No Time to Lose: A Life in Pursuit of Deadly Viruses (40 page)

WHEREAS MOST HIV
infections in India are due to sexual transmission, in the Northeastern states injecting drug use was the driver. In the states adjacent to Burma such as Nagaland, Manipur, and Mizoram, where about 1.5 percent of adults were HIV positive, heroin was easily accessible from their neighboring country. There was also a particularly nasty form of addiction among young people who were taking a legal substance—Spasmoproxyvon (dicycloverine hydrochloride), sometimes prescribed for intestinal colic—mixing it with water and injecting it like heroin. It made their veins hard as the powder does not dissolve in water and accumulates at the point of injection, blocking the blood flow. I could feel their veins like stone pipes running down their arms and legs. They developed abscesses, had body parts amputated, and died from infection. And because possession of a needle was a criminal offense in India they also shared needles; thus many were HIV positive.

This was a
legal
substance, of dubious pharmaceutical added value; the government could easily have withdrawn it from the market. In addition, people were shooting other over-the-counter substances such as buprenorphine and dextropropoxyphene, as well as amphetamines massively produced in Burma. After a visit to the region with senior officials and members of Indian Union and state legislatures, the government promised to legalize programs for methadone substitution, and restrict the sales of Spasmoproxyvon, but implementation of the promise took years.

In every way, India was a far more responsive society to rational argument of this nature than Russia was. Albeit a bit slowly, democracy always got its way, with cross-party consensus through an All Parliamentary Forum on AIDS, which the always smiling and serene Oscar Fernandes, a yoga adept and catholic king maker of the Congress Party, had launched with a few allies from other parties. I visited New Delhi and many states of this huge country numerous times. Initially I was overwhelmed by the never-ending crowds of people and the loud pushiness of many Indians, but after a while I loved the country and its rich culture. The real problem became how to respond to the numerous dinner invitations from my growing number of always very hospitable friends and keep my weight under control. Thus in July 2003 I addressed the largest AIDS event ever in India, sharing the podium with the then Prime Minister A. B. Vajpayee, as well as Sonia Gandhi, the leader of the opposition, and Manmohan Singh, the future prime minister. Getting such consensus in the brutal jungle of Indian politics is no small achievement, but just as in the US Congress, AIDS transgressed political enmities. After initial strong denial of AIDS, the formidable machinery of the India Administrative Service got its act together by setting up NACO, the National AIDS Control Organization, supported by World Bank loans. It had some remarkable leaders: Prasada Rao, who gave it solid foundations and a strategy; S. Yacoov Quraishi, the great communicator on AIDS and later the chief election commissioner of India (I occasionally sing in his rock band); and the exuberant Sujata Rao, who solidly anchored the management in every state, working with community groups that had become very vocal, particularly the women’s groups such as the Positive Women Network (PWN+). PWN+ was founded by a tiny woman from Tamil Nadu, Kousalya, who was infected when she was twenty years old by her husband, whom she had to marry to keep property in the family. Her story was typical of many Indian women with HIV, but she fought for survival and recognition of the rights and needs of women with HIV in India. When I first met her, her English was hard to understand, but she later became a board member of the Global Fund and regularly spoke at international events. Another key initiative in India was Avahan (“call to action” in Sanskrit), a very large HIV-prevention project among the most at-risk populations, led by former head of McKinsey in Delhi, Ashok Alexander, and funded by the Bill & Melinda Gates Foundation. These combined efforts led to real achievements, with a significant decline in new HIV infections and increasing access to HIV treatment. Better AIDS programs throughout the country also meant better epidemiologic data, and in early 2007 it became clear that UNAIDS had overestimated the size of the HIV epidemic in India: we now had empirical data from over a thousand sites in this vast country, as compared to just over a hundred before, and, equally important, we had data from India’s huge rural population who turned out to be far less infected with HIV than we originally thought. I did not hesitate for a second to go public with this downward revision of HIV estimates, knowing that we would have to go through some difficult moments. UNAIDS indeed came under attack, and conspiracy theories about my deliberately inflating HIV estimates to raise more money for AIDS even made it to the front page of the
Washington Post
, when they managed to get access to an incomplete draft of our report. It was another tough moment, but our message to the world was that we put scientific evidence before political communication and, in any case, influencing epidemiologic estimates was a nonstarter, because the UNAIDS epidemiological data are generated in a process that involves literally over a hundred experts. Nothing was confidential in our work.

ADDICTION TAKES OVER
the life of not only the drug user but often family and the environment as well. One of the most moving meetings I had was in Jakarta, the chaotic capital of Indonesia, in 2003, when HIV began to spread among drug users in the country. Because of the enormous stigma of AIDS, groups of people with HIV could not even rent a space to meet, so the UNAIDS office created a safe space for all kinds of community groups. One such group was made of parents—in fact mothers—of young injection drug users with HIV. Their stories of human suffering, of bribing the police to get their children out of jail, of financial ruin, were heartbreaking, and again I felt powerless, but also more than ever determined to fight for a humane approach to substance abuse. During that trip I also met another remarkable young Asian woman living with HIV, Frika Chia Iskander, who was seventeen years old when she became infected with HIV as a drug user in Jakarta. Frika was then shy and struggling with her identity as a person with HIV, but gradually became one of the world’s best-known and respected AIDS activists, and a great spokesperson on AIDS.

THERE IS THE
real world of drug users with or without HIV infection, and there is the often surrealistic world of drug policy makers, many of whom have never even spoken with a drug user, a social worker, a prison guard, or a doctor treating addicts. As much as I hated it, I felt that in my position I had to bring the human realities of drug use to the Commission on Narcotic Drugs—the world body that since 1946 annually reviews the global drug situation. It is the governing council of the UN Office on Drugs and Crime, UNAIDS’ seventh cosponsor. In April 2003, it was that time of the year to go to Vienna, where this commission meets, with most members coming from law enforcement agencies. Justice and police versus public health. After I detailed the ravages of HIV infection among drug users and the scientifically proven methods to bring the HIV epidemic among drug users under control, I was attacked from many sides, except for some European countries and Australia. A Japanese deputy minister was very upset with me, and nearly yelled, “Would you give needles to your son?” That was the level of debate. Some “harm reduction” activists also challenged me because when I said that we must do everything we can to prevent people from using harmful drugs and to treat addiction, they felt this was code for a pure police approach against drugs. I thought, one tunnel vision against the other. The head of the UN Office for Drugs and Crime, the Italian economist Antonio Maria Costa, was ambivalent about harm reduction, because two of his major donors, the United States and Sweden, were firmly against this approach. Many countries still have not accepted harm reduction techniques and so suffer thousands of painful, entirely avoidable deaths. Scientific evidence without political will has little impact on people’s lives, and politics going against evidence can harm people.

JUST AS FOR
about anything in China, AIDS was a special case and required a specific approach. For years leaders failed to grapple with the reality of the epidemic, despite a huge cluster of contamination among people paid to donate plasma (this almost certainly amounted to well over 100,000 people, although the authorities admitted to no more than 35,000, in itself a high number) mainly in Henan province. HIV also spread among drug-users in southern provinces and via sexual transmission in the most entrepreneurial regions that were driving the Chinese economy: places that featured the “Three Ms”—Mobile Men with Money, as one man told me in a bar in Guangzhou. In the nineties Chinese AIDS patients were often punished or jailed when they were found to be HIV positive, and there was massive discrimination.

In June 2002, we issued a report entitled “HIV/AIDS: China’s Titanic Peril,” warning that China faced an epidemic of “proportions beyond belief.” The UNAIDS representative in the largest country in the world, Emile Fox was a man of practical jokes from one of the smallest countries, Luxembourg, and had added as a subtitle a quote from Napoleon: “When China will wake up, the world will tremble.” This hit a nerve, and we nearly had to close down our office in Beijing: in fact Kofi Annan called me (on a Sunday afternoon!) to warn me to change tack. He said, “Peter, you’re a brave man, but nobody has ever won against China. So start building bridges, because we need China on board and that’s not the way you’re going to change anything.” Annan was right and, in any case, our own epidemiologists were unhappy with the prediction that China would have as many as 10 million cases of HIV in the not too distant future—that estimate was not based on serious evidence. I went to China at least once a year, trying to establish a relationship of trust with various officials, urging a more robust and responsible approach, and basically acting like a fox terrier. I met with low-ranking officials at the Ministry of Health, then moved slowly up, many banquets later establishing a kind of friendship; in the meantime, I tried to become a familiar face at the Ministry of Public Security, the Ministry of Foreign Affairs, the Ministry of Labor, in several key provinces, and with Communist Party officials. Once you become a familiar face, you can build confidence and get a sense of who is calling the shots, to better understand what their main concerns are. My French friend in Beijing, Serge Dumont, was a precious adviser on how to operate in China. Serge is a fluent Mandarin-speaking gentleman who was considered the founder of the public relations industry in China in the 1980s before the current Western interest in doing business in China. As President for Asia of Omnicom, he seemed to know everybody who counted and organized the first private fund-raising event for AIDS in China; I appointed him as Goodwill Ambassador for Asia in 2006.

Things began changing on World AIDS Day 2003, when Premier Wen Jiabao visited a Beijing hospital and shook hands with AIDS patients. The SARS epidemic of 2003 with its huge economic cost (though very limited in terms of victims) was a wake-up call, and Iron Lady Vice-Premier Wu Yi was temporarily put in charge of the public health ministry. The Chinese government also announced that it would provide free antiretroviral treatment to AIDS patients who couldn’t afford it, and promised free HIV testing, free treatment to prevent mother-to-infant transmission, free infant HIV testing, and financial assistance for AIDS orphans (known as the “Four Frees and One Care” policy). Still, these were mainly announcements, with few indications that the situation was massively changing on the ground. However, I gradually got more access to address sensitive issues. Thus after a meeting with Madame Wu Yi in the Great Hall of the People in May 2004, where she asked me to report back on my observations, I was allowed to visit a rehabilitation-through-labor camp in Guangdong province (near Hong Kong). It was a sobering experience: hundreds of women who were accused of prostitution or “antisocial” behavior were working in total silence in large factory halls, making small bracelets and cheap decorative ornaments without ever looking up. I was asked on the spot to give a speech to the women, and I asked the women a few question to learn what they knew about AIDS. Two replied with a decent answer, and all I could think of was to ask the commander to free the women before their normal time. I can still not look at small ornaments without wondering who made them in China.

There were groups of people with HIV in every major town, and I sat down with them at each visit. They were still very isolated in society, and at risk of police and other harassment. As everywhere, they were supporting each other and sometimes used art to express their existential feelings. One of them, Xiao Li, member of the Home of Loving Care in Beijing, gave me a moving calligraphy with a poem expressing his feelings about when he discovered that he was HIV positive: “I was lonely and confused / I finally understand a full answer to life is never an option / . . . it reignites my dignity and determination / when deprived of wings / we can fly with our vision / . . . so come by my side, fellow fighters and friends / together we shall conquer Mount Everest . . .” Another reminder not only of the universality of poetry but also of suffering and the desire to rise above crisis.

What 2001 was for the global AIDS response, 2005 was for the AIDS response in China. In June 2005 Randy Tobias, the US global coordinator, Joel Rehnstrom, the phlegmatic Finish UNAIDS representative in Beijing, and I went to Yunnan, the province with the highest HIV prevalence in China—an estimated 80,000 people with HIV out of a total population of 44 million. Yunnan is a beautiful mountainous region with great ethnic diversity and Kumming, its capital, has a population of over 3 million people in its urban area alone. Many of them gathered every evening around the lake of romantic Cuihu Park to drink the local vintage
puer
tea, sing, and dance in small groups in the open air. The province had introduced quite progressive HIV policies over a year before, as we could see in Gejiu City near Burma. We visited a methadone treatment and needle exchange clinic, a change from the traditional draconian cold-turkey-and-beating style of operation, though the latter approach continued to exist as well. The next day brought a rather comical surprise: on arrival at the Yunnan Police Academy where we funded an education program on AIDS and drug use, I had to review a parade of honor guards while a band was playing martial music. While I was not expecting such a ceremony, I thought that it was great that even security forces started taking AIDS seriously.