No Time to Lose: A Life in Pursuit of Deadly Viruses (37 page)

Still, it was not always easy to maintain a good relationship between UNAIDS and the Global Fund. Initially the fund was fairly arrogant and rejected anything that had been done before; I imagine we may have been a little like this in the early days of UNAIDS vis-à-vis WHO. Perhaps UNAIDS was also too protective of its turf. Sometimes a small and silly incident created serious tension. In 2004, at the enormous International AIDS Conference in Bangkok, I lost a folder of documents. (This is a great failing of mine; when I was a child my mother would tell me I would lose my head next.) The folder, which I had placed beside a sink in the men’s room, contained a confidential note from me to Kofi Annan about the latest Global Fund board meeting. My notes tend to be fairly clinical, and perhaps too forthright for diplomatic reporting, but what is the point of oversanitized reports where everything must be read between the lines? Thus I had discussed in my memo some difficult discussions about the fund’s performance and accountability. Within 30 minutes, my note appeared in the media center, which always loves a good controversy. The fund felt that I was undermining them, and the relationship became a bit strained for a while, until Feachem and I had lunch in my favorite Japanese restaurant in Geneva. Another storm in a teacup, but poor Achmat Dangor, my new director for advocacy and communications—working at his first international AIDS conference, always chaotic—had to manage the damage and handle the press.

Since then I have been careful what to take to the men’s room, but I have not changed my style of reporting. Achmat is one of South Africa’s great writers, and one of my favorite novels is his
Bitter Fruit
, which, thrillingly, was shortlisted for the Man Booker Prize in 2004 while he was working at UNAIDS. He was unflappable, soft-spoken, and thoughtful. He understood domestic and international politics, having played a part in the antiapartheid struggle, and is now CEO of the Nelson Mandela Foundation in Johannesburg.

The international AIDS conferences continued to swell both in their attendance and political influence. The 18th conference in Barcelona, Spain, in July 2002, attracted 17,000 participants, and for the first time, heads of state and senior politicians attended. The general mood was upbeat. Barcelona is one of my favorite Mediterranean towns, with its eccentric architecture, warm people, and tapas bars. However, my attendance got off on the wrong foot as the police had intercepted e-mail messages with death threats to me, and I could only walk around with a bodyguard.

Wanting to push the momentum further, I gave quite a militant speech at the opening ceremony before the assembled luminaries. I said, “Let us bring forward the day when leaders who keep their promises on AIDS are rewarded—and those who don’t, lose their jobs. That’s not negotiable!” In the corridors that week, people shouted at me “Not negotiable!” but some took it very personally—as I thought they should. After activists prevented US Secretary of Health and Human Services Tommy Thompson from giving his speech, he blamed it on me, grossly overestimating my influence on AIDS activists, who occasionally would heckle me as well. Then the activists grew upset with me because I was quoted in
The New York Times
as saying I disapproved of their heckling of Thompson; I feel strongly that we should not censor people even if we disagree with their opinions.

It was important not to break up the broad coalition in the fight against AIDS. We still needed to mobilize money, and you don’t do that by yelling at the people who control the purse. Barcelona was also the moment when Bill Clinton emerged as a major player on AIDS, with announcements of further price reductions of antiretrovirals brokered through his foundation, and high-visibility events with his acquaintances. The other Bill, my friend Bill Roedy, organized an MTV debate with young people that gave Clinton an opportunity to display his unique popular charm, bringing the AIDS message to a few hundred million teenagers worldwide.

In a far more intimate event, Clinton’s former AIDS czar Sandy Thurman organized a breakfast attended by Mandela and his wife Graca Machel (the only woman who has been married to two presidents); President Jorge Sampaio from Portugal, a thoughtful intellectual who was the only European head of state at the AIDS Special Session in 2001; President Paul Kagame, the master strategist of Rwanda; and Inder Kumar Gujral, the eighty-three-year-old former prime minister of India. We discussed how to engage more top leaders in the fight against AIDS and how to boost financing for the Global Fund. The coalition was broadening into spheres never before attained by a health issue.

Then something took me completely by surprise. On August 23, 2002, I had a regular working lunch with Gro Harlem Brundtland to discuss our collaboration. Later that Friday afternoon (a classic time to bring out difficult news) Gro stunned her staff and the public health community by announcing that she would not seek a second term as director-general of WHO. She had not made the slightest allusion to this in our meeting a few hours earlier. In five years’ time she had already built a lasting legacy at WHO. Her Commission on Macroeconomics and Health showed that investing in health is good for economic growth—until then, the conventional wisdom had held that the opposite is true—and most important, she had negotiated the Framework Convention for Tobacco Control, a binding treaty that commits signatory governments to take action against the biggest killer of our time. Nonetheless, Gro had not been able to turn around the hidebound culture of WHO or improve the quality of its work in developing countries; to do that would have required another term of five years.

Brundtland’s resignation was alarming. We had developed a constructive working relationship of mutual support, even if we did not agree on everything. She surrounded herself with capable experts, but I knew that the WHO bureaucracy still largely perceived UNAIDS as an interloper, and I feared that her successor might direct the agency to return to the constant harassment of the previous regime. People from outside UNAIDS started suggesting that I run for the WHO director-general position, saying that it would be the best way to ensure that WHO would play its part in AIDS, and finally operate in harmony with the rest of the UN system But I was initially not interested as I felt that there was still so much to do against AIDS.

I truly did not care about the power or prestige of the WHO job, but I wanted the position to go to someone competent and caring for health in the poorest populations, as well as a genuine collaborator on AIDS. Too often the executives of international organizations were not chosen on merit alone but as a result of international power relations leading to some real horse trading. Of course I understood that international politics has to play a role. Votes are traded for geopolitical support, for development aid, or, even worse, for plain corruption. Paradoxically what seems the least democratic, an appointment by the UN secretary-general, has often led to better leaders (and certainly more women) in the UN system than elections, which is the rule in so-called specialized agencies such as the World Health Organization.

One of the main candidates to succeed Brundtland was Pascoal Mocumbi, the prime minister of Mozambique, a medical doctor with a decent record of government, and also, incidentally, a friend of mine. From the beginning Mocumbi was the front-runner, and the world-leading medical journal
The Lancet
was subtly campaigning for him; many said it was “Africa’s turn” to lead WHO. I went to see the young Belgian Prime Minister Guy Verhofstadt for advice, because if I were to run I would need my own country’s support first (only candidates nominated by their country are eligible). Verhofstadt was terrific. Belgium would support me, he said, but there would be no deals, no kickbacks, and no buying influence. I was proud of my country and officially became a candidate.

Then Julio Frenk, minister of health of Mexico decided to run. He had been one of Brundtland’s assistant directors-general and was also a good friend of mine, and honestly he might have been the best choice. But at the last minute Dr. Jong Wook Lee stepped up, a South Korean who had been working at WHO for 20 years.

After my own board meeting early December in Lisbon, I took leave from UNAIDS, put together a campaign team, and traveled nonstop to lobby nearly all 32 members of the WHO executive board who would vote at the end of January 2003. These were probably the most exhausting eight weeks in my life, and on Christmas day in Cairo, Egypt, I almost fainted from fatigue. Election campaigns are an endurance test as much as a strategy challenge, and also a test for resisting conflicting pressures and not losing your integrity. Issues like abortion, patent rights, the interests of the food industry, and the power of WHO’s regional offices were regularly raised but hardly any country asked for a vision on how to strengthen WHO in a changing world.

It took seven rounds of secret ballots to elect a new director-general. During the voting rounds I was sitting in my office filling in overdue health insurance and other forms to do something useful. After each round of voting, one ambassador in the closed room of the executive board called me, in Spanish, to report the (confidential) results of the latest ballot. After the vote was twice deadlocked between Lee and me, I lost the job when one country switched sides, according to diplomats present in the room, following an intervention from the US representative. The position went to J. W. Lee, whose Foreign Ministry had been aggressively lobbying board members. Remembering Kofi Annan’s advice from 1994—“don’t bleed”—I was the first one to congratulate Lee in front of the South Korean TV cameras. I was too exhausted to feel sorry for myself, and invited all my supporters to a big party at my home. Later Lee and I developed a habit of having dinner together nearly every other month when we were in Geneva, and we would drink Tignanello from Tuscany and he would tell me how South Korea had negotiated the votes. The dinner bill was always left for me to pay.

Obviously I was disappointed, but retrospectively, I would have to say that failing to get the director-general position was not a bad thing for my life. Paradoxically it strengthened my political standing, because I lost by one vote, and everyone in the UN system and in diplomatic circles knew that I had been a completely clean candidate. They saw the support I had in developing countries: it seemed that every African country on the board except Eritrea voted for me, even though there was an African candidate, Mocumbi, who was an honorable man. Losing the election also put my ego back in the right place.

After the vote I flew to Nepal for a gathering of UNICEF staff and young people from Asia with Carol Bellamy, the workaholic New Yorker who as head of UNICEF had become a great ally. While in Kathmandu I sat down (on the floor with my legs crossed, and could hardly get up after an hour) to talk with 25 prostitutes who were members of a group called WATCH. They told me about the hardship of their lives, and daily violence from their customers, the police, and their husbands. It was very moving and a sobering antidote against the intoxication of an election campaign. Then I did something I had always wanted to do: I went to the beautiful colonial town of Antigua in Guatemala for a fortnight of total immersion in Spanish, and learned about the history and suffering of indigenous people of the region. It was my consolation prize.

IN THE MIDST
of this process, President George W. Bush’s request for $15 billion for AIDS relief, made during his State of the Union address on January 28, 2003, took nearly everyone by surprise. Few people, including in his own party, had anticipated such a bold and truly game-changing step from a conservative president on what had always been seen as a “liberal” issue. I realized that
something
was cooking. I appointed Michael Iskowitz, a most unlikely but very agile operator, to be the UNAIDS representative in Washington. Iskowitz was a gay man with a ponytail who had been a staffer for Ted Kennedy and a series of other Democrats in Congress. (I developed profound respect for congressional staffers: they are the people who write the questions for the ferocious congressional hearings, for example, and they often have deep knowledge of a surprising range of issues. Iskowitz was one such.) In addition to his encyclopedic intelligence, Iskowitz also had very solid links to a number of Republican senators. Just one example: he had convinced conservative Jesse Helms from North Carolina to cosponsor legislation to fund the fight against AIDS in Africa, and he had convinced Senator Orrin Hatch from Utah to support the UNAIDS contribution in the Senate.

We had been working very closely for some time with Anthony Fauci, my old cosponsor from Projet SIDA, who was the head of the National Institute for Allergy and Infectious Diseases in Bethesda. Mainly we provided data on the epidemic and on funding needs. (Our investment in statistical expertise was paying off.) By the end of 2002 Fauci’s requests for more information were starting to come in thick and fast, so I grew convinced that something big was in the air, and I learned later that our data were instrumental in setting the level of the new US effort. Political Washington was starting to engage in a big way: Bill Frist—a cardiac surgeon who became the Senate majority leader—and Senator John Kerry launched a high-powered AIDS Task Force at the Center for Strategic and International Studies in Washington, of which I was a member. AIDS became (and still is) a rare bipartisan issue in US politics.

The day before President Bush’s State of the Union address, Iskowitz called me and said, “There’ll be a big announcement tomorrow and we need to be sure we’re ready to catch the ball.” Then came the announcement: the creation of a President’s Emergency Plan for AIDS Relief (PEPFAR), a five-year, $15 billion initiative to combat AIDS around the world. Ten billion of this was completely new funding, beyond
the United States
’ existing commitment. It was the largest health initiative ever launched by one country to address a disease, and it blew me away: not only the sum of money, but the fact that over half of it was earmarked for
treatment
. PEPFAR’s goals for 2010 were to provide antiretroviral treatment to 2 million people with AIDS in poor countries; to prevent 7 million new infections; and to support care for 10 million people (the “2-7-10” goals).