How To Lose the War on AIDS

© Gregg Gonsalves[1]

Gay Men’s Health Crisis

New York

USA

A talk

at

the 15^th

 International AIDS Conference

Bangkok, Thailand

in a session on

Improving Accountability and Effectiveness of International AIDS Assistance: What Do We Know and What Needs to Be Done?[2]

Session Room N

10:30AM-12:00PM

July 14, 2004

“I never knew a man who had better motives for all the trouble he caused”—Graham Greene, The Quiet American

“Charity, as we know, treats the human symptoms of a tragedy and politics is able to treat the causes”—Alex De Waal

Good morning, my name is Gregg Gonsalves.  I am the Director of Treatment and Prevention Advocacy at Gay Men’s Health Crisis and I am also a person living with HIV.

We are losing the war on AIDS.  We have had five million new infections this past year, an all time high.   Of the six million people who need antiretroviral therapy in the developing world, only 440,000 are currently receiving it.

This cannot be called progress. We need to be brutally honest with ourselves and face our failure, and radically change the way we do our work.  Some will point to the small gains we have made with some sense of victory, some may say things could be even worse, but the assumption underlying these perspectives is that we are on the right track and that we need to do more of what we’re doing with more resources, less red-tape, less ideology.  I want to make the case to you that we’re on the wrong track and that we bear some of the blame for the predicament we are now in.

Who are we and what responsibility do we bear in the failure of the war on AIDS?  We are the staff of both Northern and international NGOs, researchers, journalists, staff of bilateral donor agencies, private foundations, UN agencies, public health officials.  I include myself among this “we”-what Alex De Waal has called in other settings, the humanitarian international and what we can now call here today the AIDS international.

I will begin with the assumption that most of us are good people with good intentions, but good intentions are not enough as we all know.  I want to discuss several of the ways in which we do our work which can have pernicious and unintended effects and offer some solutions.

We have been supremely uncritical of our own efforts.  Other fields of humanitarian work have been much more self-critical than we have been.  Whether it is Alex De Waal on famine relief, Rony Brauman and others from MSF on disaster relief, particularly in conflict zones, or David Reiff or Michael Ignatieff more generally on the humanitarian endeavor, there has been a stronger culture of self-reflection outside of AIDS than inside.

Let’s start the conversation, let’s take a look in the mirror--as painful as it might be, it is nothing compared to the toll of new infections and deaths that confront us, if we don’t change the way we work.

We are:

• Largely unaccountable;

• Self-justifying, pursuing organizational survival and expansion;

• Proxies for policies of the major industrialized countries;

• Privileging generalized, international responsibility instead of specific, local political accountability;

• Privileging technical skill and experience over local knowledge;

• Promoting “development” or assistance instead of social change.

Those of us with resources, whether donors, advocates, journalists, NGO workers or academics usually set the agenda.  Who are we accountable to? Certainly not to countries or people with HIV/AIDS in the developing world.  We serve the interests of our own Northern governments, rich philanthropists, and too often ourselves.

We don’t have to answer to the people who matter most.

Let’s talk about some examples. A report from the US General Accounting office came out last night on the Bush Administration’s international AIDS efforts.  Almost all of the field staff interviewed for the report identified US policy constraints, particularly around the issue of generic drugs, as a challenge that could limit the ability of the agencies implementign PEPFAR to rapidly expand treatment programs.  These policy constraints have been raised by national governments, activists, scientists, WHO and others, but Ambassador Tobias will dismiss this notion, again saying to all of us that they just want to ensure that these generics are safe and effective.  Who is the US government accountable to?

Recently, on 60 Minutes, a US news television news program, they featured a story on AIDS in India, which prominently featured the Gates Foundation’s work there.  In the story, Bill Gates himself said that the focus of the foundation’s work will be on prevention though Dr. Suniti Solomon from India said in the same story said that her patients would never have come into the clinic for education and condoms in the first place if she were not offering them therapy.  Who is Bill Gates accountable to?

Some Northern activists at this conference are protesting a study of tenofovir to protect sex workers from HIV infection in Africa.  Have these activists talked to the local researchers?  To the local trial participants?  Who are these activists accountable to?

Last year in Kiev, I made an activist intervention with the Deputy Health Minister of the Ukraine during a conference there with out telling or asking permission from my Ukrainian colleagues.  The Minister was not happy with my comments and the Ukrainian activists had to clean up my mess.  Who am I accountable to?

In funding, in writing news stories, in advocacy, in conducting clinical trials, in providing direct services, we need to derive our agendas from countries and people with HIV/AIDS in the developing world, not the other way around.  It doesn’t matter if you’re George Bush, Bill Gates, or little-old me, we need to “manage our own imperialism” as my friend Zackie Achmat would say and ask what is needed rather than tell those who have less resources and power what they need and give them a venue to hold our feet to the fire when we don’t.

In the race for organizational survival or expansion, many Northern and international NGOs, academics and advocates institutionalize priorities that reinforce the relevance of their work to their own donors distorting the real needs on the ground in the developing world.

How many international NGOs and advocates from the North are now providing capacity building for our colleagues in the South on service delivery, treatment advocacy, intellectual property issues and other topics that we have particular and long-standing expertise in and using this work to secure millions of dollars in funding for their own organizations?  Have we asked what kind of capacity building is needed and if it is needed from us?

The National Institutes in the United States is recompeting all of its major clinical trials networks this year.  Over five years, these networks will spend billions of dollars on clinical research.  Many of these networks are expanding into the developing world, while the leadership of these networks remain in the United States.  The research agenda will be driven by US investigators who have specific expertise in clinical issues in the North. Will the vital clinical research questions for developing countries have a chance to be answered?

We know how to write grants, we know the funders, we ask for money for what we know how to do.  All too often, our priorities become the priorities of our colleagues in the developing world.  Donors need to be more circumspect as they fund Northern and international NGOs, academics and advocates to do work in the developing world to ensure their work has true relevance to local needs and directly fund local organizations as a priority.

Northern and international NGOs, particularly those that receive funding from the major Northern governments and multilateral agencies, end up promoting policies and programs favored by these governments and agencies.

This is readily apparent with the grantees of the Bush AIDS initiative-which promotes brand-name drugs over generics, abstinence-only prevention programming, and has put restrictions on activities with sex workers and drug users and the new conservative advocacy organizations that have sprung up to defend the Bush Administration’s policies like the AIDS Responsibility Project.

But there are less obvious examples among the NGO sector.  Why for instance did the major international NGOs, including those who are supposed to represent people with HIV or AIDS organizations, or those supporting community action on AIDS in developing countries, take a back seat during the early struggles to get treatment access on the agenda at UN agencies and among Northern governments and are still loathe to criticize these agencies or governments?  Perhaps, because as we say in the US, you don’t bite the hand that feeds you.  Many of these leading organizations are heavily supported by UN agencies or Northern governments-if treatment access wasn’t a priority for the US or for WHO, it wasn’t a priority for them.

Multilateral organizations like UNAIDS, WHO, the World Bank, International Monetary Fund and the Global Fund are also unduly influenced by their major Northern donors.  Why are there caps on health sector spending in countries such as Kenya where there are many unemployed, trained healthcare professionals that could be part of efforts to scale-up treatment in these places?

The political influence of funding from donors needs to be made explicit and examined and held open to greater public scrutiny.

Part of the way we perpetuate and enhance our own relevance is to keep many of the discussions about HIV/AIDS in the international context and talk about key issues divorced from their local contexts.

We so often hear that the “international community must do more about HIV.”  But the international community doesn’t exist as an institution, there are countries and countries have leaders. While international institutions such as the WHO, the WTO, the Global Fund have important role to play in the epidemic, we too often look to them for solutions and think that issues can be solved in Geneva.

Issues around health systems development, training of healthcare workers, trade, intellectual property and health--the list goes on and on--have specific local contexts and the solutions are going to have to be worked out on the ground.  Yet, so much of the resources to deal with these issues ends up sitting in Geneva or with international NGOs or consultants to deal with on an “international” basis.

We need to be able to fund local analyses, develop local solutions and most importantly bring the responsibility for implementing these solutions to local leaders.

AIDS is more and more being staged as a technical problem, and we have seen a proliferation of funding for technical assistance, toolkits, with Northern and international NGOs, academics and consultants more often then not providing this technical advice and these materials.  This does not foster the development of local processes for and the engagement of local experts in problem-solving, it perpetuates a environment where knowledge is seen to flow from North to South, while money flows ever Northwards.

Again, donors have to invest in local processes to solve issues even though it is often easier to fund an international or Northern NGO, academic or consultant, especially one we have worked with or known for years.

So much of our efforts in HIV/AIDS have gone towards financial assistance to programs and it is clear that countries don’t have the internal resources to scale-up programs without this money.  However, unless efforts are made to politicize AIDS on the country-level, where leaders pay a political price for NOT shouldering their responsibility to their own citizens and people living within their borders, we will never win the war on AIDS. 

AIDS is essentially a problem of governance, of leaders who offer no commitment or partial commitment to the fight and can get away with it.

 Donors need to support grassroots mobilization of communities in developing countries and coalitions of like-minded groups in the fight for the right to health in these settings, if we’re going to see a sufficient and sustainable response to the epidemic in the long-term.

I was talking to an old friend yesterday, a reporter who has been covering AIDS for as long as I can remember.  She and I were commiserating over the current depressing state of affairs.  She said to me, “I think we’ve lost our way.”  And I could only agree.

We have to find a way out and the first step is taking a hard look at ourselves.

I’ve borrowed heavily from others in this talk, particularly the work of Alex De Waal on famine relief, but his work is simply one way of thinking about the way we do our own.

I don’t expect what I’ve said today to make me popular, but I hope it can finally get us talking. And now, I’d like to hear what you have to say.