by Piot, Peter
Several weeks later the nuncio informed me that the Holy See had agreed to an appointment. I went to Rome with two objectives: I wanted to find more solid common ground between UNAIDS and the Church, and I wanted an armistice on the condom. I knew that Pope John Paul II would never promote condom use, and my inner chameleon told me that it was totally nonproductive to have our relationship dominated by this issue. But the Catholic clergy should at the least refrain from preaching against condoms, especially when such preaching involved misinformation.
I spent two fascinating days in the Vatican, walking from one cardinal’s office to another through Renaissance and Baroque corridors festooned with cherubs, talking about AIDS. They were very well organized: by the time I saw someone, he had already received a briefing on my meeting with all his other colleagues. After a delicious lunch in a small trattoria in Trastevere Archbishop Lozano and I reached an agreement: UNAIDS had no competency in theological and moral matters, but, as he put it, the Church had no competency regarding “the quality of materials.” In other words, the Church would refrain from statements about condoms and UNAIDS would refrain from criticizing the Church. This carefully worded verbal agreement saved, I think, many lives, and isn’t the preservation of life the highest moral imperative of them all?
There is more than one pope in the world, and in 1997 in Cairo, I met Shenouda III, Pope of the Egyptian Coptic Church, together with Sally Cowal (who had to cover her hair with a big scarf). The Pope was accompanied by five bishops, who looked like clones of him: all six were wrapped in black, with long beards. All I could see of him under his vestments were his impressive nose and vivid eyes. I asked him to send a message to all churches to inform his flock about AIDS, and preach tolerance toward people living with HIV. He immediately accepted, but then in loud and heavily accented, but fluent, English pronounced, “Professor, AIDS is caused by illegal fornication.”
His white beard nodded emphatically as he spoke and his sonorous, plummy voice lingered over every syllable: “Forrrnication. There are those who are born like that, and they should be treated, and there are those who do it for fun. And they should repent.”
I glanced at Sally; we did not dare to look at each other or at the rest of the meeting. It was a silly, schoolboy reaction, for we then had a very interesting and open discussion about the nature of homosexuality. It was certainly not as bad as the conversation I had had the day before with Suzanne Mubarak, the First Lady of Egypt, who had told me that no tree could be high enough to hang “these homosexuals.”
Our next appointment was with one of the most respected religious scholars in Sunni Islam, Sheikh Said Tantawy, the Imam of El Azhar Mosque. He seemed more like a professor than a cleric, in his office crowded with books. That too was a productive and essentially benign conversation, and as a result he too regularly talked about AIDS.
It can be very powerful when the whole religious leadership of a country comes together to send a message about openness and against discrimination of people living with HIV. That is what happened in 1999 in Addis Ababa, the capital of Ethiopia, following some meetings I had with Patriarch Abune Paulo of the Ethiopian Orthodox Church and President Negasso Gidada. It created a safe space for a few men with HIV to come out and give a face to AIDS in a country where the disease had been completely hidden, even though close to a million people were infected. Dawn of Hope, the first association of people living with HIV in Ethiopia, was born, and I was proud to have helped make it happen.
As so often, it was Archbishop Desmond Tutu from Cape Town who said it best, in an advertisement campaign on AIDS in South African newspapers: Sex is a beautiful gift of God. If only all his colleagues would think the same.
NOT EVERYTHING WE tried worked. In June 1998, I addressed the plenary session of the Organization of African Unity Summit in Ouagadougou, the capital of Burkina Fasso, in West Africa. It was a rare privilege for a non-African and non–head of state, and I felt it reflected an increasing realization among Africans that bold action needed to be taken against the epidemic. I foresaw an international partnership that would bring together African governments and civil society, as well as donors and the UN, to mobilize money and action for HIV prevention and treatment.
But we did not succeed in mobilizing political commitments or the new money that was so badly needed. The partnership plan was, I think, too UN-focused; it gave African governments little sense that they “owned” the project. Also, at the time donor agencies were not ready to commit serious money to AIDS in Africa. They wanted to control the agenda, instead of UNAIDS, so they undermined the initiative in many subtle and not-so-subtle ways. They still didn’t “get” that the epidemic was destroying their own programs for African development.
On the positive side, at their annual meeting in May 1999 in Addis Ababa, all the finance ministers of every African country discussed AIDS together for the first time. After I spoke about the epidemic’s threat to economic development there was dead silence. I thought it was yet another moment of supreme denial—that, following this pause, everyone would manage to compose a straight face and go back to business as usual. But then the minister of finance of Benin took the floor, saying, “Yes, we have a problem, and it is high time we face reality.” One after another the ministers spoke, sometimes referring to AIDS in their family or colleagues. That evening many joined me for a drink in the hotel, continuing the discussion, and asked how they could be of practical help.
The same year, the World Bank established an AIDS Campaign Team, ACT Africa, in the office of its vice president for Africa, with Debrework Zewdie as its head—another important development, as the bank wields great power in Africa. We also forced all the major aid agencies to discuss AIDS for the first time, among themselves, in London in April 1999, and again in December 1999—this time with African ministers, activists, and business leaders, at a meeting convened by UN Secretary-General Kofi Annan.
That meeting was a big gamble and it nearly cost me my job. I assured Annan’s deputy, Louise Frechette, that there would be high-level participation at the meeting, and I concentrated my efforts on convincing Africans to be there. They came. But we then learned that, led by the United Kingdom and Sweden, the donors planned to take a passive-aggressive approach and send only junior staff. In desperation, Jim Sherry and I called upon some personal friends to break this de facto boycott by the donors. Sandy Thurman, Clinton’s AIDS czar, and my compatriot from Antwerp, Eddy Boutmans (the Belgian state secretary for international development) changed their plans and arrived just in time to deliver strong messages of support. Annan was at his best, and the African participants made it clear then that they wanted to act on AIDS.
This, alongside Kofi Annan’s newly visible commitment, signaled to the donors that they needed to get their act together. It also meant that Africa started slowly to take ownership of the AIDS issue. We had been the catalyst in this realization. But it had taken a long time—far too long—to get to this point.
By 1999 about 26 million adults and children were living with HIV, two thirds of them in Africa. More than 9000 new infections occurred every day, or over six every minute. More than one-fifth of those newly infected were young people aged fifteen to twenty-four. Some 5.9 million African children had been made orphans because of AIDS. In 16 African countries, 1 in 10 adults had the AIDS virus. And barely one-tenth of 1 percent of them were receiving life-saving antiretroviral treatment. Our annual report on the state of AIDS in the world suggested that in 1999 AIDS had become the first cause of death in sub-Saharan Africa. Out of nothing a few decades before, a virus had taken over all causes of ill health.
But by the turn of the millennium our “brilliant coalition” was taking shape in all its diversity and apparent chaos. What could the South African Chamber of Mines, Anglican Church, Communist Party, and trades unions have in common with the Treatment Action Campaign, Médecins Sans Frontières, and UNAIDS? A common goal: defeating the AIDS epidemic and caring for its victims. A power
ful joint desire to be a force for change.
CHAPTER 19
The Tipping Point
THE CHANGE OF century brought with it a sharp and sudden shift in the world’s attitude to the epidemic. In the space of a year, it became an urgent, unavoidable subject for world leaders and organizations. I would like to think that this was partly because of our work at UNAIDS in “global health diplomacy” as it is sometimes called today—a mouthful of a term for what was an effort at combining science expertise with the tools of traditional diplomacy, where national and strategic interests are paramount, as well as a new form of transborder activism.
We succeeded in elevating AIDS to levels at which no health issue had ever been discussed before—to where the heavy lifting of international and national politics takes place. The key to this was indeed the UN Security Council, and the key to that was Richard Holbrooke: the tireless, acerbic, larger-than-life American diplomat who was the then the US ambassador to the United Nations. I had met him in a formal meeting at the US mission to the UN and was impressed, so when I learned that he planned to visit the Great Lakes region of Africa in November 1999, I asked his assistant for a detailed schedule.
I asked our staff to write up some short but powerful evaluations of the AIDS situation in Rwanda, Burundi, and Congo, and I made sure that they were in Holbrooke’s background file. Then, in every town he visited, we alerted our UNAIDS country staff and local activist groups and people living with HIV to cross his path, ask him questions, show him the conditions in which they lived. That’s what activists do—they heckle.
When Holbrooke got back to New York he gave a press conference, where he said, roughly, “Yes, the security situation is bad, but what’s really killing people out there now is AIDS and we have to do something about it.” He asked to see me, and when we met he said, “Peter, we’re going to discuss this at the Security Council, because those guys have no clue what’s really going on out there.” Of course I knew that six months before Holbrooke too had not much of a clue, but I kept my mouth shut. Then he added, “To get it on the agenda I know what the hook should be: peacekeepers.”
The Security Council is the locus of power in the UN. Anything discussed there can change lives. But its mandate is not infinite: ECOSOC normally oversees economics and social affairs. The Security Council’s decisions are (in theory, at least) binding, and it makes decisions about war and peacekeeping. But as Holbrooke now knew, UN peacekeepers (currently 120,000 personnel) may catch, or transmit, HIV. His idea was to use this as a starting point to debate the national security implications of AIDS. Furthermore, since the United States would occupy the rotating presidency of the Security Council in January 2000, Holbrooke wanted AIDS in Africa to be the subject of the first Security Council meeting of the new millennium. It was brilliant.
To pull it off in a few weeks around Christmas was quite an effort. I assigned Ulf Kristoffersen, a Swedish former peacekeeper, and my adviser Jim Sherry to the job of working with Holbrooke’s office to collate data and prepare for the meeting. Here went our Christmas break: I got confirmation mid-December that the session was on, we worked very hard when the diplomats at the UN were eating turkey or whatever back in their country, and we took everybody by surprise when they came back. All this was done in close consultation with Louise Frechette, Kofi Annan’s Canadian deputy secretary-general. She was a tough woman who at first seemed to protect Kofi Annan from engaging with what she may have seen as an irresponsible, NGO-type of entity that somehow made it into the UN system. Louise was razor sharp, a former deputy minister of defense with a good sense of humor; but once I had persuaded her that AIDS was not only important but actually had the beginning of a solution, she came on board with vigor, and made sure that I became effective in the minefields and labyrinths of multilateral politics. I owe her a lot.
US Vice President Al Gore chaired the debate on January 10, and said that AIDS was a threat to peace and security. Kofi Annan told the assembled dignitaries that the destructive impact of AIDS on Africa was equal to that of war. AIDS was causing socioeconomic crises that threatened political stability. I tried hard to focus on the speeches, but was somewhat distracted by the enormous painting hanging over Gore and Annan, a somber expressionistic work in dark colors with scenes as from the day of judgment. Very appropriate for the Security Council chamber, I thought, hoping that the country representatives might glance now and then to look at it when making their solemn decision about war.
Then it was my turn to speak, and I am often a nervous wreck before speeches, small and big. I stated the facts, redefining AIDS as a threat to development and stability—thus a new form of security threat—and asking that all peacekeeping operations have an HIV-prevention component (which the council voted in on July 18 as Resolution 1308, thanks to Holbrooke’s tireless efforts).
The meeting had enormous impact. It highlighted the way AIDS swamps a country’s health services; kills the active, productive elements of a population; and creates social and economic crises that can overwhelm and break a nation’s political stability. Moreover, the very fact that it took place at all was in itself a breakthrough for us in terms of access. For years to come, presidents and prime ministers would tell me, “If AIDS was debated in the Security Council, this must a serious problem.” Deep down I found this ridiculous, sure, but I quite literally heard that kind of reaction.
During the Security Council debate, the Ukrainian ambassador to the UN had suggested there be a Special Session of the UN General Assembly devoted exclusively to AIDS. Uniquely within the former Soviet bloc, Ukraine by this time was developing a relatively coherent approach to the epidemic, and I had visited the country twice to meet with its leadership and community groups. It was clearly paying off.
Ukraine’s proposal for a Special Session of the General Assembly took everyone by surprise, and to be honest I had no immediate grasp of what it meant. I learned that to prepare for such an event is ordinarily a two-year project, involving regional preparatory conferences and premeetings that are basically very expensive and time-consuming talk shops. I thought that this would drain our energy and I wanted the shortest possible lead time. The first slot available was June 2001. (Another possibility was mid-September 2001, which would not have happened following the events of 9/11; and that too would have changed the course of the AIDS epidemic, for the Global Fund would probably not have been launched and much else would not have happened.)
A Special Session of the General Assembly would focus the minds of the diplomatic and political decision-makers of the entire planet. It was an opportunity we could not afford to miss: if we failed this, there would be no second chance to get AIDS on top of the world’s agenda. So a few months later I sent UNAIDS Deputy Director Kathleen Cravero to New York full time to start hammering out the preparatory work. I had met New Yorker Kathleen in WHO while she was working with Mike Merson and later as UNICEF’s representative in Uganda, where she was instrumental in the country’s pioneering AIDS efforts. When she was head of the UN in Burundi she was nearly murdered while visiting a refugee camp in the midst of a civil war (two of her colleagues were killed execution style, but she escaped; it is still uncertain whether the assassins were rebels or government troops). Kathleen is a jewel in the crown of the international civil service; you can parachute her anywhere and she will do a superb job. She helped me to bring UNAIDS to another level, and when she felt I was stressed (actually most of the time) would find the joke that brought me back to life. Kathleen was the one who pulled off the Special Session for us. The protocol, the texts under debate—virtually everything was controversial, and nothing could be relied on to function smoothly.
The solemnity of the Security Council debate brought AIDS an entirely new stature in terms of the world’s political agenda. It also startled the heads of our cosponsoring agencies at the UN. And UNAIDS became a subject of study when my daughter Sara told me a year later that she had to study my speech in her MSc class in international rel
ations in London; it was presented as a first event at that level to broaden the concept of security beyond the absence of conflict.
Also, following the Security Council meeting, ministers of finance became far more interested in the economic losses due to AIDS. The media grew more attentive and that brought big corporations on board too. AIDS activists in developed countries started to focus more intently on the need to solve the problem in developing countries. AIDS started to touch a nerve among intelligence agencies, security agencies, religious leaders. The pieces began coming together.
BY 2000, OVER 4.3 million South Africans were living with HIV—the highest number in any country in the world. But because so many of these people had been recently affected, they weren’t necessarily showing up yet as sick—or as fatalities. Still, it was clear to me that would be unavoidable.
Enormous amounts of time were being wasted, at the expense of hundreds of thousands of lives, because the top leadership failed to recognize that AIDS was an exceptional threat to the survival of the nation. South Africa was experiencing one of the fastest-growing epidemics in the world, and yet even after our meeting in Davos in February 1997, President Nelson Mandela didn’t speak about AIDS in his own country until December 1, 1998, World AIDS Day, when I accompanied him to a military base in Kwazulu Natal, where in the presence of Zulu King Goodwill Zwelithini, he addressed the nation in a dramatic live televised address. Mandela said, “We admire the brave . . . who are with us today to say: We are the human face of AIDS—we are breaking the silence!” That day the most admired icon of our time also broke the silence for his nation.
When Thabo Mbeki succeeded him as president in 1999, I had high hopes for his leadership: this was clearly an extremely intelligent and articulate man of great integrity. But in March 2000, our director for southern and eastern Africa, El Hadj As Sy (he had joined me from ENDA Tiers Monde, a Senegalese NGO) alerted me that Mbeki seemed to have adopted some very highly unusual views on the epidemic. Basically, Mbeki had come under the influence of a molecular biologist from Berkeley, California, Peter Duesberg, whose profoundly erroneous theory was that AIDS stemmed from poverty and use of drugs (for recreational or medical purposes), while HIV either did not exist or was a harmless passenger virus. We had no idea to what extent these ideas had taken hold in Mbeki’s mind, and I was sure that if I could only meet with him to discuss it, I could pull him back to reality as he seemed a man of reason.