by Piot, Peter
I felt we should do more in this area, so I tried to support various initiatives to strengthen the health workforce. Because it takes decades to train sufficient doctors and nurses (and retain them in the country), task shifting, wherein medical tasks are performed by people with less advanced education but trained to perform a limited set of specific tasks, was an obvious way to go. Research in Uganda showed that specially trained assistants performed as well as full professionals when it came to follow-up HIV treatment. Sadly, though, I discovered that the people working on AIDS and those working on health service strengthening often don’t see eye to eye. In March 2008 at a conference on “Human Resources for Health” in Kampala, Uganda, when I called for a genuine partnership between our two movements, I was booed by about a quarter of the audience. I was startled, but understood that we needed to communicate better with each other.
MAKING THE UN system work together was the hardest part of my job, and where I did not feel we had made enough progress. The institutional construction of UNAIDS was based on the goodwill of every agency to work together, a few semibinding mechanisms such as channeling global funds, a division of labor among agencies, and joint reviews of each others’ global activities. To a certain extent it worked, and certainly far better than any other interagency collaboration in the UN system. However, the nature of the various agencies is so different, with a bank, technical and normative agencies, and operational organizations, that a uniform approach is a major challenge. Each agency needs to raise funds to survive, which creates competition among them and drives their often aggressive communication work. In theory this could be easily resolved if donor countries put their money where their mouth is, but in practice they were often speaking with a forked tongue: in the UNAIDS board they stressed how essential a uniform UN response to AIDS was, but then at the next board meeting of WHO they pushed WHO to pursue the full range of AIDS activities, when other agencies might be better placed. Furthermore, after having put pressure on country offices of UN organizations to agree on a joint plan of action with a division of labor (which usually took many months to pull off), donors funded activities outside such agreed frameworks. These behaviors obviously reflected how national administrations were organized in very separate boxes with little communication among them—just as the UN system. An additional challenge for us was that careers depended on promoting your own organization, not on how well you contributed to an overall UN effort. The UNAIDS partnership meant that every component had to give up a bit of power to ultimately have greater impact together.
But the struggle was not only one of power. Colleagues throughout the UN and the World Bank who were living with HIV could not be open about their condition for fear of being discriminated against or stigmatized—and in fact they often were. WHO, the guardian of health in the world, passed several resolutions condemning HIV-related discrimination but refused to apply to itself what it told the rest of the world to do (it took years to convince them to allow hiring people with HIV). In some country offices confidential access to antiretroviral therapy was also difficult. Kofi Annan met a few times with the UN+ group—an interest and support group of colleagues living with HIV throughout the UN system—as did his successor Ban Ki-moon. The latter turned out to be a strong supporter of UNAIDS, but in the beginning was more at ease in diplomatic circles than with the rich plethora of characters that make up the AIDS movement. I wanted the new secretary-general to understand what AIDS meant for people’s lives, so at the very beginning of his term I organized a first meeting with UN+ members, all living with HIV. I had briefed my new boss about the sensitivities around being HIV positive in our system, and I had had a dry run with the positive staff urging them to be concise and strategic in their demands with the secretary-general. Everything was under control, I thought, when we gathered in the august wooden-paneled secretary-general’s meeting room. But then Ban Ki-moon slowly looked around and said: “But you don’t look ill . . . you look so healthy . . .” You could have heard a pin drop. People stared at me for a signal as to what to say. I thought, disaster!, and was already thinking how to handle the fallout with AIDS activists, but Ban went on, this time saying, “it is shocking how you are discriminated, please tell me what I can do.” By the end of the meeting we did hear the daily big and small problems of living with HIV in the UN, and Ban Ki-moon announced that he would send a message to all UN staff, saying that this was one of the most important meetings of his life and that he does not tolerate discrimination in the workplace. And so he did the same day. In the end I actually preferred a man who spoke from his heart, rather than from his briefing notes, even if in the most non–politically correct way. On another occasion, at the launch of the report of a high-powered commission on AIDS in Asia that the UNAIDS Asia Director Prasada Rao had delivered with his usual efficiency, Ban Ki-moon called for the decriminalization of homosexuality and prostitution in front of all Asian ambassadors to the UN in New York. Sitting next to him. I had held my breath wondering whether he would support the recommendations of the commission, but he delivered without hesitation to an astonished audience.
HIGH TURNOVER OF staff in WHO was another challenge, as each new director of their AIDS program had a different view of priorities and how to work with us. And, in the first 14 years of UNAIDS’ existence, WHO had no fewer than nine directors of its AIDS program.
These were also very difficult times for the UN and for multilateralism in general. Relations with the United States were at an all-time low because of the war in Iraq, and before that the food-for-oil scandal, which considerably weakened Kofi Annan and the UN system as a whole. Despite the extreme stress that he was under, Annan kept a keen interest in the AIDS response, and relentlessly lobbied for the cause, ably assisted by his chief of staff and then Deputy Secretary-General Mark Malloch Brown, who was equally supportive. In December 2005 Annan sent a very unusual note to all UN country teams, directing them “to establish a joint UN team on AIDS . . . with one joint programme of support.” In other words, Annan was directing UN country teams to do what UNAIDS was supposed to establish, and to become a flagship example for his efforts to “Deliver as One,” as the UN reform report was titled. In UN terms this was a bold move, as formally the secretary-general has no authority over specialized agencies. Several commentators went on to depict UNAIDS as a “success story.” To the outside world, we at UNAIDS were an “example” of UN reform and joint action. This was nice to hear, but I felt we still had a very long way to go in this area.
NOT EVERYTHING WENT as smoothly as it looked from a distance. If prevention of sexual transmission of HIV was fraught with emotions, moral judgment, and heated academic debates, it was nothing compared to the passion and the inability to think rationally when it came to drug use. The combination of heroin and HIV epidemics was perhaps my greatest policy challenge. One place where we failed to inspire an adequate response to the epidemic was the former Soviet Union. In late nineties it was becoming obvious that there was an explosion of HIV in Russia, driven by the use of heroin. This was something we had not anticipated in any of our epidemiologic scenarios—a gross underestimation. But while courageous epidemiologists such as the soft-spoken Vadim Pokrovsky, head of the Russian AIDS Center, whom I had met during a brief visit in 1988 to Moscow, published one alarming paper after the other, the Russian government was implacably opposed to the reality being revealed. So as usual, I decided to go into the lion’s den. In the end of November 1998 I went to Moscow to launch our annual report on the global state of AIDS for World AIDS Day, which is celebrated on December 1 every year since 1988. This was of great interest for national and international media, and close to midnight at the end of an exhausting day I gave my last live interview for the French TV station Antenne2. It was my scariest interview ever: I was sitting on the slippery ice-cold ledge of an open window on the eleventh floor of the Russia Hotel near the Red Square so that French TV viewers could see the Kremlin in the background. I had a serious fear of heights
, and had a really hard time concentrating on the camera, but I smiled when I thought how my life might end falling on the heads of a group of prostitutes and bodyguards with automatic guns who were laughing loudly underneath the entrance of the hotel. It took many skills to be executive director of UNAIDS. In any case, our efforts paid off, and for the first time worldwide media picked up the rampant spread of HIV in the countries of the former Soviet Union.
I actually liked Moscow with its history, museums, and metro, and even more the Russians themselves. They were very cultivated and warm people with a great sense of humor mixed with a some special form of weltschmerz and a sense of not being understood by the rest of the world, even if I definitely could not follow the vodka toasts at the numerous banquets I had to attend (dinners with all 12 ministers of health of the Community of Independent States—all former Soviet republics—were the greatest challenge, as my toast could only come after all the countries had made theirs). However, in spite of my love for the classic Russian authors and some solid friendships, relations with the government were always very tense.
We mostly interacted with the chief sanitary physician of the Russian Federation, Gennady Onishchenko, who was a very old-Soviet style man of my age with a GI haircut. Talking with him was like talking to a wall. Russia was a very homophobic society, and as for drug users, the authorities seemed not even to understand why we cared whether they lived or died. I attended preparatory meetings for the Eastern European AIDS conferences between 2005 and 2008 with Onishchenko publicly bullying NGOs and gays. The UNAIDS representative at the time, Bertil Lindblad, an experienced Swedish diplomat, was highly respected locally and helped me considerably with the UN Special Session on AIDS. He was fluent in Russian and had built a vast network of both influential Russians and civil society activists—as I expected him to do. Bertil lived in one of the huge landmark “wedding cake” buildings from the Stalin area, and hosted dinners for me so that I could hear versions of the AIDS situation in Russia other than just the party line. The AIDS activists were very courageous young men and women, who operated in a system with little tolerance for dissident views and were always short of money.
The old Soviet Union had had a decent public health system and sanitary infrastructure, combined with a huge and often coercive surveillance system for infectious diseases, but after the fall of the wall there was a sudden cessation of funding of the public health sector, the rise of a brutal free market economy, and a general collapse of traditional social norms. Epidemics of all kinds were bursting forth in the 1990s: not just AIDS, but also diphtheria, hepatitis, typhoid, and sexually transmitted infections. Except for some isolated cases of HIV, nearly always imported from abroad, in 1988 during the Soviet Union era about 250 children had been infected with HIV by their doctors and nurses, mostly because of reuse of unsterilized syringes and catheters at a hospital in Elista, Kalmykia. Some of the infants even transmitted HIV to their mothers while breast-feeding, probably through a cracked nipple. There were other, smaller outbreaks of the same kind elsewhere. In April 1998, I visited an institution just outside St. Petersburg for HIV-positive children, many of whom had been infected by faulty medical treatment: they were essentially abandoned. They had arrived undernourished at the hospital, and nurses and children begged for my help, but what could I do? It was an incredibly depressing experience that would haunt me. I think the authorities were so secretive about this partly because it was such an indictment of the Russian medical system.
The hospital spread of HIV among children was tragic, but the scale of the AIDS epidemic among adults went out of control at the turn of the century. By 2005 around 1 million people or just over 1 percent of the adult population was infected with HIV, even if the Russian authorities rejected the UNAIDS estimates (they only accepted a number based on the officially registered cases of around 300,000). It was a young epidemic, and an epidemic among the young: 80 percent of HIV-positive people were under twenty-nine years of age, and 40 percent were women. Initially, the overwhelming majority of people with HIV were injecting drug users. So, addiction and social breakdown were at the heart of the epidemic in Russia and other ex-Soviet countries, such as the Baltic States and Ukraine. However, many of the mainly young people who became infected through sharing contaminated needles and syringes were not classic drug users, and it was not just heroin coming from Afghanistan (introduced by Afghan war veterans). More often these were occasional weekend users, sharing locally produced ordinary opiates such as kompott among friends, which made the spread of HIV even more difficult to control: harm reduction approaches like needle and syringe exchange and substitution treatment for opioid use are less likely to work for occasional users.
There was a whole corps of physicians in Russia known as narcologists, who specialized in addiction treatment—not to the mega epidemics of alcohol or cigarettes, but to opiates—and these people were a huge obstacle to any rational approach to dealing with drugs—meaning a combined approach of education to prevent people from using drugs, treatment for addiction, repression of drug trade, access to clean needles and syringes, and oral substitution therapy with methadone and other substances. Their approach was basically to put the junkie in a cold room and often beat him, and if he resisted in any way, to then confine him in a straitjacket: I am barely exaggerating. There was no medical treatment at all, and the Russian government up to this day subscribes full-heartedly to this approach, although a punitive-only approach to drug addiction only drives drug users underground. The narcologists were particularly adamant in their opposition to gradual treatment of addiction through the use of methadone, which has been the cornerstone of opioid dependency treatment in the United States since the early fifties. By delivering orally an addictive substance, methadone, that doesn’t give the “high” of recreational drugs but does remove the craving, methadone facilitates the beginnings of a dialogue with addicts, so you can start the difficult process of treatment and resocialization. It also keeps them away from injections that transmit infections that will kill them and others. In particular, Russian prisons were an absolute incubator of disease, through overcrowding, rape, and shared needles. (It wasn’t just AIDS: there was also tuberculosis, one piggybacking on the weak immune system created by the other. Exacerbating the problem, much of the TB was drug-resistant.)
Russia is one of the countries I visited the most, but without much impact. I knew Russia’s leaders were sensitive about demography. The population had been in decline since the fall of the Soviet Union, despite immigration, because of low birth rates and very high mortality, especially among men. This affected the quality of the armed services, productivity of industry, and the future of the nation from just about every point of view. Even with a modest 1.1 percent prevalence rate of HIV, AIDS would exacerbate demographic decline in Russia much more than in an African country with much higher HIV prevalence but an annual population growth of 2 to 3 percent. I thought this could be my entry point for a breakthrough in our discussions with Russian officials, but it never happened. In contrast to nearly all other countries where I asked for this, I never managed to meet the then head of state, President Vladimir Putin, but I am not sure whether it would have made a difference. In democracies, where there’s a responsive system of governance, there’s no real need to meet the top man, but I had learned that in more authoritarian traditions the state leader has a massive impact even on fairly minor things. However in 2006 in the running up to the G8 Summit in St. Petersburg—the first ever in Russia—I met the then First Deputy Prime Minister Dmitri Anatolyevich Medvedev, who would become Putin’s successor as president. Medvedev listened carefully, recognized that the country had an AIDS problem, and announced that the State Council Presidium had just decided to establish a national coordinating authority on AIDS—a breakthrough—but also confirmed the government’s opposition to methadone as “non-scientific.” This was very disappointing, but I didn’t give up, and continued to advocate for better and more humane HIV prevention,
working closely with media figures Vadim Pokrovsky and Russian speaker Michel Kazatchkine, the new French head of the Global Fund, and with groups such as AIDS InfoShare, Médecins sans Frontières, Open Health Institute, and even with the Russian Orthodox Church. During an audience with Patriarch Alexy II, I agreed to support a training program on AIDS for priests, as the Church was increasingly filling a moral and ideological vacuum after the fall of communism. I also went on media-covered street visits to see HIV prevention work with sex workers and injecting drug users—their living conditions, personal misery, and constant harassment by the police were horrific. Sadly, none of the visits made a difference for official policy, although they did for local initiatives. However, by then Russia was providing antiretroviral treatment to people with AIDS, but basically only to “good citizens,” and often at a cost above that in the West, probably because of the involvement of several middlemen.
At the end of a conference of G8 health ministers in Moscow in April 2006, J. W. Lee, director-general of WHO, and I were sharing a laugh in the hotel lobby about the absurdly choreographed meeting. This was the last time I had some social time with J.W., who was in good spirits, though looking extremely tired. He unexpectedly died on May 22, 2006, from subdural hematoma, just before the start of the annual World Health Assembly meeting. Even though competitors for the election of his position, we had developed a good relationship, and I was sad. (As so many told me afterward, I also thought of the extreme stress of this kind of position.) The irony of history was that I ended up sitting next to a chatty Margaret Chan on the flight back home from Moscow to Geneva. We had met a decade earlier in Hong Kong where she was director of health, and she was now in charge of pandemic influenza at WHO, which badly needed an entrepreneurial woman such as Margaret. Even during Lee’s funeral service I was approached by several countries to run again for the position, which I found shocking. I quickly decided that this time I would not run: I had no confidence in the electoral process of WHO and felt there were at least two excellent candidates in Julio Frenk and Margaret Chan. (Chan won, becoming the first Chinese to head up a specialized agency of the United Nations.)