by Piot, Peter
My senior team was complete when Dr. Awa Coll-Seck, an infectious disease professor from Senegal, joined us as head of policy, strategy, and research. Awa was one of those strong West African women, brave and pragmatic. She had pioneered AIDS care in her country and was a cofounder of the Society for Women and AIDS in Africa. (She became minister of health and then head of Roll Back Malaria.) I also asked Jim Sherry, whom UNICEF had tried to use as a kind of killer dog against our program, to change sides and become my special adviser, as I felt that my lack of experience of the UN system and of multilateral politics might prove to be a major handicap. He was a real political operator, with the capacity to see through apparently innocent proposals at a glance, and was of tremendous help in building a broad coalition against AIDS.
So by April I could count on a dynamic and totally committed team. We felt we could move mountains. Each of them then recruited the best possible people in their respective fields. We recruited people from a wide range of backgrounds—academia, economics, journalism, activism.
Quite early on, I also ordered media training for all the senior staff, including myself. I wanted UNAIDS to speak clear, loud, and with professional skill. We needed to catch the media’s attention and use it as a foghorn—a massive, permanent amplifier. I thought about how astutely Jonathan Mann had done this, translating the problem to journalists, ordinary people, and politicians: getting them to see what they had to do. In contrast I was, initially, frankly useless at interviews, particularly on live TV. I found them terrifying; and I was still a typical academic, accustomed to stating the problem, discussing what methods you use to examine it, and what the conclusions might be. By the time I reached my main message most people had switched to another channel.
The media training was an eye-opener, an awful experience: the trainers videotaped us in fake interviews, and played them back so we could see every excruciating hesitation and mistake. Then they told me to forget everything I might have learned ever since medical school about the scientific method. Throw it away. Cut to the chase—when you start talking, begin with your conclusion. If there is still time left, know exactly what other message you plan to deliver. Carve the message out so it’s clear. And always mention the “brand”: UNAIDS. I found this first experience of professional communication illuminating; it was as if I had always been waiting for it. And I think I became quite good at the job of coming up with messages and campaigns and themes: Making the Money Work; AIDS—A Problem with a Solution, The Three Ones, and so on.
Retrospectively I made a mistake when I agreed that our program could be housed within the WHO campus. I also should have broken more radically with their bureaucracy. The old WHO Global Programme on AIDS was still operational, and it was very uncomfortable to cohabitate between the past and the future: It also didn’t help that many of their staffers knew they would be losing their jobs. I will be forever grateful to Stefano Bertozzi, an American physician and economist, who was a master at neutralizing the tactics that were deployed by Nakajima and some of his regional directors to undermine us. After Mike Merson left WHO to become dean of Public Health at Yale University, Stefano Bertozzi had the unenviable task of closing down GPA and that included firing several hundred people. Stef was a man for all seasons and all tasks—a brilliant, if sometimes absent-minded, man and the finest multitasker over the age of thirty whom I have ever met. I sought his advice on major professional issues since we met in Kinshasa in the early nineties (He is now director of AIDS and TB at the Bill & Melinda Gates Foundation in Seattle.) But together, we wasted too much time fighting with the Nakajima administration, which would flex its power over almost every issue, from recruitment to procurement and travel.
There was also constant, never-ending friction with the cosponsoring agencies. It started the second week of January, when I called a meeting of colleagues in charge of AIDS in the six partner agencies to discuss how we would work together. This was a sobering experience. When, at the start of the meeting the facilitator asked participants the classic warming-up question about their expectations for this meeting to define the new program, the UNDP representatives bluntly said, “No expectations whatsoever.” The tone was set.
To everything I proposed, the task force of UN agency representatives at first responded no. I had to recoup, get political and diplomatic support, and go to their principals, who were far more open and reasonable than their staff but initially made little effort to stop their tiresomely bad behavior. In fairness, it was not all ill will; much of this opposition had to do with different institutional cultures—people were not used to thinking outside their own organizational box. But the constant bickering was extremely draining. I remember one meeting where WHO, UNICEF, World Bank, and UNDP could not even agree on what the words “program” and “programming” meant.
WHO wanted to keep all the technical work under its control. The World Bank emphasized in a memo that the “Bank would assume no liability” for UNAIDS and wished to have “as little involvement as possible.” So throughout my tenure the best-case scenario was essentially a juggle between conflicting oppositions, avoiding the disaster that would ensue if there were ever a united front of all UN organizations against us. Asking for consensus in our favor would have been utopian.
Today I know that we were far ahead of our times in terms of working across the very diverse United Nations system, with its nearly 50 agencies and organizations covering about every aspect of society and governance. We were trailblazers for what is now a much more unified UN system than in the midnineties. But at times I truly felt I was meeting the worst aspects of human nature. For people working in the UN to be so wrapped up in issues of turf and ego and bureaucratic politics, in the face of a human problem so terrifying, well, it was deeply demoralizing and profoundly unethical. It made me angry and more determined at the same time. My skin grew a little bit thicker every day, and I reminded my team that we should not be deterred by bureaucratic guerrilla warfare, but build out the organization, solidify support outside the system, and never forget that we were privileged to be working on one of the most important challenges of our time. That kept us going.
I missed contact with people on the ground and with people living with HIV, and decided that my first public appearance as executive director of UNAIDS would be among them. So in March, I attended the seventh annual conference for the Global Network of People Living with HIV/AIDS in Cape Town—the meeting taking place for the first time ever in Africa. By then, 850,000 people were believed to be HIV positive in South Africa alone: approximately 2 percent of the population. I spoke at the opening, together with Thabo Mbeki, then Nelson Mandela’s deputy president. He gave a remarkable speech, and although he was a little stiff, I thought we had a good rapport. I was impressed by his sharp mind and thought he would be a strong, perhaps key ally for us. (Sadly the future proved me very wrong.)
Those were historic days in South Africa. The ANC had taken power barely a year before, following the end of the apartheid regime that had ignored the looming HIV epidemic. There was immense hope of a better future for all. During this visit, I had intense discussions with AIDS activists and people with HIV from the country and all over the world. I met some remarkable people, each of whom made history in their own right—from Quarraisha Abdool Karim, who was struggling to set up a national AIDS program at a South African Ministry of Health still dominated by the old guard, to Edwin Cameron, an Afrikaner gay man living with HIV who is now a justice at the Constitutional Court. The AIDS activists’ expectations of UNAIDS were enormous—completely out of line with our resources—but I returned to Geneva re-energized and more convinced than ever that a successful response to AIDS would not be possible without restoring the health and dignity of people with HIV. I was determined to make that our core goal.
I headed back into the trenches of political rivalry. As it turned out the UN member states did not agree on the mission and structure of our new program. So despite my total lack of experience
in this field, I had to try to broker political agreement among governments with hugely diverse interests. UN civil servants are not supposed to interfere with political processes, but if I hadn’t gotten directly involved, the agenda would have ground to a halt. It was a superfast learning curve, but fortunately I could count on a number of friendly diplomats in the New York missions of countries such as Belgium, the Netherlands, India, Brazil, Uganda, Canada, Sweden, and the United States. One of my main allies turned out to be Ambassador Richard Butler, the Australian president of ECOSOC. He was a bulldozer, very committed to UN reform in the sense of agencies becoming more transparent and more accountable to member states, and he felt the UN agency heads were trying to pull a fast one. He pushed through an ECOSOC resolution that made it clear that I was principally accountable to the member states—not the cosponsoring agencies—and set up a “Programme Coordination Board” to oversee our work.
People were running around with calculators, working out which countries should be represented on the board; it ended with 22 countries, 5 each from Africa and Asia, 2 from Eastern Europe, 3 from Latin America and the Caribbean, and 7 from Western Europe and North America. Once again, I was adamant that the board include representatives from community groups and people with HIV. Not surprisingly, China and Cuba objected strongly to membership by nonstate actors. But unexpectedly the Netherlands also had objections, because they felt that only states legally represent people and can be held accountable. With a promise that this would not be a precedent for other UN governing bodies, five nongovernmental organizations were invited to take part, one each from Africa, Asia, Latin America, North America, and Europe. This was the first of a still unfinished series of exceptions made in the name of the urgency and exceptional nature of the AIDS epidemic. UNAIDS is still the only UN body with nongovernmental organization representatives on its governing board, albeit with no voting rights. (The NGOs, led by As Sy from Senegal, actually rejected voting rights, as they did not want to be held accountable for every decision made by UNAIDS.)
Thus on July 3, 1995, the Economic and Social Council of the United Nations unanimously voted to establish the Joint and Cosponsored United Nations Programme on HIV/AIDS. This resolution was our founding charter, and it laid down language that I could work with. For example, WHO would not “administer” the UNAIDS budget but would give “administrative support” to us. Trying to explain this kind of hair-splitting nuance to friends, I could see they thought I had gone insane—how could I waste my time on something so petty? But by now I knew that in international relations, every tiny word could make a huge difference.
We had hired staff, listened to people, strategized, and set down a legal foundation that I could work with. Now I had to raise money. But at the first meeting of our Programme Coordination Board, in July, there were major disagreements over our budget. I think some countries saw UNAIDS as a way to cut their contribution to the UN and expand their own, bilateral programs on AIDS. I was asking for $140 million for two years. (This was, incidentally, far less than what Mike Merson’s budget at GPA had been.) I felt strongly that we should have a small number of UNAIDS staff in countries as advisers and coordinators, but that we shouldn’t directly pay for national staff and cars: governments needed to take responsibility for AIDS programs as part of their own agendas. So I reduced expatriate staff and cut the four-wheel drive cars and per diems. I wanted to see a Kenyan person coordinating AIDS work in Kenya, paid by the Kenyan government. (Of course donors wanted this too, as this was a time of declining aid budgets after the end of the Cold War.)
Still donor countries were divided about what UNAIDS should do. The United States felt we should implement AIDS activities on the ground, and the United Kingdom argued that we should be limited to a small group of coordinators and knowledge disseminators in Geneva. Developing countries and NGOs wanted a large budget, the majority going to their activities: When I became aware of the intense lobbying by the United Kingdom and other donors in the board room, I feared that the board would decide on a budget that would make it impossible to do our job. I asked for time out. This was one of those moments in life where I could not give in. I walked right up to the lion’s den.
As the delegates milled around the atrium I went over to Dr. David Nabarro, who represented the United Kingdom; he was a capable and influential man, but he was also the main opponent of our budget. A circle with half of the delegates formed around us, and you could have heard a pin drop. What I said was, roughly, “Listen. You donors set this up. If you want it to succeed, you fund it right. Otherwise I’m out. This budget is not negotiable, because you’re setting us up to fail. And if we fail, you will be held accountable for failing to do anything against the biggest epidemic in recent history.” I actually shook him by his lapels. (David and I later became very good friends, by the way. He is now the senior UN coordinator for avian and human flu.) Before it got out of hand, Nils Kastberg, the Swedish diplomat who had headed the initial task force that set up UNAIDS in 1994, intervened to get us to simmer down, and ultimately the board gave us a mandate to develop a budget within an indicative range from US $120 to $140 million for the biennium 1996–1997.
It was lean, but we felt that we were on the cutting edge of UN reform. We were a taut little mammal in a world of brontosauruses.
We decided to launch UNAIDS at the UN in New York on World AIDS Day, December 1, 1995. Sally Cowal had ensured the participation of high-level diplomats, including Madeleine Albright, who was the US ambassador to the UN. The event was not a success. I was scheduled to make a speech in the ECOSOC chamber in the main UN building. We had invited all the delegations and a number of celebrities and activists. But we had failed to tell UN security that we were expecting outsiders, and many guests could not get past security on time. So we launched not with a bang but with a whimper.
By this time, over 20 million people were living with HIV globally. Perhaps the most serious epidemic known to humankind was now the focus of a staff of 100 people in a little office in Geneva.
Earlier that year, I had received a phone call from the private secretary of Albert the Second, king of the Belgians (and interestingly, not king of Belgium). He asked whether I would accept to be ennobled as a baron. This had definitely not ever featured in my life plan, and in fact I had mixed feelings about the persistence of these titles. But I recalled the saying about such honors—“one doesn’t ask for them, but one doesn’t turn them down”—and accepted; later, thinking about it, I found that I actually was honored. As my motto I chose “KEN UZELF: Know yourself.” But apparently I also needed a coat of arms. I wanted a red ribbon, symbol of the AIDS movement, in it. This led to some trouble with the Belgian Council of Nobility, as the red ribbon did not exist when the medieval rules of heraldry were established. But in the end they gave in. So now I have a coat of arms: an AIDS ribbon with two hands of solidarity and a pair of Nubian demoiselle cranes.
CHAPTER 17
Getting the Basics Right
FOR UNAIDS TO be able to deliver a credible message, we needed solid data on HIV; success stories; clear strategies about what to do against the epidemic; and a country presence. This, in addition to our efforts to start building a broad global constituency for the AIDS cause, was the agenda for our first couple of years.
As a scientist, I wanted to make sure that the facts about the occurrence and spread of HIV not only showed authorities and the media what the situation was in a given country and worldwide but also established a baseline against which our impact could be measured. WHO was previously responsible for numbers and epidemiological surveillance. What that meant in practice was basically that someone at WHO waited until the Ministry of Health filed a report, and then the WHO person typed it into a form: “Ah, 23 cases of AIDS in Romania.” I had seen this essentially passive system and knew it was profoundly inaccurate, leading to massive underreporting, especially considering the deliberate, official denial of reality: “We don’t have an AIDS problem here.”
Tardiness and poor standardization further sapped the data of any useful value.
I asked German epidemiologist Bernhard Schwartländer to set up the system. Bernhard is a prince among epidemiologists, with an archetypical grundlichkeit (thoroughness), and his remarkable ability to bring people together turned out to be key to success. He designed a system in which every country’s population was assessed and a sample size determined, so that, for example, 300 pregnant women (as a surrogate for the sexually active population) would be tested for HIV in a number of locations, in addition to samples of patients in STD clinics and other high-risk groups. We managed to obtain reports at standard times in a standard way, training people in almost every country to do the surveillance work, with quality-control checks on the data. It’s not a perfect system but I’m aware of no disease where this was done at this scale.
We worked hand in hand with Daniel Tarantola, Jonathan Mann’s right hand; he had moved to Harvard University, and they had started their own estimates of AIDS in the world. We also partnered with the US Bureau of the Census, which put together an impressive data bank on HIV. Finally, we asked the best epidemiologists in the world to independently review the methods and data, to make sure they were sound. The last thing we needed was to confuse the world with different and conflicting estimates of HIV!
Even though Bernhard’s system was strong, getting the facts right took way longer than I ever expected. First there was the poor status of surveillance systems in many countries. Testing everybody in a country to find out the exact number of infected people is neither feasible nor affordable, so we had to rely on relatively small samples in the population, and then extrapolate to a country as a whole—just as opinion polls are done for people’s voting intentions, for example. Estimating the spread of HIV was complicated because the virus is not distributed evenly across the population. Since it is sexually transmitted, it clusters in higher-risk groups. So representative samples of the so-called general population may not be useful; in many places HIV mainly affects gay men, or truck drivers, or drug users.