No Time to Lose: A Life in Pursuit of Deadly Viruses (29 page)

In Rwanda, President Paul Kagame struck me as one of the most impressive people I’ve met: his intelligence was not showy but it was sharp and clear, and very strategic. I was one of the first high-ranking UN officials to meet him in Kigali after the 1994 genocide. It was delicate, given the failure of the UN peacekeeping mission and the UN Security Council (along with all other world powers) to prevent and halt the genocide of around 800,000 people. Nonetheless, what had been scheduled as a 30-minute courtesy meeting went on for several hours.

Kagame received me in a sports shirt in his simple residence, which was heavily guarded by several circles of security. I asked for his strategic advice, and he asked a number of thoughtful questions before speaking up. We agreed to continue the process of jointly thinking things through, and he agreed to discuss AIDS issues with his colleagues in the region. His wife Janet, an elegant psychologist, became the driving force of the Organization of African First Ladies against HIV/AIDS; this group was active in several countries in the first decade of 2000, helping greatly to increase the visibility of the epidemic.

Kagame had put Dr. Agnes Binagwaho in charge of the Rwandan AIDS program. Agnes was an energetic pediatrician from the Rwandan diaspora in Europe, and she was a former student of mine, which made me very proud. She organized the AIDS response as a successful military operation, but with major involvement of community groups such as HIV-positive widows who had survived the genocide. I met with several of them: all had been raped during the genocide and probably became infected with HIV at that time. Many were also pregnant, and thus would be raising babies conceived by a rapist and killer, often the man who had killed their husband or older children. It created huge mental turmoil just to think about their situation. We made sure that they had access to antiretroviral drugs, and Jonathan Turgovnik—a photographer from
Newsweek
who was traveling with me through East Africa—since created a foundation to provide education for these often stigmatized children, and published a moving book
Intended Consequences: Rwandan Children Born of Rape
.

Rwanda was a haunting country, overshadowed by the horror of recent events. But I liked Kagame’s crisp management style. Once Suma Chakrabarti, permanent secretary of the UK Department for International Development, and I attended a government retreat in the Akagera National Park where every cabinet minister had to give a PowerPoint presentation reporting on their department’s performance against key indicators. In every ministry there was a chart with objectives, a timeline, and percentages achieved: it was very impressive by any standard.

Many other leaders in Africa refused to face the facts of AIDS, or hid behind moral arguments. I remember one time President Frederick Chiluba of Zambia—one of the most HIV-affected countries—actually pulled out a Bible from behind the desk he was sitting at and began reading aloud to me a passage that to him suggested that AIDS was punishment for “fornication.” I think there was also uneasiness because of the Western discourse about AIDS: this was often perceived as very offensive, redolent of the common European fallacy of Africans’ hypersexuality.

The more I thought about the reasons for the inaction of leaders facing an epidemic that was daily killing their most productive citizens, the more I thought,
Why would they?
Why
would
they care about AIDS if they didn’t care about so many other forms of civic misery? I developed a quick technique for sizing up the potential of the heads of state that I encountered: the shoe or watch test. Kagame passed it: he wore a very technical watch, with all sorts of gadgets, but it wasn’t an expensive one. In contrast, Gabon’s Omar Bongo—who actually received people such as myself while he was seated in a thronelike chair on a raised dais—wore handmade crocodile shoes with elevator heels, and his watch was encrusted with diamonds. Another president actually traveled with his own portrait, which he displayed in every hotel room where he stayed. Their wives would change their complete set of jewelry at least once a day when on foreign trips. And I could go on with quite a list.

Meanwhile, we faced a special difficulty in South Africa. Early on, despite the proximity of the country to nations like Zaire where the numbers were disturbingly high, the profile of the epidemic in South Africa was like that in a European country: HIV was almost exclusively present among gay men. In 1990, prevalence in almost every area of the nation was less than 1 percent. Then around 1998, HIV exploded, with the same spectacular velocity as it had among gay men in San Francisco in the 1980s. In this case, however, the spread did not focus on one small community: it rolled evenly across the whole society, with the dramatic, uniform, apparently unstoppable force of a tsunami.

The root of South Africa’s AIDS problem lies in apartheid, with its organization of labor that breaks up families all over southern Africa. Men working in the mines and in the cities were not allowed to bring their families; they lived separately from them for 11 months at a time in company hostels amidst other lonely men, now and then resorting to prostitution. Then came the
fall
of apartheid, which opened the gates to a surge of migration into South Africa, the wealthiest nation in a region hit by civil wars and drought. The end of homeland laws also freed people to migrate within the country.

But there were other factors too. High numbers of concomitant sexual partnerships may be a factor that contributes to the rapid spread of HIV; when you’ve just been infected with HIV your viremia level is particularly high, so if you are having sex with several people you are more likely to infect all of them. But there is no evidence that South Africans are more likely to have several simultaneous sexual partnerships than people in other nations. Lack of male circumcision? True, circumcised men are much less likely to become infected with HIV, and few men in South Africa are circumcised—but the same is true of most men in Europe, China, and other Asian countries. A particular sexual practice, such as anal sex? No evidence at all suggests it. Cofactors of untreated sexually transmitted diseases? A possibility, but one that exists in other societies where the epidemic has accelerated far less. A particular viral strain or genetic susceptibility? No evidence. Some posit that the key factor in southern Africa may have been gender relations: male dominance, sexual coercion. Others suggest it may be earlier sexual behavior, but in fact sex under the age of fifteen is not common among girls in southern Africa. More sex partners? Actually, worldwide surveys suggest that men and women in the United States have more sex partners in their lifetimes than Africans do.

My own feeling is that the disaster in southern Africa resulted from a mix of many factors. As in vector mathematics, where the resultant of a vector is the product of the cumulative impact of all the vectors, several seemingly small factors cumulatively created a multiple thrust, a perfect storm: a situation that we now call hyperendemic.

IT WAS NOT
only developing countries that had to be brought out of denial about AIDS, and to be persuaded to pay for long-term treatment. Among the so-called donor countries, the Netherlands, Sweden, and Norway were very supportive of UNAIDS, and were actually among the very few countries that respected an international agreement that the wealthiest countries would give 0.7 percent of their Gross Domestic Product to international development. However, in the first few years of the new millennium they resisted the idea of spending development-aid money on antiretroviral treatment. They saw it as a bottomless pit, an unsustainable responsibility toward people on lifelong treatment, and also just too darn expensive given a per person price tag of $15,000 a year. France, led by President Jacques Chirac, made strong statements about the universal right to treatment, but was actually among the least generous countries in terms of development aid and therefore lacked credibility.

We knew the United States was key. It was both the most powerful and the richest nation in the world, and it set trends and framed the way other countries envisaged problems. President Bill Clinton had created an AIDS unit within the White House, led by Sandy Thurman, who tried hard to sensitize members of Congress and others about AIDS in Africa. During the final years of the Clinton administration, international funding gradually increased. However, USAID officials fought against earmarking congressional funds for AIDS work overseas, to protect their traditional agendas such as population control. Duff Gillespie, then a senior deputy assistant administrator at USAID, expressed the view of most international development professionals in the late 1990s when he wrote that in the absence of simple tools such as a vaccine, AIDS activities in the developing world would only “siphon off resources” from important aid programs, with limited or no impact on the epidemic.

In June 1998, Duff and David Nabarro from the United Kingdom sent me a fairly tough letter, on behalf of all the major donors, which was somewhere between a reprimand and a dose of stern advice on how to do better with UNAIDS. (Some of the criticism about our performance was entirely fair.) The letter concluded, “
funding for HIV/AIDS activities will not come easy in the next few years
.” I blanched. But a year later, international AIDS funding for the first time exceeded $1 billion, and it continued to grow dramatically over the next decade.

Later that year, when I pressed a senior aid official in Washington to tell me why more was not being done about AIDS, his reply was, “But Peter, we did not plan for this.” As if any of the millions of people who died from AIDS had planned for it! I was outraged by such a cold bureaucratic approach.

Predicting the future is always difficult, but all these people seemed dramatically out of touch with what was brewing in Africa, in civil society, and among their own politicians. Receiving that letter from Gillespie and Navarro was a difficult moment for me, but I thought of the chameleon, replied that we would improve our performance in a number of detailed ways, and went back to my mobilizing work—basically, working to prove that they were wrong. Soon after that Duff and David became allies for the AIDS cause.

Our efforts to reach out to media and reporters were starting to bear fruit. We had become the go-to place for information on the global epidemic, and our reports were becoming front-page news. Human-interest stories on a range of AIDS-related topics from orphans in Africa to the impact of AIDS on business started appearing on a regular basis in
The New York Times, Newsday, Newsweek, The Wall Street Journal, The Economist, USA Today
,
Le Monde
,
El País
, and others. I even made it to the Hall of Fame section of
Vanity Fair
in 2000. When
Washington Post
reporter Barton Gellman called me to say that he was planning to investigate how the world was responding to the AIDS crisis in Africa, I leapt at the opportunity to expose the appalling lack of action and offered total access to all our archives and my notes, except personal ones. Predictably, WHO refused such access. The result was a sweeping three-article series revealing that “most of those with power decided not to act,” and that the response of aid agencies had been “demand management”—in other words, they had tried to minimize what should be done about AIDS by questioning the feasibility of both prevention and treatment. Gellman exposed what I suspected. Business was slowly waking up to the subject—albeit too slowly, just like everybody else. There had been some alert early-reactors, like Levi Strauss in San Francisco, but basically even companies doing business in heavily affected countries in Africa were slow to respond. As always, there were exceptions: even before UNAIDS I had done HIV prevention work with employees of Heineken breweries in Kinshasa, and in Zambia, Standard Chartered Bank had initiated a program to protect their employees. They were the pioneers, but we still needed to reach the heart of big business, companies that could help millions of employees protect themselves and that could also influence governments to do more.

The World Economic Forum in the Swiss Alpine village of Davos provided an ideal platform to get companies on board (and turned out later to be the perfect venue for negotiating price reductions for antiretroviral medicines). The Davos Forum is a very exclusive club, where you either pay a fortune to participate, which was not an option for UNAIDS, or you are invited as a key politician, academic, or thought-leader. Today there is almost always a strong contingent of heads of UN agencies, but that was not yet the case in 1997. My entry ticket to Davos was Nelson Mandela.

Through South Africa’s then Minister of Health Nkosazana Zuma, who was also the chair of the UNAIDS board, Sally Cowal had managed to persuade President Mandela to attend the Davos Forum and deliver a plenary address on AIDS. It was Mandela’s first speech on AIDS, and the Davos Congress Hall was too small to contain all those who wanted to hear the man who had become among the greatest icons of our time. He radiated a charisma I could physically feel. The other speakers at the session were Richard Sykes, CEO of GlaxoWellcome, the manufacturer of AZT, and me. There was a rather uncomfortable moment as we all sat together in the small green room, waiting to speak. Mandela’s government was in the process of passing a new law to legalize imports of generic medications. The pharmaceutical industry—Sykes included—was heavily lobbying against the new law, and in fact went on to sue President Nelson Mandela. (You don’t have to be a PR genius to see what a very stupid move this was.)

The audience was blasé, but Mandela electrified them. He called for a global effort against AIDS and urged the business community to support it. I then called for the creation of a Global Business Council on AIDS, which was launched eight months later in Edinburgh at the Commonwealth Heads of State and Government Summit. Mandela was its patron, Richard Sykes its first president, but initially only a handful of companies participated. As Ben Plumley, then working at GlaxoWellcome and the council’s first executive director, later said, “At the start, the business response was like getting blood out of a stone.” It took a few more years for most major companies to see that their bottom line may be affected by absenteeism and death.