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Lewis questions results of G8 Summit:
Calls for independent, international women's agency; challenges scientists to engage in campaign of advocacy

Stephen Lewis

UN envoy on HIV/AIDS in Africa
At the opening of the 3rd International AIDS Society Conference, Rio de Janeiro - Brazil

24 July 2005

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This is a meeting of scientists and experts in the world of AIDS. I am neither a scientist nor an expert. I'm an observer. I have spent the last four years, traveling through Africa, primarily southern Africa, watching people die. I think I understand, better than most, why your collective scientific and academic work can be said to be the most important ongoing work on the planet.

But precisely because the work you do speaks to the rescue of the human condition, you carry an immense public and international authority. I beg you never to underestimate that authority. And I beg you to use it beyond the realms of science.

What we desperately need in the response to AIDS today are voices of advocacy: tough, unrelenting, informed. The issues are so intense, the situation is so precarious for millions of people, the virus cuts such a swath of pain and desolation, that your voices, as well as your science, must be summoned and heard.

I recognize that the scientific arts absorb a lifetime. You didn't become scientists and experts to mount the barricades. But it's a quarter century into the life of the pandemic, and answers still elude us, questions still haunt us, and incredibly enough, the responses of the international community continue to be inadequate, sometimes even abysmal. At this moment in time, precisely ten years before the target date for the Millennium Development Goals set by all UN member states to tackle poverty and disease, the virus puts every goal at risk for countless nations, and particularly for the continent of Africa.

Some experts say we're ahead of the pandemic. Some experts say we're behind the pandemic. Some experts say the pandemic is in its infancy. Whatever the experts, the pandemic engulfs us; in combination with eviscerating poverty, it puts the survival of entire countries at risk. There is no choice but that every one of us, however we're involved --- but especially, I would argue, those who have voices that command influence and respect --- every one of us has to speak out on the issues with clarity and courage.

And the issues abound. Let me rapidly identify seven, and I shall not engage in diplomatic niceties as I deal with them.

First, I would argue that the G8 Summit was not a breakthrough; it was, in fact, a disappointment. I would argue that we got caught up in the music, and the spectacle, and the spin and the celebrities, and we all applauded before applause was justified.

Take debt. The cancellation of multilateral debt for eighteen countries, fourteen in Africa, was a start, but Africa still carries the insurmountable burden of over $200 billion of debt, debt that cripples the battle against poverty and the pandemic. Take trade, which everyone agrees is the centerpiece of economic revival. The G8 offered only sonorous words about agricultural subsidies, and could of course offer nothing, because everything rests on the negotiations at the World Trade Organization in its meeting in Hong Kong this December. So far the negotiations are not going well.

Or above all, take foreign aid. In principle, official development assistance to Africa was doubled by the world's wealthiest nations. But between principle and delivery, there lies an unblemished record of failure. In this instance, both Germany and Italy have already said that their commitments on future aid will be contingent on the state of their economies at the time. My country, Canada, refuses to set a timetable for meeting the famous target of contributing 0.7% of GNP to foreign aid (a target which, ironically, was originally fashioned by Canada). Japan, for its part, was undoubtedly influenced in its promises of aid to Africa by its quest for a seat on the Security Council … what happens after it gets the seat is yet to be known. And the United States, as the economist Jeffrey Sachs has pointed out, is billions of dollars short of where it should be on foreign aid, and is fond of reminding us that is has already created a Millennium Challenge Account, designed to increase foreign aid each year, except that Congress is always reducing the amount that is requested. For 2006, for example, the $3 billion dollar request for the MCA is headed for only $1.7 billion in actual appropriation.

Despite the tremendous energy and commitment of Tony Blair as current chair of the G8, we require your vigilant voices to keep everyone else honest.

Second, the single most dramatic --- indeed brilliant --- design of the last year and a half has been WHO's 3 by 5 initiative. It has made all the difference in the world. While it is true that the target will not be reached by the end of this year, and desperately painful though that is, there are now more than a million people on treatment who would otherwise be dead. By setting the target, and breaking the miasma of inertia that seemed to paralyze the world, WHO unleashed an irreversible momentum for treatment. Virtually every government I know in Africa is moving heaven and earth to get its people on antiretrovirals. In the process, we have learned that prevention also benefits greatly as more and more people want to be tested. Further, the entire language of treatment has changed: we now talk of 'universal treatment' or 'universal access' … gone are intermediate goals. The 3 by 5 initiative launched us on such a trajectory that nothing short of treatment for everyone who needs it is seen as acceptable. For People Living with Aids, who have fought the good fight for so long, it is a potential salvation.

The detractors of 3 by 5 have been routed. But make no mistake about it, it was a tough slog. Even within my precious United Nations family, let alone beyond, there were the Pavlovian voices of dissent. And from various precincts, you can still hear the surly, rivalrous mutterings in the background. It needs your tenacious voices to keep 3 by 5 on track.

Third, the Global Fund to fight AIDS, Tuberculosis and Malaria is facing a moment of truth. It requires an additional several hundred million dollars this year, an additional several billion dollars over the next two years. UNAIDS and WHO have estimated a shortfall in world-wide AIDS funding of $18 billion dollars between 2005 and 2007; a good chunk of the missing money should go to the Global Fund. Moreover, UNAIDS estimates that by 2008, we will require, annually, $22 billion for AIDS alone. The Global Fund has a replenishment conference in September, and there the tale will be told.

Please make no mistake about it: the Global Fund, whatever its teething problems, has emerged as the most formidable new international financial mechanism in the battle against communicable disease. It deserves every ounce of support it can muster. To be sure, complaints about the Fund's performance continue to be heard, and the Fund itself will admit that the criticisms have to be taken seriously. But in the world of internationalism, I cannot recall such a vast financial project taking shape with such astonishing rapidity, and what's more, beginning to save millions of lives in the process.

Again, your collective voices at this moment are indispensable. This next round of the Global Fund is receiving proposals on treatment, capacity and orphans as never before. It must not be forced to turn away countries in urgent need of help.

Fourth, I want to make a plea that this august assembly, every one of you, every group you network with, every formal consortium of colleagues and friends to whom you have access, lobbies ferociously to make gender inequality history. If the carnage of this pandemic has taught us anything, it's the terrifying vulnerability of women. I feel I must say that the greatest single international failure in the response to HIV/AIDS, is the failure to intervene, dramatically, on behalf of women. On many occasions in my travels through Africa, I have heard the words 'women and girls are an endangered species'. It makes for a good, riveting turn of phrase. It makes for good newspaper copy. It jolts the awareness, at least momentarily. But when will the world understand that the words speak the truth? We're losing the women of Africa, and increasingly, the women of the Caribbean and the women of Asia.

One of the vexing problems, believe it or not, is that we have no major multilateral organization to represent the needs and rights of the world's women. Is this conference aware of that? Does it not tell you something about the way in which men have run the world? We have UNICEF for children, we have specialized agencies like WHO, UNESCO, the Food and Agricultural Organization and the International Labour Organization for specific themes … health, education, employment, agriculture, science. We have the World Food Programme for distribution of food, we have UNDP for governance, we have the UN Fund for Population Activities for sexual and reproductive health; all of these agencies funded in the hundreds of millions, often billions of dollars. And God knows, we have the World Bank and the IMF. But we have no major international agency devoted to more than half the population of the world. And I would argue, to my last breath, that that fact bears a significant measure of responsibility for the desperate predicament of women in the face of the pandemic. Every organization pretends to address the needs of women, and no one gets around to it.

You want proof? Witness AIDS. We're in the midst of UN reform. I urge you to press upon your governments that the time has come to make women the centerpiece of those reforms, and to promote, passionately, the creation of an international agency to take the lead.

Fifth, this is a scientific conference. You will be examining everything from the fascinating results of the research on male circumcision, to viral entry inhibitors, to the particular issue of addressing violence against women in the context of the transmission of the virus during that violence. But I assume that as well, much time will be spent on the urgent search for the most compelling preventive technologies: vaccines and microbicides.

They are equally important. A vaccine is the ultimate prevention, and microbicides can save millions of lives on the way to a vaccine. The science is obviously enormously complex and difficult. But we can never allow, not for a moment, any lapse in the determined pursuit of both vaccine and microbicide. Everyone at this conference should hammer governments into submission if they fail to provide the necessary resources, or for some perverse reason, resist the trials. As I understand it, the more possibilities in the pipeline, the greater the number of trials, the better the prospects for success.

I fully recognize that it's been incomparably challenging. It is said that we're ten years away from a vaccine, and perhaps four to seven years away from a microbicide. The timing is vital, but the scientific search cannot be compromised by time. I don't want to be presumptuous, but I have to say that you scientists, here gathered, owe it to the world to pressure your governments and the scientific community, relentlessly, until the breakthrough occurs.

Sixth, is the question of human capacity. I was intrigued over the last several days, following the progress of former President Clinton's whirlwind trip through Africa, how often he raised capacity. It has become the pivotal issue in every country. It compromises everything. It's a matter of substantial irony that right at the moment when we have generic fixed dose antiretroviral combinations available, at a cost so low as to be able to treat everyone, preferably free, we lack the doctors and nurses and clinicians and pharmacists … we lack the whole gamut of health professionals to do the job. This requires tremendous ingenuity, training and technical assistance in the response. It requires, of all of you, the leadership, the voices to maintain the focus on capacity, so that when your inspired interventions are discovered or fashioned, there is someone on the ground to make them real in the lives of the potential recipients.

Seventh, I must raise and end with the orphans. The proliferation of orphans has become a deluge; it's absolutely overwhelming in country after country. Governments are beside themselves: no one has any firm grip on how to handle these millions of frantic children. Extended families and communities struggle to absorb them; grandmothers bury their own children and then try somehow to cope with hordes of grandchildren; child-headed households are an ever-growing phenomenon on the landscape of Africa: it is a nightmare.

Earlier this month, I was in Kenya, in a slum on the outskirts of Nairobi, visiting a group of women living with AIDS, tending to large numbers of orphan children. As is always the case with a visitor, there was a little performance. In this instance, a handful of children came forward to sing a song of their own composition. It began with the words "see us, the children carrying our parents in their coffins to the grave", and it ended with the words "Help, Help Help". And then from the crowd, there emerged a young girl of ten who, with the help of a translator, related the story of the death of her mother.

I have heard many such stories from many such children. But I have rarely been left in such emotional disarray. It became clear that the mother had died only a few days before, and this little morsel of a girl, as she talked of her mother's trips in and out of hospital, and then the last weeks at home, wept copiously, uncontrollably; but it was a weeping as if the depths of the sea had been plumbed; the tears didn't just flow, they gushed, they soaked her sweater and ran down her skirt, and for a moment in time, it was as if this one young girl became the pandemic incarnate.

Most of you in this room probably feel very distant from the orphans. You're not. Nothing in this pandemic works in a vacuum, or works in compartments. Everything is linked inextricably to everything else. That young girl is at the end of a continuum which starts with your scientific inquiry, and moves, inexorably, to her intense human anguish.

That's why I appeal to you to enter the fray as advocates. This is a good conference to summon those energies. We're meeting in Brazil, where the government has responded to the pandemic with astonishing enlightenment. Governments everywhere have to parallel the same enlightenment.

It's a Herculean task. But in this battle, no one is exempt: no government, no sector, no agency, no NGO, no part of civil society, no multilateral organization, no individual - no expert, no scientist, no public health professional. We can subdue this pandemic, but it will take the collective and uncompromising voices of principle and outrage to make it happen. It will, in other words, take your voices.

I salute you. Thank you for having me.

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