No Time to Lose: A Life in Pursuit of Deadly Viruses (39 page)

These were also very difficult times for the UN and for multilateralism in general. Relations with the United States were at an all-time low because of the war in Iraq, and before that the food-for-oil scandal, which considerably weakened Kofi Annan and the UN system as a whole. Despite the extreme stress that he was under, Annan kept a keen interest in the AIDS response, and relentlessly lobbied for the cause, ably assisted by his chief of staff and then Deputy Secretary-General Mark Malloch Brown, who was equally supportive. In December 2005 Annan sent a very unusual note to all UN country teams, directing them “to establish a joint UN team on AIDS . . . with one joint programme of support.” In other words, Annan was directing UN country teams to do what UNAIDS was supposed to establish, and to become a flagship example for his efforts to “Deliver as One,” as the UN reform report was titled. In UN terms this was a bold move, as formally the secretary-general has no authority over specialized agencies. Several commentators went on to depict UNAIDS as a “success story.” To the outside world, we at UNAIDS were an “example” of UN reform and joint action. This was nice to hear, but I felt we still had a very long way to go in this area.

NOT EVERYTHING WENT
as smoothly as it looked from a distance. If prevention of sexual transmission of HIV was fraught with emotions, moral judgment, and heated academic debates, it was nothing compared to the passion and the inability to think rationally when it came to drug use. The combination of heroin and HIV epidemics was perhaps my greatest policy challenge. One place where we failed to inspire an adequate response to the epidemic was the former Soviet Union. In late nineties it was becoming obvious that there was an explosion of HIV in Russia, driven by the use of heroin. This was something we had not anticipated in any of our epidemiologic scenarios—a gross underestimation. But while courageous epidemiologists such as the soft-spoken Vadim Pokrovsky, head of the Russian AIDS Center, whom I had met during a brief visit in 1988 to Moscow, published one alarming paper after the other, the Russian government was implacably opposed to the reality being revealed. So as usual, I decided to go into the lion’s den. In the end of November 1998 I went to Moscow to launch our annual report on the global state of AIDS for World AIDS Day, which is celebrated on December 1 every year since 1988. This was of great interest for national and international media, and close to midnight at the end of an exhausting day I gave my last live interview for the French TV station Antenne2. It was my scariest interview ever: I was sitting on the slippery ice-cold ledge of an open window on the eleventh floor of the Russia Hotel near the Red Square so that French TV viewers could see the Kremlin in the background. I had a serious fear of heights, and had a really hard time concentrating on the camera, but I smiled when I thought how my life might end falling on the heads of a group of prostitutes and bodyguards with automatic guns who were laughing loudly underneath the entrance of the hotel. It took many skills to be executive director of UNAIDS. In any case, our efforts paid off, and for the first time worldwide media picked up the rampant spread of HIV in the countries of the former Soviet Union.

I actually liked Moscow with its history, museums, and metro, and even more the Russians themselves. They were very cultivated and warm people with a great sense of humor mixed with a some special form of
weltschmerz
and a sense of not being understood by the rest of the world, even if I definitely could not follow the vodka toasts at the numerous banquets I had to attend (dinners with all 12 ministers of health of the Community of Independent States—all former Soviet republics—were the greatest challenge, as my toast could only come after all the countries had made theirs). However, in spite of my love for the classic Russian authors and some solid friendships, relations with the government were always very tense.

We mostly interacted with the chief sanitary physician of the Russian Federation, Gennady Onishchenko, who was a very old-Soviet style man of my age with a GI haircut. Talking with him was like talking to a wall. Russia was a very homophobic society, and as for drug users, the authorities seemed not even to understand why we cared whether they lived or died. I attended preparatory meetings for the Eastern European AIDS conferences between 2005 and 2008 with Onishchenko publicly bullying NGOs and gays. The UNAIDS representative at the time, Bertil Lindblad, an experienced Swedish diplomat, was highly respected locally and helped me considerably with the UN Special Session on AIDS. He was fluent in Russian and had built a vast network of both influential Russians and civil society activists—as I expected him to do. Bertil lived in one of the huge landmark “wedding cake” buildings from the Stalin area, and hosted dinners for me so that I could hear versions of the AIDS situation in Russia other than just the party line. The AIDS activists were very courageous young men and women, who operated in a system with little tolerance for dissident views and were always short of money.

The old Soviet Union had had a decent public health system and sanitary infrastructure, combined with a huge and often coercive surveillance system for infectious diseases, but after the fall of the wall there was a sudden cessation of funding of the public health sector, the rise of a brutal free market economy, and a general collapse of traditional social norms. Epidemics of all kinds were bursting forth in the 1990s: not just AIDS, but also diphtheria, hepatitis, typhoid, and sexually transmitted infections. Except for some isolated cases of HIV, nearly always imported from abroad, in 1988 during the Soviet Union era about 250 children had been infected with HIV by their doctors and nurses, mostly because of reuse of unsterilized syringes and catheters at a hospital in Elista, Kalmykia. Some of the infants even transmitted HIV to their mothers while breast-feeding, probably through a cracked nipple. There were other, smaller outbreaks of the same kind elsewhere. In April 1998, I visited an institution just outside St. Petersburg for HIV-positive children, many of whom had been infected by faulty medical treatment: they were essentially abandoned. They had arrived undernourished at the hospital, and nurses and children begged for my help, but what could I do? It was an incredibly depressing experience that would haunt me. I think the authorities were so secretive about this partly because it was such an indictment of the Russian medical system.

The hospital spread of HIV among children was tragic, but the scale of the AIDS epidemic among adults went out of control at the turn of the century. By 2005 around 1 million people or just over 1 percent of the adult population was infected with HIV, even if the Russian authorities rejected the UNAIDS estimates (they only accepted a number based on the officially registered cases of around 300,000). It was a young epidemic, and an epidemic among the young: 80 percent of HIV-positive people were under twenty-nine years of age, and 40 percent were women. Initially, the overwhelming majority of people with HIV were injecting drug users. So, addiction and social breakdown were at the heart of the epidemic in Russia and other ex-Soviet countries, such as the Baltic States and Ukraine. However, many of the mainly young people who became infected through sharing contaminated needles and syringes were not classic drug users, and it was not just heroin coming from Afghanistan (introduced by Afghan war veterans). More often these were occasional weekend users, sharing locally produced ordinary opiates such as
kompott
among friends, which made the spread of HIV even more difficult to control: harm reduction approaches like needle and syringe exchange and substitution treatment for opioid use are less likely to work for occasional users.

There was a whole corps of physicians in Russia known as
narcologists
, who specialized in addiction treatment—not to the mega epidemics of alcohol or cigarettes, but to opiates—and these people were a huge obstacle to any rational approach to dealing with drugs—meaning a combined approach of education to prevent people from using drugs, treatment for addiction, repression of drug trade, access to clean needles and syringes, and oral substitution therapy with methadone and other substances. Their approach was basically to put the
junkie
in a cold room and often beat him, and if he resisted in any way, to then confine him in a straitjacket: I am barely exaggerating. There was no medical treatment at all, and the Russian government up to this day subscribes full-heartedly to this approach, although a punitive-only approach to drug addiction only drives drug users underground. The narcologists were particularly adamant in their opposition to gradual treatment of addiction through the use of methadone, which has been the cornerstone of opioid dependency treatment in the United States since the early fifties. By delivering orally an addictive substance, methadone, that doesn’t give the “high” of recreational drugs but does remove the craving, methadone facilitates the beginnings of a dialogue with addicts, so you can start the difficult process of treatment and resocialization. It also keeps them away from injections that transmit infections that will kill them and others. In particular, Russian prisons were an absolute incubator of disease, through overcrowding, rape, and shared needles. (It wasn’t just AIDS: there was also tuberculosis, one piggybacking on the weak immune system created by the other. Exacerbating the problem, much of the TB was drug-resistant.)

Russia is one of the countries I visited the most, but without much impact. I knew Russia’s leaders were sensitive about demography. The population had been in decline since the fall of the Soviet Union, despite immigration, because of low birth rates and very high mortality, especially among men. This affected the quality of the armed services, productivity of industry, and the future of the nation from just about every point of view. Even with a modest 1.1 percent prevalence rate of HIV, AIDS would exacerbate demographic decline in Russia much more than in an African country with much higher HIV prevalence but an annual population growth of 2 to 3 percent. I thought this could be my entry point for a breakthrough in our discussions with Russian officials, but it never happened. In contrast to nearly all other countries where I asked for this, I never managed to meet the then head of state, President Vladimir Putin, but I am not sure whether it would have made a difference. In democracies, where there’s a responsive system of governance, there’s no real need to meet the top man, but I had learned that in more authoritarian traditions the state leader has a massive impact even on fairly minor things. However in 2006 in the running up to the G8 Summit in St. Petersburg—the first ever in Russia—I met the then First Deputy Prime Minister Dmitri Anatolyevich Medvedev, who would become Putin’s successor as president. Medvedev listened carefully, recognized that the country had an AIDS problem, and announced that the State Council Presidium had just decided to establish a national coordinating authority on AIDS—a breakthrough—but also confirmed the government’s opposition to methadone as “non-scientific.” This was very disappointing, but I didn’t give up, and continued to advocate for better and more humane HIV prevention, working closely with media figures Vadim Pokrovsky and Russian speaker Michel Kazatchkine, the new French head of the Global Fund, and with groups such as AIDS InfoShare, Médecins sans Frontières, Open Health Institute, and even with the Russian Orthodox Church. During an audience with Patriarch Alexy II, I agreed to support a training program on AIDS for priests, as the Church was increasingly filling a moral and ideological vacuum after the fall of communism. I also went on media-covered street visits to see HIV prevention work with sex workers and injecting drug users—their living conditions, personal misery, and constant harassment by the police were horrific. Sadly, none of the visits made a difference for official policy, although they did for local initiatives. However, by then Russia was providing antiretroviral treatment to people with AIDS, but basically only to “good citizens,” and often at a cost above that in the West, probably because of the involvement of several middlemen.

At the end of a conference of G8 health ministers in Moscow in April 2006, J. W. Lee, director-general of WHO, and I were sharing a laugh in the hotel lobby about the absurdly choreographed meeting. This was the last time I had some social time with J.W., who was in good spirits, though looking extremely tired. He unexpectedly died on May 22, 2006, from subdural hematoma, just before the start of the annual World Health Assembly meeting. Even though competitors for the election of his position, we had developed a good relationship, and I was sad. (As so many told me afterward, I also thought of the extreme stress of this kind of position.) The irony of history was that I ended up sitting next to a chatty Margaret Chan on the flight back home from Moscow to Geneva. We had met a decade earlier in Hong Kong where she was director of health, and she was now in charge of pandemic influenza at WHO, which badly needed an entrepreneurial woman such as Margaret. Even during Lee’s funeral service I was approached by several countries to run again for the position, which I found shocking. I quickly decided that this time I would not run: I had no confidence in the electoral process of WHO and felt there were at least two excellent candidates in Julio Frenk and Margaret Chan. (Chan won, becoming the first Chinese to head up a specialized agency of the United Nations.)

Russia’s western neighbor, Ukraine is the country most severely affected by HIV in Europe, with half a million people or 1.5 percent of all adults being HIV positive—more than France, Germany, and the United Kingdom combined. At the turn of the century, Ukraine had the most progressive AIDS policies in Eastern Europe, with drug substitution officially allowed since 2003. I visited its historic capital Kiev several times to ensure that the politically unstable country would continue its more open AIDS activities, each time nearly starting from zero with the new minister of health. I was also focused on narrowing the gap between national policies and local practices—despite clear national policies to the contrary, intimidation and even prosecution of HIV prevention workers by the police had started again in cities like Odessa, where over half of all injecting drug users are HIV positive. Each visit was closely prepared by Anna Shakarishvili, the Georgian UNAIDS representative, with people like Vladimir Zhovtyak and Natalia Leonchuk from the All-Ukrainian Network of People Living with HIV at whose founding conference I spoke, and with the International HIV/AIDS Alliance from Brighton, United Kingdom, which was the main foreign supporter of AIDS programs. As always I did not limit myself to official meetings, but also roamed through the huge apartment complexes in Kiev’s suburbs in freezing-cold temperatures to observe needle and syringe exchange programs managed by former drug users. The clients for these clean needles were not what people may expect as junkies, but included a working woman walking her dog, a man with groceries on his bicycle, and other people you cross all the time on the street. These encounters were a precious source of information for my interaction with officials. My last visit to Kiev was in 2008 with Crown Princess Mette-Marit of Norway, who was a very active UNAIDS ambassador, as was Crown Princess Mathilde of Belgium—my favorite princesses because they were smart and combined great class with genuine human empathy while remaining down to earth and approachable, though traveling with them involved numerous security and protocol constraints. They were great allies to bring the AIDS message to the public and indirectly to decision makers across Europe. I was always amazed by the princess effect on people.