: Briefing on Trip to Malawi & Tanzania

[Guest guest]

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Notes for Press Briefing by , UN Secretary-General's Special

Envoy for HIV/AIDS in Africa, on his recent trips to Malawi and Tanzania.

United Nations, New York: 12:30 PM, Tuesday, January 18, 2005

Since this is my first press briefing of 2005, I feel compelled to begin

with brief reference to the Tsunami, the Millennium Development Goals, the

debt of African countries and " 3 by 5 " , the WHO/UNAIDS initiative to put

three million people with full-blown AIDS into treatment by the end of 2005.

Collectively, they form a backdrop for what I wish to say about the country

visits to Malawi and Tanzania.

The evolution of response to the Tsunami is exhilarating and fascinating in

equal measure. The outpouring of international concern and generosity

attests well to the truth (with apologies to the Bard) that the quality of

decency is nowhere strained. But it has also raised predictable anxieties

about support for other humanitarian crises.

It is hugely worthy of applause that the Governments of the world,

overwhelmingly of the western world, have pledged, in a mere three weeks,

some five and a half to

six billion dollars.

However, it is bracing to note that in more than three years, they have

summoned, in pledges, almost exactly the same amount --- $5.9 billion ---

for the Global Fund to fight the pandemic of HIV/AIDS.

Without the slightest invidious intent, it is important to recall that there

are today, now, at this very moment, six million people dying of AIDS, four

million, one hundred thousand of them in Africa. I don't begrudge a penny to

South-East Asia. But what does it say about the world that we can tolerate

the slow and unnecessary death of millions, whose lives would be rescued

with treatment?

The Tsunami must be seen to be the turning-point. The publics of the world

have shown their desperate concern for the human condition: how long will it

take for

Governments to do the same?

Yesterday, Professor Sachs tabled his remarkable blueprint to

achieve the Millennium Development Goals. The targets for Official

Development Assistance which he sets are entirely attainable. Indeed, the

industrial world has been toying with the " .7% of GNP " figure for thirty-six

years, overlapping the centuries with hypocritical disdain. They must

finally deliver, and the UK Government's quest for an International

Financial Facility can be an important step on the road.

What is crucial to recognize, as Gordon Brown said in his speech in Dar es

Salaam last week, is that the goals are being fiercely compromised in many

African countries by the pandemic of HIV/AIDS. It is the ultimate

self-delusion to believe that the MDGs will be reached while the pandemic

roils unchecked.

But the signs are not auspicious. For whatever inexplicable reason, the

western countries, so magnificently responsive to South-East Asia, bridle in

the most unseemly way when it comes to Africa. Nowhere has this been more

dramatically underscored than on the question of debt. It took but days for

the Paris Club to espouse a debt moratorium for all of the countries

affected by the Tsunami, but time and time again --- most recently just

last fall --- the G8 refuses to cancel African debts. Even when they agree

that it must be done, they can't agree on a formula which would make it

possible. There's something indefensible at work, because it's not just

South-East

Asia. Iraq gets debt reduction; Africa festers in frustration. The G8

Finance Ministers meet next month; surely there's not an excuse left in the

armoury of rationalization

to prevent the reduction and/or cancellation of African debt.

What makes it all so painful is the possibility that we're on the

thresh-hold of a breakthrough against the pandemic. Against all odds, I

sense that WHO's " 3 by 5 " is

taking hold. Certainly that's true in every African country I visit

including, most recently, Malawi and Tanzania. The professional doubters and

detractors are losing ground. Absolutely everywhere, countries are

exercising superhuman efforts to implement treatment, helped appreciably by

the UN family, WHO and UNAIDS providing the lead, plus the Global Fund, the

Clinton Initiative, the World

Bank, and several bilateral donors, the United States in particular.

I don't want for a second to depreciate the difficulties. And some of the

countries are facing delays and bottlenecks that can drive you crazy. But

every country is trying, is resolute, and even where governments are slow,

the force of civil society sustains the battle. It would be the destructive

irony of the century, were the wealthy nations to default on their

commitments at precisely the point when 3 by 5 is within sight, and with it,

a cornucopia of hope.

Which brings me to Malawi and Tanzania.

I traveled to Malawi at the very end of October. The trip comprised the

usual elements: political encounters, civil society, groups of People

Living with HIV/AIDS, the diplomatic corps, the UN family and several trips

to projects in and around Lilongwe. This is now a tried and tested pattern,

with a debriefing for UN colleagues and a press conference as the finale.

Malawi, like every other country is preoccupied with treatment and meeting

the goals of '3 by 5'.

The adult prevalence rate is estimated to be 14.2%, and some 170,000 people

require treatment now. Originally, the government had set a target of 44,000

in treatment by the end of 2005, but they moved the date up to June of

2005, and then revised their target upwards to 80,000 by the end of this

year.

It has to be understood what a remarkable commitment this target

constitutes, and how many potential obstacles the government must navigate.

There are many in the country in high places, diplomats included, who think

the 80,000 target to be " delusional " (the word was actually used), and the

government faces all the classic problems of drug procurement, adequate

financing, astonishingly limited capacity, and weary, crumbling

infrastructure.

But nothing will stop them. They are as a nation obsessed. They have trained

three specialized health professionals --- doctor, nurse and counselor ---

for 54 treatment

sites across the country, and undoubtedly, given the level of commitment,

that number has grown since my visit. They have worked out a drug

procurement arrangement involving a tripartite coalition of the National

AIDS Council, the Ministry of Health and UNICEF. They have resolved, with

goodwill on both sides, outstanding funding differences with the Global

Fund, and resources are now flowing.

They have decided that treatment will be free in all public health

facilities, fully recognizing that this makes all the difference in the

world to the principle of access, especially access for women. They have

accepted the routine testing approach, and are focusing in particular on

patients with TB, working from the logical premise that co-infection rates

of TB and HIV are very high. My

meeting with the National AIDS Council and Ministry of Health officials on

treatment roll-out was one of the most thorough and impressive discussions

that I have yet attended.

The demand for treatment is overwhelming. In every facility, there are

waiting-lists. It is estimated that there are now approximately 9,000 people

in treatment, and the additional numbers to reach the target of 44,000 by

June this year can be found in the ragged lines of the desperately ill that

fill the hospital waiting rooms.

The biggest challenge is unquestionably capacity. In the health care sector

alone, there is an annual attrition rate within the Ministry of Health of 15

per cent, and a

vacancy rate of 67 per cent. There are five government pharmacists in the

country. The Ministry of Health has a total of 103 physicians in all

facilities. There are ten districts in Malawi without a Ministry of Health

doctor, and four districts without a doctor, period.

Based on the rough norm for Africa, Malawi should have 12,000 nurses; there

are just over 4,000. In 2003, 500 hundred nurses graduated; 70 of them ended

up with the Ministry of Health; 108 left the country, 90 for the United

Kingdom. Of the 126

obstetricians/gynecologists who are required, there are 11, leaving a 91%

vacancy. There is an 85% vacancy rate amongst surgeons and a 100% vacancy

for pathologists. All of the figures were given to us by departmental

officials, and though they may be out by small factors here and there, the

overall picture is inescapable: no, the overall picture is dreadful.

It was recently said --- so we were authoritatively told --- by a senior

DfID official, that Malawi's capacity problems were second only to those of

Afghanistan!

Nonetheless the government perseveres and will not be daunted. And in one of

the most innovative initiatives in Southern Africa, Malawi, funded chiefly

by DfID,

is undertaking a six-year $283 million capacity building plan in the Health

sector that is

extraordinary in its design and intended implementation.

Will they make it? I think they will. And I have taken this time to

emphasize why it is that '3 by 5' has become the sine qua non of treatment

in Africa. It is driving the agenda.

As in all other visits, a number of predictable patterns emerged: the

situation of women is truly desperate, and although there are plans afoot to

address the issues, little has changed on the ground; the situation of

orphans is, as everywhere, numbing in sadness and complexity, and although

there is a Plan of Action to address the needs of the estimated 900,000

orphan and vulnerable children, it has yet to be funded and implemented;

there continues to be widespread

food insecurity and malnutrition, some 1.3 million to 1.6 million people

forever experiencing hunger. In fact, highly reminiscent of a trip I made to

Malawi with , Executive Director of the World Food Program,

exactly two years ago, the repeated pleas for food were amongst the most

depressing experiences of the visit.

But as always there are images of vivacity and pain co-mingled. In a

community, just outside Lilongwe, we were taken to an orphan setting called

Consul Homes. Sustained purely by volunteers, with projects around the

country, encompassing nine thousand orphan children, it has managed to

create an environment of fun and purpose and support and hope for orphans,

widows

and grandmothers. The concentration is very much on psycho-social support

for the children, with everyone joining in, and a mere modicum of training.

But it works

because the emotional and psychological well-being becomes the prevailing

rationale.

The children had created their own " OAU " , standing for Orphans Affairs Unit,

where the elected " President " , and members of parliament, all between the

ages of 8 and 16, regularly meet to debate the issues of the day. I had a

glorious encounter with these

youngsters, who raised everything from fees for secondary school as a bar to

attendance, to sexual violence against young girls, to children with

disabilities. It was all conducted in such a tenor of mixed solemnity and

touches of hilarity as to make the ravaging ills of the world fade into the

nether distance.

Before leaving Consul Homes however, I met with seventy-five widows and

grandmothers, all of them beset by hunger and orphans. We talked for quite a

while. It confirmed for me, yet again, that grandmothers are emerging as the

heroes of the African continent: no one gives them their due; few

acknowledge that society and its children could not exist without them; no

special provision is made for their food or clothing or shelter or

healthcare or emotional needs. Does no one recognize that the grandmothers

of Africa are the ultimate and final expression of gender

inequality? All that awaits them is death.

The trip to Tanzania was just last month. It encompassed all of the elements

of the visit to Malawi, except that I traveled more widely --- to Zanzibar,

Mwanza and Arusha, as well as Dar es Salaam --- and managed to have a

lengthy and productive discussion with President Mkapa.

Tanzania is curious, in some ways inexplicable. As in all other countries,

there is a profound yearning for treatment, but it seems to get confounded

in all manner of ways, large and picayune.

The adult prevalence rate is 8.8 per cent. It is estimated that 450,000

people need antiretroviral treatment now, and consistent with '3 by 5'

goals, the government is aiming for 220,000 by the end of 2005. The first

tranche of intended treatment would reach 44,000 by June.

But there have been endless difficulties, and Tanzania is only now gathering

itself together.

Originally, the roll-out was slated for March of 2004; it was delayed until

October. There was, for a time, quite a dispute with and within the

diplomatic community, about how realistic the treatment goals were. Could

they possibly be achieved given the limits on human capacity? There was a

running contretemps over Global Fund monies, now it would seem, largely

resolved. Tanzania was even affected more than others by the delisting of

certain generic drugs, that is, taking them off the WHO pre-qualification

list . it happened at a most inopportune moment (I spent an inordinate

amount of time explaining that delisting didn't mean the drug couldn't be

used). And just when they were ready to proceed, the packs of 'starter

drugs' (special dosages required in the first fifteen days) weren't

available. And of course, as always, the limits on capacity undermined

resolve.

But Tanzania has also done some strikingly intelligent things. The

government has determined that treatment will be free. It has also

determined that the treatment regimen will consist of generic fixed dose

combinations (FDCs) which undoubtedly provides the greatest treatment

potential because the cost to the government of generic drugs is so low. The

treatment potential is further enhanced because the FDCs are but one tablet

taken twice a day so that adherence rates are very high. Further, in a

thoroughly reasoned move, Tanzania has resolved any potential competitive

difficulties with the US AIDS Presidential initiative (PEPFAR), by arranging

that the Government of Tanzania would provide the drugs for first-line

interventions (the great mass of treatment), and PEPFAR would provide the

drugs, free, for second-line interventions, as well as providing the

paedeatric medications. This seems an excellent compromise (although the

PEPFAR drugs are not yet in the country).

But seemingly inconsequential matters can turn best intentions on their

head. When we visited the hospital in Zanzibar, there were 195 people on the

list for immediate treatment, but they weren't receiving it because a) the

hospital had no CD4 counter, and they felt they were obliged to do CD4

counts before they could proceed (a misconception as it turned out), and

they didn't have the starter drugs. I raised these matters with the

President of Zanzibar who was appropriately appalled, but to this day I

suspect that treatment has not yet begun.

Why not? Because somehow the desperate sense of emergency has just begun to

grip the bureaucracy. The President is fully engaged, but his appeals to

urgency are only now penetrating the wider political establishment.

What is hopeful, however, is the feeling that the miasma is in methodical

retreat. What is hopeful is the incontrovertible fact that the government

has trained four to six health care professionals for each of the 60

facilities where treatment will be offered. What is hopeful is the

sophistication and competence of the leadership and membership in both the

Ministry of Health and the National AIDS Council. The change in priorities

can't come soon enough. Everywhere we went, people were clamouring for

treatment.

As in every visit, something arises which speaks to the broader issues. In

the case of Tanzania, there were two such episodes.

First, in a large gathering of orphans in Zanzibar we were faced with a

small number of children who needed treatment. But there was an insidious

philosophic assumption that these children wouldn't get treatment, that it

wasn't available for children, that they would simply live out their brief

young lives.

It's a classic commentary on the human condition that children always come

last. In the instance of antiretroviral therapy, the scenario for children

is, quite simply, doomsday. Incredibly enough, we don't even have paedeatric

formulations . when treatment takes place --- a rarity amongst rarities ---

doctors and nurses fumble over breaking capsules into several pieces to

estimate the dosage for a child, or scramble around to find a syrup

solution. It's bizarre.

For some reason, beyond the capacity of the mind to identify, we've all

blithely assembled the apparatus of treatment as though children don't

exist. But the numbers are paralyzing: in 2004, 510,000 children under the

age of 15 died worldwide of AIDS; 640,000 were newly-infected; two million,

two hundred thousand were living with the virus, at least two-thirds in

Africa.

How has it come to this?

Second, on both the mainland of Tanzania and in Zanzibar, I met with formal

groups of People Living with HIV/AIDS ... the people with the courage to

declare themselves and to take public stands on and against the pandemic.

Their stories rang true: no one in authority listens to them, no one in

authority consults with them, no one in authority offers treatment, no one

in authority expresses concern except on public rhetorical occasions.

There's a deep and abiding bitterness to all of this.

And it tends to be quintessential of Africa. It is a matter of continuing

concern that lip-service almost everywhere characterizes the attitude and

behaviour of government towards organized associations of People Living with

HIV/AIDS. It's hurtful and it's painful. All the blather in the world about

banishing stigma and discrimination can't mask the pall of rejection subtly

conveyed by governments.

On the other hand, by way of vivid contrast, one of the strengths of

Tanzania, is the phenomenal organization against the pandemic at district

and village level. When I traveled into the hinterland, especially in and

around Mwanza, I was stunned by the detailed planning for prevention and

home-based care activities. There were endless community committees to deal

with HIV/AIDS, working relentlessly to carry the message of prevention from

household to household. And there was a culture of caring, not notably

different from others, but made real by virtue of the support from the

district officials. I talked to families, and local luminaries, and

adolescents and elders and widows and grandmothers and orphan children, and

they shared such a collective solidarity, and they got such pleasure out of

supporting each other that I could scarce believe it. Of course it doesn't

apply across the board; there are, I am certain, great reservoirs of

alienation and isolation. But I very much had the sense that when the

government gets its treatment rollout into gear, the entire country,

district by district, will be galvanized.

A final word. In both Malawi and Tanzania, the UN country team was clearly

valued and respected by Government . the relationships were first-rate. This

isn't always the case. But in these two countries, there was the feeling

that the UN had a decisive role in pricking the leadership into action, and

then sustaining it. More, the expanded theme groups on HIV/AIDS were clearly

working, with great potential for that coarse and vulgar word we know as

" harmonization " . I am more and more convinced that faced with the greatest

calamity humankind has ever known, the UN family should be courageous,

impatient, outspoken, bold, demanding, provocative, helpful and ineffably

appealing.