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HIV and National Security

Introductory Speaker: Richard N. Haass, president, Council on Foreign Relations
Speakers: Laurie Garrett, senior fellow for global health, Council on Foreign Relations, and Peter Piot, executive director, UN Program on HIV/AIDS [UNAIDS]; undersecretary-general, United Nations
Presiders: Richard C. Holbrooke, president and chief executive officer, Global Business Coalition on HIV/AIDS; vice chairman, Perseus, LLC, and Princeton N. Lyman, Ralph Bunche senior fellow in Africa policy studies, Council on Foreign Relations
July 18, 2005
A Century Foundation / Council on Foreign Relations



RICHARD HAASS: Welcome. I'm Richard Haass, and welcome to the Council on Foreign Relations. This is an extraordinary turnout. And at first I thought it was a reflection of the subject matter. And then I said, "No." I looked at who was speaking tonight. And we've got Ambassador Holbrooke. We've got Peter Piot. We've got Laurie Garrett. And I said, "It must be the three of them, or any one of them would be enough to justify the turnout." And then I thought, better. "No, I think there are two words that explain it: air conditioning." So I want to welcome you to air-conditioned Petersen Hall.

This is an important event, and it's a time for, in some ways celebration, but also a time for further commitment. And I'll explain in a second what I mean by that. We're joined, as you can see, by Laurie Garrett, whose report is fresh off the presses, HIV and National Security: Where are the Links? It's an important report. Having read it now several times myself in its various stages, I know of what I speak.

I think it does more than anything else [to] draw the connection, the links, between HIV and national security. It's important, particularly for people like me. When I came into this field [of national security], twenty-five, thirty years ago, the sign, the badge of courage, was something called the RAND bomb calculator. And unless you could work a Rand bomb calculator, and figure out what was known as the circular area probable of a bomb blast effect, you were really nowhere in the field. And this field has changed in extraordinary ways. And one of the many reflections of it is the fact that Laurie is here as the first international health fellow here at the Council on Foreign Relations. In some ways, it's our belated, but all the same, I think, still-important recognition of the intimate relationship between transnational issues in general, international health in particular, and national—and national security. And I think she, as much as any individual, has brought this to popular attention and understanding. And the links that she spells out and will spell out today are many.

I would just simply say, it's not simply a problem for them in the sense of "them" being the rest of the world or other places. And it's also something that very much effects [us] here at home, here in the United States, both directly and indirectly. But it's actually our attempts to promote order around the world, to promote prosperity around the world, will be dramatically affected by how well we deal with this challenge.

We've also here got, as you know, Peter Piot. Peter also released his report today—it's a day for releasing reports. His is entitled On the Frontline. And the timing, shall we say, is not coincidental, because it was five years ago that the UN Security Council passed Resolution 1308 highlighting the linkages again, in this case between this disease and the entire question of international peacekeeping.

So it was therefore particularly fitting that we're joined by Richard Holbrooke, who will preside over tonight, because Richard, I believe, more than any other person, is responsible for the fact that this resolution is in fact a resolution with a number that has been passed, and that we are now in a sense having an opportunity to mark it five years later. It simply wouldn't have happened without him, and it constitutes a major milestone in the life and history of the Security Council. And it's a real tribute to his talent and persistence that it happened.

In addition to everybody in this room, we're joined by two other groups of people: one is in Washington, DC, where Ambassador Princeton Lyman, who is our Ralph Bunche senior fellow here at the Council, who heads our Africa policy studies program, he will moderate a Q&A session working with Richard Holbrooke here in Washington. And then we're also joined by another virtual group, which is by teleconference, Council members around the country. A third if our members are now national, and some percentage of them are involved in this, will be involved here tonight.

And lastly, let me say before I hand it over to Ambassador Holbrooke, in the hallway—I don't know how many of you noticed it when you came in tonight, but I'd like to call it to your attention when you leave—there is an exhibition of photos relating to the subject matter, done by [photographer] Malcolm Linton. And I guess it'll not do too much good for those of you in the national audience, or those of you in Washington, DC. But for the 150 or 200 people I see in front of me here, again, out in the hallways on the way out.

So again, thank you all for braving the heat and humidity and coming here. And let me again thank the three panelists here tonight, not simply for being here tonight, which obviously I appreciate and we all do, but really for the extraordinary dedication all three of them have made. Ideas make a difference. People make a difference. And tonight we've got people who, by their thinking but also who by their actions, have really combined to make an extraordinary difference and have a real impact on the world. So let me thank them for both. Richard, over to you, sir. [Applause]

RICHARD HOLBROOKE: Thank you, Richard, and thanks to the Council for holding this meeting. This is not the first time we met in this room on HIV/AIDS. The Council under both Richard and [Council President Emeritus] Les Gelb deserve great credit for helping redefine this problem as a national-security issue.

AIDS has now been with us for twenty-two years, identified for twenty-two years; it obviously existed for much longer. But it was only in the last few years that anyone began to make the statement that it was a national-security issue.

And when we did this first, at the United Nations, in January of 2000, during the American presidency, the day Peter Piot met and became fast friends, we were mocked. We were—that Sunday on Meet the Press, [Senator] Trent Lott [R-MS] was asked whether he agreed with [then-Vice President] Al Gore who had chaired that meeting, asked if the United States' security issues included AIDS. And he just laughed. And the old Council laughed, too. I won't identify the old Council, but I think you know who I'm talking about.

And today, five years after the resolution that Richard referred to, 1308, was passed, the resolution which demanded that the human peacekeeping division make AIDS part of its mandate, today all fifteen nations got up and talked about it and apparently were supportive of it. Five and a half years ago, when we first proposed it, and we proposed the sessions defining AIDS as a security issue, a lot of countries opposed it; some went along very reluctantly because the African members of the UN wanted it.

And to understand the background, to understand that the Security Council was designed in 1945 by the founders to deal with security issues, and ECOSOC, Economic and Social Council, was designed to deal with health and social issues. And for the Russians and the Chinese and others, this was blatant interference in internal affairs.

So to define it as a national-security issue was not welcomed. The Russians, for example, refused to participate five years ago; today, the Russian ambassador recognizing, as Peter will tell you, that his country has the fastest growth of AIDS in the world today, was quite ready to participate. Peter spoke eloquently, as did [inaudible] the head of peacekeeping, and I would just say that we've started a discussion, that there is no congratulations today, just a sense that we've made some progress. We should have had this meeting four years ago, three years ago, two years ago. We had it today, and that's simple.

Now we're going to have a conversation about AIDS, and we're going to ask all of you in New York and Washington to chime in. I'm glad Princeton Lyman is chairing this in Washington, because he served in South Africa and ran the African bureau, and understands this issue. And we will all want to hear from you. We have two tremendous people, Peter Piot, one of the great medical researchers in the world, now in his second term as head of UNAIDS; and Laurie Garrett, who I have known for about six years and admire greatly, who has done this extremely important report today.

And let's just say at the outset, the battle is over about whether it's a national-security issue or not. It is a security issue. We don't need to prove that any longer. If you need data, read this. What we need to do now is talk about the weak spots in the war. How are we doing? Are we winning? And so on. And so, in the guise of a conversation, I'm going to just start with Peter, and start with the simplest and most difficult question to answer: Are we winning the war on HIV/AIDS?

PETER PIOT: Before answering that question, just one follow-up indicator, that not only had the global response to it changed, but also the concept of AIDS. About a month ago, I met with Premier Wen Jiabao in China. And one of the first things he told me, he said, "AIDS is clearly a nontraditional threat to security." Here we have people still debating whether it's a security issue, but we have the prime minister of China making that clear statement. And he said, "That's why I am personally taking the lead in the fight against AIDS in my country." So that's an illustration.

Now are we winning or are we losing the battle against AIDS? It all depends on the country. I'm not trying to be diplomatic, but when you look at the facts, you look today at Africa. In East Africa, in about every country, we see a decline in new infections, whether it's in Kenya, whether it's in Uganda, which was already known, in Addis Ababa, in Ethiopia, in Zambia, in all these capitals, less people become infected. However, when you look at South Africa, at the southern part of the continent, it just continues to grow and grow and grow. Swaziland has 42.6 percent HIV prevalence among adults now. We're close to one in two. We have Russia and other countries of the former Soviet Union faster and faster, the spread of HIV. We've got an explosion that's going on in new countries in Asia.

So I would say the picture is very mixed. But what is clear is that we have a triple momentum. First, there is a political momentum we've never seen before, a political momentum that in this country, I would say that as the State of the Union speech of President Bush two and a half years ago was a defining moment, a turning point, with the commitments that were made. And we've seen it also at the G8 [Group of Eight Summit] in Gleneagles [Scotland] and so on. We've seen it in the fact that forty countries, the president, the head of state, the head of government, or their deputies, are leading the fight against AIDS. It's not any longer the ministers of health who are often enough the top politicians.

Secondly, there is a financial momentum. This year we will spend probably about $8 billion on AIDS in lower- and middle-income countries. When EURAIDS [European network for AIDS] was founded ten years ago, that was 200 million [dollars]. When Resolution 1308 was passed, it was $1.5 billion. So there is an enormous financial momentum that—and this is not only donor money. It's also money coming from domestic budgets that's going up there as well from the developing countries.

And thirdly, we are starting to see results. So, I think that we're in better shape than ever, but five million new infections last year, three million deaths. So overall, we are still losing the battle. We are still in the reactive mode, running behind the epidemic. And we need to get into this strategic proactive mode.

HOLBROOKE: And you can well ask, therefore, given the figures Peter just outlined, why anyone would have any cause for hope, given the fact that the actual number is still increasing, and as I said a moment ago, particularly in Russia and the Ukraine and Estonia, the countries that are just staggering.

PIOT: Central Asian republics.

HOLBROOKE: I doubt many people in this room knew that it was the former Soviet republics where the growth rate is highest.

The reason we were encouraged by the day is simply that bureaucracies move slowly, much too slowly, but they're starting to move. And at least in the small area of the UN, it's making a difference. Peter has done something quite wonderful here. He has created a little AIDS awareness card for the UN peacekeepers. And that's only 100,000 people worldwide on an annual basis. But he finally says things which people wouldn't say a few years ago, like "AIDS kills you." You couldn't get this under the propaganda in places like South Africa. When [inaudible] and I went down there around six years ago on our first trip, none of the billboards, none of the posters, told you that AIDS was fatal.

And because Peter is a very practical man, he supplied a very practical attribute inside of the—if anyone is not sure what the [inaudible] is from—

PIOT: Had to go back to [inaudible].

HOLBROOKE: Yes, I was going to say, if you don't know what it is, don't use it. But this is a terrific thing. And Peter can tell you it is now available to all UN peacekeepers in every language.

UNKNOWN: And even some national uniformed services, millions of cards.

HOLBROOKE: So Laurie has written this amazing report. And it deserves—everyone involved with it, the Council, Laurie, everyone—deserves great credit. In it, Laurie begins with a rather fascinating historical analogy, which I think you all ought to hear directly from her, and that is to the Black Death of the fourteenth century. Laurie, tell us why you were drawn back to this event, and why you see it as relevant to the current situation in the world.

LAURIE GARRETT: When you're trying to understand what impact HIV is having on the world community today, you have to try to think, well, what precedent do we have? What other great pandemics has the world ever faced? And the only one that really holds up as analogous to what we're going through with HIV/AIDS is the Black Death's impact on Europe in the middle of the fourteenth century. And it's remarkable how much of it is directly analogous. Most people don't realize that when the Black Death hit Europe, labor had no value. Most of Europe was an agrarian economy. Most of the agrarian workers were interchangeable parts, treated accordingly to the aristocrats who ran the fiefdoms and city-states of Europe. A war was raged with bloody intensive carnage, horrible one-on-one human contact, because again, the soldiers had no particular value. They were all interchangeable parts.

When the Black Death occurred, 44 percent of the survivors were under nineteen years of age, directly analogous to what HIV is doing to societies in Africa right now. Among the survivors, the biggest loss was in the productive labor force, was in precisely that previously unvalued labor force for agriculture [inaudible] forces for all the specialized skills of Europe and your army.

And it absolutely fundamentally transformed European history. It altered the entire course of European history in radical ways, including that, suddenly, warfare became a very expensive thing to wage, and it was suddenly required that they figure out how to use gunpowder and create weaponry, because they lacked sufficient human power to wage war without it. Suddenly workers had value, and they were able to demand appropriate wages or let fields go fallow. And also suddenly you had a huge burden of orphans all across Europe who were unsupervised, who had no parental input and guidance. And it fundamentally transformed Europe in a whole set of ways.

Well, what are we seeing with HIV? The only difference with all the statements I just made about what the Black Death did to Europe, the only difference in Africa in particular right now is that it's happening in slow motion. So instead of the total impact being about eighteen to twenty-four months, which was the case in the fourteenth century, we're looking at a wavelength in each round of HIV in a society of about fourteen years: eighteen months, fourteen years, between the time of infection, the time to actually getting AIDS, the time to death, and then the time to impact on your whole nexus of people who relied on you as an individual.

But the other issue is, unlike a high acute contagion as was the case with the Black Death which struck a community all at once—and all at once, Tuscany lost 80 percent of its population. In this case, it's striking in staggered time. And so what makes it difficult to see the effect of HIV/AIDS is that fourteen-year time wavelength, plus this staggered individual impact, means that there are all kinds of incremental coping mechanisms going on. Societies at every level, from the family on up, are finding ways to sort of cope. But everywhere you can see in the hardest-hit countries, those coping mechanisms are reaching the point of collapse.

And when you look at the military impacts, our reporters are concluding that some of the claims about infection rates in militaries that were issued ten years ago and so on were wildly inflated, and were totally just speculation. But we now have some concrete numbers. We now have concrete ways of determining what the infection rates are in military and police forces around the world. And let's be blunt. If more than 30 percent of your general adult population is HIV-positive, minimally, more than 30 percent of your police force and your military is infected. If that 30 percent is going to pass away without any treatment, without any intervention, without any way of preserving them, then who in fact is taking care of law and order? Of stability? Of defending your borders, and all of the things that you count on for police and military to do? So long story short, the analogies are all too perfect, and the only difference between the two is the timescale.

HOLBROOKE: That difference, however, brings us to an absolutely critical point, which is, why do we talk about this disease when there are a lot of other terrible diseases in the world, malaria and tuberculosis [TB] most notably, dysenterial diseases, which kill as many or more people, particularly in Africa. Malaria is particularly relevant here. And this needs to be understood: Why do Laurie and Peter—Peter, who is one of the discoverers of the Ebola virus—why do we all thing that it is the most dangerous disease since the Black Death?

And the answer here is because, as Laurie said, it lies undetected in a person's body for seven, eight, nine, ten years. And since testing is not sufficiently widespread, and that in my view is the weak link in the whole war against AIDS, people, according to the UN, according to Peter's statistics, and this is the single-most important statistic in all of the ones you're going to hear today, is 95 percent of the people in the world, according to Peter's organization, 95 percent of the people in the world who are HIV-positive do not know their status. They are spreading it unintentionally.

And therefore, it is the most dangerous disease we've ever seen. Peter's colleagues call it a smart disease, because it seems to trick all the medical people. And that is the—and finally, and most importantly, women are the primary victims right now. Over 50 percent of the people in the world with HIV/AIDS are now women. We—I want to—yes, go ahead. And then I want to ask you a question.

PIOT: Yes, I think it's a fundamental question. Why is AIDS not just one of many, many infectious diseases that are around? And I think it's so different, because it has this long-term effect and impact on society that we don't see with any other disease. It goes through generations. It affects those who are in the most productive years of their lives. Malaria kills the children, the babies. Infectious diseases kill people when they are kids, or when people are, they're old. But not the most productive parts. And when you look at the demographic tree—how do you say that, the pyramid?

GARRETT: —the chimney effect.

PIOT: The chimney effect, you see this is an effect; you only see in wars where you have productive adults, young adults that are taken away. In war, it's usually the men only, here it's men and mostly women; more women than men in most societies are taken out. And that changes completely the very fabric of society.

HOLBROOKE: Look at page 41, this chart on Botswana. It is absolutely stunning.

PIOT: And that is just to go back to the Black Plague, that's exactly what we saw then as well. And that's why there are societal effects on stability, on the capacity of the state of business to provide services is totally undermined.

HOLBROOKE: Now we need to underscore an additional point. If you go into the settlements or tenements at a place like the suburbs of Johannesburg, as my colleagues and I at the Global Business Coalition [GBC], and [UN Secretary-General] Kofi [Annan] and I have done, and you talk to people, they don't understand why those of us in this room are coming in and talking about AIDS.

They have no water. TB is everywhere. The fact is, of course, TB is an opportunistic disease, and they may be also HIV-positive because they don't test in the hospitals. The kids, the children are dying of dysentery. We—Peter and I went to [inaudible] on the western shores of Lake Victoria last year. You put your foot in the waters of Lake Victoria, you're going to get schistosomiasis, malaria, or dysentery. It is not a romantic place; it's a hell hole.

On the Kenyan side, you can [inaudible]. So you say to them—they say to you, "Why are you worried about AIDS? We need housing." You talk to the [inaudible] in South Africa, the mining union. They say, "We don't want to talk about AIDS. We want housing." So what seems obvious to you in this room is very, very tricky stuff.

GARRETT: If I may, in 1984, which was the first year that I went and looked at AIDS in Africa, I actually had two different ministers of health in two different African countries physically toss me out of their offices for asking them about HIV/AIDS. "How dare you? We have malaria. We have to deal with that."

But I must say, your first question to Peter was: Are we winning or losing the war? And I do think there is a point where our conversation comes back in a circle on this point. Because my great fear now is that, because we're putting such a heavy emphasis on treatment and trying to get antiretrovirals (ARVs) to as many people as possible, which we should do, but because of this, and because it's coming in against a background of an estimated four million deficit healthcare workers in the world, one million missing healthcare workers for sub-Saharan Africa alone, and just horrible conditions in the health infrastructure, what we're seeing is a poaching of healthcare workers.

If the urgency and the money is in one disease, everybody gets poached over to that disease. The danger I see, and I think it's a very real danger, is that we will be here five years from now, look back at the situation and at this moment, and realize that we've had a net increase in mortality in highly afflicted societies because we sucked away the healthcare plans from the dysentery programs, the child-health programs, the maternal-health programs. We've created competition amongst health programs, which in fact what they should be is additive, synergistic, working together, and conquering it all at once. So that villager who says to you, "Ambassador Holbrooke, why are you here talking to me about HIV/AIDS when Lake Victoria is full of schistomosiasis?"

HOLBROOKE: They won't call me ambassador.

GARRETT: "Mr. White Man," I say, there is truth there. All must rise together.

HOLBROOKE: Of course I agree with all that. I want to mention the corporate sector, because so many of you in this room are involved in the corporate sector, and because the hat that I'm wearing today is as part of the CEO [chief executive officer] of the Global Business Coalition. Most of my team is here, Trevor Neilson, who runs it, and who most of you know; a lot of other members of our team. And because several of our most members are here—William Haseltine, who is on our board; Charlie Beever from Booz Allen; Anzo Viscusi from ENI—these are among the 198 members that are now here. And we believe strongly in this organization that the corporate sector has a major role to play, just cleaning out its own workplace, treating the families of its workers, and setting the example. There are some companies that have done a great job, like Coca-Cola, Daimler-Chrysler, Unilever. But that is why we're here.

Now, Peter, I want to read to you a question. And then Princeton, after this, I'm going to turn to you and ask you to bring the first question in from Washington. But first, from our high-tech, new technology, from Atlanta, from Kathleen [inaudible], she asks, "Have U.S. funding programs"—this is an easy one, Peter—"have U.S. funding programs like the promotion of abstinence versus condoms, or requirements for the prostitution pledge, have any impact on the U.S. influence on global HIV efforts? Have these policies affected program effectiveness in any way, positively or negatively?"

PIOT: Particularly when you're working in the UN, thank you. Maybe three comments on that. First, on the policy issue: Anything in AIDS that has the label "only" is going to fail, whether this is abstinence only, whether it's condoms only, and it's—you need really a package of a comprehensive approach as we say. And that's why also I'm very concerned about the unique or the exclusive emphasis on treatments today, and forgetting about prevention.

HOLBROOKE: To which testing is the key.

PIOT: Yes, it's one of them, one of the issues. And so that's the first point. So I think we—what the new policies are, or the policies that have been pushed by this government, have added, I would say, the fact that we are now also paying much more attention to, for example, that girls have the right to not be coerced into sex and so on. That's a positive aspect. But when I hear, "abstinence-only programs," there is no scientific basis for that, first.

Secondly, you have influence—the facts again, over half of all expenditure on AIDS in developing countries comes from the U.S., from the U.S. government. So that's clearly leadership, our leadership position. And I wish that all developed countries would follow that kind of example. And there is that commitment that came out of the G8 summit at Gleneagles. Clearly, has there been a decline of influence of the U.S., internationally? The answer is no; I think it's the contrary. But my concern is that in some countries—I've seen it in Uganda, for example—where there has been a rewriting of the history of the success in Uganda, claiming that condoms have no place in the decline of HIV infection in Uganda, that it was all based on abstinence. That is simply not true. It was a mixture of approaches, promoting abstinence, condoms, and reduction of partners, and being faithful. You just need all three.

GARRETT: If I may, the single greatest success story for HIV/AIDS is none of the above. It is Thailand.

PIOT: Oh, Thailand, yeah.

GARRETT: And Thailand was the first country to declare that HIV was a national-security threat, did so I believe in 1989 or 1990.

PIOT: '90.

GARRETT: And said, "OK, what works? We think condoms work." They created a campaign called, "In Rubber We Trust." And they massively, thanks to Senator Mechai [Viravaidya], who was really a character and a half, they successfully brought the HIV rate—plummeted by 1993, ' 94. And it has never really returned to a dangerous level again.

And it's with all, 100 percent condom campaign. I know it's convenient to talk about Uganda. It's convenient to talk about a number of other countries. But in terms of a campaign that started out with a premise, it was a national-security threat, targeted military recruits, and military members as the prime target, and made condom availability the No. 1 issue, and then regulated the brothels, which were the primary vectors of the disease in that country at that time, and made it mandatory that condoms were used in all the brothels and sex trades—boom, HIV plummeted.

HOLBROOKE: I'm just curious, how many of you in this room have heard of the man that Laurie just mentioned, Mechai? This is a very well educated—in my view, he is—the Nobel committee should give him the peace prize. He is—you said he's a character and a half. That depends on whether you think that a restaurant that puts condoms in cabbages, that's a good place to eat.

This is a man who in the 1970s—he was a Ford Foundation grantee—and in the 1970s as a young man, at that point working on population and planning, would go to student demonstrations—the students were trying to overthrow the government. He would dress up as a giant condom and go to these events and then he became minister of health in the caretaker government. And he discovered AIDS. And he is the ultimate kind of what is so central here, which is destabilization. He has Miss Condom and Mr. Condom contests every year. People dress up as condoms and they win prizes. And it's an extraordinary performance. Princeton, are you still there? Princeton, do you want to pose questions, you and your colleagues, to Laurie and Peter?

PRINCETON LYMAN: Thank you, Richard. Thanks for moderating this. Thanks to you and your panel for all the work that all three of you have done on this issue. Yes, let's take a question here from Washington.

HOLBROOKE: Could you identify yourself?

LYMAN: Give your name and your affiliation.

QUESTIONER: My name is Reuben Brigety, I teach at George Mason University. For Dr. Piot or for Ms. Garrett, can either of you explain what causes—the causal factors behind those countries that are not doing so well in the fight against AIDS, and in particular, South Africa. Can you explain the governments' attitudes toward their resistance to antiretrovirals and other factors, which are making it difficult to fight the disease there?

GARRETT: The countries that are having the hardest time coping with HIV/AIDS right now are either having a hard time because the primary vector is the needle as used by I.V. [intravenous] drug users and the society at large holds I.V. drug users in such high disdain that they choose not to initiate any programs to help those drug users use their drugs safely, or not continue to spread. So that would explain, really, the bulk of the transmission in the former Soviet Union countries in particular. But in the case of South Africa, I think the story is much more complicated.

The first thing that needs to be underscored, and this goes to much of what we were talking about previously, is that South Africa really has a brand-new epidemic. They've been at it, compared to their neighbors further to the north, they've been at it for a fairly short period of time. And the vast majority of the HIV-positive population has yet to actually develop AIDS or to die. And so the society hasn't experienced this massive death toll, and hasn't gone into a state of sort of mass grieving with huge absenteeism due to funerals and all of that.

There are pockets of South Africa that have. That's part one. Part two is that South Africa's epidemic is actually not just a epidemic for the country, but rather really part of a mosaic, with very different rates of infection, with KwaZulu-Natal leading with infections rates reported to be over 40 percent in some parts of KwaZulu-Natal, and then other districts of the country having remarkably low infection rates, below 5 percent even. And so you have this very mixed level of response across the society, and then a sort of third layer on top of that is that the ANC [African National Congress] came into power with a very tough agenda to try and meet for that society, coming out of apartheid, to totally transform the entire society, to bring jobs to people where unemployment rates in some parts of South Africa exceed 60 percent, and to try to recreate the society. And they didn't want anything to derail those missions. They didn't want to divert their attention. They didn't want to think in other directions. They really wanted to stay that course.

And I think now it will be, it is, exploding in their face. Many of you may have heard about the demonstration last week, really a tragedy in Cape Town, in which a relatively small group of HIV-positive women were marching in peaceful protest, demanding access to antiretroviral drugs, which the government has continuously obstructed. And they were shot at by the police, ten of them hospitalized with gunshot wounds, for daring to demand that they have access to, by the way, the very same drugs that are readily available by government order to all members of the South African defense forces, with U.S. government support, and are available of course to parliamentarians, available of course to all the ruling elite, and to anybody with health insurance, but not available to the vast majority of the population of South Africa.

HOLBROOKE: Princeton, I want to ask you a follow-up question here, putting on your hat as a former ambassador down there. The Minister of Health Mantombazana [Edmie Tshabalala-Msimang, also known as Minister Manto]—I will say this frankly, because I'm a private citizen—is appalling. She has—

GARRETT: Garlic cures AIDS.

HOLBROOKE: She's a doctor. When we were down there with the GBC two weeks ago, she repeated her garlic and lemon juice solution. The question isn't about her. The damage she does to South Africa is self evident. My question is a political one, Princeton. Why does President [Thabo] Mbeki keep her on in the face of what she's done to the reputation of that great and terribly important country?

LYMAN: I think the answer lies in what Laurie said earlier, and that is, that President Mbeki, in spite of everything he might have said to the contrary more recently, sees this as a massive diversion from what he wants to do with South Africa. He doesn't want to recognize it as the major obstacle and potentially devastating one down the line. So they seize upon it—Laurie's point about South Africa being on the beginning of this upward swing of death is part of the reason that they can be in partial denial in South Africa.

But I think Thabo Mbeki just doesn't want to accept the fact that this could be a serious, serious obstacle to all the other things, and he wants to incorporate it, understandably, in the total developmental agenda, which is right, but he doesn't want to give it special attention. And that—and his health minister is out there in part because he allows her to be out there. And I think it goes to him and his just stubborn refusal to say, "Yes, this is a major tragedy, and we've got to deal with it as a special issue."

HOLBROOKE: Well, it certainly is a special issue. Let's move on now to the other area, Ukraine, Russia, Estonia. Because again, we don't want you to leave here thinking it's an African disease. Peter, why is the disease spreading so fast in the former Soviet Union?

PIOT: I think it's a combination of, A, what Laurie said: This is driven by injecting drug use, and it's the most efficient way of spreading HIV. It's like giving micro-transfusions with infected blood to hundreds of thousands of people. Let's not forget, there is an epidemic of heroin use in most of the countries of the former Soviet Union, based on heroin coming from Afghanistan. That's the—that's why the Central Asian republics are also now seeing an enormously fast spread of HIV.

But at the other side of the coin is the lack of leadership. Dealing with AIDS is one of the great leadership challenges. And why is that so? Because you need to go often against the stream of public opinion. You need to tackle the difficult issues of sex and drugs. And wherever I come, and I travel so much, and people tell me, "In my country it's very difficult to talk about sex and all." I said I haven't been in a single country where this is easy. I mean everybody does it, hopefully. But to tackle it seriously, not only in public communication but also in the private sphere, is really very difficult.

So it's a leadership issue. And I think we—and now I'm talking [about] the public-health community, I think we have also helped that kind of denial. Because the framework you're using, the conceptual framework, is very important. I mean, what do leaders care about? It's the economy and security. And if you come up with AIDS and drug use, this weird disease and this and that, that turns away and they say, "Go and see my minister of health, who often has absolutely no power." So that's why it's so important to position AIDS as an issue for economic and social development and for security.

When I got into this job I had three objectives, nine years ago. The first one was to put AIDS on the political agenda, because it was not there at all. Secondly, was to make sure that in order to do that we redefined AIDS from a medical curiosity into an issue for economic and social development, an obstacle for that, and as a security issue. And then, you know, there is receptivity for the arguments, and partly to make sure there is money. So I think that's why it is so important that we have that reframing.

And lastly, I would say there is an absence of civil-society action, from grassroots action in many countries. That is a tribute to South African society. The effect of this in Africa and South Africa [inaudible] to courts. This is possible in South Africa. In many countries this is not possible, where there is not that rule of law. But the countries of the former Soviet Union are the ones that I'm the most worried about when it comes to AIDS, because of this fatal combination of an epidemic driven by injecting drug use, very fast; and on the other hand, total denial, and very, very little, scant attention to any social issue in the country.

HOLBROOKE: Let's go to the audience, and the microphones. Let me just go to this gentleman. Peter's point about Ukraine is understood. The Ukrainian infection rate is thirty-five times per capita higher than China. You all have heard about China, but Ukraine has half of the AIDS victims of China, and one-seventieth the population.

QUESTIONER: I have two questions about—William Haseltine. First question relates to an area of the world you didn't talk about, which is India. And it's my understanding, and I'd like a comment on that, that India may have as many people infected as all of Africa. And there are parts of India where it is extremely prevalent, others where it isn't. So it sort of fits into that mosaic picture, but I'd like your comment on that. The second issue is a new entry to the prevention, which is chemoprevention, very much like you will prevent malaria transmission. And there are some trials of drugs, particular idinavir. And I'd like your comments on whether you think that could add a potential new way, in the absence of a vaccine, to slowing the infection, and perhaps putting some dent into the war on HIV/AIDS?

GARRETT: I think, if I may, the answer to the first and the second one, I'll take them very quickly. The first is, one of the common themes about countries that are able to persistently deny the severity of HIV in their society, and I would rank India as right up there alongside of Russia, some of the Central Asian societies, and South Africa in particular, is because, if you don't see an economic downturn, if you don't see an economic input, and you're very much a GDP [gross domestic product]-oriented government, then it's easy to say it's really not a problem there.

In South Africa, with this astronomical unemployment; in India with the enormous differential between who had and who doesn't have. If the have-nots are the ones getting HIV, then the net effect on the global economy and on their own national GDP is negligible. And therefore, you can ignore it. And that, I think, is part of what's going on in India.

My own observations in India, I absolutely reject any claim which has been made quite recently by the Indian government that they brought their epidemic down, that it's of negligible size, and so on. I think the only way you can make such a claim is to also recognize that the majority of India's states don't actually have HIV surveillance programs. So if you're only counting the wealthy states of India, because they're the only ones that have intact public-health infrastructures and surveillance systems, then maybe your numbers don't look so bad. But I'd really like to know what's going on in Uttar Pradesh, and some of the other states of India.

And as for your second point, the chemoprophylaxis, where I'd really like to see the revolution is in microbicides. Long before I can figure out how you can get chemoprophylaxis widely distributed across developing countries, I would like women to be able to protect themselves, which they currently have no tools to do. And having a vaginal microbicide that women could safely use is the breakthrough we're waiting for. [Applause]

HOLBROOKE: Kati, and then we'll go back to Washington. Peter will add a word in a moment.

QUESTIONER: Kati Marton, on the chair of the International Women's Health Coalition. Peter and Laurie, you've both touched rather lightly, I thought, on the fact that women are the primary victims of AIDS now, worldwide. What in particular is UNAIDS doing to deal with women's particular vulnerability in the prevention field?

PIOT: Before that, a few words on India. Because in terms of the figures, the official figure is that five million people living with HIV, that's probably an underestimate. It certainly isn't going to be something like more than the whole of Africa, 27 million. I think that is not realistic. It's highly variable from state to state. There are states where 2 percent of the adult population is HIV-positive. There are districts where 4 [percent] or 5 percent is HIV-positive. And [inaudible] in India is two to three million people, which means a larger population than, let's say, Botswana and many of the smaller African countries.

But there is a sea change now in the government. A new government has made fighting AIDS a part of its common minimal program—big change from the previous government. So let's say that—let's hope that that's going to be turned into action. I just wanted to say that before going to Kathy's question.

About a year and a half ago, we took the initiative to put together so-called Global Coalition on Women and AIDS, which is bringing together basically nongovernmental organizations, women's groups from all over the world, with several aims, to not only draw attention to this issue, because at the moment, in every single region, in every single country, the proportion of women among those living with HIV is going up. That includes this country. That is true in Africa, where it is already 60 percent of all people living with HIV are women. But it's true for Ukraine, India, China, just name it. I always ask the question. In most cases they don't even know, or they don't say it spontaneously. You've got to press.

What are we doing, then? We're making sure that the issue of women and AIDS is addressed in a bigger context. There is the research issue of microbicides—I fully agree with Laurie, but also making sure that if women or girls have access to education. That we know reduces their vulnerability to HIV. There is the whole issue of sexual violence. Let's not forget that the—particularly first sexual intercourse is—in many societies is rape, let's put it that way. You could say it's abuse. It's not consensual sex. There is the issue of property and inheritance rights, which puts people—women, also—in a very weak position. It's bad enough that your husband dies from AIDS. But if in addition, all the property goes to your husband's family, and you've got to marry your husband's older brother, that is also part of reality.

So there is a whole program, and it's one of our priorities. And Kathleen Cravero, who is chairing—is my deputy and now is in UNDP [UN Development Program], and she's chairing a leadership council on that. So it is really one of our top priorities as well.

HOLBROOKE: We're almost out of time. Let's have a question from Washington, and then a couple of questions here, and we'll come to a close. So Princeton, you first, and then in the back, and John Swing, here. We'll try to get to some more of you.

LYMAN: Identify yourself, please.

QUESTIONER: [Inaudible] from the NewsHour with Jim Lehrer. Laurie, I look forward very much to reading your report. But in the interim, many have made the observation that if only we could tie the HIV/AIDS problem to the global war on terrorism, one might be able to get even more resources out of the industrialized nations to fight this.

But aside from that perhaps facetious comment, what do you see, and what did you deal with in the report by way of any essential interplay between HIV/AIDS and terrorism, particularly in areas of the world that might have significant disenfranchised Muslim populations that might also be vulnerable.

HOLBROOKE: Hold off until we get a couple of more questions. Way in the back there—there was someone, and John Swing up here.

QUESTIONER: John [inaudible] Swing. I have a question I'm surprised hasn't been raised. To what extent is the lack of money—if [Earth Institute Director] Jeffrey Sachs were to wake up tomorrow morning and find that his report had been honored, and the G8 had decided to adopt his [development] goal, would money solve some of the problems? What role is money or is the lack of money playing in all this?

HOLBROOKE: And in the back?

QUESTIONER: Caroll Bogert from Human Rights Watch. I have a question about the security paradigm that you've put forward today. I understand why it's important to bump the issue from the minister of health's office to the president's office, and you accomplish that when you frame the issue as a security issue. But at Human Rights Watch, my colleagues in the AIDS division have documented a real problem with framing this issue as a security problem. Because when you unleash the security forces of a country against HIV-vulnerable populations, you drive them underground and you put them further at risk for the disease. And we've seen in many countries the use of police to—

HOLBROOKE: What are you talking about, Caroll? I don't have a clue where that theory comes from. What do you mean by that? How do you drive people underground?

QUESTIONER: When police in India are told that prostitutes or sex workers are creating an HIV/AIDS problem with their work, and they attack those prostitutes and send them further—harder to reach by public-health officials who hope to treat them, then you are in fact fueling the disease. Perhaps my colleague who has just returned from Africa, John Cohen, would like to explain further.

GARRETT: Let me, if I may, rather than going into a long dialogue here when time is running short and we have two other questions as well, let me just say that one of the things we say very strongly in the report, and I'm sure you've not had an opportunity to actually read it yet, is that when one defines national security, yes, every society defines their own security their own way—and I'll partly answer the terrorism question at the same time as this. And our society, our government, has a very violent paradigm view of security. So that terrorism ranks high on its list of how it defines the nation's security. And that is the prism through which our government currently views most security concerns.

One of the things we say emphatically in the report several times is that there is absolutely no evidence whatsoever that people with HIV pose a security risk to any state or institution, No.1. No. 2, we state emphatically that there are societies that initially approached the relationship between HIV and national security to mean that they must impose a security clampdown on a population group. We emphatically reject that as an appropriate interpretation of the relationship between any disease and national security. So that, for example, China's initial response to HIV is in a province where there was illegal blood transfusion activity going on that spread HIV, was to repress the people who were HIV-positive, people who were the victims in the very system. That was an inappropriate definition of national security, and an inappropriate use of the concept of national security.

And then let me just say, too, about the terrorism, there has been quite an attempt, and there is a whole body of written literature now and speechifying, trying to directly link the question of support for terrorism with the social impact of HIV/AIDS. No. 1, there is no clear evidence for that association at this time. However, we do have to remember that we're still in the beginning of this pandemic, and we do see certain key parts of the world where we're getting this enormous youth bulge, which is to say, a huge population distribution as we discussed earlier, citing the Botswana chart for you to look at, where you have a massive population of basically unsupervised young adults and teenagers, because their parents have succumbed to HIV/AIDS. And the parental generation has been depleted.

What does that mean over time to the stability of those societies, and to the possibility of recruitment? One of the key things that have changed in the terrorism paradigm has been the shift away from the issue of cash and the movement of dollars or currency to support terrorist activities to the use of diamonds, because they are untraceable, because millions of dollars' worth of diamonds can be sewn into the hem of a skirt, and they can be transported readily all over the world.

Increasingly, we see terrorist activity supported by the diamond trade, and it was a key reason why many different terrorist associated organizations and violence-prone organizations, to put it politely, were deeply entrenched in Liberia and Sierra Leone, and have a stake in what's going on in Congo. Now, how does that feed to HIV/AIDS? At this time, not at all, right? I have to be very clear about this. What we are talking about is projecting out ten, twenty years, imagining this epidemic unchecked, this pandemic over time unchecked, and what that could mean. Now, I think there were a couple of other questions.

HOLBROOKE: Well, let Peter do the money one.

PIOT: Yes. On security, I would say that I agree that it can be misused and abused. When I was in China we had many discussions with the Ministry of Public Security to make sure that what is a matter for instability potentially in society doesn't become an alibi for repression. And so that's why it's important to educate the security forces. And Ulf Kristoffersson is here. He's the director of our unit, and knows that in our work with armed forces, the full issue of discrimination and rights is one of the main emphases.

Now, is it because lack of money? Yes and no. We've estimated that the developing world, lower- and middle-income countries, by 2008 require about $20 billion to bring this epidemic under control, provide prevention to everybody who needs it, provide treatments, provide therapy, and take care of the orphans. We are at about $8 billion, as you can see. The problem is if today somebody would write a check for $20 billion, we couldn't spend it. We couldn't spend it.

We have to work—at the same time that we mobilize the money, we've got to work to build up that capacity. That's not only a matter of training doctors and nurses. We've got to think out of the box, first dealing with AIDS, particular prevention, that you don't need actually most of the time, you don't need a medical community. That goes on in women's groups, businesses, just name it. But we have to really invest far more into the long term. The long term, building up what we call capacity. It's human-resources development, in essence, and that's why I'm far more optimistic about Asia, how Asia will handle this AIDS epidemic once the political leadership is there, because the human resource is so much stronger than what we see in some of the worst affected countries, where in Africa, where AIDS has killed, it's undermining, it's killing the teachers, the doctors, not because you've got an M.D. or a Ph.D. that you're protecting from HIV.

So it's yes and no a matter of money. We need to continue to make sure that the financial momentum that I mentioned, that that continues, including because we actually creating entitlement programs by providing antiretroviral therapy in countries. We cannot simply—we cannot stop this, once somebody is on antiretroviral therapy, but also to invest far more in this capacity of societies to deal with this.

HOLBROOKE: But let's be very clear in the answer to money, which I think was your question, John. This is an enormously important issue. And the simple answer, John, is that no amount of money will be sufficient unless we stop the spread of it.

Now Peter earlier talked about prevention. If you want to visualize the problem in the simplest way, think of three baskets: prevention, treatment, and cure. Put cure to one side, because the search for a vaccine and a cure is daunting, it's receding before us. It can also happen. But even if somebody found something today that would work, it would be seven to ten years before it would be fully tested and online. So then you go to prevention and treatment. Almost all the money is going to treatment. And what Peter has just said, put in slightly different language, is it's a bottomless pit if all you do is treat people who are HIV-positive. Once they go on antiretrovirals, they're on them for life. Because if you go off them, you'll get a different, probably resistant strain, with all the bad implications of that.

And if you look at the statistics on page fifty-four of Laurie's study and her chart, you will see that even if WHO [World Health Organization] reached its three million people on ARVs by the end of this year, and they have no chance of doing it, they won't actually catch up with the spread during the year, because according to Peter's figures, 4-1/4 million people, 5 million, will get it this year.

You mentioned Jeffrey Sachs. With all due respect to Jeffrey Sachs, he is wrong in his call. I'm glad that Jeffrey is asking for more money, I'm glad he's a good polemicist for more money; he's helped. But he's barking up the wrong solution here. Money won't do it. It takes government leadership. We've already heard about South Africa, and Manto, the dreadful minister, her counterpart in Thailand, Mechai, who made a difference. But in the end, it's prevention. You're not going to get there unless you can stop the spread, and you won't get there unless you know who has the disease.

So those of us who are working on the issue, we're always confronted with the same question: Is it hopeless? Well, if it were hopeless, if we thought it was hopeless, we wouldn't be working on it. But don't kid yourself. We're all for President Bush's program [the President's Emergency Plan for AIDS Relief]. Most of the money comes from the U.S. And by the way, $80 million, $85 million for the Global Fund [to Fight AIDS, Tuberculosis, and Malaria] didn't get to the Global Fund last year, because the Congress said one out of every three dollars is the max to the U.S., and the rest of the world didn't match the U.S.' one-third. So, there's $85 million, $92 million just sitting there, which could have gone to the Global Fund if the rest of the world had put up $180 million more. And one-third is a reasonable percentage for the U.S.

So the long/short answer to your question is, money is essential, but no amount of money will ever do it. And think of all the diversions, John, from all the other important issues, the other health issues. We've already talked about education, infrastructure, clean water. It is the saddest thing in the world to go to Africa or India and see the money we're wasting to stop the disease because we haven't prevented it from starting. And India is Exhibit A, because they're in denial. They may be better now than the previous government, but not good enough. Peter, do you and Laurie want to have last words, and then we'll close down?

PIOT: I would like to end with a far more optimistic note, frankly, not because we are all going off to dinner, now, but because I think really, after twenty-five years in this epidemic nearly, that for the first time, let's say the stars are getting into the right alignment; is that how you say it in English? What I mentioned, there is so much more political leadership, there is so much more going on at the community level, there is so much more money, the key issue now is that leadership. I come back to that. Without leadership, and that your dollar can buy leadership, without that, we're not going to make it.

And that's why it's so important that you, all of you, and the Council and the security community and so on, that we continue to hammer on that. We can't let it go, and when a country doesn't respond to AIDS, there is something like an international responsibility to say, "Look, AIDS will not be solved anywhere until it's under control everywhere." If you have one country, let's take Myanmar, Burma, where they have the worst-stage epidemic in Asia at the moment.

HOLBROOKE: And Papua, New Guinea.

PIOT: And Papua, New Guinea, in the Pacific. And if Burma is not bringing AIDS under control, then the great efforts that all its neighbors are doing at the moment are useless, because there will be a continuous expansion, export, of HIV throughout the region. So what's why it really requires a global approach. If there is one issue today, it's that.

GARRETT: This morning the Security Council met to discuss Resolution 1308 and get their update, and afterwards, in a press conference at the UN building, we were asked by one of the reporters, "Is this an emergency?" And frankly, that is the missing element: that moment when the United Nations declares that HIV is a global emergency, that moment when the United States Congress declares HIV is a global emergency, and when its counterparts around the world do the same thing. It is absolutely stunning that we're this far into this epidemic, and that the notion of it being extraordinarily urgent has yet to drive home. I am, personally, very heartened that Gleneagles brought a higher commitment from the G8 to funding programs. Yes, money does matter—maybe not the exact sums that have been bandied about, but money matters. And I'm glad to see that flowing.

And I think we should all be heartened by that, and see that as a push in a good direction, just as Resolution 1308 was a push in a good direction. But the direction is moving like this, and the epidemic, swoosh, is soaring like that. The level of political commitment and leadership is not there, yet. And it simply is not yet fueled by that sense of, "We are in a state of emergency."

HOLBROOKE: Richard began by commenting on the size of this turnout. And in New York and Washington, Princeton, and all your friends and colleagues down there, thank you for participating. Thank you all for coming. I hope you—you are the committed ones, or you wouldn't have shown up tonight. But please get the word out to everyone that it is an emergency. This is a great, great report. Thank you very much. [Applause]

GARRETT: Thank you all.







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