Cry for Action: Shameful Neglect and the Search for Hope in AIDS-Ravaged Africa

An interview with Stephen Lewis

Formerly the Special Envoy for HIV/AIDS in Africa to UN Secretary-General Kofi Annan, Stephen Lewis is co-director of AIDS-Free World, a new international AIDS advocacy organization, and author of Race Against Time: Searching for Hope in AIDS-Ravaged Africa. He is a Professor in Global Health at McMaster University in Hamilton, Ontario. From 1995 to 1999, Lewis was Deputy Executive Director of UNICEF at the organization’s global headquarters in New York. From 1984 through 1988, Lewis was Canada’s Ambassador to the United Nations.

Multinational Monitor: Why does it make sense for the world to be focused on AIDS, as distinct from other diseases?

Stephen Lewis: AIDS has emerged as the premier development issue rather than simply a health issue. AIDS has led to the evisceration of productive generations between the ages of 15 and 49 in every country where the prevalence rates are high.

That means countries’ capacity to function is decreased significantly as they lose their doctors and nurses and pharmacists and farmers and civil servants and teachers — all of the occupational gradations are ransacked by the virus. So not only do you have a huge human calamity of 25 million people dead and over 40 million people infected, but you also have a terrible dismembering of the economic and social structure.

MM: What has been the impact of HIV/AIDS on food production?

Lewis: Because so many farmers have died or become ill — and it is overwhelmingly women who do the farming — the levels of household food security have declined dramatically.

The problem is even worse than the mere inability to grow food. So much of any family’s income is spent when there’s illness — dealing with the illness, dealing with the death, dealing with the funeral. All of these costs mount up, and there’s no disposable income available to purchase grain and purchase food.

And then there is a particularly alarming problem for people who are on antiretroviral treatment, because they don’t respond well to that treatment unless they are reasonably well nourished. The food is not being produced, and so there is a calamity of hunger in many countries. People are desperately hungry.

This situation looks as though it may be complicated further by the wild ricocheting of weather patterns as a result of global warming. In Southern Africa, there is intense drought and clear evidence of famine in a number of countries. In other parts of Africa — like Uganda, Kenya, Ethiopia, the Horn of Africa — there have been incredible rainfalls resulting in terrible flooding of farmland and, again, a loss of food. Wherever you turn, it looks as though climate change is going to complicate things even more fiercely for Africa, like some kind of conspiracy directed at the continent. It is going to be very, very difficult for people struggling with disease, not just HIV and AIDS, but malaria, tuberculosis, other diseases, because of the absence of food.

That’s why the World Food Program is indispensable. They have understood that they can’t only respond to natural disasters, but they must also respond to human need in vulnerable communities.

MM: What was the 3-by-5 initiative and what did it achieve?

Lewis: The 3-by-5 initiative came from the World Health Organization. It was an effort to put 3 million people into treatment by the end of the year 2005. It was in its day truly visionary because nothing was happening on the treatment front. 

They did not achieve the target. They didn’t come anywhere near it. They had about 1.3 to 1.5 million people in treatment at the end of 2005. But what it did was to unleash a momentum around treatment which got every country working hard at supplying antiretroviral drugs, and rolling out the treatment and keeping people alive. I suspect that by the end of 2007 we’ll have about 3 million people in treatment worldwide. So we will have achieved the target two years late, but we wouldn’t have achieved anything if it hadn’t been for the 3-by-5 initiative.

MM: How does the 3 million compare to the need?

Lewis: The 3 million falls desperately short of the need. Probably somewhere in the vicinity of 8 million people in developing countries now need treatment, so we’re very much less than 50 percent down the road. We’re probably between 35 and 40 percent of the way there at maximum; it could be that the percentage is even lower.

The target of the world is to reach universal treatment, prevention and care by the year 2010. That would mean all of those whose immune systems have declined to the point where they require treatment — not all of those who are living with AIDS — would receive antiretrovirals by 2010.

That’s going to be a tough target to reach, and the donor countries are already retreating from the target, both in the numbers of people who need treatment, and in the finances to support the treatment. That is just unconscionable. It started at the last G8 summit in Germany in July 2007. And now there is a tremendous behind-the-scenes battle to get the donor countries to restore their faith in universal access by 2010.

MM: Why were countries so slow to respond to the epidemic and to provide treatment?

Lewis: I guess any disease that is sexually related is always going to be responded to slowly because society is so clutched about matters sexual. When matters of human sexuality are concerned, there is a tendency to be cautious, to go into denial, to resist, to be passive, to be inert. Nobody wants to deal with sexual factors. And that had a terrible consequence in responding to the pandemic.

In addition to that, I think that the political leadership, certainly within the continent of Africa, was so overwhelmed, so aghast, so traumatized by the sudden force of the pandemic, and the numbers who were affected and infected, that they went into silence and denial. It took a while to yank them out of that and to realize that they would be fighting for survival if they didn’t get to it pretty quickly.

On top of everything else, and this is part of the sexuality, the stigma and discrimination that’s associated with HIV slowed everything down. To this day, matters of stigma slow everything down. People are reluctant to be tested, lest they be found to be HIV positive. When you’re HIV positive, what happens when you disclose it? What kind of reaction is there in the community? In your place of work? In your family? In your school? It’s a very, very difficult situation.

MM: Is stigma due to forces deep in the culture, or is it a problem that governments and political leaders should have been able to cure or are responsible for?

Lewis: I think it’s more deeply implicated in the culture. In places like Eastern Europe and parts of Asia, the disease is primarily transmitted by injecting drug use. But in Africa, where it is overwhelmingly heterosexually transmitted, the stigma around sexual transmission and HIV positive status is very intense.

That’s a cultural phenomenon which might have been broken by more progressive political leadership, but the leadership wasn’t there. Had the political leadership of these countries, had the prime ministers and the cabinet, gone out and taken a test publicly, and had they stood up for the rights of infected persons publicly, and had they dealt with the issue openly and frontally, things might have been different.

The only country that really did it in a dramatic, open way was Uganda and President Museveni. Uganda’s prevalence rate declined dramatically from something in the vicinity of 20 percent plus in the late 1980s to around 6 percent today.

Where you didn’t have that kind of political leadership, where they didn’t confront the pandemic openly, then inevitably the stigma took root.

By the way, all of this stuff about whether or not we moved too slowly, is equally applicable to the international community. Indeed to this day, the slowness of the international community is appalling. There are some good voices like that of the new Prime Minister of the United Kingdom Gordon Brown; and there are some tremendous interventions, like those of the Clinton Foundation, which is probably the most progressive force dealing with AIDS at the moment on the continent, maybe in the world, primarily because they treat it as an emergency and they work with such urgency, in a way very few others do. But by and large, the international community is still terribly, terribly slow in response.

MM: You’ve pinpointed how education and schooling is intertwined with the crisis.

Lewis: Education is intertwined on so many levels it’s hard to know where to begin. It’s intertwined in the sense that so many teachers have died, or are ill, that many of the educational systems of Africa have been stripped of huge numbers of teachers. In a country like Zambia, there were moments in time when more teachers were dying than were graduating from teachers’ college. And there have been a number of tremendously upsetting instances where teachers have infected their students —  where male teachers have engaged in either rape or sexual violence, sexual molestation, of young girls.

But the other aspects of education are equally important. There are so many orphan children now who are desperate to be in school to have a sense of self-worth and self-confidence and peer relationships, and even the one meal a day they might get from a school feeding program sponsored by the World Food Program. Very often they can’t get to school because of the school fees. It’s not just the basic fee; it’s the cost of the uniforms and the text books and the parent-teacher association fees and the examination fees, a whole panoply of costs. Very poor families and orphaned children in particular can’t afford these costs, so they are denied the education which should be the vehicle for preventative work — to alert children to what they’re facing and how transmission occurs and what they can do to protect themselves.

The education system itself becomes so fragile under the assault of the virus that it cannot fully respond. There are too few teachers, and classes are too large, so parents lose confidence. Young girls are yanked out of school to look after ill and dying parents and relatives. There are sexual predators within the school system. There are kids who can’t go to school because of fees. All of these things come together to compromise education, when it should be the centerpiece of the response.

That isn’t to say that the ministries of education and the education systems aren’t trying. They are. They’re trying very hard, but it’s a tough slog.

MM: Can you elaborate on the impact of school fees in poor countries and where they come from?

Lewis: My understanding, and it’s borne from endless questions and a good deal of reading, is that school fees were by and large unknown in Africa before the structural adjustment programs imposed by the World Bank and the IMF, mostly by the World Bank, were introduced in the 1980s and 1990s. And one of the conditionalities of structural adjustment programs was the Bank saying to a country, “We’ll give you the loan on condition that you impose user fees.” And part of those user fees were fees for health services, so you had to pay when you go to the hospital. Part of the user fee was a fee for education, so you had to pay when you go to primary school.

All kinds of children who would otherwise be in school couldn’t go to school because their families could not afford to pay the fees. And that’s not some abstraction. That’s been shown in a definitive way by the experience of the countries that removed the fees. When the fees were removed in countries like Uganda, Tanzania and Zambia, a tremendous number of children that weren’t there before turned up at the doors of the schools.

The most dramatic case, perhaps, was Kenya. In the important Kenyan election in December 2002, the old regime got beaten and replaced by the government of Mwai Kibaki. The key political promise that Kibaki made during the election campaign was to remove school fees. After he was elected, he immediately honored his promise. Within a matter of weeks, 1.3 million children turned up at the doors of Kenyan primary schools who had not been in school before. They represented fully 20 percent or better of the school-age population. It was quite stunning.

Great damage was done by the World Bank and the IMF, with a policy they subsequently renounced and advocated against. But the damage that’s been done continues to linger, because there are still many jurisdictions where school fees continue to be applied.

Even when you remove the school fees, there are so many other added costs, that it’s a deterrent to attendance, particularly for girls.

By the way, one of the most unsettling things that’s now occurring in African countries that have removed primary school fees is that a huge number of students are now graduating from primary school with nowhere to go because the school fees for secondary schools are even higher. There is no jurisdiction on the African continent which has yet abolished secondary school fees. That’s a tremendous deterrent to young adolescents, who are now roaming the streets of the villages without being able to get into secondary school because they can’t afford the costs.

Again, it’s particularly tough for girls. Incredibly enough, of all the kids in secondary school in Africa today, only 14 percent are girls. That shows what a struggle there is around gender.

MM: Can you provide an overview of the healthcare worker shortage? How well are countries doing in trying to expand their health work forces?

Lewis: In terms of having enough health workers, the situation is a catastrophe. It’s not just the kind of shortages we face occasionally in the Western world, it’s shortages which are absolutely catastrophic.

So many health workers have died or are ill that you never have enough people in the health sector to do the job. We rely very, very heavily on nurses now, but even they have lost massive numbers.

The problem is further complicated by the fact that even when these countries manage to train and graduate, say, a cadre of nurses, the nurses are poached by the Western world. The route tends to be that they first go to South Africa and then they end up in the United Kingdom. The United Kingdom will say, “Look, we subscribe to the Commonwealth regulations on poaching of health professionals. We don’t do it anymore.” That may be true at a government level, but they do absolutely nothing about the recruitment agencies that set up in the countries and that recruit health professionals and bring them back to the United Kingdom.

So the situation is Africa is doubly compromised. First, by the fact that they don’t have enough health care professionals because they’ve lost so many. And second, by the fact that the few they have get poached on.

How do you change this? The most important thing to do is to improve the salaries and working conditions of the professionals and quasi-professionals — the nurses and the doctors and the pharmacists, but also the community health workers. And that means a tremendous infusion of dollars. The best example of how this should be done is what the British development agency DFID [Department for International Development] is doing in Malawi. They’ve assigned something in the vicinity of $368 million, over a period of five years. They have topped-up the salaries in the civil service, with a particular focus on health. They have improved working conditions and benefits. They have built housing, which was desperately needed. They are creating new career lines, which are not as sophisticated as doctors or nurses, for work in health services. I think last year was the first year in Malawi where there wasn’t a significant out-migration of nurses because of the money that had been invested by the British development agency, working hand-in-glove with the government. That is the answer to keeping the health workers in place.

The World Health Organization says that Africa requires more than a million additional health care professionals. And they have an initiative called TTR: Treat, Train, Retain. And they’re going to move heaven and earth to initiate significant training programs to retain new professionals and quasi-professionals in these countries where the situation is so abysmal.

MM: How significant do you rate the influence of the IMF in restraining countries from spending more on health?

Lewis: The IMF had taken a position where it said that you couldn’t breach the macroeconomic framework. If you wanted to hire, as in Kenya, two or three thousand retired nurses, the IMF wouldn’t give you permission to do so. I’m completely bewildered by this business of an international financial institution dictating to a sovereign government, when the country is fighting for survival because of a pandemic. There’s something so perverse and crazy about that that I can’t intellectually absorb it.

I think that it’s also true that the IMF doesn’t know what the hell it’s talking about. It never sufficiently takes into account the damage that is done to a country when you strip the social sectors. That was the problem of structural adjustment. That’s why structural adjustment failed and ultimately collapsed. And the IMF hasn’t yet learned the lesson. The IMF is too rigidly ideological. That’s why everybody is calling for the reform of the IMF. That’s why even Western governments are beginning to question whether or not the IMF has relevance — because it takes positions which are frankly absurdist. But I think the IMF is beginning to retreat from the absurdity of its position. They backed down in Kenya finally and allowed the government to hire the nurses. I think they’re beginning to understand that their position is a bit untenable.

MM: Globally, there are two big programs to support treatment and prevention in Africa and elsewhere in the developing world, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight Against AIDS, Tuberculosis and Malaria, but you’ve been hugely critical of the political and financial commitment from rich countries.

Lewis: I’m critical mostly because they actually make commitments and then dishonor them. In the case of most of the Western countries meeting at the G8, they have very inflated promises. Look at the Gleneagles promises in July of 2005 where they promised to double aid to Africa by the year 2010. That was a solemn commitment to provide an additional $25 billion — that’s what doubling would have been. And even Gordon Brown, in a speech to the UN in July of this year, talked dramatically of the betrayal by the G8. They commit themselves and then they betray the commitment the moment it’s made.

    They don’t seem to understand the consequence that has, in a continent like Africa, where the governments are frightened about undertaking major financial and programmatic commitments if they cannot rely on the resources promised by the West.

  The shortfall is massive. We’ll be lucky if in 2007 we reach $10 billion overall in aid for HIV/AIDS. What was required in 2007 was $18 billion. In 2008, $22 billion will be required; and it probably rises to over $40 billion in 2015. So we’re going to be billions short because the promises that are made are not delivered on and the promises that are made are increasingly short of what’s required.

Even PEPFAR, by the way, is inadequate. The first edition was $3 billion a year for five years. The second edition of PEPFAR promises to double that, to $30 billion over five years. But reflecting its percentage of world economic product, the United States should be offering between $50 and $60 billion over five years, not $30 billion. The amount of money sounds like a lot, in fact it’s a relatively small part of the American foreign aid project.

MM: How do you account for a culture that makes it possible to spend almost anything on a war, but feels very severe restraints in dealing with something like HIV/AIDS?

Lewis: You’re asking me a question which I have failed to answer adequately in the past and would fail to answer adequately again. I don’t know the answer because I don’t understand that kind of human behavior or that kind of political behavior.

The world is now spending between $10 and $15 billion a month on Iraq and Afghanistan, prosecuting those wars. As I said, we will be lucky to raise $10 billion in one year, in the year 2007, for AIDS. Things are completely out of whack. It’s just totally nuts.

Why so much money is always available for conflict, I’ll never understand. Why so little money to repair the human condition, I’ll never understand. It’s as though vast numbers of human beings are simply expendable whereas the purported national interests involved in Iraq or Afghanistan are absolutely indispensable. The Americans justify it with the war on terror, of course. I don’t know how others justify it. Wherever you turn, there is always some sort of crazed conflict, which eats up massive amounts of resources when the human needs are so intense.

MM: Amidst all the tragedy, what trends or particular country experiences leave you hopeful?

Lewis: There’s no question that the rolling out of treatment is the most dramatic measure of progress and the most thrilling and the most optimistic development in any individual country. Because people who were at death’s door, literally, suddenly gain weight, look better, feel better, go back to work, they don’t die, their kids aren’t orphans. There is a whole atmosphere which is so much more positive as a result of rolling out treatment. (This is why the slowness of a government like South Africa in providing treatment is so criminally delinquent, although to be fair to them, they have recently launched on a different path — though it is now unclear whether that path will be honored.)

I also think the efforts that are being made on prevention offer reasons for optimism. Everywhere one turns, there is a tremendous search for a vaccine, a tremendous search for a microbicide. It is now clear that men who are circumcised are subject to infection at levels 60 percent below the norm and therefore male circumcision becomes a preventative technology which will be evermore widely applied. Just recently, the government of Rwanda announced it is going to engage in mass male circumcision under very careful and medically appropriate environments.

There is for the first time a very real emphasis on pediatric drugs — pediatric formulations to keep children alive — which companies are producing as a result of negotiations of the Clinton Foundation.

And there is a renewed effort to prevent the transmission of HIV from mother to child during the birthing process, which is the way young infants are infected. Over half a million a year get infected during the birthing process and breast feeding afterwards, and that is being now addressed because there are drugs available to put an end to that transmission.

MM: Where do you see the greatest shortfalls in the global response to the epidemic?

Lewis: The huge problem about which we have made very little progress at all over the last six years, is number one, gender. The tremendously disproportionate vulnerability of women remains the aching dimension of the pandemic. The disproportionate numbers are heartbreaking, with very young women being infected and dying. The absence of gender equality is the most perverse driving force of the pandemic.

The other dominant unaddressed problem is what to do about the huge numbers of orphans. There will be 15 million orphan kids by 2010. It’s so difficult for communities to absorb them because the communities are so poor. That’s why the grandmothers have suddenly emerged as such a heroic force on the continent. Millions of grandmothers looking after millions of orphaned grandchildren are redefining the human family.

So the orphans and the women and girls are the real worries. The problems for women and girls are increasingly accentuated by the spread of sexual violence, which is not just intimate partner violence. The sexual violence during conflict has reached levels of brutality which are beyond the capacity of the human mind to comprehend. What’s going on in the Eastern Congo at the moment is a carnage the likes of which we’ve probably never seen on the planet. And although everyone knows about the rape and sexual violence being inflicted on women, which of course often results in infection, as we saw in Rwanda, no one seems to be doing anything serious about it. And that is just one of the saddest, unconscionable, damned things around.