Notes for Press Briefing by Stephen Lewis,
UN Secretary-General’s Special Envoy for HIV/AIDS in Africa,
on his May 19-23, 2004 trip to Ethiopia.
United Nations, New York: 12:30 PM, Tuesday, June 1, 2004
Every trip to Africa, examining the status of HIV/AIDS, yields
some
surprises. My visit to Ethiopia two weeks ago was no exception.
To be sure,
it was a brief, if intense, trip --- just four days, surrounding
a
conference on children, and I therefore don’t want to pretend
to be
definitive. But I covered a lot of ground, and the impressions
are very
strong. I’d like to highlight three broad areas: treatment,
orphans, and a
fascinating new programme known as “community conversations”.
First, treatment. In Ethiopia, as everywhere on the continent,
the passion
for treatment is all-consuming. And in Ethiopia, as everywhere
on the
continent, the challenge of implementation is enormous. There
are between
two and three hundred thousand Ethiopian people who need treatment
now, and
perhaps five thousand in total are receiving it. The Government
has made
elaborate preparation, training professionals and fashioning guidelines,
but
what is missing is the money.
Ethiopia submitted a proposal to the Global Fund for more than
four hundred
million dollars over five years, in order to launch a truly significant
treatment programme. The proposal went to the Expert Review Panel
of the
Fund some two weeks ago, along with dozens of submissions from
other
countries, and no one yet knows whether or not it was approved,
even in
part. What we do know, sadly and strangely, is that only one-third
of the
country submissions, totalling $964 million of $2.8 billion requested,
were
approved, and it’s entirely possible that Ethiopia could
end up on the
resource cutting room floor.
That would be a tragedy of cosmic proportions. If the money were
approved,
it would mean that there would be a major Government programme
for
anti-retroviral treatment, through the public health system, in
conjunction
with “PEPFAR”, President Bush’s initiative,
which will be administered
through various outlets and overseen by the American Embassy.
If the Global
Fund money is not forthcoming, Ethiopia will face the anomaly
of having the
largest part of its treatment programme in the hands of a major
donor
Government. Logic tells me that that is not an auspicious outcome.
Don’t
misunderstand me: getting treatment to anyone is a desperate imperative,
but
a sovereign Ethiopian Government exists to govern, and any treatment
initiative should surely be part of that over-riding governance,
in this
case the specific governance of the Ministry of Health.
But logic tells me more than that. It’s entirely likely
that the PEPFAR
money for treatment will go to the purchase of brand name drugs,
at prices
very much higher --- possibly three to four times higher --- than
fixed dose
combination, generic anti-retroviral drugs, pre-approved for first
line use
by the World Health Organization. I note the resolution passed
just last
month by the World Health Assembly meeting in Geneva, which re-affirmed
the
importance of WHO pre-qualification, the importance of ‘3
by 5’, and the
importance of the WTO consensus on the legitimate export and import
of
generic medicines.
But I also note the US Government’s announcement, on the
eve of the WHA, of
a fast-track FDA process that will, ostensibly, allow for the
approval of
generic fixed-dose combinations. Perhaps Ethiopia should be the
first test
to se if the US approval process will get drugs to people without
delay, at
the cheapest prices possible. If so, as I said at the time, it’s
an entirely
welcome development. But if it slows procurement, or excludes
non-American
manufacturers from the market, or casts doubt on WHO pre-qualification,
then
we’re in trouble. If you can reach three to four times as
many people
through generics, and the people are quite literally dying for
treatment,
then surely we should use the WHO pre-qualified generic combinations.
And there are two other components of treatment which are compelling.
The
number of sites for the Prevention of Mother to Child Transmission
(PMTCT)
is abysmally low. As a result, only a miniscule fraction of HIV-positive
pregnant women receive the drug nevirapine. From what I could
gather, the
Government believes that women should be the priority entry point
for
treatment, and this is all to the good. But it will require an
urgent
roll-out of PMTCT facilities to reduce the number of HIV-positive
infants,
and then an equally urgent roll-out to ensure that women actually
get full
course antiretroviral treatment. It’s also terribly important,
in this
context, to initiate treatment for the HIV-positive children.
Further, more than any other country I’ve visited over the
last couple of
years, Ethiopia is riding a crest of testing. All over the country
testing
and counselling have somehow become ‘de rigeur’, and
in particular, there is
a widespread public conviction that partners should be tested
before
marriage, so that both parties will be fully informed before entering
into
marriage. Indeed, in parts of Ethiopia, the public clinics run
out of test
kits while people are lining up to be tested. It’s an acrid
irony that one
of the usual barriers to treatment --- getting people tested ---
is no
impediment at all, but the treatment still isn’t available.
It’s important to recall that Ethiopia has the second largest
population in
Africa, nearly 70 million, with two to three million infections.
The
prevalence rate is over 6%, rising to over 13% in parts of Addis
Ababa and
other urban settings. Ethiopia is in crisis.
Second, orphans. I regret to say that Ethiopia is only now beginning
to
understand the vast extent of the growing orphan crisis. The country
is
simply unprepared, at this time, to cope with the avalanche of
children
orphaned by AIDS; it’s estimated that there are already
a million orphans in
Ethiopia. The Prime Minister pointed out to me that there is still
some
capacity, in the rural areas, to absorb orphans into the community
through
the extended family system. But he acknowledged that in the urban
centres,
where the great majority of orphans are to be found, there was
as yet little
capacity to respond.
Frankly, unless the country devises an almost instantaneous strategic
plan
for orphans, backed by massive resources and focused intervention,
Ethiopia
will soon be reeling from the onslaught of abandoned, rootless,
bewildered
and despairing kids of all ages. It will feel like a raging torrent
of child
trauma to which everyone responded too late. Tens of thousands
of young
lives will be lost and ruined. I cannot put it strongly enough.
And there’s another aspect of this which is deeply troubling.
Everywhere my
colleagues and I visited, people talked of school fees as a bar
to school
enrolment. Yet, Ethiopia has ‘abolished’ school fees.
What is going on?
Well, consistent with other countries that have abolished fees
--- Uganda
and Malawi spring to mind --- there are always variations on the
classic fee
structure which prove damaging to school attendance. There are
‘registration’ charges, and ‘examination’
charges, and the costs of books
and uniforms, and limits on the number of children in any given
family who
are eligible for subsidy. Taken all in all, most countries, in
one way or
another, are in violation of article 28, sub-section 1(a) of the
Convention
on the Rights of the Child: “Make primary education compulsory
and available
free to all”.
It’s just not happening, even in Kenya, where the recent
abolition of fees
meant the sudden additional attendance of over a million children
but some are still not getting to school. Those who suffer the
greatest loss are
inevitably the children orphaned by AIDS.
I must admit that I am at my wits’ end on this issue. I
have asked,
publicly, countless times over, why it isn’t possible to
launch a
continent-wide campaign to abolish fees? Maybe it’s my own
naivete, but I
fail to see why we should all stand by while children are denied
their
childhood, and their prospects for the future. To tell the truth
--- and
this is undoubtedly a desperate gasp on my part --- I’m
thinking of using
the Envoy role to find a number of NGOs, many of them in Africa,
with whom
to collaborate on a campaign, relying on major African leadership.
It drives me crazy to see such vast numbers of kids out of school,
hungry
and impoverished, when a school would put orphaned children in
regular
contact with adults again, restore a sense of self-worth, provide
a place of
security, perhaps offer a meal at lunch, and ignite the wonders
of
friendship. We seem to have endless responses to the pandemic,
on treatment,
care, prevention and support, but almost no adequate response
to orphans,
despite a warehouse of repetitive reports, documents, statistics,
roundtables, conferences, seminars, assessments and enough monographs
to
fill Britannica.
Is it absurd to suggest that we might stop writing and start doing?
Third, and final, the stunning revelation of “community
conversations”.In
the Southern Region of Ethiopia, not far from the Regional Capital
of
Awassa, in the little community of Alaba, a remarkable experiment
in
community participation is taking place. It was designed by the
United
Nations Development Programme, in conjunction with “KMG”
(Kembatti Mentti
Gezzima), a powerful local NGO. The intention is to draw on the
natural
organic power of conversation, inherent in most indigenous communities,
surround it with inspired facitlitators, and get everyone in the
village ---
and I mean EVERYONE --- talking about subjects that have always
been taboo.
The theme is AIDS; the subjects are sexual.
I will admit that I’m not quite certain how UNDP managed
this: it is to
their everlasting credit. What is happening takes one’s
breath away.
I was privy to two such conversations, one involving about two
hundred
villagers who had been meeting once a fortnight for a couple of
months, the
other involving fifteen or twenty people (with dozens of onlookers)
who had
been engaged in these conversations for more than a year.
What are the subject matters, publicly discussed, without so much
as a touch
of embarrassment or shyness? How’s this for a catalogue:
female genital
mutilation, bride sharing, early marriage, polygamy, child abduction,
condoms, sexual violence, People Living with AIDS, and women’s
rights. And
behaviour actually changes! This community had lived with 100%
FGM for
centuries: it’s down to 10 to 15% within just one year as
a result of the
conversations.
We talked to the Islamic religious leader of the community, a
man in his
seventies, who told us everything had changed in the villages,
and how he
had led 130 men to be tested in order to set an example for others.
Then we
heard from two young girls, no more than fifteen years of age,
sitting three
places down the row, who said with enormous confidence and élan
that the
conversations had taught them a) the meaning of women’s
rights and gender
equality, b) that they must never allow a child of theirs to be
genitally
cut and c) that they would never entertain a marriage proposal
from a
boyfriend who hadn’t been tested.
It was all quite extraordinary. We talk forever about countries
where the
level of awareness of HIV/AIDS is very high, but behaviour change
is
negligible. These community conversations have resulted in huge
behaviour
change. I’ve always believed that it would take generations
even to show a
willingness to address gender equality, and here it seems to have
happened
virtually overnight! Can the pattern be replicated elsewhere in
Ethiopia?
It’s already begun to spread. Can it be replicated outside
of Ethiopia? Who
knows, but it’s certainly worth a try.
UNDP and the local NGO have somehow structured an environment
where people
could talk freely, and unself-consciously, about all manner of
hitherto
private and whispered subjects. They’ve simply understood
how to harness the
power of simple conversation and made of it a community fetish.
More power
to them.
I don’t want to get carried away into a world of unreality
by extravagant
praise for these “community conversations”. The task
facing Ethiopia is
mammoth; no one should underestimate the struggle ahead. It’s
all quite
overwhelming. And on top of everything else, Ethiopia is in an
endless
struggle to achieve food security in the face of unrelenting hunger
and
famine. But in terms of HIV/AIDS, I felt that I’d had a
rare glimpse of the
future, and it gave me hope.
