Remarks at the American Enterprise InstituteAmbassador Randall L. Tobias, U.S. Global AIDS CoordinatorWashington, DC February 5, 2004 Thank you Jim. It’s a great pleasure to be here. Nearly a decade ago, in my former life in the private sector, I was a trustee of AEI. It is good to be back -- albeit now in a very different role.
Thanks to all of you for being here this morning, many of you representing organizations fighting the battle against HIV/AIDS, as advocates, as service providers, and as policy makers. Many of you were among the first responders to this crisis, assisting people and communities devastated by HIV/AIDS, and generating international momentum against the disease.
I stand before you today as the first United States Global AIDS Coordinator, with the extreme privilege -- and the awesome responsibility -- of leading a 5-year, $15 billion effort to combat global AIDS. The President’s plan represents the largest commitment ever by a single nation for an international health initiative. There’s been nothing like it for any humanitarian purpose, perhaps since the Marshall Plan.
As Jim has told you, late last year, he and I and my friend and colleague, Secretary Thompson -- who will be with you later this morning -- and a number of others, visited Africa, for me, the second trip since being confirmed in early October.
Again, as on my trip in October, I was struck in every country we visited -- this time Zambia, Rwanda, Kenya, and Uganda -- by the amazing work being carried out in partnerships among communities, non-governmental organizations, governments, and donors.
In part, President Bush’s decision to launch this initiative is a testament to the work of many of the organizations represented here this morning. You brought voice to the devastation of this pandemic, you helped develop strategies to combat the disease, you provided armies of women and men serving people and communities in need.
I know that many of you are very familiar with the statistics on the global devastation of HIV/AIDS. But they bear repeating as an affirmation of our commitment, and in recognition of the people who suffer the greatest burdens of this disease.
During 2003 alone, 3 million people died from the complications of AIDS, leaving behind anguished loved ones, orphaned children, and ravaged communities. At the same time, 5 million people became newly infected, bringing the total to 40 million people infected worldwide. Do the math. We’re losing the war.
In claiming the lives of societies’ most productive populations -- adults ages 15-45 -- HIV/AIDS threatens a basic principle of development -- that each generation do better than the one before. This disease has deepened poverty, reduced life expectancy, diverted resources, and left a generation to grow up without the love, guidance, and support of parents and teachers.
This year, however, may bring the hope of a new approach. The global community is coming into alignment to focus on HIV/AIDS as never before, with every sector -- public, private, religious, non--governmental, multilateral -- bringing focus to the fight. But we do need to engage the developed world in making a greater commitment of resources.
In 2002 and 2003, this government’s international HIV/AIDS contributions totaled more than those of all other donor governments combined. If one assumes the contributions of other donor governments remain flat in 2004 (which I certainly hope they do not) then in the current year, the U.S. international contributions to HIV/AIDS will be approximately twice those of the rest of the world's donor governments combined. And as you may be aware, the budget request for combating global HIV/AIDS just announced in the President’s budget for FY 2005 is 16% above what’s just been appropriated for FY 2004.
Nonetheless, increasingly, the world is rallying, and national leaders of the most afflicted nations of the world are admitting that they do in fact have an HIV problem in their countries, and will in fact devote more resources to fighting it, and generally will welcome the assistance of those who want to help.
Lessons have emerged and leaders are beginning to take heed: We now have proven methodologies for combating HIV/AIDS, including effective prevention and behavior -- change strategies that have produced real results, approaches to fighting stigma and discrimination, and proven programs that partner government with civil society. We know that global and national leadership is essential, that early and effective action can contain and even roll back epidemics and reduce the burdens of disease on families, communities, and nations.
The United States clearly has stepped up to the challenge of global HIV/AIDS with President Bush’s Emergency Plan for AIDS Relief. As the President has stated, “in the face of preventable death and suffering, we have a moral duty to act, and we are acting.”
The President’s Plan does bring unprecedented resources to bear against HIV/AIDS -- but as importantly, the Plan’s implementation will not be “business as usual.” Coordination; innovation; results-oriented implementation and a focus on achieving real goals in the areas of prevention, care, and treatment are hallmarks of the President’s Plan.
The President’s 5-year initiative targets $9 billion in new funding to 14 -- soon to be 15 -- countries in Africa, the Caribbean, and elsewhere, representing over 50% of the world’s population living with HIV/AIDS. The President has identified the ambitious goals of providing treatment medicines to at least 2 million HIV-positive individuals, preventing 7 million new HIV infections, and caring for 10 million people living with HIV/AIDS, orphans, and other vulnerable children directly impacted by the disease.
The Plan provides $5 billion to continue our bilateral assistance to nearly 75 countries worldwide. It also includes $1 billion in contributions to the Global Fund, bringing total U.S. contributions to nearly $2 billion through 2008 -- more than one third of all pledges to the fund to date.
While the plan has a particular focus on turning the tide in some of the most highly impacted countries of the world, we recognize that no country in which we currently support HIV/AIDS activities is unaffected by the problem, and some face emerging epidemics. The President’s Plan offers a fresh opportunity to harmonize HIV/AIDS policy and management across all of our bilateral programs to create the momentum that will truly turn the tide against HIV/AIDS -- as well as to provide leadership and other kinds of support to the rest of the world.
The plan begins in FY 2004 with $2.4 billion in funding, rising to $2.8 billion in the 2005 budget request, and steadily increasing to reach a total of $15 billion over the 5 years -- exactly what the President committed in his 2003 state of the union address.
I might add that these annual budget requests in the start-up years have been a source of contention in ways that are very unfair to the President. Some have done the simple division of dividing $15 billion by 5 years, assumed the President had committed to $3 billion in each year, and then criticized him for not keeping a commitment he did not make. The President committed to $15 billion over 5 years, to be deployed in a way that increases expenditures over time in order to spend the money as efficiently and effectively as we know how. And that is exactly what we are on course to do.
We know that we are embarking on an effort unrepresented by any other nation, with the mission of turning the tide against HIV/AIDS. We also know we are taking a focused health care approach that will require working with target countries to develop necessary human and technical infrastructure to use these funds in innovative ways.
In the four months that I have held this position, I am pleased to report that we have made what I believe is historic progress in laying the foundation to achieve the goal of the President and the Congress -- to bring prevention, treatment, and care to millions of adults and children courageously living with HIV/AIDS -- to replace despair with hope.
On January 22, the Senate passed the appropriations bill that provided the initial funding for this program. On January 29, we sent forward Congressional Notification that we are ready to deploy more than $350 million from the Emergency Plan, through mechanisms we’ve been aggressively putting in place in anticipation of this appropriation -- mechanisms that will allow for the rapid expansion of existing effective, accountable, and sustainable prevention, care, and treatment programs that are already underway and can be scaled up rapidly. These programs are in five target areas:
But this is only to get us started. At the same time we’re putting in place our plans for longer term and diversified programs that will involve both current partners and new ones. As we do that, we need to keep in mind what Albert Einstein once said: “Stupidity is doing the same thing over and over, and expecting different results.” That applies here. To do this job effectively, in some cases, we need new paradigms.
The battle against HIV/AIDS has historically been fought with only the weapon of prevention. And the numbers clearly tell us not very effectively, at that. The integration of prevention, treatment, and care -- one of the fundamental principles of the overall plan -- represents one of our new paradigms. This comprehensive and unparalleled approach is essential if we are to be successful. This is a disease that is 100% preventable, so prevention is the chief weapon in the spread of HIV, and it must be our number one priority. And testing -- knowing one’s status and what to do about it -- is one of the keys to prevention. Tragically, very tragically, most of the 40 million people worldwide who are infected with HIV do not know their status. Far too few people are being tested, and this is an issue that must be addressed, and must be changed, urgently. Without knowing their status, people can neither protect themselves nor others from the ravages of the disease.
Stigma, denial, and fear, however, remain enormous barriers to testing. Discovering one’s status is thought to be the beginning of living with stigma and abandonment -- and a certain sentence of death. Thus prevention is not the only answer. The provision of life-saving antiretroviral treatment provides hope and incentive for people to be tested and to learn their HIV status. That, in turn, contributes to prevention efforts. Thus, where there used to be a “treatment versus prevention” debate, today few dispute that these are not “either/or” issues. There are no bright lines between prevention, treatment, and care. They all contribute, and are interconnected, in achieving results against HIV/AIDS.
Another new paradigm is our focus on evidence-based, results-oriented approaches to prevention, treatment, and care. We need to take a fresh look at the evidence-based results -- at what has worked and what has not -- in the variety of countries, communities, and populations that will be served by this program.
One of the distinctions of the President’s Plan is its promotion of abstinence, being faithful, and the use of condoms. Research indicates that the ABC approach, as it is known, correctly understood and implemented, is a powerful tool against the spread of HIV. The ABC approach was pioneered with success in Uganda, and recently I had the opportunity to see the program at work in a primary school outside of Kampala. It is straightforward, relatively inexpensive, and enormously effective. The message has three components:
Each and every one of the interventions selected for rapid scale-up in the first phase of the Plan is a proven approach that has borne results against HIV/AIDS. And while we will actively pursue innovation, these innovations too will be subject to rigorous review to ensure their effectiveness as well.
We have been granted the decision-making control and flexibility to leave no stone unturned in our fight against AIDS, but we will be guided by evidence, by our experience gained over two decades of fighting HIV/AIDS internationally, and our progress toward achievement of the goals of 2 million people receiving treatment, 7 million infections prevented, and 10 million people receiving care.
Finally, we have brought a new paradigm to how we organize to attack this issue. I’ve asked all of the departments and agencies to leave their uniforms at the door, to come together into a single United States Government team. I’ve asked the U.S. Ambassador in each focus country to take responsibility for pulling together all of the resources of our government in the development of an integrated plan to implement the President’s initiative in that country, and to provide leadership to all elements of the U.S. Government on the ground in making it happen. Our activities in this area will now be U.S. Government programs, drawing on the strengths and capabilities of individuals and organizations in whatever ways make the most sense.
While the policy decisions and the strategic direction are my responsibilities, I am mindful that the statement by the late Tip O’Neal that “all politics is local” applies equally to public health. The battle against HIV/AIDS will, in the end, be won or lost in the small places -- places so small you may not find them on any map of the world. I feel strongly, from my experience in the private sector, that the implementation of our programs must be field-driven, such that people on the scene can be responsive to the specific circumstances and available human and material resources in each country, and can leverage the innovations of field staff, communities, and others joining the fight against AIDS. We’re well along in that process, and I’m very pleased with the work that is underway in all of these countries, and with the attitudes of the people involved in putting our efforts together.
A second aspect of how we organize to attack this issue is coordination with all of the other organizations making vital contributions to the fight against global HIV/AIDS. The crisis of global AIDS is greater than what any one agent can solve. Turning the tide will require a sustained collaborative effort from a multitude of international, national, and local organizations leveraging their comparative strengths. Not only are there extraordinary resource needs, but the diverse drivers and consequences of the disease, and its many complicated interactions with a variety of other social, political, and economic circumstances, demand an equal number of diverse actors with varied expertise.
The President’s Emergency Plan focuses unprecedented resources on achieving targeted goals within prevention, treatment, and care by strengthening the capacity and infrastructure of health care systems to respond. While we maintain our focus on the task at hand, we will coordinate with multilateral institutions and other donors and international organizations working with great dedication to combat HIV/AIDS to build a comprehensive and amplified response to global AIDS.
An example of our efforts here is our support of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The United States led the creation of the Global Fund, and was its first contributor. The United States leads the world in donations to the Fund, accounting for 37.4% of total pledges and 31.1% of contributions to the Fund. The Global Fund, with its unique partnership structure, has the potential to achieve great results against HIV/AIDS, and we are committed to the fulfillment of this vision and of the Fund’s full potential.
As many of you know, Secretary Thompson, is currently Chairman of the Board of the Global Fund. And through his extraordinary commitment to this issue, on behalf of the United States, he is giving special leadership to the Fund in its formative stages.
There is no doubt that HIV/AIDS represents one of the greatest challenge of our time. Experts predict that without intervention, 100 million people could lose their lives to AIDS by 2020. I have witnessed, however, the amazing work being carried out in partnerships among communities, non-governmental organizations, governments, and donors.
Regardless of barriers imposed by stigma, silence, lack of leadership, or very limited resources, I am convinced that our efforts will result in real gains in the fight against HIV/AIDS, a fight in which every battle won is measured in lives saved, families held intact, nations moving forward with development, and the future secured. I’m an optimist. It is my nature. And I want to leave you today with a story of hope.
On my most recent trip to Africa, along with Jim Glassman I visited a tiny farm settlement in Uganda just outside a small town called Tororo. There, the Centers for Disease Control of the Department of Health and Human Services is partnering with TASO, a community based support organization for persons living with AIDS, providing patients with safe water, an antibiotic to prevent opportunistic infections, and -- importantly -- antiretroviral drug therapy.
While I was there, I visited two of those patients and their families, in their homes -- mud structures with straw roofs and dirt floors. Community health workers who are part of this program visit each patient weekly, on small motorcycles, to monitor their condition, their adherence to the therapy regimen, and to deliver their supply of medication.
Their progress since beginning treatment is amazing. And their adherence to the therapy regimen is nearly 95% -- much higher than our experience in the United States. Some have opined that ARV treatment is too complex for these environments. They are mistaken. What’s been reassuringly demonstrated by this project is the ability of these community health workers to impart complicated information that is fully comprehended.
One of the patients I visited -- a man named John -- is HIV positive and on the antiretroviral therapy program. His wife -- also HIV positive -- is not. When I asked him, through the interpreter, if there was any conflict in the family, any temptation because he had access to this life saving medicine and his wife did not -- was there any temptation to share the medication?
Through the interpreter, he told me it was not an issue because his CD4 cell count was 162 and he needed the medicine now, but his wife’s CD4 cell count was 312, and she didn’t. He said they understood that when her count dropped below 200, she too would be put on the program. Understanding can be conveyed and ARV therapy can be effectively administered in very primitive places. And so can care and so can prevention.
With our support and leadership, people like John and his wife -- and their children -- will be able to continue to do what they are doing -- working, parenting, contributing. The future will again appear on the horizon. We can, indeed, bring hope. Thank you very much. Released on February 10, 2004 |
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