by Piot, Peter
While the response to AIDS became more vigorous across the world, HIV had become hyperendemic in southern Africa, meaning a very high HIV prevalence with continuing new infections. I continued to fail to understand what made southern Africa so different in terms of AIDS from the rest of Africa, and the rest of the world, but in any case I was convinced that the region required a truly exceptional response to bring the epidemic under control. Besides numerous visits to South Africa, I also went to the surrounding smaller countries that had HIV epidemics that were at least as bad. In the tiny landlocked mountain kingdom of Lesotho 31 percent of adults were HIV positive in 2005, in some areas even over 60 percent! Life expectancy at birth had fallen to thirty-five years, down from sixty-five without HIV, but the international community completely ignored this country which had become a major sweatshop for mostly Chinese factories. The country was confronting an unprecedented triple humanitarian crisis combining poverty, malnutrition, and AIDS. So I joined forces with Jim Morris, the Indiana native head of the World Food Programme, and Carol Bellamy from UNICEF to gather international support and also to see how a pioneering nationwide door-to-door HIV testing campaign worked in practice. The uptake was surprisingly high, and you could feel the impact of AIDS everywhere. In community after community people, mostly women, were organizing themselves to cope with AIDS in the family, and there was a lot of openness about the problem, though less so about condoms. In contrast, the government had a fairly bureaucratic approach to the AIDS crisis, something I raised with King Letsie III, who was concerned about the very survival of his people and had declared AIDS a national disaster. Similarly landlocked, but somewhat wealthier, Swaziland—remember my mission from WHO in 1977 to “eliminate sexually transmitted diseases”—had the highest HIV prevalence in the world by 2004, with a staggering 42 percent of pregnant women being infected with HIV. The Swazi epidemic had “feminized,” with over 55 percent of all people with HIV being women. Life expectancy at birth had collapsed to thirty-two years as a result of AIDS. In an alarming report, the UN Development Programme concluded that the “longer term existence of Swaziland as a country will be seriously threatened,” reminiscent of the plague in the Middle Ages. It is hard to imagine that in modern times a virus can have such an impact but already in 2005 Swaziland had about 70,000 orphans out of a total (and shrinking) population of 1.2 million, with child-headed households common. In Mambatfweni village I saw how communities tried to protect these children from all kinds of exploitation, including sexual abuse, and support them while leaving them in their original family homes rather than putting them in an orphanage. It was impressive how, with very limited resources, the community joined forces without waiting for help from outside, though the drugs to keep them alive came from international aid. Several times I met King Mswati III, the last absolute monarch in Africa, who had banned women under age eighteen from having sex inspired by an ancient chastity rule, but then promptly married a seventeen-year-old girl as his 13th wife. There was a huge credibility gap between his policies and his own behavior. Given the continuing high rate of new HIV infections, and the lack of circumcision among Swazi men, the country was an obvious candidate for a large-scale male circumcision campaign.
Even if it was confronted with an equally daunting HIV epidemic, Botswana on the other hand seemed on the path to recovery thanks to the exemplary leadership of President Festus Mogae and his entire cabinet, the considerable and well-managed resources from diamond mining, and international support, particularly from PEPFAR, the Gates Foundation, Merck, and several US universities.
However, the country was less successful in terms of preventing new infections, and sexuality and gender relations were still very sensitive issues.
SINCE THE DISCOVERY of HIV in the 1980s we had all implicitly hoped that AIDS would go away one fine day and that technology—a vaccine, perhaps a cure—would eliminate HIV. No such luck. HIV is firmly embedded in both human cells and societies. I was very concerned about sustainability of our efforts: Who would pay for decades of treatment? Would we have new drugs when HIV became resistant to the current ones? How would second line antiretrovirals become affordable (Brazil’s HIV budget for medicines was already doubling because of the increased need for second line drugs)? How would political and community leadership be sustained? Prevention efforts? Lifelong adherence to treatment and safer sex? Etc. As President Festus Mogae had rightly asked when we discussed male circumcision—why were we not emphasizing more circumcision of newborn boys, instead of only adolescent and adult men as this would protect the new generations? I liked his long-term view, but stressed that we need to deal with the acute and the long-term—unfortunately international policy remained limited to the short-term, which I felt was a mistake and missed opportunity.
So in 2003 I initiated several projects to think through what the long-term trajectory of AIDS could be, and in particular what we needed to do now to ensure the best possible long-term outcome. We started with AIDS in sub-Saharan Africa, as the obvious priority, teamed up with Shell’s forecasting division in London, involving hundreds of concerned people in Africa. Under Julia Cleves’s leadership this resulted in a 2005 report “Three Scenarios for AIDS in Africa by 2025,” which made it clear that the worst was still to come in terms of impact of AIDS in southern and eastern Africa. It also made a strong case that it would not be enough to devote more resources to HIV treatment and prevention, but that supportive policies and good management would be equally key for achieving impact—nothing revolutionary, but important to state at a time when all attention went to raising money. Two years later I launched an initiative called “aids2031” (as the year 2031 will mark half a century since the first reports on AIDS in 1981). This was again an effort involving hundreds of AIDS experts and others, and was led by Heidi Larson, who had done work on the future of AIDS in the Asia region, and Stef Bertozzi. It turned out to be far more difficult than I anticipated to think so far ahead, perhaps because we were all struggling with daily crises of delivering HIV care and prevention. The highly politicized environment on AIDS might also have prevented people from daring to think outside the box, and some in the AIDS community feared that long-term foresight would deter from much needed action today. Not surprisingly it was young people who came up with the most innovative ideas, particularly during an aids2031 event at the Googleplex (Google’s headquarters in Mountainview, California), which led to the creation of the Global Health Corps by Jenna and Barbara Bush and Johnny Dorset, then in their twenties—an initiative that twinned young people from the United States and a developing country to work together in a health project.
The aids2031 recommendations called for a redesigned AIDS response, far more tailormade to the specifics of the multiple and diverse HIV epidemics across the world, and proposing various ways to optimize HIV programs. By the time the report came out in 2010, most of its recommendations had already been taken up by several funders and AIDS programs, all concerned now about sustainability, optimal use of resources, and long-term impact. Thanks to enlightened leadership from people such as ministers Tedros Adhanom Ghebreyesus and Agnes Binagwaho, countries such as Ethiopia and Rwanda made smart use of dedicated AIDS funding to strengthen their health systems overall, but most countries strictly followed the rules of the donors, thereby missing an opportunity for a more sustainable response. In times of financial crisis all these issues became key, and will be so for years to come.
When near the end of my term in July 2008 I launched the traditional biannual UNAIDS report, just before the International Conference on AIDS in Mexico City that Ban Ki-moon attended, I could for the first time announce a significant decrease in both deaths from AIDS as well as in new HIV infections (except in the former Soviet states). Finally, I was the bearer of good news.
SUNDAY NOON, NOVEMBER 30, 2008, Ndjili Airport, Kinshasa. I had just come from an informal breakfast at the private residence of the young Congolese President Joseph Kabila with whom I discussed how to address
widespread sexual violence and rising HIV infections in eastern Congo, which was still in full-armed conflict. We were waiting in the very loud and chaotic VIP lounge for a South African Airways flight to Johannesburg where I would give my last World AIDS Day address as head of UNAIDS, and the first one in South Africa since the resignation of President Mbeki in September. Then my BlackBerry vibrated: “Dr. Piot? The secretary-general would like to talk to you. Please hold the line.” Ban Ki-moon thanked me for my input in the selection process for my successor (my mandate was coming to an end, beyond the maximum 10 years at this level in the UN), and he told me how impressed he was by Michel Sidibé during his interview. The telephone connection was very bad, and the noise and music in the airport lounge were as loud as in a bar in Matonge, but through it all I heard Ban saying solemnly in his soft voice: “I have decided to appoint Mr. Sidibé as executive director of UNAIDS with effect of the first of January 2009. Can you please call him, and ensure there is a smooth transition between you and Mr. Sidibé” I felt great relief; UNAIDS would be in good hands. I immediately called Michel in Geneva, nearly shouting through the Congolese crowd speaking loudly in their cell phones: “Mon frère, toutes mes felicitations! Ban Ki-moon has just appointed you. We’ll celebrate later this week in Bamako.” (We had planned a while ago to visit Michel’s native Mali together.) The connection broke off abruptly. The circle was completed in Congo, where my professional life had first taken off.
EPILOGUE
ON DECEMBER 26, 2008, I closed the door of my now empty office and walked for a last time between the huge Mary Fisher sculptures in the nine-meter-high glass lobby of the Zen UNAIDS building, with its hanging and floating rocks. I would miss greeting the guards in the morning, having a quick word with the devoted women and men in my office who kept me sane during all these years—Marie-Odile, Sylvie, Karen, Caroline, Anja, Julia, Julian, Ben, Roger, and Tim—and rushing by the thought-provoking contemporary African art in the corridors. My successor Michel Sidibé would take over in a few days, leading UNAIDS and the global AIDS effort to the next stage. Just as he would arrange the furniture in his office differently, he would manage the organization differently and communicate differently, reflecting the rich heritage of Mali, France, and UNICEF under Jim Grant. I was proud that sometimes succession planning works in the UN.
I was not down nor relieved to abandon the influential pulpit of the UN, nor the snake pit of multilateral politics, and I had no withdrawal symptoms from the relative power and comfortable support that went with the job (except when once again those hopeless IT breakdowns hit me), because I had mentally and practically prepared my departure for a year. I must admit though that it was a great feeling to no longer be held responsible for anything that goes wrong on AIDS anywhere in the world. The moment I walked through the door it was all over, and my mind was set on the future. Just before the end of the year I would fly from Geneva to Harlem, New York, to start a new chapter of my life.
At a farewell dinner in December in Geneva, I asked Kofi Annan for advice on what to do in January. His answer was prompt and brief: “Sleep! Sleep as much as you can. When the responsibility falls off your shoulders, only then you will feel how tired you are.” As so often, he was right. Every cell in my body had accumulated a decade of lack of sleep and constant jet lag—not to mention the never-ending stresses fueled by what were mostly pseudo crises. I often woke up in the morning and wondered which government would complain, which angry e-mail some activist would fire at me, which donor would announce the nth evaluation of UNAIDS, which UN agency would complain that UNAIDS behaved like an independent agency, which confusing or nasty newspaper article I would have to face that day. Just as in political positions, these are demanding jobs. Others may handle this better than I did, but I rarely could relax, even on vacation, when the US Government Accounting Office or a reporter would decide it was the best moment to launch another investigation. Work dominated life far too much, and my family paid a high price, which I deeply regret. Without their tolerance and support I probably would not have made it.
These are also lonely jobs, and there were very few people I could confide in and who understood what was at stake in terms of AIDS, how complex the environment was in which I had to operate, and how bizarre the behavior was of people I had to interact with. It was not easy to explain to friends and family how exactly I spent my days, as I was so often a victim of the 80/20 law, and it sounded like all I did was attend meetings, give three speeches a day, and sleep in planes. What I enjoyed the most was trying to convince people to act on AIDS and to strategize on how to move the AIDS agenda, globally and in each country. This required in the first place thorough preparation of each important encounter, a solid knowledge of the culture and political environment, and the background of the individuals I would meet, much more than the AIDS situation. Bearing in mind what my mentor Stanley Falkow told me about understanding how bacteria cause disease when I was working in his laboratory in Seattle, I tried to put myself in the position of the person I was going to meet. Trying to understand people’s needs was also a guiding principle when developing policies—something insufficiently done in health policy.
Working in the United Nations system (it was an extended family with many very diverse members) was often not easy. Together with humanitarian aid, and very recently women’s issues, UNAIDS was the most advanced attempt to “deliver as one” in the UN. Over the years I became increasingly skeptical as to whether the current UN coordination governance could ever be effective operationally, despite the goodwill of many, if not most, staff. The two main obstacles for delivering as one UN were the institutional interests of individual agencies—careers, political influence, budgets—and the incoherence and volatility of its member states, which not only had different, sometimes mutually exclusive, interests, but which also lacked internal coherence, as they promoted different agendas in different UN agencies depending upon which national department they represented. My conclusion on UN coordination was that it was a collective failure, and that the international community either goes for some bold mergers and acquisitions as the current plethora of institutions is too expensive, or that it accepts that pluralism is a strength, as long as only effective and well-managed institutions are supported and others closed down. The creation of new institutions outside the UN system to fix problems of the UN is not a solution, as much as I worked to make the Global Fund to Fight AIDS, Tuberculosis and Malaria a success.
Despite all imperfections, working as a senior UN official was a great privilege and allowed me to influence the global agenda in a way that very few positions offer—certainly when coming from a small country like Belgium. I also met an extraordinary group of smart and caring people at all levels of the system, and occasionally we even had fun during the otherwise dead-serious retreats of the chief executive board of the UN secretary-general. UNAIDS also provided a unique platform where the various AIDS actors came together globally, as well as in individual countries, and therefore could drive the agenda. So, our achievements were not so much inside the UN system but in the world at large, which is what ultimately counted. I always thought that I was paid to make a difference against AIDS, and if along the way I could contribute to a better UN, all the better, not the other way around—otherwise it would have been “operation successful, patient dead.”
The contrast between my formative years as a scientist-adventurer and leading a UN agency could not have been greater, but I thoroughly enjoyed the different lives I had. The transformation was gradual and took years, and rather than shedding the approach of a researcher, I worked hard to complement it with diplomatic, managerial, and political skills. My scientific background also gave me some credibility, but was most useful for analyzing the potential implications of new scientific information for policy. I had a double mantra: keeping AIDS as a global issue, not one of poor Africa, and keeping science, politics, and programs on the ground in sync. Science without politics has no impact, politics witho
ut science can be dangerous, and without programs people don’t benefit. However, when I was appointed as head of UNAIDS, I had to learn everything the job required, except AIDS. My years as an activist in medical school were probably at least as useful as my actual medical training. When writing these memoirs, it struck me how many of the same people played a role at different moments in my life. Without their advice and support I would not have been able to function properly.