No Time to Lose: A Life in Pursuit of Deadly Viruses (25 page)

All this and much more went through my head in that first sleepless night after I was appointed. The only real measure of our success would be in lives saved.

THE DAY FOLLOWING
my nomination, I went to UNDP, UNFPA, and UNICEF (which are based in New York), as well as to some of the permanent missions to the UN. Immediately the discussions moved to battle stations. The heads of cosponsoring agencies had determined that the new AIDS program should be staffed by people on loan from existing agencies. In other words, I would get people whom they did not want to keep or people whose loyalties lay with the agency that was paying their salary. They also wanted the cosponsoring agencies to determine our budget envelope, which WHO would “administer.” It was my belief that this was intended as a consolation prize for Nakajima, since in losing AIDS, WHO had lost its biggest program. Furthermore, the cosponsoring agencies wanted us to “coordinate” their work, but to have no programs on the ground. We would be a simple secretariat, as weak as possible. The impact we could have would be close to nil.

Now my mind was buzzing with questions of a wholly different kind. First, I wanted clear answers to two basic questions: who was my boss; and who had the right to hire and fire. The agency heads wanted me, as director of the AIDS program, to be accountable to them. But I argued—throwing around some big words here—that we were necessarily accountable to the people and, that, in UN terms, meant governments. My boss should be an executive board, on which should be represented not only governments but also people with HIV and NGOs. I wanted to feel answerable to the people who were on the front line. Such a thing had never been done in the UN, but for me it wasn’t in any way ideological. I just felt I couldn’t do a good job without them; anyone who was part of the problem needed to be part of the solution. I also felt that I could not at the same time coordinate the programs implemented by six UN agencies and be accountable to all six of them; it was a recipe for nonaction and nonaccountability.

Moreover, I wanted the new program to have a small but strong central core, and I wanted us to have offices in affected countries that would be in charge of all the UN’s AIDS efforts, staffed by people whose one main commitment would be fighting the AIDS epidemic. There were also a number of other key questions to thrash out: what size budget we would have at our disposal; how to channel it to countries and for which priorities; how to fully involve the various UN agencies; how to create incentives for them to act together in a harmonious way. It was going to be a long, long series of battles. I had only 12 months in which to define, structure, and staff a new UN organization: we were due to become fully operational in countries in January 1996. I suspect that WHO was convinced I could not pull all this off, and that after a year or so it would all just go back under WHO’s control. So I kept a low profile and let them feel secure in that opinion, until such time as I would be strong enough to raise my head. As I had heard in Seattle, “The first whale to surface is the first to be harpooned!”

It was around this time that Kofi Annan sent me a note. He was head of UN Peacekeeping Operations back then, and I had met him to discuss the problem of peacekeepers infecting Cambodian women with HIV. (Later, of course, Kofi Annan became one of the most distinguished secretaries-general of the UN.) His note read: Congratulations, Peter, and now let me tell you a story. There’s an old man who feels he is going to die. He tells his two sons to come with him into his fishing boat and row him out into the ocean. When they row so far that he can’t see the coastline any longer, he tells them to stop and says, “Sons, let me tell you. The sea is full of sharks. So don’t fall into the water. And if you fall into the water, don’t bleed.” Good luck, Kofi.

I’ve thought about that story many times as I’ve navigated the choppy waters of multilateral politics.

MY PRIORITY WAS
to bring together a top-notch team to build the secretariat in Geneva and a few key countries. At first most of my core people came from the WHO Global Programme on AIDS, in particular the administrative staff, who initially were firm guardians of WHO orthodoxy. They knew how to move money and job descriptions through the system, but it took several years for them to develop a more can-do culture and shed their determination to follow WHO’s habit-encrusted rules. I sought advice from trusted friends who had not been involved in the interagency negotiations, which I now had the dubious honor of chairing.

Dr. Seth Berkley, who was then working for the Rockefeller Foundation (now head of GAVI, the Global Alliance for Vaccines and Immunization), offered me the use of their center at Bellagio, in northern Italy, for a brainstorming seminar. So in February 1995 I invited a dozen people there for a weekend. It was a discreet little meeting, and we had agreed that there would be no record or report: this way people could speak their minds. I subsequently used this approach occasionally, particularly when I felt we were not progressing enough or when there was the need for a strategic reorientation. I wanted to hear from all kinds of people and take in what they thought we needed to do. Besides Berkley, attendees included Jim Curran, head of AIDS at the CDC; Jean-Baptiste Brunet, the young French epidemiologist with whom I had first visited Lubumbashi; Rob Moodie, an Australian public health specialist who had worked at Médecins Sans Frontières; Roland Msiska, the director of the Zambian AIDS Program; and Winston Nzulu, the Zambian activist who encouraged me to run for the job of director; Susan Holck, seconded from WHO, who introduced me to the labyrinth of the UN; Noerine Kaleeba, founder of TASO (which had just received the prestigious King Baudouin Prize for Development); and Werasit Sittitrai, a Thai AIDS activist with the Red Cross. Three representatives of development agencies instrumental in the creation of our new entity of UNAIDS also joined us: Jo Ritzen from Norway, Joe Decossas from Canada, and Hans Moerkerk from the Netherlands. Not a terribly representative group, but one I could rely on.

Basically we designed the core functions and structure of the new program. The first task was going to be to develop solid data on HIV and AIDS, worldwide, from Albania to Venezuela. This wasn’t just for policy purposes. Sure, sound epidemiological data and mathematical modeling are essential to any kind of program, scientific or sociological: they predict, they illustrate, they are the baseline for evaluating the impact of what we do. They also give power: if you’re trying to coordinate the work of many actors, it’s key to be at the hub of knowledge. To make AIDS a higher priority in terms of policy and budgets, we needed an unimpeachable reputation for solid facts; they make the news, and they give credibility.

But although hard evidence would be the basis for our policy and advocacy, we decided that, with the exception of epidemiological estimates, we would not engage in research as GPA had done. It seemed to us that we would have no comparative advantage against major AIDS research funders with huge budgets, such as the US National Institutes of Health or the European Commission, and that it could divert from our core business. So our first core functions besides political and resource mobilization were knowledge translation, policy development, the evaluation of policies and action on AIDS, and dissemination of real-world good practice regarding AIDS.

Clearly our program had been set up to coordinate the UN system’s response, but I strongly felt that coordination for coordination’s sake is not only a brain killer but also would probably lead the new program to focus exclusively on administrative and political processes, with hardly any impact on people’s lives. It was neither my strong point nor my interest. I felt our most important test would be how well we could support the response against AIDS in countries, on the ground: this was how I wanted to be judged. All of us agreed that if we were just a Geneva-based headquarters, we would be irrelevant, both for governments and for the people, and we would fail. So who should we work with: The Ministry of Health? of Finance? The office of the president? The nonprofit private sector? Business? Community groups? Religious entities? Where would our office be based? How would it relate to the rest of the UN system, and other administrative/political bodies?

Thus we planned a series of regional consultations on every continent, to be organized by Dr. Purnima Mane, a tiny, energetic woman from Mumbai with an infectious laugh, originally a social scientist specializing in gender issues and a real powerhouse. I saw these meetings as a kind of customer research: we wanted to bring together a wide range of actors, from governments and academics to people with HIV, and ask them, “What do
you
think will work?” They would also serve to try to wake up local leaders and provide an opportunity to market the new program and to recruit staff.

Finally, we picked out a name for the new program during the Bellagio meeting: UNAIDS. The working title had been “Joint and Co-sponsored United Nations Program on HIV-AIDS”: you couldn’t even figure out the acronym. “UNAIDS”: that says what it is. My then fifteen-year-old daughter Sara designed the logo: a red ribbon over the UN logo, as straightforward as a teenager can be. But when I went to the first formal meeting of the cosponsoring agencies in Vienna and proposed the new name and logo, there was an instant bracing of spears. I ultimately won the case, but it was a struggle, and this pattern became a very familiar one. Sometimes the issues involved were trivial, but I often felt like Gulliver: hobbled and hamstrung, when what I needed was help. At the end of the Bellagio meeting I asked Rob Moodie and Werasit Sittitrai and Noerine Kaleeba to join our staff. It was a real act of faith for them, and I am still grateful that they took the professional and personal risk to come in and help build something that really only existed in a few UN documents. Rob organized our country work, Werasit our prevention activities, and Noerine marshaled community-based action.

Dr. Susan Holck, Mike Merson’s former right hand, was key at helping me maneuver through the UN and the endless coordination meetings of the first six months. Then Sally Cowal, a former US ambassador with a long history of postings in various countries, joined as director of External Relations. Sally was dynamite: one of the first female US diplomats who could stay on after she got married (until 1972, married women were banned from the US Foreign Service), she brought us some much needed diplomatic savvy, even though patience was not her greatest feature. She was good friends with some heavy hitters in the US government.

My senior team was complete when Dr. Awa Coll-Seck, an infectious disease professor from Senegal, joined us as head of policy, strategy, and research. Awa was one of those strong West African women, brave and pragmatic. She had pioneered AIDS care in her country and was a cofounder of the Society for Women and AIDS in Africa. (She became minister of health and then head of Roll Back Malaria.) I also asked Jim Sherry, whom UNICEF had tried to use as a kind of killer dog against our program, to change sides and become my special adviser, as I felt that my lack of experience of the UN system and of multilateral politics might prove to be a major handicap. He was a real political operator, with the capacity to see through apparently innocent proposals at a glance, and was of tremendous help in building a broad coalition against AIDS.

So by April I could count on a dynamic and totally committed team. We felt we could move mountains. Each of them then recruited the best possible people in their respective fields. We recruited people from a wide range of backgrounds—academia, economics, journalism, activism.

Quite early on, I also ordered media training for all the senior staff, including myself. I wanted UNAIDS to speak clear, loud, and with professional skill. We needed to catch the media’s attention and use it as a foghorn—a massive, permanent amplifier. I thought about how astutely Jonathan Mann had done this, translating the problem to journalists, ordinary people, and politicians: getting them to see what they had to do. In contrast I was, initially, frankly useless at interviews, particularly on live TV. I found them terrifying; and I was still a typical academic, accustomed to stating the problem, discussing what methods you use to examine it, and what the conclusions might be. By the time I reached my main message most people had switched to another channel.

The media training was an eye-opener, an awful experience: the trainers videotaped us in fake interviews, and played them back so we could see every excruciating hesitation and mistake. Then they told me to forget everything I might have learned ever since medical school about the scientific method. Throw it away. Cut to the chase—when you start talking, begin with your conclusion. If there is still time left, know exactly what other message you plan to deliver. Carve the message out so it’s clear. And always mention the “brand”: UNAIDS. I found this first experience of professional communication illuminating; it was as if I had always been waiting for it. And I think I became quite good at the job of coming up with messages and campaigns and themes: Making the Money Work; AIDS—A Problem with a Solution, The Three Ones, and so on.

Retrospectively I made a mistake when I agreed that our program could be housed within the WHO campus. I also should have broken more radically with their bureaucracy. The old WHO Global Programme on AIDS was still operational, and it was very uncomfortable to cohabitate between the past and the future: It also didn’t help that many of their staffers knew they would be losing their jobs. I will be forever grateful to Stefano Bertozzi, an American physician and economist, who was a master at neutralizing the tactics that were deployed by Nakajima and some of his regional directors to undermine us. After Mike Merson left WHO to become dean of Public Health at Yale University, Stefano Bertozzi had the unenviable task of closing down GPA and that included firing several hundred people. Stef was a man for all seasons and all tasks—a brilliant, if sometimes absent-minded, man and the finest multitasker over the age of thirty whom I have ever met. I sought his advice on major professional issues since we met in Kinshasa in the early nineties (He is now director of AIDS and TB at the Bill & Melinda Gates Foundation in Seattle.) But together, we wasted too much time fighting with the Nakajima administration, which would flex its power over almost every issue, from recruitment to procurement and travel.