No Time to Lose: A Life in Pursuit of Deadly Viruses (23 page)

Ketoconazole is an effective treatment for the painful fungal infections of the mouth and throat that make swallowing nearly impossible. This was a breakthrough: we had made a first, if very modest, step toward international support for care for people living with HIV. We still had to set up a distribution system to accredited hospitals in sub-Saharan Africa, which took much longer than I had anticipated. However, our biggest challenge to conclude the deal was not with Janssen, but with WHO’s lawyers, who came up with one objection after another—the organization was not ready yet to deal with the private sector.

AFTER A WHILE
I found that I was thriving at GPA, somewhat to my surprise, and that I was feeling useful. People took my advice seriously, and the officials I met (and hoped to influence) could have, at the very least, enormous nuisance power and, at best, could make important decisions. Brokering ethical guidelines for vaccine trials or recommending treatment guidelines for STDs meant that I could actually influence public health policy and shift health practice. Each step might be slow, but the ripples it created were extremely broad and their impact was real.

I started to become interested in decision-making at the highest level. I could see how political AIDS is, because it’s not just a matter of making sure the labs function and the condoms are available and the drugs stay cold: you need the political heavy lifting to have an impact. Budgets must be voted, and political will and leadership are vital. I was still planning to go back to Antwerp, because I had no desire to become part of the WHO system. But I felt that, here and now, I could deliver something very specific: rigorously constructed research projects that bound together medical queries with social science to generate the best possible evidence for policy and decision making on AIDS. When Mike Merson asked me to stay on for another year, I agreed to do it.

Mike was by now embroiled in discussions with the UN Development Programme (UNDP), the World Bank, UNICEF, UNESCO, and UNFPA (the world population agency), along with a group of representatives from major donor countries and nongovernmental organizations, about how to transform the Global Programme on AIDS. This task force, set up in April 1992 by the GPA board, was frustrated by the lack of coordination of international work on AIDS. The positive news was the that the big agencies of the UN system had begun to set up AIDS programs when AIDS started to affect their areas of activity, but as is typical of the international development system, they were doing this separately, almost in competition.

There were some strong personalities in charge of this process: Jim Sherry at UNICEF, Elizabeth Reid at UNDP. They had their own views on what to do and frankly they worked at loggerheads, laying down different policy recommendations, sometimes accusing Mike Merson of not understanding the epidemic. And all the agencies were going to the same donors and saying give the money to
my
agency, not to
his
. The donor countries, meanwhile, could see that WHO’s political and administrative modes of doing business were creating enormous inefficiencies, because routing everything through regional offices meant that a lot of money was stuck there. There was no question of corruption but often sloppy management and entrenchment: “If I’m not running this project, it won’t happen.” At the same time, major development agencies such as USAID and the UK’s Department for International Development were setting up their own AIDS programs and were reluctant to channel their money through the multilateral system over which they had less control and which did not directly benefit their own international development organizations.

There was a lot of disenchantment with WHO, which was under attack for its weak management, although Nakajima was reelected as director in 1993 in controversial circumstances. This coincided with a move by many Nordic countries and others to reform the whole UN system, and re-creating a new world AIDS program became a big part of that. In addition, a number of developing countries, especially Uganda, felt that not enough money was coming into Africa to deal with AIDS: again, the bottom line was that AIDS needed a higher profile international organization. However, the other UN organizations wanted only a weak secretariat-type coordination: they wanted to continue to run their own shows. It was an unpleasant and conflicted process. But I was not involved in this gestation. I didn’t feel emotionally or intellectually interested in it: I thought of it as Intra-UN equivocation. All I knew was Mike would disappear for a few days for some traumatic meeting with an interagency task force that was shaping the skeleton of a new UN program on AIDS, with a lot of drama and accusations of double-dealing and personal ego.

It was Hans Moerkerk who first approached me to become head of the UN’s new, reformed AIDS entity. (“Entity” was the word employed, since even the word “agency” was the subject of bitter conflict.) Hans was the chair of GPA’s board, since the Netherlands was the number one donor to AIDS. (The Dutch have a big development-aid budget, and they target it strategically: they don’t just sprinkle it uniformly, they target a handful of issues and deliver a big packet.) Hans was a “nuchter”—as we say in Dutch—no-nonsense and stubborn Dutchman, who was in charge of AIDS at the Ministry of Foreign Affairs and had been at the forefront of the gay rights movement in his country. We had become friends over the years, when he negotiated more money for AIDS, sought resolutions against blocking people with HIV from entering countries such as the United States and China, and demanded stronger accountability for international assistance. He is a smart diplomat and activist all rolled into one. But I said no. This was not for me: I was not interested in becoming a UN bureaucrat.

Then Jean-Louis Lamboray, a Belgian public health doctor who had worked for the Belgian medical cooperation in Zaire, came to town. He and I had worked on setting up outposts of Projet SIDA in Kinshasa, where we could recruit people for our research projects, add a nurse or two, train them, beef up the lab, set up a functioning freezer. Jean-Louis had joined the Africa division of the World Bank, and he was probably the first World Bank person to be interested in the impact of AIDS on African economies. In fact in the late 1980s he organized a presentation for me at the bank in Washington. In my simplistic view of the world from Kinshasa, where I had seen the influence of the World Bank in Africa, and the failures of WHO, I felt that the bank was the international institution to get on board for the fight against AIDS. So I went to Washington to make the case. It was a complete failure. I was urging the bank to invest massively in AIDS control, but the audience was mostly economists and they blew me out of the water with arguments about cost effectiveness and return on investment. I had not come with a plan, with bullet points that said each specific action will save this many lives and thus produce this positive impact on the economy. I hadn’t considered the hardnosed arguments you need to influence policy—a mistake I tried not to make again.

In any case, Jean-Louis represented the World Bank in this interagency task force preparing this new UN entity on AIDS. One day when we met for lunch he said, “We’re going nowhere because there’s no leadership and all the players are trying to undermine each other. We need a leader. What about you?” Again, I said, “You must be joking.” Director of a UN agency? I thought this meant someone with great political clout, someone charismatic, who could move politicians to make decisions and mobilize donors. I didn’t think these were my strengths.

But when I heard who the main candidates were, I thought, Why not? It was a mix of UN officials and politicians, such as Dr. Jesus Kumate Rodriguez, the then minister of health of Mexico, who was a friend of both Dr. Nakajima’s and of James Grant’s, the UNICEF director (who, incidentally, in 1990 objected to include a reference to AIDS in the Declaration of the Rights of the Child). Dr. Kumate was already seventy years old and quite conservative in his views on issues such as condom promotion. There was also Elizabeth Reid from UNDP, who was very committed to the AIDS cause, and other internal UN candidates.

I had real practical familiarity with AIDS on the ground. I knew quite a lot about a range of AIDS issues: epidemiology, microbiology, vaccines, policy, clinical, lab. I had a whole network of contacts and experts to fall back on, I was connected with activists, and I was fast acquiring experience at how to function within the UN. On the downside I lacked political experience and was not familiar with the ins and outs of the United Nations system—but that could also be perceived as a plus. So, I didn’t one day wake up with the illumination that I wanted to direct a UN agency.

At the time in 1993/1994 I was going to Tokyo almost every month. I had made it a condition of my employment at WHO that I could continue to function—without pay—as president of the International AIDS Society, to prepare the first of the annual international AIDS conferences to take place outside Europe and North America. In those days these conferences influenced the AIDS agenda in a big way, and the work of structuring them meant you could spotlight specific aspects of the epidemic and key figures of the AIDS movement because that is what it had become: a movement. My agenda was to bring in more of a developing-country perspective to these conferences, as that had not been the case until now, and to bring in networks of people with HIV and community organizations because I felt strongly that this could not be just a conference of doctors and scientists: the people affected and the NGOs definitely had a major role to play in the AIDS response, and were often the driving force to obtain budgets and get things done. I also promoted caucuses, one on women because they were marginalized at these conferences, not only as presenters in plenary sessions but also in terms of women’s issues. People were missing a whole dimension of the epidemic—not only heterosexual transmission, aspects of coerced sex, and risks in stable couples, but also how to ensure that HIV prevention programs would not perpetuate macho behavior.

Setting up the 1994 Yokohama conference was a huge headache, but it made me appreciate and like Japanese society, food, and culture. Japan bans prostitutes and drug users from the country, and nearly all Asian and East European countries even ban methadone—a form of substitution treatment for heroin addiction. We anticipated activists with big placards reading “I’m a junkie,” possibly derailing all media attention from the substance of the conference to the protests. We needed to be sure everyone would be allowed entry into the country to participate in the conference and we needed to train police and staff in hotels and restaurants that you can’t get HIV infection from serving someone at a table and so on. It was a huge opportunity to raise awareness about AIDS in Japan, where the AIDS agenda had been dominated by a scandal around contaminated blood substitutes for patients with hemophilia, and where traditionally the voice of marginalized communities has been very weak or even suppressed. I was the middleman between the official deciders and the international activist community, represented by the Canadians Richard Bruczynski and Don de Gagné, and a nascent Japanese NGO community, which included activist civil servant Naoko Yamamoto and my good friend Masayoshi Tarui, a professor of philosophy and expert on Immanuel Kant at Keio University. We convened every night at Daigo’s, a bar—actually just a tiny counter for six customers—near Shinbashi train station. Since that time, whenever I am in Tokyo, I go to pay my respects to Master Daigo and drink a few glasses of his sake with the Japanese who used to work with me in UNAIDS, such as Hiro Endo, Tammy Umeda, Chieko Ikeda, and Aikichi Iwamoto.

Decision making was painfully slow. Then one day I was invited to a shadow committee. It turns out, decision making for the conference occurred in circles. You have a big circle, where nothing is ever really decided, but ideas and opinions are gathered. Within that is a smaller circle, the first shadow committee, where fewer people are seated but have more power. I got to a second shadow committee eventually, and I still don’t know whether there was another, third, core group.

The conference was opened in great pomp by Crown Prince Naruhito and his wife Crown Princess Masako in August 1994, in Yokohama—after Nagasaki, the first port in Japan opened up to the world in the nineteenth century. It went very smoothly, although there were no scientific breakthroughs announced. These were the terrible years of HIV’s continued, apparently unstoppable expansion—years of despair among scientists because of the lack of progress in research. During the conference I began talking to friends from all over the world (some of whom I hadn’t seen for a while) to discuss whether it would be a good idea if I became a candidate to direct the new UNAIDS program—and if I were a candidate, whether I had any chance of winning. I found it was particularly my African colleagues who encouraged me, even pushed me. People like Ibrahim Ndoye, the head of Senegal’s national AIDS program, Ugandans Noerine Kaleeba from the AIDS Support Organization TASO and Sam Okware from the Ministry of Health, and Winston Zulu, a Zambian activist living with HIV. They trusted that I would speak up for them.

I had a very strong bond with the NGO community and with “Positive People,” as they were called, and they were also encouraging. Then I met with Franz Bindert, a German official whose main concern was that a European direct the new program. He said that if I were candidate, Germany would support me; moreover, because Germany held the rotating presidency of the European Union that semester, they would try to rally all EU member states behind me. I wasn’t as familiar then as I am now with the backstage power calculations of international politics, but even so, I knew that this was big news. I also spoke with other possible candidates for the job, such as my old friend Helene Gayle, who was then head of AIDS at USAID, and is now president of Care International, one of the largest private aid agencies in the world. Helene had extensive public health and AIDS experience and was popular with AIDS community groups in Africa. We agreed we would stay in touch, whatever happened, even if, as she predicted, “it would be dirty.”