Our next topic of discussion is: HIV-AIDS, the global pandemic, a priority for the 21st century. Ms Marika Fahlen, director, social mobilisation and information department, UNAIDS, will give the opening address.
HIV — AIDS.
Chairman
Ms Marika Fahlen
I thank the Chairman and the Irish Presidency for inviting UNAIDS to address political leaders who are voices of strong advocacy and people of influence in society. AIDS requires the involvement of such people as it is increasingly part of globalisation. It requires global action as well as a local response. It is multi-sectoral in nature and not only a health issue. In badly affected countries it touches upon all walks of life.
What is happening to this epidemic 20 years after it was first diagnosed? From being seen in the beginning as an ailment of a few isolated groups, predominantly men in a few isolated places, AIDS currently spares almost no single country. HIV, the virus that causes AIDS, continues to spread, mutate and seek out environments where it has hitherto not made itself known. Last year saw five million new infections, more than at any other time. This figure indicates that, despite all we know today about AIDS, new generations of young people have not, as yet, escaped the risk of infection. This is particularly the case where countries and communities are still in denial about it. Fortunately, this is less and less of a problem, as informed advocacy, civil society activism, the involvement of people living with HIV and emerging political commitment have made headway.
Risks and vulnerability to AIDS are also taking root in places where it has been relegated to oblivion or is being looked upon as a problem of others, not me or us. Here in Europe and other high income regions, complacency appears to have taken hold where AIDS, with the advent of treatment, is being perceived as just another chronic disease. Even in this part of the world young people no longer receive adequate amounts of information on AIDS. Their awareness of the disease and how to prevent infection is dwindling despite the rich scientific and other evidence-informed knowledge available. UNAIDS calculates that millions of new infections could be averted if a comprehensive package of prevention programmes was set in place.
In 2001 the 189 member states of the United Nations committed themselves to such comprehensive programming. When it unanimously endorsed the declaration of commitment on HIV-AIDS, the most complete existing framework of political accountability on AIDS, the declaration clearly stated prevention was the mainstay of response. Like smallpox 25 years ago, the HIV epidemic could also be defeated but making the next generation AIDS-free witch will not come by itself. It requires the sustained involvement of all sectors of society and political leadership from individuals, governments and constituencies. It requires money and that stigma and discrimination are replaced by tolerance and inclusiveness. It requires the respect of human rights and social justice because AIDS is very much about social exclusion.
In short, the response to AIDS simply requires honouring commitments already made and being serious about national and global accountability for making them come true. Investing in AIDS and saving human lives from a premature death is investing in development. In hard hit countries, most of them in sub-Saharan Africa and the Caribbean, AIDS has already cut back decades of life expectancy, distorted the demographic balance and brought the dependency ratio for single household breadwinners to unsustainable levels. Previously stable communities simply break apart and development moves backwards instead of forwards. AIDS is also an issue of human security and social stability.
AIDS is now a major global killer. Last year it took three million lives and, cumulatively, has made 14 million children orphans. In some sub-Saharan countries, 15% to 20% of the child population already is, or will soon be orphaned due to AIDS. By 2010 the number of orphans is estimated to reach 20 million to 25 million. What protection and support can they expect? What kind of future will they hope for and what kind of future leaders will they make? UNAIDS review of progress in the implementation of the 2001 declaration of commitment shows that while policies are put in place, very little systematic support is getting to affected children or the families and communities that take care of them.
Since the beginning of AIDS, 60 million people have been infected, of whom more than 20 million have died. Today, about 40 million people are living with HIV or AIDS. Notwithstanding the 25 year history of AIDS, it has still not matured. Its toll in terms of preventable mortality will be felt for generations to come. It continues to trap sexually active, energetic, ambitious and productive young people, an increasing number of whom are women and girls. Today, women make up almost half of all people living with HIV. The face of this epidemic has now turned female, a face often belonging to a faithful married young woman with no sexual experience before marriage.
The feminisation of AIDS tells us about glaring gender inequality in the private and public affairs of life exposing women to disproportionate risks of infection. As long as women are unable to enjoy rights equal to those of men in terms of access to education, property ownership, economic security and freedom from violence, progress on the AIDS front will pass them and others by.
AIDS cannot be conquered successfully without addressing its legal, social, cultural and economic features, whether as determinants or consequences of infection. Earlier this year UNAIDS launched the Global Coalition on Women and Aids to stimulate actions in critical areas such as prevention, equitable access to treatment, property and inheritance rights, the role of women in home-based care, keeping girls in school and ending violence against women. On all fronts, this makes AIDS a political issue and places it squarely on the agenda of parliaments.
In about a month's time, UNAIDS and WHO will release new country estimates on the epidemic. Yet again, without revealing the details, evidence shows that while prevalence as a percentage of national populations might remain stable, new infections continue to occur with the result that the number of people living with HIV in many places continues to grow. Even in countries that have successfully proven it is possible to reverse the epidemic, such as Uganda, the number of orphans will grow as death rates among infected parents mount.
AIDS and its impact take different shapes in different parts of the world. In Botswana, a country with a HIV prevalence as high as 40% of the adult population, the number living with HIV is far less than in populous countries such as China or India, which have prevalence rates well below 1%. The main transmission modes are also different. In Botswana, as in most of Africa, it is transmitted mainly through heterosexual relations. In Asia, at least at the outset, it was transmitted through high-risk behaviour among identifiable populations, such as injecting drug users, sex workers, their clients and mobile populations.
Failing to understand the contexts which drive HIV transmission will misguide the response. The spread of HIV is extremely dynamic. Should it take hold of 1% of China's population, this would immediately translate into 13 million people being infected. Such a frightening scenario could be averted with determined and comprehensive prevention and treatment programmes. There has been a wake-up call in China and, clearly, the time to act is now so as to avoid great human, societal, developmental and political pain later.
In India, another huge country, the national prevalence may not appear alarming compared to that in Africa, for instance. However, a closer look reveals that the rapid spread of HIV has increased the prevalence in some of the country's states, which have a higher population than most countries in Europe, to levels that could foreshadow major societal impact in the future.
In other countries, in both Africa and Asia, with national prevalence levels of approximately 1%, data indicate that up to 20% of certain populations are infected. This means there is a potentially high risk of HIV spreading into the general population unless rights based prevention is placed high on the political agenda.
Where do we stand on treatment? With access to treatment finally entering the centre stage of response, the opportunity for successful prevention has not been greater than at present. In the developing world, there has recently been welcome progress in making treatment more broadly available. However, only a mere 440,000 people are on treatment, representing less than 10% of the 5 million to 6 million in immediate need of medicine.
In the worst affected regions in sub-Saharan Africa, less than 2% have access to treatment. This treatment gap must now be rectified. With UN involvement, prices of brand-name pharmaceutical AIDS products have been reduced from $12,000 per year to just under $600 per year, which is still far above the average national income in most developing countries.
Donation programmes of vital AIDS medicines and diagnostic equipment have increased and generic products have penetrated the market, with competitive prices at around $300. Treatment regimens have become easier to manage for both patients and health staff, inter alia, through fixed-dose combination medicines produced primarily by the generic industry.
Notwithstanding the progress that has been made, the WHO and UNAIDS initiative to have three million people on treatment by the end of 2005, the "3 by 5" initiative, requires extraordinary efforts although it is achievable. Health personnel need to be trained and coached, not poached from where they are badly needed to serve employers in richer countries. Health systems and infrastructure need to be improved and institutional capacity strengthened, not drained because of AIDS.
Public private partnerships need to be developed, involving civil society, people living with HIV, communities and the private sector in treatment programmes. At the same time, "3 by 5" has clearly energised efforts and prompted investments in treatment access. Increasingly, it is now recognised that saving lives and investing in the health of societies result in a good rate of return for everybody and for society as a whole because AIDS does to society what HIV does to the human body; it undermines the immunity and resilience of the system.
I wanted to say something about the level of resources required and outline the current position. I could do so if there are any questions in this regard. The levels of official development assistance have been referred to. There is no way in which we can address HIV and AIDS, which require about $15 billion per year in comprehensive prevention and treatment programmes, without increasing official development assistance to a level at least closer to 0.7% of gross national income than that which exists at present.
In conclusion, I thank the Presidency for facilitating the Dublin declaration on the partnership to fight AIDS in Europe and central Asia because it must be stated that AIDS is not only an issue for far away countries. In the neighbourhood of Europe and in parts of Europe, the virus is spreading more rapidly than anywhere else.
Chairman
Thank you. Our first respondent is Fr. Owen Lambert of the AIDS partnership with Africa.
Fr. Owen Lambert
I am very grateful for this opportunity afforded to me to share my personal experience, on which I wish to focus. The topic of AIDS as a global pandemic is uniquely deserving of our absolute attention and maximum response. The topic is not academic — it is an issue of life and death. In most cases in which I am exposed to working with it, AIDS is a death sentence. The premature deaths of thousands of people is happening as I speak. Over the three days of this conference, approximately 30,000 people will have died of AIDS, most of them in sub-Saharan Africa. This is a massive problem.
I worked in Ethiopia between 1974 and 2000 and, in the past four years, I have pulled out of all other work to give total attention to the AIDS pandemic. During my period in Africa in the mid-1980s, I witnessed revolution, civil war and famine on a scale which had not been witnessed in modern times. One is reminded of the Great Plague or the Famine in the 1840s in Ireland. The revolution and the war were terrible times for the people of Ethiopia, as was the famine and its consequences which impacted massively on the rural poor in particular.
By way of comparison, in May 1984, I had been in Ethiopia six months prior to Michael Buerk's famous film which exposed the tragedy on our TV sets and I was in Ireland trying to tell the story of what was happening in Ethiopia at that time. I had come from the Soddo area of south west Ethiopia in which 10,000 people had died per month in the previous three months. I could not get a politician in the Irish Parliament, any NGO or the press to take note. We received ten lines in the News of the World from that tragedy. The silence was frightening, inhuman and absolutely disgraceful. However, the public in Ireland and across Europe wanted to know. They did not want to remain silent. Even the singers did not remain silent. The groundswell was enormous, forcing public representatives to respond and act on their behalf for the rights of the people of Ethiopia to the basic needs to survive.
The HIV-AIDS pandemic in many countries in Africa is far more devastating than what I experienced during the time of the revolution and the famine. It is far in excess of the slave era in Africa. With famine, we could respond and see the results rapidly but this is a silent disaster. What we are now witnessing and speaking of is an unfolding Holocaust and I have no hesitation in referring it to as such. HIV-AIDS has turned Africa into killing fields in just 20 years. Between 6,000 and 10,000 people are now dying daily and, as Marika has pointed out, we have not yet seen the peak. UNAIDS upgraded its prediction at the beginning of this year to state that 480 million people will die of AIDS in the next decade or two, most of them in sub-Saharan Africa. The figure of 480 million people is more than the entire population of the expanded EU and almost twice the population of the United States.
The consequences of AIDS are horrific for the people of Africa and for humanity and those who bear the brunt most are women and children. In the late 1980s and early 1990s, we hardly saw a single AIDS case in Ethiopia. In the area bordering Kenya and Sudan in south west Ethiopia where I worked, we had just a few cases in the hospital. However, within 20 years, 3 million people are now officially infected and the real figure is likely to be much higher than that. I was back in Saula, where I worked for several years in a mission in a remote part of south west Ethiopia, and when I was told of people who died, it was like the long list of the dead which was read after mass on a Sunday in November in times past.
There is no family in the Arba Minch area in which I lived and worked that did not have one, two, three or four per family who had died from AIDS. In Bahirdar, where we have a huge programme spanning six zones and 10 million people in north west Ethiopia, 32% of the ante-natal mothers are HIV positive. Some 82% of young women working in hotels and bars are HIV positive. In Bahirdar hospital, at least six out of every ten patients are not just HIV positive but are dying of AIDS. Some five laboratory technicians died in 2000 in that regional hospital. In February of this year I visited Pawe, which is a very big resettlement area towards the Sudanese border which is supported by the Italian Government. It collapsed recently and medical staff there told me that nine out of ten out-patients attending the hospital are HIV positive. In the Yekit revolutionary hospital in Addis Ababa, it was reported in the Ethiopian press that 12 doctors died in the hospital in the space of one year.
Many delegates who have been in Ethiopia will know the massive 500 bed Blacklion hospital. I was there with a medical team visiting from Italy and the doctor, a professor from the university, was in great distress. He stated that we should have brought guns to shoot the patients coming to the hospital because they have absolutely no medicine to treat them other than what they can smuggle in using hostesses on Ethiopian Airlines and Lufthansa. This hospital is within a half mile and in the shadow of the European Commission building.
In 1999, 527 teachers died in the Amhara region of north west Ethiopia, all of whom had degrees. In Dessie town, a place which was seen on the television during the famine, five people in the orthodox parish were being buried per day. These statistics are hard to take on board. That was my difficulty in trying to present something on the massiveness of the situation. In Bagamoyo Hospital, eight out of ten patients are HIV positive. Dr. Ali, the director of the hospital, stated it was no longer functioning as a hospital but was a hospice for the dying. Kinondoni Hospital has 1,200 outpatients per day. It has fantastic staff who are 100% dedicated. There is little or no medicine, even for opportunistic infections or for home based care. It has no blood bank, no testing kits and little or no protective material and it is situated in the shadow of the UN offices in Darasalam. On education, 400 teachers died in the central region of Tanzania in 2002.
This statistic is one which frightens me because I read it in the newspapers in Kenya while passing through last year for meetings in Nairobi. Some 25% of all students of 15 years and older across Kenya are officially indicated as HIV positive. In the major centres like Eldoret, Mombassa and Nairobi, the percentage concerned could rise to as high as 40%. These people are the future of the country. Talking with students, I even heard whispers that we could be facing mass suicide. The will to live is hard to keep going in that kind of situation.
In Swaziland, there is a 35% drop-out of children attending schools. In Botswana, which we heard yesterday had a good GNP growth rate, 38.5% of the adult population are HIV positive. As Ms Fahlen stated, the numbers of child headed households are rising massively. According to my research, less than 50,000 people in Africa are receiving anti-retroviral treatment.
I wish to bring a number of overhead slides to the conference's attention to indicate something absolutely terrible and incredible is happening. One does not see these kinds of figures — for example, in Botswana the present life expectancy of 74 years dropping to 26.7 years by 2010 — unless something terrible is happening within the country on a par with the extinction of the dinosaurs. These are tragic figures. This happened in Ireland. The population fell from 9 million to 3 million or 2.5 million by the end of the 19th century when something terrible had happened in the country. Those figures indicate that something of enormous consequences is taking place. In Malawi, average life expectancy is dropping from 59.4 years to 36.9 years. In Swaziland, it is dropping from 74.6 years to 33 years. Those figures are indicative of what is happening in many parts of the African continent.
The growth in the number of orphans, mentioned by Ms Fahlen, indicates the massiveness of the problem. Perhaps 14 million or 15 million children on the continent of Africa are parentless. The total number of children outside of Africa orphaned due to AIDS is 954,000. That, to me, indicates that something of enormous proportions is taking place on the continent.
This final slide indicates a grim future. The last part outlines a study conducted in 1999 by the renowned Medical Institute of Africa and its prediction that 60% of the present adult population of Ethiopia would be dead by 2015 due to AIDS.
What I am witnessing at first hand is of astronomical proportions. Life expectancy, orphans and the massive levels of debt are indicative of a disaster on an unprecedented scale taking place right in front our eyes. Is this not selective extermination of human beings on a massive scale and in the economically poorer regions of the world?
The delegates, who are public representatives, must tell the truth to the people of Europe. If nations, parliaments and financial institutions cannot respond, I am quite sure the people of Ireland and every other country in Europe will respond and will ask politicians to allocate the resources required so that this kind of devastation would not take place in their names. Bishop Desmond Tutu recently said, "speak up and speak out". I ask the delegates, as one of the greatest things they could do as leaders in Europe, to speak up and speak out, and to do that now. "Don't try to brush this under the carpet because there is no carpet big enough", according to Mr. Don McCullin in Independent Catholic News magazine, on this report of 12 May 2001. The free world fought its way right to the gates of the concentration camps in World War II. The same must be done in respect of AIDS. As Nelson Mandela has said repeatedly, we must declare war on AIDS.
Up to the end of 1999, if my research is correct, less than £300 million was going into sub-Saharan Africa to combat AIDS. A recent appeal for $10 billion by the Secretary General of the United Nations resulted only in 16.5% of the required funds being pledged.
"What happens to the aid in Africa?" is often a criticism and we heard this from several contributors. There is only a pittance, the coppers from our pockets, going into Africa. When Ireland joined the EU, it received tens of billions in grants to get us on our feet. I have been hearing in recent reports that this year Ireland plans to spend €6 billion on road infrastructure alone. Such a sum is not being spent in this tragedy facing Africa. If my figures are correct, the World Bank allocated €500 million to sub-Saharan Africa in 2003 to combat AIDS. This amount would hardly suffice to run one of the major hospitals in the city of Dublin or in any of the capitals of Europe.
We have the resources, we have the capacity and we have the medicines. Every aid organisation, every humanitarian worker and government institution on the ground in Africa is starved of resources in respect of AIDS. I spent two weeks in Zanzibar last year filling out forms and completing all the documentation and it resulted in €7,000 of aid coming in with the strictest conditions.
I will finish by asking the question asked by Bono. Can we afford as human beings and humanitarians to let so many people die and not honestly call it by its proper name: genocide, mass murder, extermination? In a famous speech to the League of Nations in 1935, after the invasion of Ethiopia, Heile Selassie finished by saying, "It is us today, it may be you tomorrow."
Chairman
Our next speaker is Her Excellency Melanie Verwoerd, Ambassador of the Republic of South Africa.
Ms Melanie Verwoerd
It is an honour to be here today, even though it is difficult to speak on this topic, especially as an ex-parliamentarian. I am not sure how to follow Fr. Lambert, particularly because I am not a scientist or expert, I am an ex-politician and now a diplomat.
I am, however, very passionate about the HIV-AIDS crisis and find myself working more and more in this area, particularly with AIDS orphans. I have just returned from South Africa, where we opened an AIDS hospice and foster homes built partly with funding from the Irish Government. The idea is to keep children in the community and out of institutional care.
I will try to outline the three challenges we face in dealing with the HIV-AIDS pandemic. I come from a continent where the question now is how to find enough land to bury people. I come from a region where a quarter of the doctors are dying from HIV-AIDS and life expectancy has dropped to between 30 and 40 years. I come from an area of sub-Saharan Africa where the infection rate reaches 35% and where a child born between 2003 and 2010 can expect to die before reaching 40, a shocking statistic. In South Africa the infection rate is between 19% and 24% and we are weekly faced with the deaths of colleagues and friends. The wailing cry, "abantu abaafa", "the people are dying", is something we live with on a weekly basis.
The problem has been highlighted today that when we talk about development, we must face the fact that unless we deal with the HIV-AIDS crisis, we run the risk of erasing all the development work that has been done until now. Development is about hope for the future and changing economic and social trajectories for the better. The problem is that HIV-AIDS does not only change individual lives, it changes the trajectory of entire societies, countries and regions. We are seeing the disappearance of an entire group of economically productive people, with a generation of parents and the knowledge they have disappearing. I recently read about a young girl in Uganda who was dying with HIV-AIDS and she said she did not mind dying but to die without a child was the most painful thing because she will go to her grave knowing that no one will remember her name.
If one measures development goals in terms of life expectancy, we must face the reality that we are seeing a reverse in most of the progress made of the last decade. The statistics reflect this, with life expectancy in Zimbabwe of 39 years, instead of the 70 years it would be without HIV-AIDS, and in Botswana of 38 years where it should be 70 and with children born in the next four years expected to die before they are 40 years old.
If we take development seriously, it is pointless to talk about anything unless we put AIDS and the HIV crisis right at the centre. HIV-AIDS has been described as the first real pandemic of a newly globalised world. It is ironic and frustrating for those of us working in the area that even though we live in a society that is so much more closely knit and information is so freely available, there is such a slow reaction.
We must understand why this is happening. Some of the research indicates that people feel the effects of the HIV-AIDS epidemic is not as immediate as starvation, which can be seen and requires an immediate reaction. It takes a couple of years for the real severity of the epidemic to show and perhaps that is a reason there has not been an appropriate response until now. It could be fatigue, something we should all beware of when working in this field. A problem with the statistics we highlight is that people have a sense of hopelessness, especially when the statistics are so numbing. Of course, those most affected are far from Europe and we know that Europe carries only 5% of the HIV-AIDS burden.
Ignorance is another reason. I recently sat at a cricket field here in Ireland where my children were playing and listened to two of the fathers of my children's friends talking about their children becoming sexually active. I mentioned that I am concerned that HIV-AIDS education in Ireland or in Europe is not high up on the agenda. When my children came to Ireland at ten years of age, they came home from school and said that no one in the class knew how people contracted AIDS so, to the shock and horror of the Catholic teacher, they told them. On this occasion these fathers responded by saying to me with disgust that their children do not use drugs and are not gay. I found it significant that even in highly educated, middle class Europe that is the perception about how AIDS is contracted.
This pandemic raises the question of how we value other human beings and human lives. This is my first challenge to the conference — we need a global response. This is not something Africa or the developing world can do on its own. There is an ethical and moral responsibility when looking at the statistics and listening to the stories to respond. I have been challenged on this, people ask why and tell me they are tired. Even if people do not want to accept the moral and ethical responsibility, it is in the interests of Europe and the developed world to respond. Inevitably as the flow of people continues, despite fortress Europe, this will become an issue that Europe must face and deal with along with Africa and the developing world, as has been seen here. We received a call at the Embassy in Dublin from a medical institution where an asylum seeker from South Africa had given birth to a baby shortly after arriving in Ireland. She did not have very good medical care prior to arriving in Ireland and she gave birth very shortly after arriving here. Something went wrong during the birth, linked to her HIV-AIDS status, and by the time the embassy was informed she was on life support. The baby was fine but was HIV positive as well, and the mother died shortly afterwards. Nobody had come to ask for her and nobody knew where she was. Her parents thought she was just working here, and after a huge effort from our side we tracked down the parents.
When one finally stands at the funeral of a person with no family members there and just a lonely South African flag on the coffin, knowing that her little baby, who received excellent care from the Irish State, is now an orphan in the Irish State, one is really shaken into remembering what is wrong in the whole distribution of health care in our world. The first challenge is the global response. The second is choosing the appropriate response. This is very important. Of course, the main thing, as already mentioned, is the need for a preventative programme because ultimately, as much as we talk about vaccines and antiretroviral therapy, the best way is of course to prevent the disease. We therefore need people to be trained in Africa.
It has already been mentioned that capacity is a huge issue, and AIDS is making it worse. I again emphasise that the last thing these developing countries need is the poaching of their medical staff and teachers by many of the countries in Europe. We need training, capacity and people. We need appropriate messaging in the preventative programme. It has increasingly become an issue in Africa that the conventional ABC message — abstain, be faithful and condomise — does not seem to be appropriate.
First, the question around abstention seems to be a very hard issue, especially as fertility and lineage are very important in African custom. Secondly, the issue of being faithful seems to be adding to the stigmatisation rather than helping. Once people actually have to admit that they have HIV-AIDS, they have to either admit that they have not been faithful or that their partners have not been faithful. That in itself is causing huge issues in the whole stigmatisation approach to this. The whole issue of condomising seems to be the last priority, but it seems that more and more people working in the field in Africa are saying that this should be put up front, whether the churches like it or not.
The other issue is of course that of a vaccine, although there is huge concern that if that issue is pushed publicly too much it will actually make people less careful in terms of safe sex. Then, of course, there are mother to child transmission drugs. In terms of treatment and antiretroviral drugs, the sad thing now is that cost defines who lives and who dies. The HIV-AIDS epidemic defines those who can purchase their well-being and those who cannot. The drugs have become cheaper, and South Africa has of course been pushing very much in terms of parallel importing and generic drugs. It was the key advocate in a court case around that, but the cost, as has been mentioned, is still prohibitive to most countries, and certainly to most individuals.
We need to understand that care and preventative treatment must be appropriate also. One of the examples in South Africa has been that most of our infections among mothers are in rural areas, where there is still a lack of safe water and sanitation, even though we have made huge progress. It has changed now, but the conventional theory was that if one gave mother to child transmission drugs, the mother should not breast feed afterwards. The problem is of course that, in Africa as a whole and South Africa specifically, diarrhoea remains one of the main killers of children. One gives the antiretroviral drugs but then tells the mothers not to breast feed, so they go back into the rural areas, where the risk is tremendously higher that they will die of diarrhoea within a few months. That is the complexity when people talk very glibly about just giving people antiretroviral drugs without understanding that the whole infrastructure must be in place to actually assist with that.
The last point I wish to make in terms of antiretroviral drugs is that, of course, research and development must also go into those areas which might not necessarily be profitable. One of the huge problems we are facing in South Africa with children and antiretroviral drugs is that they are only available at the moment in a form which is apparently vile tasting. It is a huge effort to give children these antiretroviral drugs — I have watched people do that — because the taste is so awful. There has been huge pressure on the pharmaceutical companies to try to develop a pill which they can give to the children orally. However, because most of the children infected are in Africa, where the profits would not come, absolutely no progress has been made in those terms. Those are the issues in terms of antiretroviral drugs.
The last challenge I want to put, a challenge to all of us talking about AIDS, is to remember the human face of the tragedy. Father Lambert has been very good at highlighting that. Nelson Mandela recently gave his prison number to be used in the fight against HIV-AIDS. There was a concert in Cape Town in November 2003 called the 46664. When he was sentenced to life imprisonment, Nelson Mandela was prisoner No. 466 of 1964. Of course, the apartheid Government tried at all costs to reduce him and his fellow prisoners only to a number. For years we were not allowed to mention his name in South Africa. He became only prisoner No. 46664.
Of course they did not succeed, and when Nelson Mandela stood up in November and went on to the unlikely place of a rock concert stage, this was the point he tried to make. He emphasised that it is so easy for us, when we look at this epidemic or pandemic, to talk about people with HIV-AIDS only in terms of numbers. The danger of the statistics is that we get embroiled in talking about numbers — is it 11 million orphans, 13 million orphans or whatever figure — and actually forget the human face of this huge tragedy.
We talk about between 11 million and 13 million orphans. That is four times the population of Ireland. Where are they? Is anybody asking that? We know that they are being absorbed at the moment in their extended families, but if we had 13 million orphans somewhere in Europe, I think we would all suddenly have stood back and said "wow, this is a huge crisis."
I would like to tell the committee one story to illustrate the human face of HIV-AIDS. The orphanage I have worked with is that of the Irish Sisters of Nazareth. They care only for HIV-AIDS positive orphans. Ironically, it is a lovely, positive place, but as one exits the door there is a copper plaque listing all the names and dates of children who have died under their care. What struck me as interesting is that groups of children die within a short space of time, followed by a big gap, and then suddenly, again, one finds five or six of them dying within a week or two.
I asked the nuns why this is because it struck me as strange. The Sister said that they have no scientific proof of why this is, but that children know when they are dying. What they also understand after years of working with these children is that they seem to make pacts with one another in their little friendship groups. They have an agreement that if one goes they will all go. That is in fact what happens every single time. As soon as one in the little friendship group goes they seem to all give up and die within a short period. We can talk about statistics but that is the human face. This is about children agreeing to give up and die.
The important thing to remember is that we can overcome the HIV-AIDS crisis. We have overcome other pandemics and other things which we thought impossible. That is the message which those of us who work in the area want to get across today. It is a human tragedy but it can be overcome through an appropriate global response. I end with one line from a little boy who very much became the public face of AIDS in South Africa, Nkosi Johnson. The committee might remember that he very bravely stood up at the World AIDS Conference just before he was 12, one of the oldest children we had at that stage with HIV-AIDS. He said at the conference:
Care for us and accept us. We are all human beings. We are normal. We have hands, we have feet, we can walk, we can talk. We have needs just like everyone else. Do not be afraid of us because we are all the same.
Chairman
Thank you, ambassador. Our next speaker will speak at the next session so he will address the subject briefly now although he could talk for a long time on it. Mr. Norbert Mao is a Member of Parliament in Uganda. He is also a board member of the parliamentary network on the World Bank and a world fellow at Yale University in the United States. He will return to Uganda this autumn.
Mr. Norbert Mao
The previous speakers Father Lambert, the Ambassador and Ms Marika Fahlen, our friend from UNAIDS, seem to read from the Book of Lamentations. I will read from the Book of Genesis: when God caught Adam and Eve violating his commandment he decided the time had come to distribute some punishment across the board. The harshest punishment was given to the snake whose right to cry out was withdrawn. In our culture anyone who sees a snake assumes it is fleeing a death sentence and has the right to execute that sentence. The snake does not have the power to cry out even when one beats it.
As human beings we have that right and capacity to cry out. That is why this gathering is particularly important because political will could be renamed political capital. We are trying to mobilise the political capital of the individuals here who have power in their various parliaments to raise this alarm. They have the information about Nkosi Johnson,Uganda etc., but ultimately they must commit themselves as individuals and write to the chairmen of the largest pharmaceutical companies in their countries asking them to commit at an individual level. Those are things they can do, whether or not their committees are with them. If at its next board meeting the International Federation of Pharmaceutical Manufacturersreceived a one page letter signed by these chairmen it might regard it as a nuisance but it would put the matter on the agenda. The federation knows these people can affect their contracts and who wins tenders, and that they meet the board members of the World Bank which spends over $1 billion on pharmaceutical products. In this roundabout the chairmen can act and all the stories we tell are designed to commit them to doing so.
The Ugandan case is world renowned. Our Government decided we were too poor to treat people who fell sick and that it was the best thing to prevent them from being infected. There was a political commitment at the highest level to speak openly about HIV and AIDS. As a university student in 1991 I saw Government officials visiting an emaciated popular musician, a Ugandan who was based in Sweden but came home to die in Uganda. The officials visited him and touched him, saying one cannot catch AIDS by embracing someone. Our president spoke about AIDS in every speech. He might attend an Independence Day dinner gala but would "spoil" the speech by saying he knew people would have fun and get drunk but they should remember they could also get AIDS in the excitement. It became his characteristic approach. People knew when he was making a speech that the phrase "and now before I sit down" signalled a reference to AIDS. At first many of us young people regarded him as a nuisance and as impolite and discourteous but eventually that is what saved people's lives.
He then mounted a campaign to tell young people to get married as quickly as possible. He warned them not to think they could test drive for marriage by dating many people to find the best one. They should make up their minds, commit themselves and get married. He gave the example of a person who goes drinking in various pubs and gets drunk before finding the best wine and is too besotted to make a proper judgment. That person will collapse on the street whereas somebody who has sought expert advice on the best drink will make a beeline and get the best drink. I recall those early lessons learnt. Donor funds are not necessary for a prime minister to speak about AIDS or to activate our national self interest. Once we saw the effectiveness of this at presidential level we decided at parliamentary level to go to our constituencies and talk about AIDS. I also attend large youth parties and at the end of my speeches warn people about AIDS. They probably think I am a nuisance but that was the beginning of the Ugandan miracle.
There was a public campaign about traditions which can promote AIDS, for example, female genital mutilation. The Government published a policy saying it would not tolerate this criminal practice which violates human rights and it passed a strict law against defilement. In some of our cultures people want to marry off their daughters at the ages of 12 and 13 so we passed a law making it illegal for any sexual relations to take place with a person under 18 years of age, with a death sentence as a punishment. That scared off many who were fond of defilement. No one has yet been hanged but the fear of the punishment has saved the lives of many young people who would otherwise be victims of defilement. The number of teenage marriages is also dropping. The policy of universal primary education, which many of the governments represented here have supported in Uganda, has also helped. Parents used child marriages as a means to acquiring more money by marrying their daughters to wealthy men but now with the option of education many young girls postpone marriage and plan to do more than simply be wives. That has worked and Uganda's universal primary education is a significant policy tool in the fight against AIDS.
The campaign against domestic violence has also helped. The Government set up a family protection unit in every police department and any young girl, abused mother or wife can report a case at the special desk called the family protection force. The force is not very diplomatic and it assumes that the suspect is guilty but at least it empowers women. If a woman threatens to report a man to the family protection unit he knows that he will be kicked around first and asked questions later. It is a draconian response but it has helped to show women that the law protects them also. We continue with the ABC, in that order. AIDS is still on the offensive in Uganda. Scientists say that only when the incidence falls below 5% can one say that it is on the retreat. As long as it is 5% or more it is a losing battle. The situation in Uganda may look good, but seen from that perspective, it is clear that efforts must continue. In our case, the testing stigma must be removed. Many people get tested so that they know their status. Testing in Uganda is simple, with results given within half an hour.
There is an issue regarding the utilisation of civil society organisations. We have an organisation started by a lady who is now in Geneva. Her husband died of AIDS but she was not infected and she survived. She then set up the AIDS support organisation called TASSO. Its work could be copied all over Africa. It is not a Government organisation. Those running it are highly accountable. They visit families and monitor cases of infection. They can detect the viral load. They call themselves not AIDS victims but AIDS victors. They have given a boost to people who thought they were helpless victims of this epidemic. Suddenly, people are fighting back. This is helpful.
We emphasise sexual abstinence, though not for ever. We emphasise it for people who are not in a recognised relationship. Whether people look at it from a traditional or religious perspective, it is a way of staying away from trouble. If you are not on the highway, no car will run over you. When we were young we were told that if we sat on the roadside our mothers would die. We were told this so that we ourselves would not be run over by cars. No-one wanted to be motherless, so we decided not to cross the road alone.
Urging faithfulness is simply a way of emphasising a traditional value. We need to retain space for that kind of message, even if many people think it impracticable because of all the video shows featuring young men going about with tarty women. When a man chooses one we say he is devaluing the family. There is still a place for people to talk about faithfulness. Regarding the use of condoms, the churches understand the situation. In the Ugandan Parliament we have a way of explaining it by saying that there is a difference between decisions made by an army in the war room and the decisions made on the battlefield. We leave people with the option to make battlefield decisions. One can make a plan in the war room and promise to be faithful, to abstain — but one never knows: after a Guinness or two, a condom in one's wallet may save one's life. Those are field decisions and the right to decide must not be taken away from people. The churches seem to understand that.
I emphasise the relationship between AIDS and armed conflict. In Uganda there is an armed conflict in the north of the country, a part one does not usually hear about. One hears more about the economic boom and so on. The conflict is the underbelly which spoils a good story. All our development partners in the World Bank have been under great pressure with demonstrations in various places. They need a good story, and Uganda is one such story, so people seldom talk of the aspect which spoils the story. We need to face up squarely to that which undermines our capacity to fight AIDS, namely armed conflict.
There is a peculiar relationship between armed conflict and AIDS. I have made some notes about the infection rate. Among the Ugandan armed forces the infection rate is 66%. The rate in Zimbabwe, at 80%, is worse. In Malawi, the rate is 75%. Experts have been studying this. A colonel in the UK's Royal Army Medical Corps published a report and said that history is littered with examples or armies falling apart for health reasons. When an army is infected to such an extent, and the country's President is not particularly democratic, one becomes paranoid. The world AIDS epidemic has affected our armies in Africa. In northern Uganda, pregnant women were tested in a hospital run by Italian missionaries. The infection rate was found to be 30%. That is not the Ugandan percentage. In Uganda we do not want to hear of any AIDS percentage figure above 6%. There is an explanation.
I call on Uganda's partners to invest more in conflict resolution. That is one way of fighting back against HIV-AIDS. Experts have asked why the infection rates among soldiers seem to be so high. A few reasons have been given. Soldiers are among the most sexually active age groups. That goes without saying. They are also posted away from their home areas and uprooted from the social sanctions. There is nobody around the barracks to suggest to a solider that the woman he is with is not his wife, and ask what he is doing with her. The soldiers are so far away from home. Imagine being in Baghdad. Nobody will ask whose hand one is holding. Soldiers are also among the most lonely and stressed individuals and their sexual over-activity seems to be a way of responding to that stress and loneliness. Soldiers are almost among the most highly paid in a deprived community where there is a war. Because they have a great deal of money to spend, they get into all these relationships. Consigning people in a barracks also attracts people such as prostitutes and drug dealers. Studies have also found that military culture seems to glorify risk-taking. I have heard Ugandan soldiers say they detest using condoms. They ask if one would eat a sweet without removing the wrapper. That is the attitude. They say they have survived so many wars, and have so many scars, and still have not died, so they believe AIDS will not get them. That is the culture.
We need to invest much more in conflict resolution. We do not have the statistics from the Congo, but when they arrive they will shock everybody. We have had seven recognised armies and four quasi-armies like UNITA, the SPLA and various militias. If we are now saying this is an epidemic, we need focus. I call upon those present, dear friends, to join Africa's efforts in conflict resolution. I know that the UN Secretary General, Kofi Annan, has convened a three-year process under the UN auspices to take an original approach to conflict resolution, similar to the one used to calm down the Balkan regions. I call upon delegates to give that effort all support possible. Indirectly, when the conflict ceases, intervention can be made. While there is war, all the retroviral treatments will never reach people. If food convoys are being ambushed, then what of convoys taking anti-retroviral drugs or the various anti-AIDS drugs cocktails? Peace is a major prerequisite for any intervention effort. Economists have said that by 2012, AIDS will reduce Africa's GDP by as much as 20%. That should incite us to act even more urgently. It is not just about resources. It is about applying the resources correctly.
I will end by revealing that $200 billion was spent on fighting the millennium or Y2K bug. I do not know how much will be used for this. Many say there was never a millennium bug but somehow we were all so scared of it that €200 billion was spent worldwide. It was called "an imaginary epidemic". How much more should we spend on a real epidemic such as the HIV-AIDS epidemic?
Chairman
We have two contributors from the floor.
Mr. Jann Sjursen
Thank you very much for the very interesting presentation that we have just heard. Mr. Mao has sent a very strong message to us, as parliamentarians, and reminded us of our obligations and the fact that everyone counts. I will not comment further but the point has been taken and one can now expect us to take action.
I direct a question to Ms Fahlen. At the end of her presentation she touched on the fact that the pandemic was not simply something that affected Africa, even though we always talk about this. It has certainly also reached Europe and will increase in the coming years. I would like Ms Fahlen to elaborate a little on how that fact will affect the information coming from UNAIDS. We all talk about HIV and AIDS. Would it matter if we forgot Africa, or will it come so close to us that in the end we will act? It would be interesting if she could say a few words on this.
Mr. Hugh Bayley
I have one question for the future and one for now. The question for the future is directed to the two Africans. There are 13 million AIDS orphans in Africa who are largely cared for by their grandparents. In ten years they will have children of their own but by definition no grandparents. As most will be HIV positive, who will care for them? What preparations are being made to put together a social rescue package over the next ten years? One quarter of teachers will die. One needs massive training programmes for teachers, carers, nurses and so on.
My second question is for Ms Fahlen and UNAIDS. If UNAIDS and the WHO are successful and by next year three million people are receiving anti-retroviral drugs, one will still have to make difficult choices about who gets them. One will have to set clinical criteria such as at what stage in the infection one starts providing drugs, or social criteria such as keeping the second parent alive for as long as possible where one has died, or saving mothers and pregnant women. There may be economic criteria such as keeping teachers or nurses alive but one needs clear criteria. No African country has clear, transparent criteria developed in dialogue with the people.
Few countries have the capacity to conduct such an exercise to set health priorities. A lead must come from the WHO and UNAIDS — not instructions, since such decisions must be taken locally. However, there must be a tool kit to allow countries to decide where the priorities ought to be. If that does not happen, it will simply be a case of those in towns, the men, the rich and the powerful getting hold of the drugs. How does one stop the spending on treatment leaching resources away from prevention, which, as Norbert said, will save more lives per euro spent than anti-retroviral drugs?
Ms Marika Fahlen
On the situation in Europe and its neighbourhood, it is very important that the enlarged European Union take a lead to demonstrate solidarity among its members. Some of the new member countries have an alarming and rising rate of infection. It started at a low level but the rapid rise in the rate of infection is a matter for concern.
In Europe, one should not talk about aid but a way of interaction, institutional co-operation and support to enable countries which may not have access to the latest technology to invest more in research into appropriate medicines which would be easy to take and cheap to distribute. There must be institutional interaction between the member countries of the European Union. That is part of its way of working. One must simply add HIV-AIDS to it. It should also be more visible in the European Union as a priority concern. For instance, why not have one of the new Commissioners with clear responsibility for AIDS? It need not necessarily be the Commissioner responsible for health or development co-operation but there must be one charged with this responsibility, which is not the case. Currently, it is subsumed into the development co-operation portfolio.
The European Union is not putting any more emphasis on addressing this issue within its own constituency or its neighbourhood, for instance, in co-operation with the Russian Federation and beyond. That would demonstrate that it was a global concern, as the South African ambassador and I emphasised. The problem is not AIDS in isolation, since it is very closely linked with other ills in society such as the drugs trade and human trafficking for sexual abuse and exploitation — even of children — which are also associated with the spread of HIV. A rapid route for its spread is injecting drug use. There are three million users in Russia alone, many of whom would not consider themselves as such; it is a Saturday event. Sometimes only one contaminated needle is enough to infect a person with HIV.
Europe should lead by example, which would strengthen co-operation and support for Africa. As has been emphasised here, work on AIDS is very much part of a general strengthening of good governance, transparency in society and development. The Head of State of Botswana even referred to AIDS as an issue of national survival. In that country 40% of the adult population are infected. Botswana is not suffering from economic mismanagement or bad governance. It is not a destabilised society, yet it is suffering badly with HIV.
That leads me to the question from the United Kingdom about whether an emphasis on treatment would reduce an emphasis on prevention. As I said, access to treatment is a golden opportunity for prevention. If there are five million new infections, we must admit that we have failed with prevention. That does not mean, however, that no effort has been made but the message may have been inappropriate, as the South African ambassador said. Young people are aware of AIDS but it does not affect their daily behaviour. There are also examples from Europe and elsewhere of young people feeling that it need not concern them.
Treatment and prevention are closely linked. It is not possible to deal with treatment as an issue of medicalisation, by providing medicines or anti-retroviral drugs only. This leads to questions about equity in access to treatment. The truth is that 95% of those living with HIV do not know they are infected. We need to scale up access rates to testing. Some 100 million tests need to be on offer to reach out to three million people. An enormous effort is required to reach out to those living with HIV.
What is the barrier that induces people not to know their status? I believe it is stigma and discrimination. Why has Uganda been successful? Importantly, it is a society where AIDS has been spoken about openly, from the President downwards, including the churches. It has been an issue of daily social discourse with the result that stigma, in particular, as well as discrimination have been reduced. This has encouraged people to seek testing. Access to treatment will make this meaningful. Without treatment, there is not much point in knowing one is HIV positive and saying: "I need to prevent others from being infected but I will also be stigmatised and discriminated against." I hope there will be an increased demand from people to know what their status is in this regard.
The equity issue referred to is very important. We have addressed different criteria about equity in access but it is not only about their application in the clinical setting, it is also about communities appreciating that the criteria are relevant. There have been demonstrations to see if this is possible with community involvement in terms of accepting who will receive treatment. In some regions in South Africa it has been the community with health staff and family members who have reached consensus on who should receive treatment first. We need community involvement to help those in receipt of treatment to adhere to their regimes. If not, we may find resistance to medicine which would mean a disaster on top of another.
Ambassador Verwoerd
On the AIDS orphans issue, it has to be acknowledged — UNICEF bears this out — that the whole issue of the AIDS open house is being neglected because it has been largely invisible. It has not been highlighted in the media. The pictures have not been coming through.
In general, what is understood is that we cannot move to a situation involving institutionalised care. If we think about this logistically, to put 20 million children in big orphanages is clearly not an option. In general, it is understood that there should be a supporting network in communities in whatever form that is culturally appropriate to facilitate others in taking in orphans. In South Africa the state pays for foster parents to take in AIDS orphans. That is the way we see matters developing. Part of the money we receive from overseas is being used to build foster homes, where the state pays for a foster mother to look after various young children who have been orphaned. The benefits are that it is much cheaper and that children may be kept within the community. Siblings can normally be kept together.
Although it does not happen in South Africa, I am aware, anecdotally, of whole communities headed by children whom NGOs have been giving wind-up radios, basic health care information on how to cook and so on. That is sad but it must be acknowledged. We must seek to work within communities, not think in any other way. More than anything else, this has been a neglected area in the entire HIV crisis, something to which the international community and ourselves in Africa must apply our minds much more.
There have been large questions surrounding how we train teachers. Somebody said the other day that when a nurse was trained, within a few months she was standing next to a bed and actually involved in health care provision. Teachers are trained for four years and only engage with children at the end of that period. Is this appropriate? Clearly, we have to rethink how teachers are trained and sent into the field. We need more to be trained and also more volunteers from overseas.
As regards equity and equality, this is something with which we need to be careful. It is something with which we all have to deal. I know this is not what is being indicated but if we were toget to a position where Europe would tell us in Africa who should be getting anti-retroviral drugs and who should be dying, that would be an enormous disaster. In fact, there would be the most severe backlash. If the decision was taken in collaboration with the community, that would be different but, of course, we certainly cannot allow that situation.
The one danger in talking about HIV-AIDS is that we will forget that which will ultimately change the whole crisis in Africa — economic investment and the alleviation of poverty. The danger is that the story as we tell it today will turn out to be a disincentive for investment, trade etc. It should not do so because there are great opportunities for investment and trade in most African countries. Ultimately, that will make the big difference.
Chairman
I thank each one of the speakers for a very interesting session. One cannot get all of the information one needs in one session but at least people will have made contacts and come to know some of those directly involved. From this it is possible to get the information needed to spread the word about AIDS and its enormous importance in terms of development.
We are under great pressure on time. I ask you to go to the stairway outside for a "family" photograph. We can then directly go and have a quick cup of tea or coffee. We must return at 4.30 p.m. for another important session.
Sitting suspended at 4.20 p.m. and resumed at 4.40 p.m.