I was then in a very delicate position: I didn’t want in any way to be perceived as a pawn of Nakajima’s; I had a very different vision on what this new program on AIDS should do. But I understood that without WHO’s support no director would be successful.
The appointment was due to take place on December 12, 1994, at a meeting in New York of the executive heads of the Committee of Cosponsoring Organizations. A task force cochaired by Nils Arne Kastberg, a Swedish diplomat, Bernadette Olowo-Freers, a Ugandan diplomat, and El Hadj As Sy, a Senegalese NGO leader organized the process. They sent out what they called a “straw poll” to all governments and well over a hundred NGOs, asking them who they would like to see as director. (This was unprecedented, as far as I know, in UN history.) On December 2, I had lunch with Helene Gayle, and she said she was giving up her candidacy for personal reasons, and would support me. On December 5, the results of the poll came in and I was flabbergasted to see my name so prevalent among them. I did not know a soul in many countries nominating me. In the meantime, at an AIDS summit hosted by the French government, several countries said they supported my candidacy.
On the morning of December 12 I was drinking tea at the Belgian Permanent Mission across the street from the UN headquarters in New York when I got a call asking me to come immediately to the meeting of the Committee of Cosponsoring Organizations, which was deliberating on the new appointment. I had no idea this would be part of the process, but the principals of all six agencies—WHO, World Bank, UNDP, UNICEF, UNFPA, and UNESCO—wanted to interview me. I had never even set foot at the UN headquarters, and I didn’t think to ask for the number of the meeting room. When I got to the building, the security guards wouldn’t let me in, and I literally just ran past them. (This was before September 11!)