Dimensions of Disease.

Piot, Peter

International cooperation and the AIDS epidemic

Peter Piot, a native Belgian, was appointed executive director of the Joint United Nations Program on HIV/AIDS (UNAIDS) and assistant secretary general of the United Nations in 1994. He was formerly associate director of the Global Program on AIDS of the World Health Organization and president of the International AIDS Society. A doctor by training and a former professor, Dr. Piot has done extensive field research and is the co-discoverer of the Ebola virus.

Dr. Piot leads UNAIDS in its effort to direct the activities of its organizational members (UNICEF, UNDP, UNFPA, UNESCO, WHO, UNDCP, and the World Bank) as they try to reduce the threat and spread of HIV, provide support for those affected by the epidemic, and address the socioeconomic consequences of the disease. Senior Editor Patty Li spoke with Dr. Piot in February about the international impact and understanding of the AIDS epidemic and its implications for both developing and industrialized nations.

HARVARD INTERNATIONAL REVIEW:

Over 16 million people have died from AIDS since the disease was first recognized, and over 33 million people currently have HIV or AIDS. The AIDS epidemic is having a substantial impact on societies and economies around the world. Has the scope and seriousness of the AIDS problem finally been understood by the international community?

If you are referring to the average person on the street, I do not think so. I don't think people in the Western world can imagine how bad the problem is in the most affected countries. I think there is a much better understanding today in international circles (particularly after the issue was raised in a debate in the UN Security Council) among those who are involved in international politics, development, and economics. This issue has been on the agendas of finance ministers' meetings in Africa, and there's talk now of putting it on the agenda of the next ASEAN summit. The issue is also a high priority for the World Bank, at least in the African region. All of this indicates that the problem is getting more global recognition.

But it is hard for most people to imagine or fully comprehend the dimensions of the crisis. It's even difficult for me to grasp, and I have been working in this field for over 15 years. Every time I visit one of the heavily affected countries, I'm shocked just by the number of orphans. It is hard to imagine that one out of four adults in a country (such as Zimbabwe and Botswana) is carrying HIV and is going to die.

Beyond the serious medical concerns raised by AIDS, what are some of the broader consequences for the affected societies?

Beyond the suffering of individuals who lose their friends and family members, AIDS has a clear economic impact on society in general. AIDS is unique, first because it affects people in the prime of their lives, killing them during their most productive years. Second, it affects both the rich and poor. Most health problems primarily affect the poor, but in this case AIDS also kills the managers, the teachers, the doctors, the engineers. This erosion of human and social capital makes the impact of AIDS extend so far beyond any disease we've seen up to now, especially because it is epidemic. AIDS has a tremendous stigma attached to it, which makes the problem difficult to talk about and get political recognition for. People are afraid to come out and admit they have AIDS because they may lose their jobs, their housing, and so on.

I think it's increasingly clear that the economic impact of AIDS is going to be a major factor of destabilization in the heavily affected countries. Not only are more people being driven into poverty, but there are also so many more orphans and households headed by kids; the world now has an entire generation of what I call desocialized youth. This generation includes kids who haven't been to school, who have no future, who haven't grown up in a normal environment. And this threatens what is increasingly being called human security in general--not just security in the classic definition, but security in a broader, more general sense.

The AIDS epidemic in Africa has received a great deal of media attention, but what other regions face serious threats from the spread of the disease?

In Asia, India has the world's largest number of infected individuals, about 5 million people, out of a population of one billion people. There are also countries where AIDS has spread very rapidly, like Cambodia, which today has an infection rate of about 4 percent in the general adult population. The big unknown is what will happen in China, with tens of millions of people moving about the country looking for work (a so-called floating population), which will make dissemination of the disease more likely. With the development of their economy comes greater inequalities, making the population quite vulnerable to the spread of HIV through practices like prostitution. I don't think anybody can tell us what will happen in Asia, but that means that there is still time to do something to prevent future problems. Another region to be concerned about is the Caribbean, which is the second most affected part of the world.

UNAIDS is responsible for coordinating a global effort to fight the spread of AIDS and its deadly consequences. What are some of the biggest challenges facing UNAIDS as it tries to foster cooperation between so many different international actors? How does UNAIDS respect the integrity and sovereignty of the governments it deals with while directing reform and relief efforts?

UNAIDS was established a little over four years ago in order to bring the entire UN system and the World Bank together to fight AIDS, rather than having each of the different groups going in separate directions. I think the situation has improved enormously because the approach that we have taken is what you might call "product and goal oriented." This is an alternative to dealing with everyone's individual mandates separately, which gets into flag planting and sometimes still poses a problem.

But when it comes to AIDS, the whole system is speaking with one voice; we have the same message. There's one strategy in each of the developing countries and economies in transition. There are theme groups on HIV/AIDS; these are platforms for bringing the UN system together around AIDS and developing an integrated work plan. In other words, agencies such as the WHO and UNICEF agree to support the countries affected by AIDS in various ways because the countries are ultimately responsible for solving their own AIDS-related problems. That approach has now been so successful in several countries that bilateral donors are also joining these groups, because this method provides a platform for good coordination. But we hardly ever just talk about coordination because that's never a goal in itself; it is just a method that is supposed to be more efficient and effective.

I would say that the key to our efforts is focusing on the issue of AIDS and the goals the world wants to achieve while remembering that the government of the affected country should ultimately be in control.

There were major problems in the past with convincing some of the heavily affected nations of the severity of the AIDS problem, along with problems of cooperation and coordination in reform and relief efforts. But you recently stated that a turning point has been reached with these issues. How have attitudes changed since the early 1990s? Has substantial progress been made?

When I look at these nations, particularly in Asia and Africa, many heads of state, prime ministers, and presidents have spoken out about AIDS as a high-priority issue for their country, as a matter of national security, and as a major obstacle to development. These pronouncements are generally followed by some form of action, usually the establishment of a national AIDS commission that answers to the president or the prime minister. These innovations are important, not only because of the high political visibility that they give to the issue, but also because they allow for what we call a "multi-sectoral response," which means that different departments or ministries will be engaged. We've known from the beginning that even though this is a medical problem and a serious disease, there is no medical solution. What this means for these governments is that AIDS is not only an issue for the departments of health, but also for the departments of education and law. They all have a major role to play. Now many cou ntries are also increasing the amount of resources they devote to AIDS problems, including India, Mozambique, and Malaysia. I think that UNAIDS has contributed to these positive developments. That does not mean that the problem is fixed, but it means that there is the recognition, the first step in solving any problem.

AIDS as an epidemic is a problem that mainly affects developing nations. Do the wealthier, industrialized nations have a responsibility to help alleviate this problem? Is there a moral responsibility involved, and do you feel that you have the support of these nations for your work?

I think there is indeed a moral responsibility. People ask why we are getting involved in AIDS in Africa or Asia; they claim that it's only a local problem. But was the Holocaust a European problem? This is a situation where you truly have a moral responsibility; the moral aspect is a matter of developed states sharing resources with poorer countries. But I would say that there is also an enlightened self-interest, which will probably guarantee a more sustainable sort of involvement than moral indignation. AIDS is an element of destabilization in parts of the world that may be far away, but today with the forces of globalization, AIDS affects businesses around the world and international security. The West just cannot afford to have major foci of political instability or poverty in the rest of the world, because they will have an impact on the Western world as well.

The economic factor also places the fight against AIDS in everybody's best interests. This is more important for Asian countries than for African countries, but we can include South Africa as well. Many of these countries are emerging markets, and even with the Asian economic crisis, most of the countries are already back on track toward economic growth. If the AIDS epidemic is going to worsen, a lot of economic opportunities will be lost.

Do the Western countries, the rich countries, support us in our efforts? I would say that is also where I have seen a major change over the last year--certainly in the United States, where several announcements regarding AIDS have been made by President Clinton. Last year, a doubling of the budget for international AIDS work was approved by the US Congress, and this year, the president has proposed a tripling of the budget. The same phenomenon is occurring in several European countries. That is a very important sign, because words are words, but money talks.

How can the work being done to address AIDS lead to progress in other arenas, such as health care, education, and women's rights? Does AIDS help to bring about a better understanding of how to deal with other social problems? What are the implications for cultural understanding in issues of development?

This is an important question because I think AIDS has already contributed to solving other issues. When you look at the industrialized world, AIDS has fundamentally changed the way that doctors and patients interact with each other. This revolution is the result of AIDS activism, and the fact that the disease initially affected well-educated, middle-class gay men. But in the broader international arena, I would say that the links between health and development, between health and human rights, between health and gender issues, and between development and gender have never been so clear. AIDS has also contributed to the understanding that if we want to tackle a social issue, then we need a so-called multi-sectoral approach. There are no simple technical fixes here. One needs to not only deal with the immediate risks of AIDS by, for example, condom promotion, but also tackle some of the broader social issues that make individuals and populations vulnerable to the spread of HIV, such as women's rights, as well . Another example of a social issue illuminated by AIDS would be housing policies. Because of the lifestyles imposed by colonial policies and apartheid, as in South Africa, men were forced by economic necessity to live together with thousands of others in compounds around mines, far away from their families. That certainly has contributed enormously to the spread of diseases like AIDS. We need to take all these social factors related to AIDS into account in our development models.

Finally, I would say we also have a greater understanding of the importance of culture in development. We may have the best models, approaches, and technology, but these are always used in a certain cultural environment, and the real answers have to come from within the community. The critical importance of community work, I think, has been re-emphasized with the AIDS epidemic--community work for development in general. We have an enormous opportunity here to learn from and influence development on a broader scale.

In some of the most heavily affected areas, is it too late to prevent or reverse the major economic, political, and social damage caused by the AIDS epidemic?

In some areas it's late, but it's never too late. Every year, millions of young people become sexually active for the first time, and we certainly shouldn't give up on them. There is time now, even in badly affected countries, to not only prevent new infections but to alleviate the impact of this epidemic as well. We need to think about what social policies, what types of actions we as societies need to enact to live in a world with AIDS. There is no choice; it is just a matter of how fast it can be done and how it can be done. But these countries have no choice but to deal with it. For most countries in the world it is not too late--think of Asia. The opportunity for action is in Asia, as far as I'm concerned, There is a window of opportunity that is open now, but will not be ten years from now, because by then we might have a scenario that is more dire, as is the case in Africa.

How has your past experience in the field influenced your work as executive director of UNAIDS? Has your background given you a better understanding of the problems the organization must deal with? What perspective has your work experience given you?

I've spent much of my career in Africa, working with many local communities. That has been very helpful because it has led me to believe that you can't seriously tackle a public health problem without dealing with politics, without forging strong alliances with, in our case, human rights organizations, businesses, and development groups. Without engagement of the political world, nothing is possible. That perspective has been, for me, a guiding point in my work It is not only my technical expertise that has been helpful, but also the fact that I have worked in broader development issues and also in politics--you need a combination of both.

Peter Piot is executive director of the Joint United Nations Program on HIV/AIDS (UNAIDS).