A Conversation with Peter Piot

Monday, June 18, 2012

LAURIE GARRETT: And I'm very, very pleased and excited about our discussion today. We have a real treat because we not only have Dr. Peter Piot, the founder of UNAIDS, the United Nations AIDS program, but we also have the current executive director of the UNAIDS program, Michel Sidibe, with us. So we have a true continuity that spans several decades, believe it or not, and I think we'll have a very lively and fantastic conversation.

I -- what I -- what of course brings us here today is "No Time to Lose: A Life in Pursuit of Deadly Viruses," Peter Piot's memoir. I think it is important to recall that it is a memoir. It's not a(n) attempt to write the definitive history of anything, but rather an attempt to describe how the world and the history developed through the eyes of a key player who really was on the front lines at each individual step along the way.

Because it's a memoir, it's far more accessible. At times it's almost a roller-coaster read through an adventure cycle. And I suspect it will prove to be a recruiting device for the next generation of epidemiologists, infectious disease specialists and public health leaders, because it makes it seem, wow, like, one of the most fun things you can possibly do with your life. (Chuckles.)

And many of the events that Peter describes in "No Time to Lose" we experienced at the same time but from a different perspective. We both were on the front lines watching a new disease unfold, which later came to be known as AIDS, I in San Francisco and he in Antwerp. We both watched as a series of events unfolded that brought us to this collision course that we're on now in global health. And actually, of course, I wrote in my first book, "The Coming Plague," a description of the 1976 Ebola outbreak, in which Peter was a key player. So we'll have a chance to talk about all of these points.

What we're going to do today is Peter and I are going to have a conversation for about 20 minutes, and then we're going to bring Michel into the conversation for a bit, and then we're going to open it up to all of you here in the audience. So if you have questions as it goes along, try to remember them for later on.

So Peter, you were a whopping 27 years old.

PETER PIOT: (Chuckles.)

GARRETT: You had finished medical school, but you were just getting started in your Ph.D. efforts in microbiology at the Institute of Tropical Medicine in Antwerp. A -- mysterious test tube samples show up in terrible condition, and you figure out that there is some new disease in Africa. And you have the chutzpah to turn to Stefan Pattyn and say, I know I'm only 27, but I want to go there. I want to go to Africa. Let me go. I want to be in the middle of this adventure.

PIOT: Of course.

GARRETT: How could you have such -- where did all this gall come from? (Scattered laughter.)

PIOT: I'm actually a pretty timid and shy person.

GARRETT: Oh, yeah, right. (Chuckles.)

PIOT: And -- coming from Flanders, where the -- my mother always said, speaking is silver, silence is golden, son. But anyway, I'm -- I think I'm a bit different.

No, I was -- first of all, I had an incredible urge for discovery from when I was a child. And when I was a teenager, I worked for a travel agency and went one month to Morocco, one month to Turkey, at a time when there was basically no touristic infrastructure. And when I was 10, I think I had only one goal in life, and it was get out of here, out of my village, which was a bit in a -- kind of a very conservative Flemish village.

And -- but it was a combination of this sense for adventure but also the incredible curiosity for things, which was to the despair of my mother and my whole family, because when I was like this, I always asked why, which drove everybody nuts, you know. That was the kind of kid I was -- and not to annoy people, but I really wanted to know. And so -- and I also had not much respect for hierarchy and authority. And so -- yeah, that's why I said yeah, let's go for it and let's do it. And it's not because, you know, I'm 27.

Also, later on, most people who had more seniority and so on, and more experience, they actually were not so jumping up and down to fly to Zaire and to go --

GARRETT: Because they knew what a hellhole it would be -- (chuckles) -- and you didn't.

PIOT: Yes. Yes, yes, I guess so.

GARRETT: But coming away from -- the way you describe the episode, there's four things that I think are the key experiences or realizations, the "aha" moments for you, out of the Ebola 1976 episode, because this strange test tube and this 27-year-old flying to Africa for the first time is, as it turns out, the Ebola epidemic.

And the four things were, first, you experience Africa and you fall in love with Africa.

PIOT: Right.

GARRETT: Secondly, you discover internationalism and all the difficulties of coordinating and working together with scientists and all sorts of other folks from around the world.

You discover the relationship between global inequity and nosocomial disease; that if people are so poor they don't have sterile syringes, there will be spread of disease.

And then you discover do-gooders can do so badly that it would be better they weren't there in the first place.

So let's take these apart.

PIOT: Yes. You really read the book.

GARRETT: (Chuckles.) Let's take these apart. Why did -- why -- what was it that this young Flemish 27-year-old fell in love with in Kinshasa?

PIOT: Well, it was Kinshasa and then elsewhere. I think it was the warmth of people, you know, the human side, the creativity. I cannot hide also the music and the dancing. (Chuckles.) But the fact that I thought there was on the one hand so much to do, incredible needs, which are still there, and the will to improve it.

And so I saw opportunities, and which I think are very underestimated today in Africa. When you look at just growth of GDP today in the world, I mean, the highest rates today are no longer in Asia, but they're in Africa. I'm not saying that Africa is now -- has made it. We see natural resources that are there.

So, I mean, I think it's -- I didn't know all these things in these days, but it was a combination of the gut feeling and the warmth of people, the -- you know, the human side, but also the sense -- I got also very upset and angry because of the inequalities and of the -- you know, Zaire was then ruled by Mobutu. And there was a group of plutocrats, you know, stealing the country to death, literally. And on the other hand, you know, young people -- there was a great university in the old days, you know, but nobody was paid, there was no -- even no electricity and so on. So people were denied some basic opportunities. But it's -- I can't explain it why, but I was bitten by the virus for Africa, and --

GARRETT: There is a lot of dancing in the book, if you haven't read it. (Laughter.) There are many times when Peter is so ecstatic he breaks out dancing all over the place.

PIOT: Yeah.

GARRETT: Now, this also was your first experience trying to work with American scientists.

PIOT: Yes.

GARRETT: And the Americans came in and said, we're in charge --

PIOT: Right. I didn't like that.

GARRETT: -- particularly Karl Johnson from the CDC.

PIOT: Yes.

GARRETT: And you found African colleagues to collaborate with and fellow Belgians, particularly some who came a little bit later after you'd been there a while. Tell me about what you learned in '76 that guided you forward about international cooperation.

PIOT: Yeah. One, I discovered that where I came from, the means we had both financially and technically were far inferior to what was, you know, available here in the U.S., and whereas -- I resented that. Indeed, you know, we had isolated this virus for the first time, and then the folks from CDC came, and they said, OK, we're taking over. And so I resented that. That's absolutely true. But then I saw, you know, that I could learn so much, and -- someone like Joel Breman, who really initiated me into field epidemiology, and I'm really still grateful for him.

And it was not only the U.S., but there were -- it's like in some of these jokes; I mean, there was a Frenchman and a South African and a Brit and a Belgian and an American and then -- and some Congolese in a plane, and what happened and what do you do? But the power of coming up with --from different perspectives I found fantastic.

But I was very impressed by the superiority, the technical superiority and the strategic superiority of the -- our American colleagues. So while I was there, I said, you know, I want to go to America and learn and just see that the next time we find a new virus and so on, you know, I can be in charge also. I mean, it was not only for myself, but just to be -- you know, to share this. And rather than to stay in America, I came back to Belgium and, OK, here we went.

GARRETT: The sad thing you discovered after seeing patients bleed out, the horrors that are Ebola, it's a -- if you haven't seen it, it's a very terrible disease, and it's an awful way for anyone to suffer before dying. But a particularly sad thing for you, as a Flemish (kid ?), grown up in Belgium at a time when French speakers were the dominant, you know, power structure of Belgium and the Flemish were all held down -- and you get out into Yambuku, this very, very remote village in Zaire and discover the responsibility for it all really rested with fellow Flemish Catholic missionaries.

PIOT: Right.

GARRETT: Tell us what that meant to you. What did you discover?

PIOT: Well, on the one hand, I was full of admiration for these women, particularly the -- because the sisters there were dealing with -- you know, they had a school and a hospital and so on. The fathers were into more proselyting type of activities. And they were hardworking, dedicated.

But they were running a hospital, and there was not one person who had a formal training in nursing or in medicine, and 110 beds. And as -- and so one of the things I learned is that it's not enough to -- wanting to do good; you also need basic competencies. You know to -- you know, you need some basic expertise. Otherwise, you wouldn't give injections to everybody who comes to -- you know, to this hospital and to the outpatient department with -- when you only have three or four syringes and a few more needles. So that was one thing.

On the other hand, I also discovered that it was like the time had stood still. So these were Flemish nuns who had left Belgium years before, and they were still thinking of the motherland as if time had stood still in Belgium also, which you find often with expatriates. And they have an idea of the country of origin that doesn't correspond anymore with how it evolves. And so that was also -- it reminded me of my grandmother, my -- you know, my ancestors. And that was something I hadn't expected. And eating, like, winter stews in the -- on the equator, you know, just -- where it's very hot, that's not very adapted to the environment.

GARRETT: But you even today are still in touch with one of the priests, yeah?

PIOT: Yes.

GARRETT: And he's still there?

PIOT: Father Carlos (sp), yes, in Bumba, in a town on the Congo River, as it's called now again, and where the river is about 20 kilometers wide. It's just incredible. And he's there, but now in contact with him by email.

And when I talk about this to students, they stare at me as if I'm coming from the Stone Age, that there was no -- not even cellphones, where it didn't exist. Satellite phones didn't exist, no fax, no Internet, no Facebook, no -- et cetera, et cetera. So communication was very slow, to say the least, and inaccurate.

But now I'm still in touch with him, and he's really -- has started a secondary school. There is, you know, the hospital and so on. So in the -- you know, in theory, in Congo, outside the missions, often nothing else is functional, so that's also the reality.

GARRETT: I mean, to flash forward a little bit, the last time anybody took a count that I saw, in the post-2000 era 60,000 NGOs related to AIDS in Africa alone have been created. And when you think back to those missionaries -- who thought they were doing the right thing, but goodness, if you don't know how to use syringes properly and the basics of sterile -- and hygiene, perhaps it would be better you weren't there in the first place.

What lesson do you see, looking forward to this explosion of NGOs, that can be informed by that experience?

PIOT: Well, the good news is that, you know, global health -- the term of which didn't even exist until about, what, 12, 13 years ago -- I try to figure out when did it appear for the first time, but it's -- global health was created by the AIDS movement, in a sense. But -- so the incredible interest and money and so on, that's the great news.

But on the downside, often it's not always going with the most professional approach. And so the key is to combine the enthusiasm, the dedication, the commitment with know-how and with strong evidence and -- based practices. And that's not always there. That's one of the reasons I was so interested to move to the London School of Hygiene and Tropical Medicine, even if I had said never again in academia -- (laughter) -- after I left it, just like I said never again in the U.N. But now here I am. And -- because we want to train the next generation of leaders in global health, and that's the best institution to do that.

GARRETT: In 1979 you participated in a(n) autopsy on a Belgian sailor, and you say in the book, I wasn't smart enough to see that it was a new syndrome, but I knew we'd never seen anything like it before. And it was?

PIOT: AIDS, as we know today.

GARRETT: What was so striking about it that you knew just looking at this body before you that this was a new disease?

PIOT: Yeah, it was someone who was a fisherman on one of the big lakes in Congo. And the person died with what's called disseminated atypical mycobacterial infection. What is this? Mycobacteria -- we know mycobacterium tuberculosis causes TB, and then leprae causes leprosy, but then there are also, in the environment, ubiquitous mycobacteria which don't really create any problem. We -- probably most of us here have somewhere are covered with it. But when you're immune-deficient, you -- that can kill -- it can kill you. And so we had never seen that. And you just -- well, cut in the -- you know, just in the muscle and so on, and there were these mycobacteria. You can see them under the microscope -- very strange. And we started seeing then some others with other weird infections. It's the same way that AIDS was described for the first time in this country, but then with other opportunistic infections.

GARRETT: You decide that sexually transmitted diseases are acutely important. And it's so interesting that you adopt that as one of your major interests when, you know, almost anybody else would say, eww, sexually transmitted diseases, yuck, ugh.

PIOT: Yeah, it's not very high on the hierarchy in respectability. (Laughter.)

GARRETT: And there's all these little, you know, cultural bleh -- (laughter) -- and this -- you come to the United States, you had a whole bunch of training in that area, particularly from King Holmes at the University of Washington, who's still there in Seattle and still a real leader in STDs. And then you go back to -- in 1983 to Kinshasa, with some of the same people that you were in the 1976 Ebola epidemic with. You're in that massive -- I mean, anybody that's ever been in Kinshasa knows what I'm talking about -- massive colonial hospital, the Mama Yemo. And you say in the book -- you wrote in your diary: "Incredible, a catastrophe for Africa. This is what I want to work on. It will change everything." What was so incredible? What would change everything? What were you looking at in Mama Yemo?

PIOT: Well, Mama Yemo -- which, by the way, is the name of Mobutu's mother. One of my observations is that dictators seem to really love their mother, and they have something -- (laughter) -- and they name all kinds of things after their mother.

But no, I had been there in '76, gone through the files and so on. And here I enter the wards of, you know, internal medicine, men, women, and suddenly, you know, they were full, full with young men and women, in these days, of my age, and dying, emaciated and all kinds of these opportunistic infections, cryptococcal meningitis, just name it. And we had had like a hundred cases in patients coming from central Africa and Belgium. That's why I went there with Tom Quinn (sp) and Joe McCormack (sp). And it was so overwhelming because I knew that was not there before. And also, Dr. Kapita, the head of the internal medicine there, had, you know, put aside for us like 50 files of patients who had died already in the previous month or so. And just was the extent of it, the fact that it was, like, slightly more women than men, which was very unusual.

Let's not forget in '83, what was the dogma? This is a gay thing. And I never understood why a virus would care about the sexual orientation of its host, you know, because for a -- for a virus, what is it -- the purpose of a virus is to perpetuate its life, so jump from one host to another. That's all. That's what sex is about. So I saw that, and I said, I can't believe this must be -- you know, it's heterosexual -- that's one thing I said -- and there are far more -- there's far more heterosexual sex in the world than same-sex sex. And knowing also from my studies on sexually transmitted diseases that they were very rampant in these days in Kinshasa, I said, this is going to be a catastrophe. And unfortunately, I was right.

GARRETT: Well, and then you, together with Jonathan Mann, and American, set up Projet SIDA, which is AIDS Project, in Kinshasa. And the first time we met was 1985. It was the first International AIDS Conference, in Atlanta, Georgia, which fit almost --

PIOT: In one ballroom.

GARRETT: -- in this room, yeah.

PIOT: In -- yeah, in the Omni or something like that.

GARRETT: Hard to believe, because the upcoming AIDS meeting is going to have about 25,000 people. And first of all, I don't think we could possibly have imagined -- I know I couldn't -- in 1985 at that meeting that we were at the front end of something that would still be around in 2012, that would by then have sickened or killed about 74 (million), 75 million human beings, that in 2012 there'd be 34 (million), 35 million people alive with this disease, on every continent on earth. We couldn't have imagined it.

But what I remember most distinctly about that meeting is there was a moment when this very tall white guy was translating for a much shorter Zairois fellow. It was Dr. Kapita. And a cluster of us were standing around you. And a Wall Street Journal reporter, who was absolutely sure that HIV was a gay disease, wouldn't accept the notion of general heterosexual transmission, said to Dr. Kapita, isn't it true that Africans have sex with monkeys? (Laughter.) And I remember this guy trembling with rage. Your face changed colors. And yet you knew you had to translate. What was Kapita's response?

PIOT: Yeah, I was this tall white guy. So -- well -- (chuckles) -- Kapita -- so first he pretended that he didn't understand English, so that gave him time to think. So that's why I was -- it was my role. And then he said -- well, he said, we don't -- something -- I'm not aware -- we don't do this, or something like that. He was very calm. But I've heard about things here with dogs, you know, and -- (laughter) -- (inaudible) --

GARRETT: And don't people go to Tijuana to see donkeys, yes. (Laughter.)

PIOT: To see dogs -- yeah, donkeys, yeah, something like that.

GARRETT: But if you think about it -- and I -- and I do want to bring Michel in in a moment here. But to flash forward and frame that period -- because your title is "No Time to Lose," and all through the book you express a sense of urgency to respond and regret that the response wasn't faster. And if you look back to that critical period in the 1980s and '90s, before we had effective treatment in 1996, we had many moments when interventions were blocked because of the human rights issues, so that we never could tackle HIV the way we did syphilis or gonorrhea. And the -- and the rationale for not doing so was, well, there's treatment for syphilis and gonorrhea, but there's no treatment for HIV, so if you identify someone as HIV-positive, they will simply lead a life of discrimination. When you look back, do you feel that there are tools of public health that we failed to embrace powerfully enough? Putting aside the blame to international political leaders, but within the public health arena, are there things that, when you look back, you feel, we should have done this, that and the other thing, before we had medicine?

PIOT: Well, we definitely lost a lot of time. We wasted a lot of time by not recognizing it. In every country, when you think how, be it President Reagan or Prime Minister Thatcher, could simply not even pronounce the word AIDS until the very end, which is -- I'm not a psychiatrist, but in psychoanalysis, that means something. So the fact that -- the lack of willingness to deal with the issue, also in public health circles, first dealing with AIDS because it was -- you know, first, it was in the category of sexually transmitted diseases and all that, which is not on the -- yes, exactly. (Laughter.) We stay away from this. We are not like that. But then also later on, when it came to treatment -- and I know we were going to talk about that later, but it was the public health community, and some of which was the biggest problem, in a sense that they had all these reasons why it's not possible.

I think there were also some absurd activist demands -- (inaudible) -- like I was shocked in Atlanta, there was the whole campaign, no test is best. I remember that was the -- which I didn't fully understand. On the one hand, it's true that because of the discrimination and the stigma that all we could offer was kind of negative, death sentence because there was no treatment, and then discrimination -- you would lose your job, your insurance and so on. But I think that retrospectively, indeed, we should have had a far more adult conversation about what can be done. But you can't see public health in isolation from what's going on in society. That's the problem.

GARRETT: But we had -- we had a case example of tremendous victory, and it didn't catch on. It didn't go viral, so to speak, as we would say today. And that was Thailand. I mean, if you look at the late 1980s, the Asia Development Bank had predicted Thailand was going to collapse under the pressure of AIDS. The 17-year-old recruits into the military were running as high as 3 percent HIV-positive at the age of 17. And by the time they were 22 in the military, the rate was way beyond that. And it looked catastrophic. And they had no tools except condoms, and they brought it completely under control.

PIOT: Well, I don't know that's true.

GARRETT: Why didn't that become the model for the world? Why was everybody -- why do we all look at Thailand as if it was this isolated case?

PIOT: No, I think that's a good example of why did it work in Thailand? Because of strong leadership and not to -- worrying too much about public opinion and said, you know, 100 percent condom promotion. It was enforced in a way, you know, with the -- not only public health people, but -- who went to see the brothels and so on. It was of course to preserve Thailand's sex industry, which is worth billions of dollars. But it's something that there was no willingness to do. Even today do you see an ad for condoms on, you know, prime time on TV in this country?

GARRETT: On MTV we do. (Chuckles.)

PIOT: Oh, you do. OK. On what -- OK, good. But it is this double standards about sexuality and sex and, yeah, not wanting to deal with the issue. I think --

GARRETT: Even today the Thai example does not resonate.

PIOT: Yeah, but Thailand has also problems. For example, they're not dealing with gay men. They're not dealing with injecting drug users for years, and they don't want to go for needle exchange and methadone. So it's -- but they were very, very effective, particularly when Mechai was the -- in the Office of the Prime Minister. And in Thai now, a condom is now called a Mechai. That's the ultimate success in branding, when your name is -- (laughter) -- becomes the thing, you know. Yeah.

GARRETT: Well, I can't move on without giving you opportunity to hit two of your most remarkable encounters. First, an office that -- if I think I remember right -- was mahogany-lined; everything about it seemed like you had gone to Oxford, and there's a gentleman sipping expensive Scotch and smoking a pipe, and it's -- and he's telling you great paranoid conspiracy theories, and you cannot wake him up. Who is that gentleman, and what did he cost African lives?

PIOT: This is President Thabo Mbeki. There was also a fireplace -- so to complete the picture. (Laughter.)

GARRETT: Oh, a fireplace.

PIOT: And yeah, after a very late-night encounter and conversation, he told me, but Peter, don't you know this is a conspiracy of the Western pharmaceutical companies to poison us Africans? And it was -- has always been a mystery why such an intelligent person who's done a lot of good things, a strategic thinker, could believe such a thing. Fortunately -- and that has costed about 300,000 lives, according to a study from Harvard, because it delayed the introduction of antiretroviral therapy, of prevention of mother-to-child transmission in the country, and maybe also in some neighboring countries, although his colleagues, other African presidents -- maybe they were sometimes listening politely, but they didn't follow him, fortunately, in this.

And now today South Africa has the largest HIV treatment program in the world. And things have changed really the day that he -- you know, he was actually fired as president. But it's a tragedy, and it must be -- yeah, I don't know why -- what it is. I really don't know.

GARRETT: Well, in a very different mood, you're with someone who, over -- oh, it seems like two days of rum, if I follow the description, but an ample quantity of alcohol is consumed -- to discuss mandatory quarantine of HIV-positive people in Cuba. And this would be with Fidel Castro.

PIOT: Right. Commandante, as they call him there. Yes. I went to Cuba already in the early days for several reasons. One, there was compulsory quarantine, because in Cuba most of the Cubans with HIV were former soldiers, the military who were fighting in Africa and who came back infected with HIV and were locked up, basically. And in a conversation with Fidel Castro, human rights is not something that is very discussable, so we talked about it that -- basically that it's not effective, that it doesn't work.

And today what happens in Cuba is that when you're found to be HIV positive, you've got to follow a six-month course as -- I don't know, this is a few years ago, whether it's still the case, but to prepare you for life with HIV. The drugs are there. And then many people become HIV educators. Since everybody's a state employee, basically, it doesn't matter what you do. So you're reoriented.

But it was -- yeah, it was -- I came there, and the first time I met Fidel was in the middle of some kind of tornado, and he was talking about how many liters -- Mr. -- Ambassador Portocarero (sp) is there; you were ambassador there -- (chuckles) -- and so how many liters per square meter per province -- (inaudible) -- and so on. And, you know, he's a man of figures. And then after I said, Commandante, I came here to talk about AIDS, I express my solidarity with the people affected by the floods in Cuba, et cetera, ah, yes, he said, and then he started talking about how many cases in Jamaica, how many there, how many there. And anyway, sometimes he knew the figures better than I do, because in spite of the fact that I've been a professor of epidemiology, I have a hard time remembering these figures.

And so then he said, OK, let's have a drink in my office. So we went in the office and I asked for water because, I said, I just arrived from Europe, jet-lagged, and I said I need to make sure I do my best here. And so then he said, no, no, no, you don't drink water; so what else? (Laughter.) So mojito, OK, you're in Cuba. And then anyway, to make a long story short, we then ended up with -- as he does sometimes -- he called in half of the government, and the vice president, we had dinner and we talked a lot about all kinds of things, including the decline of -- the imminent decline of capitalism.

GARRETT: Oh, it will be dead any second.

PIOT: And over this last century, it still hasn't happened.

GARRETT: Well, I would like Michel to join us. And as he's coming up to the stage, there -- it's interesting, you end up deciding to go for the job of creating this new agency in the U.N. called UNAIDS, United Nations AIDS program. And it didn't even have a name then, but it's this new entity that's going to happen. And there are two African colleagues that offer you smart advice. Kofi Annan says, beware, the sea is full of sharks.

PIOT: Yes.

GARRETT: Yes. And he's not secretary-general, yet, of the U.N. at that time.

PIOT: Plus he said -- oh, no.

GARRETT: Go ahead.

PIOT: And also he said also, so don't fall into the water. And if you fall into the water, don't bleed. (Laughter.) So it's -- (laughter).

GARRETT: Don't bleed.

GARRETT: And then a certain Michel Sidibe, who I believe was at UNICEF at the time, tells you the story of the chameleon. One of you want to tell -- what was the chameleon? What was that advice?

PIOT: That was in Kampala, when we met in a restaurant -- (inaudible).

MICHEL SIDIBE: Chateau -- Belgian restaurant.

PIOT: Yes.

GARRETT: And what was the story?

SIDIBE: No, I think the story is a story from our childhood. The Fulanese generally, when they are 13 years old, they ask them to observe a chameleon, and after that, they ask them, what did you learn? In general, the smartest children will say that he's changing color; but that's not important. The most important one is that they taught you a few lessons for the life. They said, OK, the first thing is that the chameleon is always walking without moving the head, so in life it is very important to have an objective, objective set in a very clear manner. So that's first lesson.

Second lesson is that it's good to have an objective, but if you don't have a good understanding of the environment and you don't put that in perspective with your strength and your weaknesses, you will never move. That is the second lesson.

The third one is that even if you have well -- you understood the environment, you have the objective clear, you try to never make people always your target, because they can miss you once, two, but maybe one day they will not miss you. So it is important to really give some time -- a space for people to give you what they know so you can learn more. And that's third.

Fourth is that you have to be prudent in life; follow, that is clear, but be prudent.

PIOT: Go step by step.

SIDIBE: Go step by step.

And the fifth one is that even this chameleon, if he's just one second before his target, he will never change the space. He will always have a self-control. So in life it is very important to have self-control. If not, you can do all of that and you will miss your objective.

And the last one is adaptation.

GARRETT: Adaptation.

SIDIBE: An adaptation.

PIOT: (Inaudible.)

GARRETT: Well, I mean, this is like the story of creating UNAIDS, because what you describe is that the entire U.N. system was against you. It's almost a miracle the organization came to exist. And you describe episode after episode where either a major Western donor or -- donor agency, or a rival that should not have been a rival agency representative from within the U.N. system was, like, sabotaging what you were trying to do.

PIOT: Yeah. Certainly from a number of agencies. I would say that Nafis Sadik, who was then executive director of UNFPA, you were an exception. You gave me a hard time at the interview, but the rest was fine, which has been -- (laughter) --

NAFIS SADIK: (Off mic) -- him a hard time at the interview. I didn't know him. (Laughter.) I crossed him off my list.

GARRETT: Oh, you -- she said she crossed him off the list. (Laughs.)

SADIK: (Off mic) -- rang me up, and he said, how could not cross HIM off?

GARRETT: We need a microphone if we're going to have -- (laughs).

PIOT: Oh, that I didn't know.

SADIK: (Off mic) -- my recommendation. And he said, would you be willing to interview him? I said, OK. So they brought him in, and here comes Peter. By this time, I've read up on him. So then I'm so embarrassed that I have crossed him off. But I did interview him, nevertheless. And of course, the rest is history.

PIOT: Yeah. No, but it's true. I mean, when you see where -- it was at several levels, but particularly mid-level management, there were people like in UNICEF and UNDP, and they told me, if you ever become, we'll do everything we can to undermine you and to make sure this doesn't happen. In WHO, it was Nakajima was then the director general, and basically he thought that in one year time, it would be -- you know, it would be -- how to say -- we will just kill it, et cetera. I mean, anyway, it's kind of too ridiculous to even talk about it. When I was writing about it, I said, oh, my god, how is this possible?

But to go beyond personalities, there is indeed an issue in the U.N. system that -- which is very rich in terms of its diversity and different agencies, and everybody is looking for money, fundraising, so, you know, there is a lot of turf and all that going on. And I don't think that coordination is actually the solution and is the work.

But I must also say that probably it's in AIDS that we're the most advanced, best integrated. There is nothing that comes close, as far as I can see. So, I mean, unless something happens --

GARRETT: So, Michel, it's all one big happy family now?

SIDIBE: No, I -- let me first say that what is very difficult is what Peter was talking about. You have the conflicting interests sometime, and that people have to fight for their agenda. They have to make sure that they are relevant. So it makes the coordination sometimes very difficult.

But what I am seeing now, which is encouraging me, is that we manage to be a little bit beyond those individual agenda, to identify cross-cutting interests and identify key result areas, which is making us certainly moving collectively together; saying that, for example, it's so important to save life of people. And saving life of people means what? Is to bring people at the center. If we bring people at the center, we are not talking about UNICEF, UNFPA and others; we start looking on how we can create a synergy to act together. I think that is helping us.

But at a the beginning it was not possible. It was not possible. Peter was coming from WHO, and WHO was not understanding why this organization has been created, and each organization was fighting to create their own identity with HIV. So his job was a very tough one.

GARRETT: A giant turf battle.

PIOT: Yeah, but what I've seen is that the U.N. system is at its best when it coalesces around a very concrete outcome and deliverables.

SIDIBE: Exactly.

PIOT: And then it can move mountains. And if it just concentrates on process, as is often the case, particularly here in New York, then it's hopeless and a waste of time for everybody.


PIOT: So that is, I think, my conclusion. And I don't know -- Ann Veneman was executive director of UNICEF, and your body language tells me that you agree. (Laughter.)

GARRETT: Well, Michel, today, at this moment the G-20 leaders are probably drinking tequila at Los Cabos, and they've probably had a day of accomplishing very little. And also at this moment in Rio, they're probably drinking rum at the Rio plus 20, and there's very little optimism for that meeting. We're in a moment where everything seems to pivot on the euro crisis. The amount of money on the table keeps shrinking. The sense of generosity is shrinking. And we've seen since 2008, with the financial crisis, ever greater dependency on one source, the United States government, which is now, I think, about 60 percent of support for international HIV efforts.

What does this mean for you in terms of trying to coordinate a global response?

SIDIBE: You know, I think it is very important. Peter said something. He said that the world is changing, and I believe on that one. You know, 10 years ago when we were talking about Millennium Development Goals, Africa was nowhere. We were not talking about growth rate there, average of 6 or 7 percent. Even highest growth rates, like, in Ghana, we have 15 percent, Ethiopia 11 percent. We are not talking about emerging nations, China, Brazil and others as key players in the new global governance system.

So for me what is important today is that what we are trying to push is to bring the debate about shared responsibility, saying that the world is changing, we cannot use the old paradigm, which is obsolete development paradigm which we have been using until now. So what we are trying to push is to have a burden-sharing, bringing different players. We have been able to work with the Chinese, and the Chinese now are paying for their own AIDS response, which is very important, is less billion dollars which global fund will pay. We have been working with India. India decided to pay for all their response from this year. So we are seeing South Africa increasing to $1.5 billion. So we are seeing the world coming in this response in different way, and we need to push that.

We need to make sure that, of course, it will base on social justice, better redistribution of opportunities. That is critical, because if not, we'll not be able to make it. I was in San Francisco. I met someone there who -- I said to Peter he told me that his treatment cost is $72,000 per year per person. How that can happen in Mali or Burkino Faso? If we know that we have 9 million people waiting for treatment in Africa, we need innovation; we need real change.

So I think I'm seeing that, like, a new movement coming, and which is very important. And that is built on what Peter Piot did. Peter is -- I know Peter very well. He was my boss and my mentor. He's one of the best scientists, probably, we have. And he has also this humility to not share all what he has been able to do for the world. Because today if we save millions of lives, it's Peter Piot on HIV. I want to say that.

Honestly, we were nowhere 10 years ago when Peter brought me. We are looking for result, country by countries, where it's working, why it's not working. Today we have almost 7 million people on treatment. That is Peter. Peter move us from million to billions in term of resource mobilization, demonstrating that solidarity from individual collectives, solidarity from American -- was indispensable to save life of people. And I want to say thanks to Peter for that. And I am building on that.

PIOT: Thank you. It's nice, Michel.

But when you look at the index of this book, it's only people, and that's on purpose. And why? Because, OK, I was maybe the front person, which have -- not only it's -- (grows anew ?) -- anything that was going wrong in -- anywhere in the world in terms of AIDS was my personal fault, of course.

SIDIBE: (Chuckles.)

PIOT: But what I wanted to show is that this is a movement, and there were so many people contributing and all equally important. But what's important also is that -- that it -- making sure that it's not a Brownsian (sic) movement, which sometimes it looks like, going into all direction, and to try to align the stars, as I said, you know, where the politics and the science and programs on the ground are kind -- in harmony or supporting each other. And that is going to be very important.

Now it's not normal that the Global Fund for years funded programs in Argentine -- in Argentina, in Mexico --

SIDIBE: Chile.

PIOT: -- in Chile and in China and so on. And that was actually basically denying money to the countries that are in the greatest need. There are countries in Africa -- take Zambia. According to our projections that we did, you know, in -- by 2030, '31 --

SIDIBE: Thirty-one.

PIOT: -- fifty years after beginning of the AIDS epidemic, will require like 4 percent or more of its GDP to treat people --

SIDIBE: Only on treatment costs.

PIOT: -- just on treatment costs.


PIOT: And with low --

GARRETT: And that's if we don't have to go to third-line therapy because of drug resistance.

PIOT: (That's true ?).

SIDIBE: Third-line therapy. Right.

PIOT: That's the minimum. There is no way on earth that that can be done without international help.

But every -- even poor countries have a budget. So there is in -- the case for shared solidarity, but also for a smarter use of our resources, I think, in these days.

GARRETT: Let me ask you both the same question. I want a very quick answer, so that we have time for the audience.

PIOT: Yeah.

GARRETT: And that is, we're about to have the International AIDS Conference in the United States for the first time since 1990, in Washington, D.C., next month, when we are in the most hotly contested presidential election we've seen in I don't know how long. At this moment, most experts say you can't call who will be the next president of the United States. When the last time the AIDS community convened in Washington, D.C., they publicly denounced a vice president, George Bush, during the Reagan presidency and angered him so much that when he took over as president, he said, I don't want to hear about this AIDS problem; get out of the room.

What -- if there's one message that the American people take from this upcoming conference, and you had the ability to wave a magic wand and make it happen, as opposed to many other scenarios of what may very well happen, what would that message be?

SIDIBE: Hm. You know, I am just coming from a listening tour -- New York, Washington, San Francisco, Oakland -- and I want just to say that it will be a missed opportunity to not say to the American that their individual and collective effort save a life of million of people. And that is not to please them; it's true.

Without this cross-party effort -- and I said from Republican to Democrat, because we have a sense of urgency brought by President Bush -- it has been completely changing all our response. And then with what President Obama brought by bringing the debate around shared responsibility, looking on sustainability, ownership or just natural movement, which we need to share. And that -- I hope this message we will be able to convey, because American people individually in their different (home ?) need to hear that they have been saving life of million of people and we are making the effort to share the burden with other countries now. And that should be the message.


PIOT: Yeah, along the same lines, I would say taxpayers' money has saved millions of lives and has also, I think, improved American image in the world --


PIOT: -- to a large extent. Decreasing that effort now is not only going to cost millions of lives, because people will die, but also, I think, would be stupid from a perspective of smart foreign policy.

Now let's see how our friends -- the biggest problem, I think, at that conference may be how do -- American AIDS activists going to handle that. That is, I think, the biggest challenge.

GARRETT: Well, that's a good note to take questions from the audience. I will ask that you raise your hand and wait until the microphone reaches you and please be sure to identify yourself and give us a real question.

So I see one right down here, if we can come down front. Robert Marten from the Rockefeller Foundation.

QUESTIONER: OK. Thank you, Laurie.

GARRETT: Would you stand?

QUESTIONER: Sure. And thank you for the book. I flew through it in a few days, Peter, and so I would agree with Laurie that it's definitely going to inspire the next generation.

And following on that, my first question, which is -- is what -- what advice do you have for the next generation of global or public health leaders? And then the second question is that at one point in the book -- I think it's towards the end, when you're leaving UNAIDS -- you have something like a -- maybe like an Oskar Schindler moment where you think, you know, I could have done more or I could have done things differently. And so the question is, if you could go back and redo the last 10 or 15 years, what would you do differently, if anything?

PIOT: OK. The first advice is -- one is that the world is becoming really a very global place, so there is a great future in -- I think, in working on global health.

Don't plan your career in detail, because it -- one, it will be boring --

SIDIBE: (Laughs.)

PIOT: -- and also you will miss then the great opportunities. I think I certainly didn't imagine I would ever become a U.N. bureaucrat --

SIDIBE: (Laughs.)

PIOT: -- or discover a virus or whatever. But be prepared. This is my old Boy Scout time -- you know, "Be prepared." So invest in your training and -- but skills and all that, so that you can seize these opportunities.

There are many open doors that are there that -- but people don't go through them, even if you don't know what's behind that. So take some risks.

Now what would have been done -- what would I have done differently? I think probably politicized AIDS faster, in a sense. By that I mean, when I started in UNAIDS, I was quite naive. I would say that -- thinking that if we have the evidence, the facts and so on, this is going to change everything.

SIDIBE: (Chuckles.)

PIOT: Michel laughs. You knew this before I did. But -- and of course that was not the case. And so we -- I should have brought it earlier to that kind of -- to the big political agenda. But maybe it was not possible. I think that's probably the biggest -- yeah, just -- I don't know -- I still wonder: Could I have had accelerated things? It was all so slow. But I (ought to ?) -- on the one hand, I am a man who have no patience for things, and on the other hand, you know, you have to go through certain things. I don't -- I really don't know. I wish I knew.

GARRETT: Right here. Gary. Stand up, please.

QUESTIONER: OK. I always tell people I am standing. (Laughter.) That was the story of my life as a child.

So a question -- Gary Cohen -- for both Michel and Peter. In my more recent travels in sub-Saharan Africa, working with fantastic people, from CDC and elsewhere, who are fighting this battle, you get the sense that we're at a turning point. I don't know if it's quite a tipping point, but the success of PMTCT, this concept of an AIDS-free generation, the use of ART for viral suppression -- so to lower the viral load -- I'm getting a clear sense of -- signs of encouragement that in fact the end point, if you will, could be in sight for the first time, making this a particularly critical time to ensure that that momentum is not lost.

First question is, would you agree with that characterization? Second is, what could help drive that momentum forward? Alternatively, what could risk it?

PIOT: Michel, you want to go first?

SIDIBE: Well, I think it's a very good point. And you know my optimism. For me, getting to zero is my vision, is zero new infections, zero discrimination and zero death.

Of course the zero -- absolute zero means nothing, but it is a vision for making society more inclusive, taking the decision to say we don't discriminate (sic) people based on their race or based on their sexual orientation or based on their social status. It is our decision, and we can get it.

And I am seeing progress every single place. When I decided to push for zero new infections amongst babies by saying by 2015 -- and Ann Veneman was supporting me very strongly -- by 2015, we don't have baby -- we don't need to have baby born with HIV, people were saying, again -- (snorts) -- it's a dream. Where -- from where we will get that?

Today we are seeing -- again, I will share this number with you -- but from last year to this year, a decrease by 100,000 -- 100,000 -- the numbers of babies which were born by (sic) HIV last year compared to this year.

We are seeing also an increase in numbers of people, even in this crisis period, on treatment. We are seeing a new momentum, showing clearly that if we put people early on treatment, we can reduce by 96 percent the new -- number of new infections.

So for me, I am seeing hope there. I want to push for these ideas of getting to zero by knowing that it will be multiple zeros, but we can be there if we work together and we mobilize different constituencies.

And for me it's time to really bring this can-do approach, because it will be a missed opportunity if we don't do that.

PIOT: Yeah, I agree with the vision too, because we cannot accept anything less, in a sense. But I also think we need to be prepared for decades of investments and of continuing it, starting with people who are now on antiretroviral therapy. I mean, we all hope that that will last and be effective for decades, with normal life expectancies. So we need to be prepared for that. That's -- and I think we are not prepared for it.


PIOT: We need to --

GARRETT: We're seeing a rising tide of drug resistance already.

PIOT: Drug resistance. The pipeline of new drugs is drying up, and generic manufacturers are pulling out because the prices have come -- become so low that, you know, this -- they don't make profit and they're moving to drugs for diabetes and cardiovascular disease and -- where the needs are even greater in terms of units that can be sold. So -- and also in terms of prevention.

So I think we need to have that ambitious vision, but also we need to -- we should not -- yeah, we need to be prepared for this longer-term effort.

But I agree that there is kind of a momentum there where we see, I think, a return of the investments of the past decade, basically, because these things don't happen overnight.

SIDIBE: You know, I think I agree with Peter. We need to be able to manage the response with the perspective of the long term.

But what we need now is to change completely our way to deal with the innovation. With the type of innovation we have today, we'll not be able to scale up so quickly.

PIOT: That's right.

SIDIBE: It's impossible for me to believe that you will go to 15 (million), 20 million people in Africa if you have to have to CD4 machine everywhere and if you need to know the CD -- so the simplification, having, like I said in my letter to the partners, a green pill, a yellow pill and a red pill, which will simplify it -- one pill a day -- and trying to look up how we bring, like Peter is helping us to do now, pharma groups together to look at how we work together to simplify. If we don't simplify, it's not possible.

Today -- let me give you one example. With the CD4 machine, just to make sure that we have the 9 million people who are waiting for treatment -- to make them -- initiating the treatment will cost $700 million. And most of those CD4 machines are not working in a difficult environment.

So I was in Burnet Institute in Australia, in Melbourne, and they are trying to -- they are testing this tool today in Malawi. With $1 they can take the blood, they can -- three minutes later they can tell you if your CD4 is above 350 or below 350.

So for me, I am looking for those type of innovations. It can help to shift the task --

PIOT: Yeah.

SIDIBE: -- to give it -- work be done by lower-educated people and reinforce the interface between service provider and community, and increase the demand.

But if we don't have a shift in innovation, no way. It's impossible --

PIOT: I agree with that. I agree.

GARRETT: I should clarify for our full audience --


GARRETT: -- that CD4 cells are a type of cell of the human immune system that are very specifically targeted by the HIV virus. So as your CD4 count goes down, you're clearly heading towards a far sicker stage of the disease.

I think we have time for at least one more question. I think I saw Ann Starrs of Family Care International back there.

QUESTIONER: Yeah, thanks, Laurie. I'm Ann Starrs from Family Care International. And I wanted to ask if you could comment specifically on what you see as the priorities and the trends and the possibilities in sub-Saharan Africa, which is the region where the problem of HIV/AIDS is of course most severe in terms of population and, in particular, looking at it from the perspective of this long-term -- the long-term potential and the question of what is the most strategic approach in terms of dealing with HIV/AIDS as more or less of a vertical issue or integrating it with the provision of basic health services, reproductive, maternal, newborn and child health services, looking at the issue of NCDs coming down, what you see as the most appropriate strategy for dealing with this in Africa.

SIDIBE: No, I think I'll build on what Peter did when we were working together. When Peter started, Peter managed to demonstrate that it is an exceptional disease. And if -- and it was very important to bring that onto the political agenda, demonstrate that these are developmental issues.

But since that, what I've tried to push is to take AIDS out of isolation and seeing that it's not possible anymore to deal with AIDS in the corner. We need to look at what is the intersection with housing, the intersection with cancer, cervical cancer and HIV. You are talking about HIV and reproductive health.

If you take Africa, I will say three major challenge we have. One is women, women, women, the whole issues of violence against women, the issues of positioning of women, making sure that women could get all the information on reproductive health so we can have less young girls being unnecessarily pregnant and going for unsafe abortion and others. That's, for me, one priority if we want really to deal with this epidemic.

The second one will be certainly human rights, I think all the human right issues, restoring dignity of people, making sure that all those people who are not part of the mainstream of society and how we really address the human right issues so they are not excluded, so they are not in the periphery, they have access to services, whatever their social status or their sexual orientation.

And third for me is still sexuality education, universal sexuality education to make sure that young people are equipped with the skills so they can negotiate their sexuality in a responsible manner. And that is -- I would go for those three as a major, major challenge.

Of course, treatment and others need to be there. But that's, for me, our societal change which could -- we need to address if we want to move.

GARRETT: Peter, the final word.

PIOT: Yeah, I agree with that. I think also that there are many Africas. So it's going to be important that we customize what we do to each society. And that is something that is a big challenge for any global movement -- (inaudible) -- so we tend to have, you know, a bunch of experts come together, and that's good -- that's the package, and that's good for everybody. Frankly, that's not how the world functions, and that's not how any customer-oriented company works, consumer-oriented -- (inaudible). And so we need also much better and finer analysis of the local epidemiology, cultural, et cetera, situation, and then provide the menu, although what Michel -- what you mentioned, these are generic issues that have to be applied everywhere.

But then let's take southern Africa. You still have -- (inaudible) -- an incredible incidence, 2 (percent), 3 (percent), 4 percent per year of young women become HIV-positive. There you need an all-out effort. There is nothing more important. When you go in West Africa, a country like Mali or, you know, Senegal, it's now -- HIV prevalence is lower than in New York City. And you know, you need to there fully integrate and do it in a different way. And I think that's a -- that's also a lesson in humility for the global community.

GARRETT: Well, I want to thank Peter Piot for writing "No Time to Lose." I want to thank Michel Sidibe and Peter for joining us here at the Council on Foreign Relations today. Thank you very much. (Applause.)

PIOT (?): (Inaudible.) Thank you very much.









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