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Katherine Marshall
World Bank, USA
(draft) It is a great honor and pleasure to join this important panel. It is exciting to be present in this large and diverse gathering of leaders, deeply concerned about poverty, reflecting on the ethical challenges ahead, dedicated to social justice, and committed to addressing the scourge of HIV/AIDS. We were inundated this summer with a barrage of news of Liberia, Iraq, and the War on Terrorism, but this meeting and its focus on fundamental human imperatives are particularly timely, poignant, and challenging. We gather this year in Aachen, charged to: �establish new possible paths for meeting and a common commitment to peace.� Among the countless issues that this objective suggests, none is more urgent and central than �treating AIDS in Africa.� AIDS is an epic challenge for the new millennium, demanding a global commitment to its eradication. If we imagine ourselves 50 years from now, looking back on the year 2003, surely no issue will assume greater importance than this pandemic, and no question will emerge as clearly: what were you doing, personally and as an institution, to meet the challenge? 1. AIDS is above all a human crisis. AIDS has already killed more than 20 million people, left more than 42 million infected, and orphaned approximately 13 million children. Four children are orphaned by AIDS every minute. As we all know, to date the impact on Africa is by far the worst. 2. AIDS is a potential major threat to security as its impact both nationally and regionally � more by far than any war in human history -- has profound destabilizing effects. 3 But, more than anything, AIDS is a development challenge, with all the complexities and linkages that this implies. AIDS threatens in countless ways our global efforts to help improve people�s lives and living standards. My remarks focus on this development dimension of HIV/AIDS, examining issues around gender, prevention and treatment and some ethical concerns arising from expanded access to antiretroviral drugs. No-one here needs convincing, I know, that this is a central issue � you are �the converted�, aware and concerned. The central message I hope to leave with you is the critical importance of building, with creativity, wisdom and passion, new and stronger partnerships among public and private institutions and with civil society, including faith institutions, which have a special role to play in combating the pandemic. Development and HIV/AIDS In September 2000, the UN Millennium Declaration proclaimed: �we will spare no effort to free our fellow men, women, and children from the abject and dehumanizing conditions of extreme poverty, to which more than a billion of them are currently subjected.� The Millennium Development Goals set a target date of 2015, when we, the global community, should have assured that poverty is cut by half, the spread of communicable disease is halted, we have ensured that all children go to school and at least finish primary school, and we have truly worked to protect and improve the environment. Goal 6 of these Millennium Development Goals is we have halted the spread and begun to reverse increases in HIV/AIDS. This is a daunting challenge since we know that only a very few countries thus far are seeing decreases in HIV/AIDS. Overall, we know that the disease continues to spread. HIV/AIDS is already the leading cause of death in Sub-Saharan Africa and the fourth largest killer worldwide. As chilling as the statistical data are, they do not tell the whole story of the devastation and desolation of AIDS. 1. In far too many households, families have been impoverished , both in a material sense, as the family breadwinners have been incapacitated and lost, and in a social sense, as they have been stigmatized, scorned and excluded. The basic element of the social fabric, the family unit, is quite literally being rent asunder. 2. At a national level, HIV/AIDS threatens to wipe out the economic gains that many countries have struggled for decades to achieve. Life expectancy has fallen by 10 years or more. GNP is eroding significantly as the disease strikes those in their most productive years. Some estimates suggest this decline will amount to 20% within the decade for the hardest hit countries. 3. In Africa alone, so far more than 18 million people have died, more than two million last year alone � this is 10 times the death toll from the continent�s infamous civil and regional conflicts. 4. The impact on children is especially horrible: AIDS has created an explosion of orphans. Today 13 million children, mostly in Africa, have lost one or more parents to HIV/AIDS. AIDS is robbing children of their rights to childhood and education, as they must become heads of households, breadwinners and caretakers. There are inspiring examples of faith groups taking this vulnerable group under its wing � Mother Theresa�s sisters of charity are perhaps the best known � and there are thousands of other examples of institutional and household level care by Christians, Orthodox, Muslim groups. Unfortunately, the needs far outstrip the capacity to meet address this issue. The reach of HIV/AIDS goes far beyond any classic understanding of a disease or health problem: 1. In education, the sector which many people feel, is the hope for Africa�s future, teachers are dying, rapidly and disproportionately. Parents are afraid to send children, especially girls, to school, fearing sexual harassment and HIV infection; 2. Countless medical workers are themselves infected. Hospital beds are overwhelmingly occupied by AIDS patients, leaving scant room for those fighting other illnesses. In Addis Ababa, a recent newspaper article estimated that 80% of beds were taken up by AIDS patients; 3. In agriculture, the bedrock of many African economies, as AIDS spreads to rural areas, morbidity and mortality increases are cutting crop production, in some instances by 40% or more, putting a critical dent in food security efforts. 4. In the industrial sector, some employers in Southern African countries are reporting having to train 2-3 workers for every job, in the anticipation that others will be lost to AIDS. This is not sustainable. Among those lost are teachers, health care workers, and farmers, forcing schools and clinics to shut and threatening famine and chronic hunger. By infecting young people disproportionately � half of all new HIV infections are among 15- to 24-year-olds � and, by killing so many adults in their prime, the epidemic undermines development in a serious way. A recent World Bank research report warns that HIV/AIDS will potentially cause much more damage to national economies than we had earlier thought or even imagined. The report suggests that a country like South Africa could face economic collapse within several generations if the AIDS continues to deplete its human capital and its ability to educate future generations. AIDS is killing adults in their most productive years, robbing children of their parents and the love and nurturing that children so desperately need, undercutting both formal and informal education gains, thereby tearing apart the social fabric and undermining the basis of economic growth. Perhaps, the worst indictment of AIDS is the erosion of social capital, the loss of hope, and the disintegration of the family and the community. The scourge of HIV/AIDS disproportionately devastates poor people everywhere. Where poverty and ignorance is greatest, HIV prevalence rates are particularly high, and it is, everywhere, the poor who suffer most and are the least able to mitigate the impact of disease and its effects. Social services, especially health, available to the poor are woefully inferior to those available to the wealth; poor health, inadequate nutrition makes people more susceptible to the virus; and, more recently, despite precipitous declines in the price of anti-retrovirals, especially generic varieties, few poor people have access to medicines that could extend and improve the quality of life. Of the millions and millions of Africans infected with the virus, only some 20-50,000 today are on life preserving anti-retroviral mediation. This represents a shocking waste of a vast human potential for this and future generations. We must recognize that the AIDS epidemic is tied to the eradication of poverty; we must be combating both AIDS and poverty if we are to beat even one of them. How do we address a development problem we know is this massive and complex? Thus far, many actors have taken up pieces of the challenge -- governments, foundations, international organizations, and community and faith based organizations � and are working tirelessly in prevention, treatment, and advocacy efforts. Increasingly institutions are coming together in partnership -- coalitions like UNAIDS and the public-private-partnership, the Global Fund. There are promising emerging organizations like the Hope for African Children Initiative, which aims to scale up community-based interventions for orphans and vulnerable children. Many of these efforts bring innovative thinking to bear on AIDS issues, and organize people together to do something about the pandemic. The pandemic, however, is defeating these efforts in its reach and its virulence. We lack sufficiently coordinated responses; our partnerships, heartening and constructive as they are, still are inadequate, with the result that vast numbers of the people who infected and affected by HIV/AIDS are underserved. Partnerships Among the all too few success stories in the fight against the HIV/AIDS, one of the clear messages is that partnerships (and the key concomitant, leadership) largely account for success -- close and on-going collaboration from a broad spectrum of actors � governments, external donors, private sector players, secular civil society and � the stakeholders with perhaps the greatest influence on people�s daily lives, the faith communities. If the scourge of HIV/AIDS is to be addressed, it will require networks across and within each of these communities. Although the enormous potential of faith groups in combating many AIDS-related issues � stigma perhaps the most important -- is today much more widely recognized than it was in the past, there is still much scope for strengthening the partnership between faith and development organizations. This reflects in part a traditional divide between these two worlds. Candidly, there remains great skepticism on both sides of working together � reflecting different values, different norms, different languages, different approaches. But the role of community and civil society is clearly fundamental to success and sustainability. And the role of faith based groups is especially vital. Religious communities are among the most trusted and relied-upon sources of information, health care, and social services throughout many parts of Africa. Besides prevention and treatment work, the moral standing of the local religious leaders offers to many a special role in combating the stigma and stereotypes associated with HIV/AIDS. Who better to raise difficult issues such as sexuality, the use of condoms, the role of women? But this requires courage, leadership and will to move beyond the classic contexts of faith and religion into less familiar territory. Our world hungers for significantly more dialogue, partnerships, and cross fertilization across cultures, faith traditions, and development practices to be able to formulate a more comprehensive global AIDS strategy that is still able to maintain the core and integrity of faith traditions. We need to better understand and to deal with the stigma associated with HIV/AIDS and, crucially, to ensure that the faith-based organizations that are doing effective HIV/AIDS work are able to access funds to continue that work. An area in which faith communities are especially important is in providing the long-term inspiration for sustained work and in facilitating the partnerships necessary to extend the reach of AIDS prevention, treatment, and related social services. Prevention and treatment issues Prevention and treatment are multi-faceted and closely inter-linked issues, underpinned by a complex web of choices among financial, ethical and policy issues. Most fundamental is the balance between prevention and treatment interventions. With scarce resources, it is tempting to focus on prevention, clearly the less costly of the two options. And we do know that the disease is preventable. Yet designing effective messages, targeted toward the most at-risk populations has thus proved difficult, particularly in raw political terms. Nonetheless, it is important to underline that programs HAVE worked where people have had the guts and support to implement them. While we know that condoms prevent the spread of the disease, this has raised sensitive issues and concerns within many communities, who instead advocate an abstinence campaign. It is unlikely that a single prevention strategy will be effective in all settings. Nevertheless, prevention efforts need to remain at the heart of any effort to halt HIV/AIDS, and this raises once again the question or partnerships to which I have already alluded. However, it has been amply demonstrated that prevention and treatment are closely interrelated. Access to life saving medication has been shown to motivate people to undergo voluntary testing and subsequent preventative measures. We should not highlight a largely false choice between prevention and treatment. We need to do both; it would unconscionable to forego one for the other. Significant expansion of treatment calls into question health sector infrastructure in Africa, and whether many countries are capable of responding providing sufficient monitoring and diagnostic facilities. A number of alternative distribution models are being tested for their effectiveness and applicability to specific African environments involving a combination of public/private/community based partnerships. As many of you know Sant�Egidio is among the pioneering organizations in this field with its efforts in Mozambique, efforts, which I am proud to say the World Bank is associated with. There are hugely important ethical questions which demand consideration in a resource constrained environment. Should certain categories of people have privileged access to treatment, say the medical profession or teachers? Or should we work for an equitable treatment dissemination program? Government policies need to be developed and refined to address these questions, and international leaders need to take a stand here. We need to insist that treatment coverage be as equitable and comprehensive as possible, and we need to help provide governments ways to make this possible. Mother to child transmission issues raise especially poignant human concerns. We know that transmission from mother to child can be prevented with nevirapine. But there is a too often told anecdote that infected mothers in Africa refuse the drug, lest their child face a parentless future, with the prospect of becoming street children, without education, victim to crime and prostitution. This is a heart-rending challenge for all of us. There are also many complementary issues around treatment�it is well known that a holistic treatment program, which stresses the importance of good nutrition and treatment of overall health is best. Treatment of opportunistic infections can prolong life and extend the period before which drug therapy is appropriate. These complementary issues need to be at the core of any treatment program. All of this underscores how treatment and prevention options pose difficult challenges and the right questions need to be asked. Those of us here should invite our organizations to use their convening power to bring together the primary stakeholders in the AIDS pandemic, at a global and individual country level, to better our understanding of the complexity of the issues involved and to coordinate our efforts. Gender Dimensions Particularly crucial, and too often forgotten or ignored, are the gender issues highlighted by the AIDS pandemic. Women are at a disadvantage in protecting themselves from contracting HIV. Women are biologically more susceptible to contracting HIV. And, socially, few women in developing cultures are able to control their sexual relationships. While there are some options in some countries for female contraception, in most places women are subject to the discretion of their partner in the use of protection during intercourse. In so many places in the world, in heterosexual relationships, this means that men are the ones deciding whether or not to use a condom. Women are often unaware of their partners� HIV status, and vice versa. An important issue relates to commercial sex workers� industry which brings women into contact with men with multiple sex partners. This endangers the sex workers as well as the wives and other partners of these men. The stories are legion of HIV spreading along the routes of truckers, in so many parts of the world. These situations remind us of the urgency of protecting women and girls, ensuring that they are educated on HIV/AIDS and able to protect their own bodies. Men should be educated on gender issues, and ensure that they too are working to ensure the protection of their wives and daughters as well as themselves. As all of us know, it will take much more creative, innovative thinking and partnerships, significant funding, and efficient implementation of treatment and prevention programs, to properly address the enormous challenges posed by the AIDS Pandemic. The scourge of AIDS requires better coordination of the global efforts of NGOs, faith-based organizations, international organizations, and governments. We need to be working together, coordinating our efforts, in unprecedented ways. World Bank Role and HIV/AIDS There is much to say about the World Bank�s role in combating HIV/AIDS. Briefly, our President Jim Wolfensohn has committed the institution to direct support, at whatever financial level it takes, and to a rich array of partnerships. The specific details on the Bank�s programs are available in documents which you can find here. Briefly, the Bank has committed US$1.6 billion in grants, loans and credits for HIV/AIDS programs worldwide, and is especially engaged in Sub-Saharan Africa. As of July 2003, the Bank had committed nearly US$80 million for HIV/AIDS programs in 24 African countries. The Bank has pledged that no country with an effective strategy for fighting the disease will go without funding. The approach to AIDS is to support multi-sector, multi-actor strategies, providing funding and strengthening national HIV/AIDS strategies and supporting a wide range of interventions at the level of community based organizations. The World Bank is working with all regions in the developing world that are affected by HIV/AIDS. The Global HIV/AIDS Program and ACT Africa (AIDS Campaign Team for Africa) within the Bank are both helping to coordinate this work. In partnership with African countries, a series of Multi-Country HIV/AIDS Programs (MAPs) have been launched. The common approach of these projects is to place HIV/AIDS in the context of a multi-sectoral development challenge. Working through national HIV/AIDS groups, these projects are supporting a full range of interventions�prevention, care, treatment and capacity building. Within the funding allocated to each country�s program, on average, about half is meant to be channeled to community level interventions�there is widespread consensus within the Bank that it is in these communities, your communities, that the question of sustainability will be addressed. World Bank efforts to work with religious leaders on HIV/AIDS have been patchy, but still yield some important lessons, as the participation of faith groups in these MAP projects, while uneven, is strategic. Some examples illustrate the scope and nature of such joint efforts. In Kenya, faith groups have been actively engaged in testing out the operational manual for the MAP project and receive many subproject proposals. In Ethiopia, a country where the importance of religious ties to their respective communities cannot be overstated, MAP envisages particular outreach efforts to religious communities throughout the design of the project. Faith groups are represented on the national council and review boards and faith groups are represented among the approved projects. In Cameroon, more than 30 subprojects under that country�s project are being implemented by faith groups. In Ghana, an active outreach campaign is planned for all of the country�s major faith traditions, to ensure they participate in the MAP to the fullest possible extent. In Uganda, the religious community have been vital players in shaping messages as well as implementing projects. Dialogue between the World Bank and Sant�Egidio: The World Bank has recently had a remarkable experience in working with Sant�Egidio, and are supportive and hopeful looking to Sant�Egidio�s work in treating AIDS in Africa. Our two organizations have a history of cooperation -- in providing assistance to Kosovar refugees in 1999, expansion of a hospital in Guinea Bissau, to name a few. Most recently, the World Bank and Sant�Egidio have signed a formal partnership agreement covering a wide scope of activities where we have common concerns and in which we will work together in the years to come. One aspect of this partnership which is of particular relevance to our discussion today is Sant�Egidio�s AIDS treatment program, which will be supported by a World Bank project called Africa�s Regional HIV/AIDS Treatment Acceleration Program (TAP). The aim of this special program is to address the very practical problems involved in moving from relatively small pilot projects for holistic treatment to much larger programs that offer the potential of scale to serve significant groups of AIDS affected people, even in the poorest countries. The program will involve cooperation with a small group of countries in expanding treatment activities supported by NGOs and/or by a public/civil society/private partnership to test their efficacy in a decentralized, cost-effective and equitable manner. It will also assist participating country governments to refine their national treatment policy and adopt WHO recommend treatment protocols to their individual situations. This program will offer countries unique opportunities and methodology to train staff on the job and better target poor urban and rural neighborhoods, the youth, women of childbearing age and professional and technical staff at high risk. The program envisages a cross country learning process in the selected countries, including Mozambique. The TAP will be patient-centered, and meet treatment needs of People Living with AIDS and their families. By relying on NGO and community-based support programs it will diminish reliance on purely hospital based programs. Participating in the TAP aims to strengthen countries� capacity to coordinate, mobilize and work collectively with stakeholders in HIV/AIDS treatment. The program will extend the scope of the MAP beyond prevention and risk mitigation without slowing down other activities. Hopefully in the years to come, Sant�Egidio�s International Meeting will be a forum for discussing, and breathing relief over, effective HIV/AIDS interventions, by Sant�Egidio and by your organizations. Final Comment I end with a personal experience, which highlights some dilemmas we face, notably in keeping a sharp focus on the individual human significance of this global issue and challenge, while also pushing harder to ensure that our individual and collective efforts meet the challenge of scale of this vast human crisis. We need to multiply our efforts, ensure synergies among our efforts, respect the inputs that each brings, even as we recall always the face of each person who suffers.. Many years ago as a student in Nigeria, I was suddenly enlisted to help at an overwhelmed hospital during a cholera epidemic. Suffering people were crowded everywhere and every available body was drafted to help � changing IV tubes, comforting, and cleaning. The vibrant city of Ibadan suddenly took on an entirely different face � the face of poverty. A doctor�s passing comments have stayed with me - first, that cholera was a real threat only to the poor, and second, that even in this dismal hospital scene, the patients were privileged, few women, children, and old people even reached the hospital yard. The efforts of the group there were vital and helpful but they barely scratched the basic problems that caused the epidemic. Those problems needed much broader, deeper efforts that went far beyond any that were underway at the time. The world viewed through the lens of HIV/AIDS, brings into sharp relief the deep disparities between the privileged and the poor of the world, between wealthy countries and struggling ones, in quality of life and access to resources. We need to redouble, retriple our efforts to address the core issues which have allowed this pandemic to devastate so many people, communities and countries. Conclusion: I invite all of us here to �to establish new possible paths for meeting,� to organize our efforts on AIDS and to join together in commitment to address this Pandemic. We know what we can achieve, and we know that this pandemic must and can be addressed. In 20 years, it is possible and essential that the picture will be quite different, that our story will be one of conquest, a rising to one of humanity�s greatest challenges. To arrive there, though, we need to take up this challenge together. We have much work ahead of us. Some references: http://www.developmentgoals.org http://www.worldbank.org/afr/aids/
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