by Piot, Peter
Randy Tobias, a former CEO of Eli Lilly, was named to head PEPFAR, and during a lunch in Washington we immediately found common ground—perhaps natural between a down-to-earth Midwesterner and a man from the Flemish fields. Tobias had made a fortune in the communications and pharma industries—a Republican who wanted to give something back to the world. He didn’t know much about AIDS, but he knew business. He had been all over the globe and had direct access to the White House. But again, there was suspicion all around. He was said to be just another symbol of how Bush’s programs were sold out to industry, were just operations to funnel money to the big pharmaceutical companies, and so on. But AIDS needed that money, and we developed a very strong alliance between UNAIDS and PEPFAR, which continued under Eric Goosby, the dynamic head of PEPFAR under the Obama administration.
We soon found out that in terms of interagency rivalries Tobias and I had similar challenges, but the big difference was that he controlled the money, and had real administrative and political authority. He rolled out his mega program in record time, by a bottom-up, decentralized approach to much of the planning and implementation in priority countries. Initially, PEPFAR’s activities were mostly implemented through American nongovernmental organizations and universities, for whom PEPFAR became a major source of revenue—sometimes I believe at the expense of the core mission of a university. However, as so often, the US Congress micromanaged many aspects of the initiative, leading to inefficiencies and ideological priorities.
Over a dinner in Paris, where both of us were attending a moderately interesting conference, Mark Dybul and I had a first session of a still-ongoing series of picking each other’s brains about how to end the epidemic. Mark was Tobias’s deputy, and when Randy resigned in 2006 he became the US global AIDS coordinator at the age of forty-three—and the first openly gay man with the rank of assistant secretary of state. He had an unusual combination of scientific and political intellect, artistic and spiritual sensitivity, and a street fighter’s guts. We became firm comrades in arms, and I was very upset when one day after Obama’s inauguration in January 2009 Mark was fired, despite being asked initially to stay on by the transition team. He was the victim of intolerance, blamed for previous US congressional policies that were not necessarily his.
At times it was difficult: to start with, PEPFAR did not fund generic drugs, thereby not only wasting taxpayers’ money but also causing treatment chaos in countries. For example, in Tanzania, all US-funded programs had at one point a different prescription for antiretrovirals than programs funded from other quarters, since the latter opted for the cheaper, generic drugs. This changed gradually after 2004, when the US government accepted to buy generic antiretrovirals from anywhere in the world as long as they were approved by the Food and Drug Administration, even if they were not marketed in the United States. Once more AIDS rewrote the rules of the game, this time by bypassing the Buy American Act of 1933 and domestic pharmaceutical policies.
On other issues, the government and Congress turned out to be highly inflexible, ignoring scientific evidence. Randy and I “agreed to disagree” on them: a ban on federal funding for needle and syringe exchange programs (going back to the Clinton years); the antiprostitution loyalty oath, and abstinence-only promotion as one-third of all HIV prevention funding, despite evidence that it is not only ineffective but actually actively counterproductive. (Research in the United States found that teens trained in “abstinence only” tend to have sex a little later than their counterparts, but when they do have sex, they more rarely use condoms and actually have more sex partners.) Although President Bush had exempted PEPFAR from the “global gag rule” on abortion and family planning, there remained confusion in the field, and many of the faith-based organizations who became major beneficiaries of PEPFAR funding only promoted abstinence and fidelity, whereas it was key to offer a spectrum of options to prevent the sexual transmission of HIV (called “combination prevention”). Very few developing countries turned down the conditions associated with US funding; Brazil is the only one I am aware of. Paradoxically, at the same time, the US government was also the world’s largest provider of condoms!
While I kept criticizing these counterproductive policies in interviews, speeches, and in meetings with legislators, we managed to work around our scientific and ideological disagreements, brokering bespoke funding arrangements so that PEPFAR could fund programs that it approved of, while other donors, such as the Dutch, the British, and the Nordics, picked up programs in more controversial sectors. This kind of cherry-picking by donors can be very dangerous, because the unpopular pieces can get left out, but the UNAIDS country coordinators handled the job very well, developing rational overall country plans with very few funding gaps.
Above all, PEPFAR threw its funding massively to the work of making antiretrovirals widely available, saving millions of lives. And it led the way for other countries to step up funding too, because in multiple ways, the United States still set the world agenda. Thus in July 2003 Tony Blair pledged £1.5 billion (then approximately $3 billion), the first one to follow Bush.
In September 2003, Richard Feachem from the Global Fund and I joined the new WHO Director-General J. W. Lee to launch “3 by 5,” his flagship initiative to provide antiretroviral treatment to 3 million people in developing countries by 2005. Gro Brundtland, Lee’s predecessor, first suggested this initiative in 2002 at the AIDS conference in Barcelona, but WHO did not follow through until Jim Kim, Lee’s creative American adviser and Paolo Teixeira, the Brazilian director for AIDS, turned it into an energizing campaign which was not without risks, as it nearly undermined the launch of the President’s Emergency plan for AIDS Relief by giving the impression there was no longer a need for an American effort. Even if the money was elsewhere (with the United States and the Global Fund), “3 by 5” put pressure on both donors and ministries of health in developing countries, none of whom liked the challenge. For a brief period, WHO became again very active on AIDS treatment, which was very welcome, but it often went alone and was again duplicating work that other agencies were better placed to do. It seems institutions never learn.
Four years later, 3 million people with HIV were on treatment. The “3 by 5” initiative was not reached in time, but the target played its role, and did better than many other initiatives such as WHO’s 1978 goal of “Health for all by the year 2000.”
MY RELATIONSHIP WITH donor countries was a complex one. Some were reform-minded, and some were true allies. However, I felt that my primary loyalty should be to the most vulnerable populations and the countries most affected by the epidemic—all developing countries, most of them in Africa. So whenever I had to choose, I chose for them, not for the donors’ interests; this was most acute in the unnecessarily long debate about access to HIV treatment.
UNAIDS had no guaranteed budget from the UN, every cent had to be earned year after year. This is fair enough, as it was performance based, but it also meant I had to spend about one-third of my time on fund-raising, when I needed all my energy to fight AIDS. Also, to some extent we had started off on the wrong foot. Some donors saw the creation of UNAIDS as an opportunity to reduce their contributions, compared to what they used to give to WHO’s old Global Programme on AIDS. With some donors, in particular the United States and the United Kingdom it was tough love: the UK Department for International Development was politically a great supporter—in particular when Hilary Benn was secretary of state—but at the same time constantly invented new performance targets, demanded one report after the other, and was obsessed with “global architecture” and evidence for “value for money,” desperately trying to quantify coordination. Their interventions at times came close to torture, but some of that was constructive, as it forced us to sharpen our focus on accountability. And in the early days of UNAIDS our US-based funding came from USAID, which treated us like any other contractor, a competitor for American nongovernmental organizations. This improved greatly when US funding came from PEPFAR.
The challenge in the United States was micromanagement of the federal budget by Congress, to a degree far beyond anything I have seen in any other country. So I had to spend a lot of time meeting with members of Congress and their staff, trying to convince them that we were worth the investment. Less than a year after our creation, the Government Accountability Office, the investigative arm of US Congress, issued a report on UNAIDS, saying we had not delivered: it was a tough moment when I had to appear at a congressional hearing, but at the end of the day everybody agreed that such conclusions were premature and that you can’t stop the AIDS epidemic in a year.
But I preferred by far the tough love of the United Kingdom and the United States to the lip service of some other countries who were long on words, but short on cash. France, a G8 member, was only our 17th largest donor, way behind Luxembourg, and was always pushing to recruit French nationals. (France did become a major donor to the Global Fund—when French national Michel Kazatchkine became its second executive director.) Italy was probably the worst at making promises, but often not paying at all. While I was a candidate for WHO, Italian officials unashamedly gave me the CVs of five fairly junior Italians for recruitment as a condition for their vote for me.
Each country required a specific approach in function of their political and societal culture. Thus in my annual meetings with my favorite donors, the Dutch (consistently the largest donor to UNAIDS) and the Nordic countries, I had to put all our problems on the table like some kind of confession (they knew anyway), explain almost penitently what I would do to improve our performance, set some goals. After a very direct discussion, they announced their contribution, and paid promptly. Trying to spin-doctor problems or be too diplomatic was counterproductive in their culture. In contrast, I learned not to show any problems in other places such as Washington, as that would have been interpreted as weakness. Throughout, I called on my inner chameleon: Adopt protective coloring; look from side to side; but keep your head pointing toward the real goal.
CHAPTER 22
An Unfinished Agenda
BY 2004 WE had figured out the politics, the money, and the in-country programs, and we knew what to do, but thousands of people were still dying and thousands became newly infected every day, even if the spread of HIV had started to slow down. We had to move from a start-up to a large-scale operation. The key challenges for the next five years of UNAIDS were to make the money work for people on the ground, ensure sustainability of funding and activities, and overcome some difficult issues, from HIV prevention among injecting drug users to AIDS-related human rights violations.
With literally thousands of small and a substantial number of big players in the fight against AIDS, developing countries faced transaction costs, duplication of efforts, conflicting policies, and gaps in essential activities. Their small number of officials had to receive sometimes hundred of missions from donors and the multilateral system per year, who all wanted to meet with a cabinet minister, even if it was a junior delegation. This was not unique to the AIDS field, but the sudden influx of AIDS funding exacerbated this burden on governments, particularly those in Africa that had the weakest capacity. All this happened in spite of clear agreements among donors at conferences in Monterey in 2002 and Paris in 2004 to harmonize their procedures and in-country work. When I started receiving a growing number of complaints from Africa I knew it was time to step in—desperately needed resources for HIV treatment and prevention were being wasted and further lives lost.
I asked Sigrun Mogedal to document what was going on, and to propose some solutions. Sigrun was a seasoned and highly respected international development expert, who had been state secretary for international development in her native Norway. She was personally also very active in the AIDS activities of the Lutheran Church, and I liked her no-nonsense approach with people and institutions. After extensive consultations with various actors in Africa and in donor capitals, Sigrun sent me a report in September 2003. It was a sharp analysis but the report had too many recommendations; I put it down a few times, until a few weeks later I read it again, trying to distill the essential action points to improve international support for AIDS. Suddenly I saw them: One national AIDS strategy developed with all partners; one national coordinating authority; and one system for monitoring and evaluation of activities (as every donor imposed its own system and indicators on countries). I had just seen an exhibition of Chinese propaganda posters, and wrote on top of the paper “Three Ones!” This became a simple concept to bring some order and greater efficiency in the AIDS response in developing countries. The Three Ones were endorsed by all donors and a number of developing countries at a meeting cochaired by Randy Tobias from the United States, Hilary Benn from the United Kingdom, and myself, on April 23, 2004, in Washington in the margins of the World Bank/International Monetary Fund Spring meetings—a powerful gathering of treasury and economics officials. AIDS started to influence international development practice, paradoxically by having generated both new types of distinct funding mechanisms (PEPFAR and the Global Fund), and new ways of working together. The principles were straightforward, but progress on it was slow, due to a combination of weak governance capacity in some African countries and legal conditionalities in many donor countries.
By 2005 HIV treatment and prevention programs were well under way, and there were over 1 million people on HIV treatment in low-and middle-income countries. This was serious progress, but we still had a long way to go; frustration took a front seat. The UK government was keen to push through stronger donor coordination and impose a division of labor among the various UN cosponsoring agencies of UNAIDS—not a bad idea, but not something one can fix in one meeting or impose from outside, as I had learned the hard way. We also agreed with Gareth Thomas, the UK parliamentary under secretary of state for international development, and AIDS activist Robin Gorna, his AIDS director, to use the “Three Ones” platform to agree on a financial framework for international AIDS funding. What should have been a routine and fairly technical event turned out to be a nightmare with some of the worst behavior I have seen from UN staff, donors, and activists. What was the problem? UNAIDS had refined the estimates of what was needed to confront AIDS, and for the first time I had asked to do two things: remove elements not directly related to AIDS such as caring for all the orphans in the world and paying for medical infrastructure and staff development; and prepare different scenarios to take into account a gradual building up of implementation capacity in countries instead of assuming that developing countries can offer full coverage of all necessary services and interventions—basically good planning practice. When in addition I said that we must improve how we were using AIDS money because resources are not infinite, all hell broke loose. I was attacked by colleagues in the UN for sabotaging fund-raising for their particular interest, by the Global Fund for undermining their resource mobilization events, by activists for minimizing resource needs and suggesting that we try to spend money better, by donors for inflating funding needs and for not keeping UN agencies under control. For once I had succeeded in upsetting nearly everybody, and poor Achmat Dangor, Jim Sherry, and Ben Plumley worked day and night with Robin Gorna to repair the damage and try to reach consensus.
In the running up to the meeting called “Making the Money Work” in London on March 9, 2005, I regularly received mass hate e-mails from American AIDS activists, the nicest being titled “Peter Piot Puppet of the Donors”—even if we called for a near doubling of AIDS funding by 2007 to about $14 billion, up from $8 billion available in 2005 (the actual sum spent in 2007 was $10 billion). In those days there was simply zero tolerance among some for anything other than advocating for more money, and while non-AIDS interest groups claimed that AIDS got too much money, they lobbied hard to get their issue included in AIDS budgets—often with success. For months trust among UNAIDS cosponsors evaporated. It was not possible for me to have a conversation with some of our cosponsors that wasn’t immediately leaked to activist
s, who then put everything on the Internet, making the development of a consensus very difficult. The lines between scientific evidence, professional institutional loyalty, and activism blurred. In the end we did not have to give in on the technical foundation of our work, and I was glad we had launched the discussion about optimizing, not only mobilizing resources. I still failed to understand what provoked the violent reactions but they clearly illustrated the passion of those working on AIDS, and the difficulty in international relations for an evidence-informed and transparent dialogue. It was also striking that the whole debate was among people and institutions from the the north; those directly concerned were not involved—they were doing the work. I often fantasized about the following experiment: a team of junior African economists goes to London or Washington, and tells the government what they must do to reduce public debt or to reform health care. There would be a general outcry all over the media and in Congress and Parliament, but isn’t that what happens every day in low-income countries?
In many developing countries there was and is a major crisis in terms of the health workforce. This was a serious obstacle to providing HIV treatment. I saw this acutely during a visit to Malawi in 2004 with Suma Chakrabarti, the permanent secretary of the UK Department for International Development. Suma was a remarkable man in many respects, very young to be permanent secretary, and committed to reforming international development policies and UN reform. We had met for the first time in Moscow, where I had challenged him to get personally involved in the AIDS response, and we had agreed to regularly travel together, which was a feast for the brain. On every trip I learned something from him. After witnessing firsthand the dramatic shortage and emigration of doctors and nurses in Malawi, we mobilized the government and all donors, to launch that same year a $273 million “Emergency Human Resource Relief Programme” for six years, which has now resulted in an increase in doctors and nurses in the country. This agenda required urgent attention, but few countries had a systematic approach to it, as did Ethiopia whose minister of health, Dr. Tedros Adhanom, one of the most dynamic ministers in Africa, embarked on massive medical and paramedical training programs, often with AIDS money.