HIV/AIDS in Africa – an unprecedented disaster

Remarks by Stephen Lewis at the Opening Plenary of the Council on Foundations Annual Conference, Toronto, Ontario, 26 April 2004

Thank you for so warm and amiable an introduction. Your Honour, eminent guests and ladies and gentleman.

I am profoundly delighted, tickled, flattered to be here. I love leaving the Philistines, whom I normally address, and coming to this crucible of enlightenment. I have always thought that it is useful, from time to time, for Americans to be subjected to a Canadian speaker. After all, in an act of almost supernatural generosity, we signed the free-trade agreement with the United States, thereby rescuing the American economy, and engaging in a selfless degree of self-immolation.

The other pleasure I get in a gathering like this is that it serves so deliciously my instinctive and Pavlovian egocentricity. People constantly welcome me as Ambassador Lewis, and I was telling Bill Richardson just the other night at a gathering that happened at the Kaiser Foundation Board, that in Canada the designation of Ambassador is profoundly fraudulent when you have left your tenure. Indeed, Canada has the rather savage punitive response of taking away your title and you revert to mortal obscurity again. Only in the United States are you once a Senator, always a Senator. Once a Governor, always a Governor. Once a President, always a President. The United States is sustained by titular self-aggrandisement and in Canada, we regard that with a certain bemused and quizzical affection.

I must begin with a disclaimer. I don’t want to pretend to any particular expertise on the subject matter. You will be relieved of course to know that that will not stop me from speaking. I learned a long time ago never to allow an absence of knowledge to impede opinion. I share that view with the political leadership of my own country and I therefore will disgorge what I came to disgorge. But I must say, and there is not a stitch of this which is meant to be gratuitous, I was really quite bowled over by the remarkable opening from Dot Ridings (President & CEO, Council on Foundations). I have been to many openings of a similar kind and have had to listen to vacuous, prosaic, mediocre expositions. But instead today, you got a call to principled action, and I cannot imagine a stronger opening to a gathering which is focused on leadership, and I want to thank Dot personally for having been here.

Because I don’t have particular expertise in your field and because you have so many knowledgeable people who will address you in the various streams and activities which you will engage in over the next few days, I want instead to draw out three or four different themes, attempt to reconnoitre them as adroitly as I can, and try to wend my way to some kind of symmetrical finale. The themes I have chosen are four in number.

First, it goes without saying, and everyone in this room is fully aware, that governments around the world, and particularly in the donor world, are retrenching strongly, drawing back from their prior embrace of social priorities – leaving huge gaps in the realm of human need. Whether one looks at those gaps as food banks, or homelessness, or welfare mothers, or aboriginal priorities, or indeed as my colleague from Canada, Mr Cardozo talked of – the community priorities – all of these things are increasingly undermined as governments, for whatever complex reasons, resist the human side of the equation.

I don’t regard this as some kind of unusual and unexpected evolution. I think this is, by and large, an integral part of the process of globalization, globalization as it is often manifested through the World Economic Forum in Davos, Switzerland. This is where all of the major leaders of multinational corporations, and frequently of state governments, and frequently of United Nations agencies, engage almost instinctively in a kind of orgy of triumphalism in favour of what we call neo-liberalism.

For them, there is a focus on a country’s financial architecture. They focus on debts, and they focus on deficits, and they focus on tax reductions and on balanced budgets. The question of the human dimension gets short shrift and that is what we are feeling in so many societies. In other words, it is not a moment in time, it is part of an overall gestalt. And what is so fascinating is that we are now learning that globalization has tremendous difficulty dealing with global problems, global issues.

Globalization hasn’t been able to handle poverty. That is obvious, and when I heard that line from Langston Hughes used in the first song (performed by the Nathaniel Dett Chorale), ‘where wretchedness will hang its head’, I thought to myself we are a long way from the abandonment of wretchedness. Globalization can’t handle conflicts. I needn’t elaborate. Globalization is having tremendous difficulty handling the environment. Globalization is certainly having impossible difficulty handling communicable diseases. And when all of these profoundly human dimensions cannot be handled by the basic ideological construct which drives the world, then increasingly foundations step in to pick up the slack, or, if I may put it another way, foundations step in where others fail to tread. And that is the enormous strength of foundations. And when you are dealing with leadership challenges, how you step in, where you step in, how you choose your priorities, how you reinforce the social amalgam of the human priorities – that’s what gives the foundations their fundamental strength and reason for being.

This leads me to the second point I wanted to make, which is really to underscore strongly what the Council’s CEO Dot Ridings enunciated. In the process of taking these positions, it is surely absolutely fundamental that foundations demonstrate an exemplary ethical integrity. There is, as everyone knows in this vast room, so much loss of faith in the normal processes of international society. So much loss of faith in the political construct, the corporate construct, the media construct. There is such an absence of leadership in these areas – areas which could build idealism and hope but instead build frustration. Citizens are jaundiced, they are suspicious, they are dismissive. How could it be otherwise?

Take a look at Iraq – from whatever ideological direction – and look at what it reveals about the internal processes of political decisions, and the way those decisions exclude those affected the most, and the way in which those decisions inevitably build a loss of confidence.

I don’t have to elaborate on the corporate failings, I need only use the word Enron. I don’t have to elaborate on the media failings. I need only refer to Fox News as a kind of cultural reductio ad absurdum of contemporary society. There is a certain larceny in language and in behaviour in much of the media which again removes people from a sense of confidence and engagement.

But foundations have a certain aura. You may occasionally have the bad apple, and I quite agree that they are microscopic in number. But fundamentally, foundations and philanthropy have an increasingly important place in the world. They are a sector which shows principled leadership. It is a sector to which people turn as a kind of antidote to what is happening elsewhere. And therefore the exercise on which you are now engaged is so important; it is important that you make of the foundations’ edifice something that is unassailable. And in the process, people will respond fervently and loyally, and supportively.

Which leads me to the third point I want to make. Foundations are increasingly activist and interventionist. And that means foundations are inevitably influencing public policy, inevitably making a great many decisions about public policy, and it is critically important I think that all of us reflect on the implications. Are foundations sufficiently well staffed and structured to make those decisions? What happens when those decisions run afoul of government priorities? Is there enough thought given to the kinds of decisions which inevitably follow the grantmaking process?

I see it all the time in the international work I do. Foundations are having a huge impact on what happens to developing countries. The Bill Gates Foundation sets the priorities when it decides to support vaccine initiatives or gives very significant amounts of money to India for specific purposes around the pandemic of HIV and AIDS. Rockefeller headed a coalition of several foundations in an attempt to provide treatment for mothers who were HIV positive. The mothers had taken drugs to prevent the transmission of the virus (from mother to child) during the birthing process, but the mother was often then abandoned to die. The Rockefeller consortium of foundations brought together and introduced treatment for the mother, treatment for the partner, treatment for the child, and in the process established an agenda which was embraced by nations right across the world, and particularly across the African continent.

The Clinton Foundation has just negotiated a price for generic drugs with two generic drug companies in India, which will set the standards for treatment, if treatment is possible, around the world. But that decision – with which I happen entirely to agree, and embrace excitedly – that decision runs directly contrary to the policies of the present administration of the United States. How those things get harmonized, and how a foundation thinks through the implications of what it does, relative to the political power, is something that is profoundly sensitive and worthy of contemplation.

One of the differences between Canada, my country, and the United States is that we have decided to pass a piece of legislation which will allow for the manufacture and export of generic drugs, amending otherwise sacrosanct patent law and defying the patent drug companies directly. This is making it possible to give expression to an international agreement which was reached at the World Trade Organization on 30 August last. For the Government of Canada, then, we are doing something which no other G7 country in the world is doing. There will be a great many foundations who implement public policy, and one must ask: how does all of that mesh with the broader international political environment.

Even in the tiny little foundation in which I am personally involved (the Stephen Lewis Foundation, www.stephenlewisfoundation.org), I know that every time we make a choice as to recipient, we are inevitably establishing certain policy. All foundations, whether they decide on prevention over treatment, or orphans over grandmothers, or religious bodies over secular recipients, or abstinence over condoms, whatever the choice that is made, it speaks to very significant implications in the field. And because foundations are playing an ever greater role, both internationally and nationally, it is necessary to have a staff who are tutored and knowledgeable, and who sit down and make very careful decisions about the consequences of the interventions. They have to recognize that foundations are making public policy in the absence of appropriate government policy. I feel relatively dispassionate about it. These things occur and usually they are an elixir to my soul. But I also understand that there are competing priorities, and that foundations therefore have to be centres of excellence.

And that leads me to the last point I wanted to make, which is to emphasize my appreciation for the increasing attention which foundations are paying to the international pandemic of HIV/AIDS. I don’t think there is any need here for special pleading. Just yesterday at the World Bank Meeting in Washington, an unprecedented event took place. The World Bank, and the United Nations, and the United Sates, and the United Kingdom, those four groups in particular, supported by almost every single donor country you could name, came to the conclusion that if they didn’t come together unanimously on responding to the pandemic of HIV/AIDS, this world was faced with the decimation of humankind, the likes of which we have never faced before. It is the Secretary of State of the United States, Colin Powell, who said that ‘HIV and AIDS is the greatest single threat to the planet’; he actually used the juxtaposition that it is a greater threat than weapons of mass destruction. And I don’t think anyone can take exception to that.

From my modest experience on the African continent, the pervasiveness of death breaks one’s heart. I remember being in a little Grade 5 primary school class in David Livingston Elementary School in Harare, Zimbabwe, where all the kids were aged 10. The life skills teacher was attempting to raise their consciousness about the pandemic, although these kids knew more about sexuality and the transmission of the virus and how to protect oneself and what the implications were than any group of 10-year-olds imaginable. And the teacher said rather artfully, ‘I want all of you to write on a piece of paper what bothers you most, and then I will collect the pieces of paper in this little box, and then we will pull them out one by one and we will discuss the contents.’ And on eight out of every ten pieces of paper, appeared the word ‘death’.

These are 10-year-olds. Ten-year-olds. And when they wrote what bothered them most, they wrote the word ‘death’. Death of a parent, death of an uncle, death of an aunt, death of a friend. And when the teacher asked them ‘what do you do in the face of such death?’ the children responded almost as one, ‘we pray’. And I asked the teacher afterwards what all of that meant. And she said to me, ‘Mr Lewis, if you went to funerals at lunchtime and you went to funerals after school, and you went to funerals the entire weekend, you would fully understand what it meant. That is the atmosphere for these children. That is how they live.’ And I am reminded of the fact that when you drive down so many streets of urban centres in Southern Africa now, you see a clutch of children in brightly coloured school uniforms and you think they are in a school yard … when they are actually attending a funeral.

The reality of gender and inequality on the African continent means a tremendously disproportionate number of women are being infected. Because of culture and inequality, women have no capacity to say ‘no’ to sex when there is predatory male sexual behaviour, or to say ‘wear condoms’, or to say ‘I want to negotiate safe sex’. None of that is available to the great majority of women on the continent. And, as a result, we are depopulating parts of Africa of its women. And one of the realities which has emerged over the last few weeks in a number of studies, which is absolutely shocking, is the way in which one of the most dangerous environments for women is marriage.

They are being infected by their intimate partners. They are being infected by their permanent partners. The prevalence rates within marriage are often greater than the prevalence rates in the surrounding society. And women absorb the entire burden of care. The men get infected in the city, they come back to the village to die, and the women look after them. And then they get infected, and they look after themselves. And they look after their friends, and they look after the orphans. It is indescribable what is happening and yet, these women are so strong. They are so determined to overcome the force of the pandemic and they are struggling and they are looking for international assistance from foundations like some of those in this room.

As a result of this constant wearing away of society, all of these countries are losing capacity. Most famine, earthquakes, communicable diseases, droughts strike at the very young and the very old. But AIDS strikes at people in their 20s, 30s, 40s, 50s. The productive capacity of society is disappearing before your eyes. And so in the agricultural sector where once the women did the farming, there isn’t any maintenance of agricultural productivity. You don’t have household food security because there aren’t enough people alive or well enough to farm. And the same is true in education, where some countries are losing more teachers than are graduating from teachers’ colleges. And doctors and nurses at risk of infection reflect the prevalence rates of the general population. And in the private sector, they sometimes hire two or three people for every job, so there is someone to occupy the job. It is hallucinatory. You watch these people fighting the good fight. You watch the generosity, the compassion, the decency, the extraordinary sense of heroism in the face of adversity and one has nothing but admiration. But they are struggling, in significant measure, alone.

And what we are now inheriting is the largest number of orphans that the world has ever seen. Fourteen million children under the age of 15 are orphaned in Africa. There will be 25 million by the year 2010. Everyone is reeling; no one knows how to handle it. And these orphan kids are wonderful and lovely kids as children always are. But they wander the landscape of Africa bereft, angry, bewildered, desperately searching for love, desperately searching nurturing of some kind. And the community tries to absorb them, but the community is pushed right over the edge because it doesn’t have the levels of capacity to take them in. The impoverished family can’t handle one extra mouth to feed.

And as the orphans are shunted from family to family, ever further from the core family, little girls are subject to sexual violence and the little boys are subject to child labour. They can’t even go to school because they can’t afford the school fees, or the books, or the uniforms. They end up being looked after by grandmothers. It is the ultimate violation of the harmony of life: the grandmothers bury their own children and then they look after their orphaned grandchildren, sometimes 10, 12, 15, 20 of them. And when the grandmothers die, there is no one coming up behind, so the children are in child-headed households. Households headed by the eldest sibling. I was recently in Swaziland which has a significant number of child-headed households where the age of the child heading the household is 8. How do you have a household, what kind of grotesque aberration of the human family is it, to have a household headed by a child of 8?

But I have to make it clear that we are facing something international because the pandemic is spreading ineluctably to China, India, Russia, the Caribbean. We are facing something which must engage the decent responses of all of us who have capacity. I also have to make it clear that none of this has to be happening. There is tremendous sophistication at the grass roots on the continent of Africa. And there is great strength amongst the people, particularly women, and they know how to handle prevention.

Uganda has reduced the prevalence rates significantly by using prevention adroitly, and they also know how to handle treatment, and they know how to interrupt the transmission from mother to child, and they know how to do home-based care. And the political and religious leadership is now engaged. What they lack are resources. If, through the foundation world, we are able internationally to summon some additional resources, however modest, it profoundly changes the lives people lead and gives them hope. It will make treatment possible, and it will make prevention possible, and there will be a possibility of breaking the back of the pandemic.

So without driving the nail through the wall, I simply want to conclude these remarks, perhaps with a touch of self-deluding romanticism. I have always thought of the philanthropic community as a community of inherent human decency, a community which is prompted and motivated by the struggle to advance the human condition. I have always believed that it is an ethical community. I have always believed that it has principled standards. I have always believed that it is uncompromising and tenacious in the pursuit of its goals. I have always understood that it has a certain adaptability to move from domestic to international and back to domestic when circumstances warrant. People say to me, Stephen, we have got to respond to Africa because it can be a security threat, the extremes will breed terrorism if we don’t hold these countries together. Or they say to me, Stephen, they are going to be our trading partners down the road. We have got to come to their defence now to keep trade in place.

I rather prefer the old biblical injunction that we are our sisters’ and brothers’ keepers, and that when you respond to the human predicament in another part of the world, all that is really required is a quotient of decency and compassion, and that no more need be called upon than that. And that’s what diffuses the philanthropic community. I was much, much taken by the line from one of the songs (performed by the Nathaniel Dett Chorale) at the end, that ‘you can’t plough straight by looking back’. The beauty of philanthropy is that it looks forward and there is a whole world waiting for that look.

Thank you for having me.

Stephen Lewis is the United Nations Special Envoy for HIV/AIDS in Africa.