by Piot, Peter
But then I had no idea where the meeting was. So I asked someone what floor the secretary-general’s office was on; I thought a meeting that important, creating a new UN agency, must be on his floor, the 38th. Finally someone told me it was taking place in the basement—a bad level, I thought, to start a new career. I arrived half an hour late, a nervous wreck. I was asked a number of tricky questions, as each agency wanted to test me on their area of interest, sometimes in conflict with the viewpoint of another agency. The atmosphere was not pleasant. This antipathy had more to do with institutional territory than with my person as such. As individuals these were mostly decent and competent people, but the whole process of creating this new agency—whose mission was, let’s not forget, to help people—was in fact driven by the urge for control and power.
I waited in a corridor for about 15 minutes and then someone came out and said I had been chosen. I went back in, everybody congratulated me, and then they promptly moved to the next item on the agenda. Although I was still digesting what had just happened to me, I realized that the discussions were basically aiming at undermining the position of the newly elected director—me. Dr. Jim Sherry, who represented UNICEF (the director, Jim Grant, was by now terminally ill), passed me a very small piece of paper with five words on it: “Peter. Congratulations, you poor bastard.” Friendly and cynical at the same time—at least he was honest! I decided on the spot that I wanted to hire him.
Around noon Nakajima took me up to meet UN Secretary-General Boutros Boutros-Ghali, who formally appointed me. We shook hands for a photo; I never saw him again. We then went straight to a press conference where the first question was, “What is the position of this new UN program on masturbation?”
Another trick question. A few days before, President Bill Clinton had fired US Surgeon General Joycelyn Elders because, when asked whether it would be appropriate to promote masturbation as a means of preventing young people from engaging in unsafe sex, she replied, “I think that it is part of human sexuality, and perhaps it should be taught.” Outrage ensued. Such a trivial episode; so surreal, that something like that could end a fine career. But I knew about it, and realized that the wrong answer could be the swift demise of my own, ultrashort career at the UN. So I responded to the reporter’s question very blandly: “To a scientist it’s very clear you need two to transmit the virus. Next question, please.” I dodged the bullet—my political skills were already improving.
Then CNN asked me for a live interview for the world news, strung me up with some equipment, and the world was told about my existence and that of this new program that would stop the AIDS epidemic. So began the media whirlwind that would last for 14 years. There was no return possible, and I knew that. I went back to my hotel and wrote in my notebook: “I feel very lonely, with an impossible task.”
THAT NIGHT I couldn’t sleep: hundreds of thoughts tumbled through my head at once. Eighteen million adults and over a million children were estimated to be living with HIV already, and the curve was rising steeply. In the following 12 months, over 3 million more people became infected worldwide. China began reporting fragments of data in what was soon recognized as an epidemic of at least 30,000 to 50,000 people who had been infected when selling their blood in the central Henan province, through criminally careless medical practice. No country in the world could be called “safe” from AIDS, and it was absolutely unclear whether HIV would start spreading as fast through Asia as it was already doing in Africa—we simply did not have the information. There was no treatment. The lives of people with HIV could be prolonged, but they could not be saved. And there was not even the beginning of a real vaccine.
We needed a massive, very profound behavioral shift. People around the world had to learn to use condoms at every sexual encounter except confirmed monogamy—whether they be acts of prostitution, of homosexuality, or casual encounters of any kind. Injunctions to “just say no” whether to curb epidemics of syphilis, smoking, gambling, or heroin use—were ineffective.
Community-based programs like TASO (The AIDS Support Organization) in Uganda, on the other hand, showed evidence of real success. Noerine Kaleeba, a physiotherapist whose husband Christopher had died from AIDS, founded TASO with the help of 12 others. Noerine was a superlative communicator and organizer, with a vitality that her country badly needed; Uganda had just emerged from years of civil war, only to be confronted with deaths from another man-made disaster, AIDS. Like the White Ravens support group whose board I had worked on in Antwerp, these programs helped individuals in small and large ways, through acts of human solidarity and compassion and they provided the street-level intelligence that I knew was crucial to any kind of program for social change. They supported each other, helped each other to endure the sorrow of illness and the mourning of loss.
Noerine’s TASO organizers were also fun, joyful people, who understood their society. For example, Noerine understood how difficult it was for people to even say that they were infected with HIV, and developed the idea that you should select one safe person—perhaps even a stranger within the TASO network—and share with that person until you were more at ease with the words necessary to informing your partner. TASO also launched a very moving project of “Memory Books,” where parents with HIV would write down their lives in a book, so that their children, once orphaned, would carry the fullest possible memories of their parents. I will never forget witnessing a conversation between a woman with HIV and her daughter, with the mother recounting her life and discussing her unavoidable death with striking calm and dignity. It was human strength at its best. I thought then—not for the first time—that AIDS not only brings out the worst in people, with rejection and discrimination, but also the best.
TASO grew and grew, and at last tally, had provided treatment and support to 200,000 Ugandans with HIV and their families. Groups like these are the unsung heroes of the AIDS epidemic, and I very much wanted to sing them. In fact, I wanted to tie in community organizations like TASO to all the work we did, globally as well as within countries. People needed to realize that AIDS was different. In the worst-affected countries, AIDS transmission was a matter of national emergency, because it was clearly set to grow exponentially, and its long-term and ripple effects on society were exceptional. In contrast to most diseases that affect primarily children and the elderly, AIDS affects young adults, the productive and reproductive elements in society; their children are orphaned or infected, and grandparents then have to take care of them. Even if we could stop AIDS today—stop it cold—in terms of new transmissions, it would still have a massive impact on generations to come. The economic losses and social damage may go far beyond anything that we have seen with an epidemic in modern times, and nobody’s going to resuscitate the parents of the 14 million orphans.
So we needed to get world leaders on board. All the UN agencies needed to pull together into a joint approach to AIDS programs, with much less duplication and far less back-biting. We needed to have more powerful responses to AIDS in every country. We needed to develop policy guidelines for HIV prevention and treatment: people were hungry for examples of policies with concrete results on the ground. I also wanted us to develop a more solid epidemiological data base. I didn’t want us to actually run programs on the ground, as I felt strongly that this should be done by local governments, NGOs, and businesses, rather than by expensive international civil servants who may actually undermine local capacity by doing work that locals could do. But I felt we could have real value added in terms of coordination, evaluation, and policy guidance, because the supranational nature of the UN meant we could have a better view of what worked than anybody in only one country and that we should become the world’s advocate for AIDS, mobilizing desperately needed resources. As I saw it, we might be small but we should be smart and powerful—a catalyst for support to developing countries.
All this and much more went through my head in that first sleepless night after I was appointed. The only real measure of our succe
ss would be in lives saved.
THE DAY FOLLOWING my nomination, I went to UNDP, UNFPA, and UNICEF (which are based in New York), as well as to some of the permanent missions to the UN. Immediately the discussions moved to battle stations. The heads of cosponsoring agencies had determined that the new AIDS program should be staffed by people on loan from existing agencies. In other words, I would get people whom they did not want to keep or people whose loyalties lay with the agency that was paying their salary. They also wanted the cosponsoring agencies to determine our budget envelope, which WHO would “administer.” It was my belief that this was intended as a consolation prize for Nakajima, since in losing AIDS, WHO had lost its biggest program. Furthermore, the cosponsoring agencies wanted us to “coordinate” their work, but to have no programs on the ground. We would be a simple secretariat, as weak as possible. The impact we could have would be close to nil.
Now my mind was buzzing with questions of a wholly different kind. First, I wanted clear answers to two basic questions: who was my boss; and who had the right to hire and fire. The agency heads wanted me, as director of the AIDS program, to be accountable to them. But I argued—throwing around some big words here—that we were necessarily accountable to the people and, that, in UN terms, meant governments. My boss should be an executive board, on which should be represented not only governments but also people with HIV and NGOs. I wanted to feel answerable to the people who were on the front line. Such a thing had never been done in the UN, but for me it wasn’t in any way ideological. I just felt I couldn’t do a good job without them; anyone who was part of the problem needed to be part of the solution. I also felt that I could not at the same time coordinate the programs implemented by six UN agencies and be accountable to all six of them; it was a recipe for nonaction and nonaccountability.
Moreover, I wanted the new program to have a small but strong central core, and I wanted us to have offices in affected countries that would be in charge of all the UN’s AIDS efforts, staffed by people whose one main commitment would be fighting the AIDS epidemic. There were also a number of other key questions to thrash out: what size budget we would have at our disposal; how to channel it to countries and for which priorities; how to fully involve the various UN agencies; how to create incentives for them to act together in a harmonious way. It was going to be a long, long series of battles. I had only 12 months in which to define, structure, and staff a new UN organization: we were due to become fully operational in countries in January 1996. I suspect that WHO was convinced I could not pull all this off, and that after a year or so it would all just go back under WHO’s control. So I kept a low profile and let them feel secure in that opinion, until such time as I would be strong enough to raise my head. As I had heard in Seattle, “The first whale to surface is the first to be harpooned!”
It was around this time that Kofi Annan sent me a note. He was head of UN Peacekeeping Operations back then, and I had met him to discuss the problem of peacekeepers infecting Cambodian women with HIV. (Later, of course, Kofi Annan became one of the most distinguished secretaries-general of the UN.) His note read: Congratulations, Peter, and now let me tell you a story. There’s an old man who feels he is going to die. He tells his two sons to come with him into his fishing boat and row him out into the ocean. When they row so far that he can’t see the coastline any longer, he tells them to stop and says, “Sons, let me tell you. The sea is full of sharks. So don’t fall into the water. And if you fall into the water, don’t bleed.” Good luck, Kofi.
I’ve thought about that story many times as I’ve navigated the choppy waters of multilateral politics.
MY PRIORITY WAS to bring together a top-notch team to build the secretariat in Geneva and a few key countries. At first most of my core people came from the WHO Global Programme on AIDS, in particular the administrative staff, who initially were firm guardians of WHO orthodoxy. They knew how to move money and job descriptions through the system, but it took several years for them to develop a more can-do culture and shed their determination to follow WHO’s habit-encrusted rules. I sought advice from trusted friends who had not been involved in the interagency negotiations, which I now had the dubious honor of chairing.
Dr. Seth Berkley, who was then working for the Rockefeller Foundation (now head of GAVI, the Global Alliance for Vaccines and Immunization), offered me the use of their center at Bellagio, in northern Italy, for a brainstorming seminar. So in February 1995 I invited a dozen people there for a weekend. It was a discreet little meeting, and we had agreed that there would be no record or report: this way people could speak their minds. I subsequently used this approach occasionally, particularly when I felt we were not progressing enough or when there was the need for a strategic reorientation. I wanted to hear from all kinds of people and take in what they thought we needed to do. Besides Berkley, attendees included Jim Curran, head of AIDS at the CDC; Jean-Baptiste Brunet, the young French epidemiologist with whom I had first visited Lubumbashi; Rob Moodie, an Australian public health specialist who had worked at Médecins Sans Frontières; Roland Msiska, the director of the Zambian AIDS Program; and Winston Nzulu, the Zambian activist who encouraged me to run for the job of director; Susan Holck, seconded from WHO, who introduced me to the labyrinth of the UN; Noerine Kaleeba, founder of TASO (which had just received the prestigious King Baudouin Prize for Development); and Werasit Sittitrai, a Thai AIDS activist with the Red Cross. Three representatives of development agencies instrumental in the creation of our new entity of UNAIDS also joined us: Jo Ritzen from Norway, Joe Decossas from Canada, and Hans Moerkerk from the Netherlands. Not a terribly representative group, but one I could rely on.
Basically we designed the core functions and structure of the new program. The first task was going to be to develop solid data on HIV and AIDS, worldwide, from Albania to Venezuela. This wasn’t just for policy purposes. Sure, sound epidemiological data and mathematical modeling are essential to any kind of program, scientific or sociological: they predict, they illustrate, they are the baseline for evaluating the impact of what we do. They also give power: if you’re trying to coordinate the work of many actors, it’s key to be at the hub of knowledge. To make AIDS a higher priority in terms of policy and budgets, we needed an unimpeachable reputation for solid facts; they make the news, and they give credibility.
But although hard evidence would be the basis for our policy and advocacy, we decided that, with the exception of epidemiological estimates, we would not engage in research as GPA had done. It seemed to us that we would have no comparative advantage against major AIDS research funders with huge budgets, such as the US National Institutes of Health or the European Commission, and that it could divert from our core business. So our first core functions besides political and resource mobilization were knowledge translation, policy development, the evaluation of policies and action on AIDS, and dissemination of real-world good practice regarding AIDS.
Clearly our program had been set up to coordinate the UN system’s response, but I strongly felt that coordination for coordination’s sake is not only a brain killer but also would probably lead the new program to focus exclusively on administrative and political processes, with hardly any impact on people’s lives. It was neither my strong point nor my interest. I felt our most important test would be how well we could support the response against AIDS in countries, on the ground: this was how I wanted to be judged. All of us agreed that if we were just a Geneva-based headquarters, we would be irrelevant, both for governments and for the people, and we would fail. So who should we work with: The Ministry of Health? of Finance? The office of the president? The nonprofit private sector? Business? Community groups? Religious entities? Where would our office be based? How would it relate to the rest of the UN system, and other administrative/political bodies?
Thus we planned a series of regional consultations on every continent, to be organized by Dr. Purnima Mane, a tiny, energetic woman from Mumbai with an infectious laugh, originally a social
scientist specializing in gender issues and a real powerhouse. I saw these meetings as a kind of customer research: we wanted to bring together a wide range of actors, from governments and academics to people with HIV, and ask them, “What do you think will work?” They would also serve to try to wake up local leaders and provide an opportunity to market the new program and to recruit staff.
Finally, we picked out a name for the new program during the Bellagio meeting: UNAIDS. The working title had been “Joint and Co-sponsored United Nations Program on HIV-AIDS”: you couldn’t even figure out the acronym. “UNAIDS”: that says what it is. My then fifteen-year-old daughter Sara designed the logo: a red ribbon over the UN logo, as straightforward as a teenager can be. But when I went to the first formal meeting of the cosponsoring agencies in Vienna and proposed the new name and logo, there was an instant bracing of spears. I ultimately won the case, but it was a struggle, and this pattern became a very familiar one. Sometimes the issues involved were trivial, but I often felt like Gulliver: hobbled and hamstrung, when what I needed was help. At the end of the Bellagio meeting I asked Rob Moodie and Werasit Sittitrai and Noerine Kaleeba to join our staff. It was a real act of faith for them, and I am still grateful that they took the professional and personal risk to come in and help build something that really only existed in a few UN documents. Rob organized our country work, Werasit our prevention activities, and Noerine marshaled community-based action.
Dr. Susan Holck, Mike Merson’s former right hand, was key at helping me maneuver through the UN and the endless coordination meetings of the first six months. Then Sally Cowal, a former US ambassador with a long history of postings in various countries, joined as director of External Relations. Sally was dynamite: one of the first female US diplomats who could stay on after she got married (until 1972, married women were banned from the US Foreign Service), she brought us some much needed diplomatic savvy, even though patience was not her greatest feature. She was good friends with some heavy hitters in the US government.