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Report back on Swaziland

Stephen Lewis, UN Secretary-General's Special Envoy for HIV/AIDS in Africa

Notes for Press Briefing, United Nations, New York: Noon, March 31, 2004

Copyright: United Nations
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I want briefly to reconnoitre my visit earlier this month to Swaziland, focussing on one potentially dramatic development. Along the way, I shall also make short, if pointed remarks, about the 3 by 5 program of WHO, and the current tension between brand name antiretrovirals and generic fixed dose combinations.

For the Kingdom of Swaziland, the written logo of its existence is expressed on the front cover of the most recent HIV prevalence report: "A Nation at War with HIV/AIDS". The rise and sweep of the virus has been inexorable, and thus far, irreversible. The HIV prevalence among pregnant women attending ante natal care centres in 1992, was 3.9%; in 1994, was 16.1%; in 1996, 26%; in 1998, 31.6%; in 2000, 34.2%; in 2002, 38.6%. By my calculations, that's a jump of almost 900% over the course of a decade. But hear this: eighty-seven per cent of these infected women are under the age of 30; sixty-seven per cent are under the age of 25. What is to become of this lovely little country?

Swaziland now holds the dubious title of the highest prevalence rate in the world.

It was a difficult trip because the sense of death is so pervasive. In the adult female medical ward of the Mbabane General Hospital, the women lie shockingly ill on all the cots in the ward, and the women lie shockingly ill on the floor under every cot in the ward. When the ward is packed --- and the nurses told us the ward is almost always packed --- it's a scene out of Kafka; in fact, using the Kafkaesque analogy seems paltry and inadequate. When I visited Mbabane hospital three years ago, 60% to 70% of the beds were occupied by AIDS-related cases; now, it's over 90%.

You can see the virus on people's faces in the street; you can see the virus on the faces in a crowd, you can see the virus on the faces of rural villagers. HIV/AIDS has reached into the viscera of Swaziland and is tearing it apart.

And as if the sickness and the suffering weren't enough, large parts of Swaziland are desperately hungry. For four consecutive years, crop production has been disastrously low, and though there is currently a drought and there have been droughts before, it's now clear that the classic scenario is at work: so many farmers --- almost all women --- have died of AIDS or are ill, that the fields are shrivelling from neglect. You don't eat if you can't plant. If it weren't for the World Food Programme, a large part of the population would be starving. Everywhere I went, people asked for food. It's terribly distressing when everyone … the children, the adults, the grandmothers … are reduced to imploring for food. I know the donor world can't bring itself to provide the financial resources adequate to turn the pandemic around, but food? We don't have an abundance of food? It is to weep.

And there's one other inescapable aspect of Swaziland, flowing directly from the pandemic, from the huge numbers of infected women: the orphans; orphans absolutely everywhere. I've just never seen anything quite like it. Child-headed households proliferate; fully ten per cent of the households are 'sibling families' When I met with the cabinet, one of the Ministers, in heated agitation, talked of the 'explosion' that had engulfed his country, and the fact that children of the age of eight were heading families. Of course, that's not a family; it's a brutal rupture of the family constellation, where every child is vulnerable and at risk, and no child has a childhood.

Swaziland estimates it will have 120,000 orphans by the year 2010, somewhere between ten and fifteen per cent of the total population … not ten to fifteen per cent of the child population, but of the total population. And because the virus is so widespread, a lot of the children are HIV positive, their faces and bodies marked by scars and rashes and lesions. It's simply awful to think how much pain they endure. They're children for Heaven's sake: I'd like to take the entire political leadership of the G8 and plunk them down into Swaziland for a week --- not for a day but for a week --- and see if they'd ever be the same again. Maybe Oprah can do it; maybe Bono can orchestrate it: no mortal flesh and blood human being could be impervious to what's happening to those children; you can be darn sure that the attitudes of the western governments would change. Failing that, however, one simply has to ask; how is a tiny country like Swaziland to cope?

Well, to ask the question is to recognize that Swaziland is a vivid microcosm of all the similarly-afflicted countries of Southern Africa. At the grass roots, where it counts, there's a superhuman determination to bring the pandemic to heel, and to overcome the tremendous assault on the human condition. I'm not romanticizing: in the midst of the worst the world has to offer, the people of Swaziland simply refuse to succumb, and they're fighting back with every means available.

In three areas in particular, the response is inspired.

First, Swaziland intends to put between 4,000 and 4,500 people into antiretroviral treatment by the end of this year (there are about 1,500 in treatment now); 10,000 to 13,000 by the end of next year. That will represent almost 50% of those who are eligible for treatment, a much higher ratio than most other countries. Can they pull it off? The answer would appear to be yes, because the National Emergency Response Council on HIV/AIDS (NERCHA) is extraordinarily impressive, well-led and single-minded. More, it has devised a computer tracking system for drugs and adherence and side-effects, available to physicians in the public and private sector to follow patients, while sealed in absolute confidentiality. I saw the entire apparatus, watched a full simulation, and it may well be that Swaziland has fashioned a brilliant technology that can be emulated by other countries.

At this point, allow me the digression I announced at the outset. One of the reasons Swaziland is moving so effectively on treatment is because of the presence of a team of experts from the World Health Organization, who have helped with every aspect of implementation, including infrastructure and capacity. This is exactly what is meant by putting three million people into treatment by 2005 or "3 by 5". It's not that WHO will do the treatment itself; far from it: WHO will make it possible for everyone else to do the treatment and get to the goal.

It is therefore a matter of continuing concern that the seed money WHO needs --- 200 million dollars over this year and next to do this indispensable, life-saving work--- is still not forthcoming. I raised this subject in a separate briefing back on March 3rd, and it is a measure of my astonishing influence that the money is still not forthcoming. On the other hand, I learned a very long time ago that you just keep hammering away until the encrusted cerebra are penetrated. The donor governments have to understand that if the goal of putting three million people into treatment by the end of next year is not reached, it's on their heads. And every person short of that three million, which will undoubtedly represent a life lost, is also on their heads. Let it be said now, in advance, that the United Nations family and the World Health Organization will be blameless. WHO can make the target if WHO has the seed money. Surely some western country, amongst the cornucopia of wealth and power, can find the dollars.

And there's one other aspect of this that must be addressed. In Swaziland, as in so many other countries, the preferred course of treatment, because it's so much less expensive and it works (I have personally seen it work in country after country), is a generic fixed-dose combination: three drugs in one pill taken twice a day. We know from Medecins sans Frontieres, and from treatment initiatives in both the public and private sectors, and from excellent outfits like the Community of San'Egidio, all of whom are using FDCs, that there's no over-riding reason to use alternatives. This is particularly the case when the World Health Organization has pre-approved the generic combinations after subjecting them to a rigorous scientific quality-control process.

Of course, countries can do as they choose, and if they choose to spend more money, so be it. And obviously donors can place conditions on their financial contributions. But the Global Fund permits the purchase of generics, and UN agencies encourage the purchase of generics, and the World Bank has no opposition to generics, and countries want generics, so the one thing that cannot be countenanced is for the WHO pre-qualification process of these drugs to be in any way discredited. That would be destructive to cost and to health.

Second --- and this is the exciting item --- in order to deal with the vast numbers of orphans, NERCHA is proposing to establish a cadre of ten thousand women to act as a kind of surrogate parent for the children. These are women who have families of their own, still do all of the tasks related to those families, still care for the others who are vulnerable in their villages, but on top of all of that, will somehow find several hours of the day to feed and support the orphans.

It's a classic example of how women sustain African society, usually unheralded and uncompensated. What really amounts to conscripted labour, is described as 'voluntary'.

Well, NERCHA is blazing an amazing trail. In its latest submission to the Global Fund, NERCHA is asking that the ten thousand women be paid for the specific work they will undertake with the orphans. Predictably, it's a very modest stipend --- roughly $40 a month --- but it's a stipend. And it's not ad hoc or quixotic. It's explicitly in recognition of the additional work over and above all the other work that is normally done. It will be monitored carefully, and the money will be paid.

So the fascinating question is: what happens to the proposal when it hits the Global Fund? If it's thrown out by the Review Committee, or the Board, there should be a public uproar that shakes the Fund to its foundations. It would make a mockery of the struggle for gender equality. If it is approved, it will set an astonishing precedent: suddenly, one international organization will finally have recognized the value of women's unpaid work in an environment where that work is appallingly difficult and challenging, and where no one else would consider doing it.
Third, again given the surfeit of orphans, schooling and feeding are vital. In Swaziland, you have the predicament characteristic of many other countries: school fees prevent school attendance. In response, NERCHA and UNICEF and WFP, working with powerful local chiefs, have fashioned a truly imaginative initiative, serving as a model in a number of communities. The communities are offered a grant (through UNICEF) to be used as they see fit (including school fees, but sometimes teachers or materials or refurbishing of classrooms), and the entire purpose is to get kids back into school. Tens of thousands of children are currently out of school.

It's working. The children are returning in large numbers; WFP feeds them a couple of meals a day; school gardens are planted to give the children some agricultural experience and to enhance the diet; it's organized around "Neighbourhood Care Points" … points in a chiefdom where villagers gather for the purpose of attending to children, and NERCHA is overseeing the construction of a number of Social Centres to serve as a focal point for all community and orphan activity. It's quite the model, and it's giving joy and hope to a lot of orphan kids.

Finally, this briefing would be suspect if I made no mention of the King. Swaziland is a monarchy which has yet to experience significant constitutional reform. Some of the policies and practices of the King are highly contentious, from polygamy to proposed extravagant expenditures. I met with the King in the presence of a UN delegation and his own advisors for some considerable time. I'm not going to pretend that I raised difficult issues in that context; I simply alluded to them. However, the King and I (what a phrase: I never thought it would cross my lips) then had a private and very frank conversation. It's not for me to reveal the contents, except to say that I think the King understands that the donors are restive about Swaziland's political and economic priorities, particularly in the face of a pandemic that feels like Armageddon.

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