No Time to Lose: A Life in Pursuit of Deadly Viruses (41 page)

Most crucially, Premier Wen Jiabao had agreed to an audience on Monday, June 13, and this was to be one of the most interesting meetings of my life. It took place in Ziguang Ge (the Hall of Purple Light) in Zhong Nan Hai, the
really
Forbidden city, banned to ordinary mortals, which is next door to the old Imperial Forbidden City well-known to tourists. In this complex of buildings—a mixture of traditional Chinese architecture and a more Stalinist style, with an artificial lake surrounded by precisely manicured gardens—the top echelons of the Communist Party of China live and work. I was prepared for a rather difficult conversation. I wanted to raise the subject of HIV in prostitutes and drug users, as well as the ongoing serious human rights violations of HIV-positive people and AIDS activists, several of whom had been beaten up or arrested. So as usual I had a little note tucked up my sleeve with a number of talking points, all of them grim.

Without wasting time with the usual expressions of diplomatic nicety, Premier Wen came straight to the point—after all he is a geologist. He said, in essence, “I know what the problem is; just tell me what works to fight AIDS, and be specific. Forget who we are, I would like to know what works, and we will then see what can be done in our context. I realize these drug users are not only criminals but are also ill, and we should treat them as patients.”

Instantly, my task became easier. After commending Premier Wen for his leadership on AIDS and praising Gao Qiang, the new minister of health whom I respected and liked a lot, I went for it, discussing the need for much more openness about the problem and the fact that although the virus is spread by behaviors that might be illegal or socially unacceptable, to protect society as a whole and ensure the much cherished
xiaokang
(harmony in society), you need to work
with
the people affected, not just jail them. For those who use drugs, you need substitution therapy, clean needles, and humane, medically proven substitute treatment. For prostitution, I said it was not my business what China as a nation decided to legislate, but I had been coming to China since the late 1980s and it was striking to me that in many hotels I stayed there were obviously several prostitutes, so it was essential to make sure that this commerce was done safely to protect the women and the population. I also pleaded for countryside training programs for police forces and the Ministry of Public Security, because although Premier Wen may personally have shaken hands with AIDS patients, policemen were still harassing them.

It was one of most open and direct conversations I had with someone of his stature. Premier Wen was an impressive man, he thanked me after one hour of discussion in front of a large number of dignitaries who had taken note of every word, and promised to follow up. Two days later on Wednesday I was scheduled to give a talk to the Central Party School of the Chinese Communist Party, something few outsiders have done, and nobody from the UN until then: they are the guardians of orthodoxy, and they train all the future top leaders. I spoke about AIDS as one of the great challenges to society and the need to solve such “secondary” contradictions as Chairman Mao had written in his famous essay and speech—I had done my homework for the school. At the unavoidable banquet after my speech, the director of the Party School made a final toast to my speech, concluding (that part in English) “party (has) two meaning [
sic
] in English, and we are good at both.
Gan bei
(bottoms up)!”

The following day, China’s State Council issued a progressive new decree on AIDS that could not have been more concrete. Some pieces of it were literally translated word for word from UNAIDS documents, so it must have been put together very rapidly: it would be hard to present better evidence of our influence. It highlighted the need to fight discrimination against HIV-positive people, and the need for needle exchange programs and drop-in centers for methadone treatment, along with specific targets and a commitment to specific budgets. And all this, they delivered.

The cluster of medically transmitted AIDS cases in Henan was still a tricky issue. I had mentioned it to Premier Wen; I talked about blood safety and suggested a fund for compensation of those infected and their orphans. He admitted that “we have not been good at being open about this problem” and I got the distinct impression that he himself did not have a clear grasp of the statistics. China is a far less centralized country than many people think; regional governors are very powerful and in Henan they seem particularly secretive. No one significant was ever punished for it, and there must have been powerful people involved for the information to have been suppressed.

Much earlier in 2001 I went not to Henan but to Shinxan-Wuxi county in Shanxi province at the northern border of Henan, where the problem was similar although smaller in scale. In the mid-1990s people had been paid to give blood, some of which was returned after the plasma was separated out, in highly unsanitary conditions mixing blood from several people, some possibly infected with HIV. A very high proportion of the donors developed HIV infection and died. I met eight of them at the Warm Heart Center (hard to believe that such a name was chosen for a very cold and isolated cement building). They still had no treatment in 2001 and were condemned to death without antiretrovirals. The whole landscape of the area was blighted, an industrial wasteland of small coal mines and pollution; you almost couldn’t see the sky for smog, and I could hardly breathe. When I had dinner with the governor back in the provincial capital of Taiyuan (again over 3 million inhabitants) I said, “Well, I’m here to talk about AIDS but I can imagine you have some other major health problems, with respiratory disease and lung cancer and so on.” His response: “No! Why would you think that?” and lit another cigarette. It was total denial. Things that were not supposed to be simply were not. It was only in July 2007 that I was allowed to visit the villages in Henan province where most of the victims of the criminal blood donations had lived, and many died. I was surprised to see that the blood trade had initially brought prosperity to the community before bringing death. Greed in its most macabre form.

Despite all this encouraging progress, it was “one country, two systems” (as China says about its relationship with Hong Kong), for the AIDS response. In 2006 I visited another southern province, Guizhou, that had over 60 “rehabilitation and detoxification” and “methadone maintenance treatment” centers for a population of just under 50 million. In Zhijin County I visited re-education-through-labor facility, along with some officials from the Ministry of Health in Beijing. (None of them had ever visited such a facility.) It was a prison inhabited by pale young men in gray pajamas, nine in one cell with an open toilet in the corner. They were confined in their cell until 2
P.M.
and had to study for six months the one-page house rules, which were the only thing on the wall of their cell. While we were talking I could see several of them shaking, possibly from withdrawal pains, and one fainted as I spoke. There was no medical treatment; if they became too violent they were strapped down. You could see the menace of the place: these men were clearly absolutely terrified of the guards. From there we went to a Western-style drop-in center for supervised methadone treatment, and needle and syringe exchange. Nearly all the drug users had spent time in a detoxification camp and were afraid of being sent back. One told me that it was a matter of luck or of police bribing capacity whether to end up in the methadone clinic or in prison.

But in general, China began moving forward quite swiftly with a much more rational response to the epidemic. The following year, when I met with the Chinese ambassador in New York, I was startled when he pulled out a copy of the speech I had given at the Central Party School, highlighted with yellow marker, and asked questions about the exact significance of various statements I had made. Apparently all Chinese Communist Party members were required to study this document: undoubtedly my most widely read speech.

BY MID-2005, SOON
after China switched sides and joined the ranks of the rational, I found I could no longer hold off the pressure from UNAIDS board members who wanted an official strategy statement on HIV prevention, as this would then not only be official policy for the whole UN system but also provide authoritative guidance for countries. I had for years been ducking this task, because I feared that what would emerge in a board made up of member states with highly divergent positions would be a more or less meaningless and diluted document, when what we all needed was clarity. To be at all meaningful, a prevention strategy needed strongly worded positions on gay and women’s rights, needle exchange and drug substitution programs, and interventions for safe sex, including within the context of prostitution. Purnima Mane, Jim Sherry, Ben Plumley, and I worked intensely behind the scenes to generate overwhelming support for our position, and particularly to neutralize the opponents to needle exchange programs, though that was interpreted as capitulation and weakness by harm reduction activists as I deliberately kept publicly quite silent while preparing the board meeting. The document was hotly debated for three days until late at night, but eventually all except Russia and the United States agreed to harm reduction policies, with countries like Japan and Sweden not objecting. Thanks to the flexibility of the PEPFAR leadership, the United States did not block the consensus, as long as we would add a footnote saying that it could not be forced to support needle and syringe exchange. For the first time the world had an agreed HIV prevention strategy, and the basic principle of “combination prevention”—that it takes multiple interventions to stop this epidemic—was formally anchored in global policy. I hoped that this would put an end to the
fata morgana
of the magic bullet solution for HIV prevention, but that turned out to be wishful thinking. In addition, as with so many things in AIDS, knowledge and technology evolved, thanks to continuing major investments in AIDS research, and more recently our armamentarium to reduce HIV transmission became far more extensive than in 2005, with circumcision of men, antiretroviral treatment as prevention of HIV transmission, and vaginal microbicides and pre-exposure prophylaxis (taking antiretroviral drugs before exposure to HIV). The challenge now is to customize the optimal combination for different populations.

HUMAN RIGHTS ISSUES
were never far away when working on AIDS. They were not just part of our values, but we had learned that discrimination and stigma were major impediments for both prevention and access to treatment. Therefore AIDS-related human rights promotion was an essential part of our work. There were extreme cases of violence and even murder, targeting women or gay men infected with HIV. The brutal murder of Gugu Dlamini in her community on the outskirts of Durban, South Africa, in December 1998 after she had appeared on TV, where she talked openly about being infected with HIV shook the world, but it was by no means a unique event. As typically occurred in such cases, no one was ever found guilty of her murder. Another major obstacle to HIV prevention were laws criminalizing consensual sex between adults of the same sex, which is the case in 76 countries, punishable by death penalty in seven countries, including Iran, which has executed more than 4000 people for homosexuality since 1979. So I had to raise this issue in my meetings with numerous prime ministers and presidents—not always easy, to say the least.

Quite often UNAIDS had to intervene when once again HIV prevention workers or activists were harassed, arrested, or incarcerated—usually when they were working in the homosexual community, such as in several African countries, in Central America, or in Nepal, or with drug users and prostitutes. In China, AIDS activists were regularly picked up by public security agents, and we tried to find out where they were held to negotiate their liberation. We intervened with the authorities, and a few times even provided legal assistance.

In a truly surrealistic, but unfortunately very real, case, a Palestinian doctor and five Bulgarian nurses accused of having deliberately infected over 400 children with HIV in a hospital in Benghazi were prosecuted and repeatedly tortured. As so many others had, I tried to convince the Libyan authorities to free the medical workers; there was absolutely no evidence for their alleged crimes. But the madness of the Kadhafi regime was only fueled by the volatility of AIDS. Later, in December 2005, I thought I had found an opening during a breakfast with President Obasanjo in the Villa—the presidential residence in Abuja—as I felt an African-inspired solution might be more acceptable to Kadhafi than pressure from the West. Obasanjo immediately called the Libyan ambassador to Nigeria and asked for a discussion with Kadhafi on this, suggesting also some form of compensation for the children in return for the liberation of the health professionals. Nothing happened until July 2007, when French and European Union efforts resulted in the liberation of all six.

Another major issue I had to deal with throughout my tenure at UNAIDS was travel restrictions for people with HIV in over 20 countries, even for a brief visit, such as to the United States. This complicated our work at the United Nations in New York, as we always invited people living with HIV to participate in events we organized. Some had to lie about their status, and others were marked with a special status. It was so unfair, and from a public health perspective unjustifiable in a country with more than 1 million people already infected with HIV. As a result of this travel ban going back to the Reagan presidency, no international AIDS conferences could be held in the United States. Fortunately, following the lift of the travel ban by the United States in 2009, other countries followed. Even China abolished its travel restrictions in 2010, but Russia once again chose to remain on the side of obscure policies.

MUCH OF MY
time was spent on better coordination of AIDS efforts among various agencies, and on the Global Fund to Fight AIDS, Tuberculosis, and Malaria, with its numerous board and other meetings. It was clear that without the Global Fund AIDS treatment and prevention was plainly inaccessible in many countries, as the US AIDS effort by necessity had to concentrate on a limited number of countries. So, ensuring its success and continued funding was one of my top priorities, and UNAIDS country staff spent up to half of their time working on Global Fund proposals and ensuring smooth implementation once a grant was awarded. The fund was able to jump-start HIV treatment in a minimum of time, and by 2011 it had committed $22 billion in 150 countries—a remarkable achievement by any means.
These funds were
also mobilized thanks to relentless campaigning by grassroots activists, the Global Fund, and public figures such as Bono, Nelson Mandela, Bill Gates, and Kofi Annan.
As a completely new type of international organization, the fund had to invent its entire modus operandi, and it often went through rocky times managerially. After too long an interregnum, and two turbulent board meetings in which developing and high-income countries became very antagonistic, Michel Kazatchkine was elected as its second executive director in February 2007, winning the ballot with a very small margin from my deputy Michel Sidib
é
. A true Parisian intellectual and passionate AIDS physician with Russian roots, Michel Kazatchkine was an old friend from the days he headed the French National Agency for AIDS Research, and it was easy to harmonize our messages. We particularly worked together to raise money during a series of “replenishment” conferences to fill the coffers of the fund. I admired the fund for its transparency: you could find details of their grants, expenditures, and audit reports on their website—a model for the international system, even if their courageous exposure of corruption or poor management in some of their grantees sometimes turned against the fund. However, I was frustrated by a fairly dysfunctional board, with donor countries micromanaging the fund secretariat but not providing strategic direction and holding the developing countries hostage to their conditionalities, and because few board members had the guts to refuse to endorse the ever-escalating demands from activists for more money, even when those demands came from countries that had hardly started to implement the previous grant. I was further annoyed because, until recently, the Global Fund was financing AIDS, TB, and malaria activities in so-called middle-income countries that were well able to fund these activities from their own domestic budgets.
This failure of governance, combined with management challenges and the international financial crisis, led to the fall of Kazatchkine. Safeguarding and fully financing the Global Fund is vital for defeating not only AIDS but also malaria and TB.