"A constellation of change and commitment" in response to AIDS - Stephen Lewis
My trip to Zambia last month was the fourth time I'd been to the country in the last two years. The change on this occasion was startling. It isn't that I did anything of particular novelty: there were the usual useful meetings at high political level - the President, Cabinet Ministers and senior civil servants - and there were encounters with the full range of civil society, the diplomatic community, associations of People Living with AIDS and the United Nations family. And as is always the case, I spent a great part of my time in the field, on this occasion centred primarily on the copperbelt region.
But the shift in the response to HIV/AIDS was palpable. Don't misunderstand me: there was pain and frustration and death in egregious quantity, but there was also an entirely new level of determination and hope that I had not encountered before. As a result, I left Zambia in an unaccustomedly hopeful frame of mind.
I've been reflecting on that over the last couple of weeks, trying to put my finger on what it is that has shifted the ground so dramatically. Predictably perhaps, I don't think there's any one particular element; rather, it's a constellation of change and commitment that has altered the entire tone and content of the response to the pandemic.
It's worth taking a look at the ingredients. First, Zambia has just made the decision to provide free antiretroviral treatment. Up until now, it's been free only in selective parts of the urban capital, Lusaka, but elsewhere in the country, throughout all of rural Zambia, people have been required to pay 40,000 kwacha per month, equivalent to roughly 8USD.
And that's only the cost of the drugs. When you added in the cost of transportation and laboratory tests, it could rise to 135,000 kwacha per month, or somewhere between 25 and 30USD. In such an impoverished country, people couldn't possibly afford it. Everywhere I went, there was a desperate clamour for free treatment, at the very least for subsidies to cover the cost of the drugs. The Government has answered the clamour.
Second, the Government was able to change its policy thanks to the Global Fund on AIDS, Tuberculosis and Malaria. Originally, the cost-sharing requirement was introduced because the Government wasn't at all sure that it could sustain the flow of resources necessary to guarantee the consistent availability of drugs and treatment. But in round four of Global Fund proposals, Zambia received US$253 million, much of it designated for treatment. Voila! Free treatment.
Third, it now looks, therefore, as though Zambia will reach its target of putting 100,000 people into treatment by the end of 2005. That's Zambia's share of the WHO goal for "3 by 5". At this point, there are between 17,000 and 18,000 people in treatment: it's a great leap forward to 100,000, but the momentum is powerful.
Fourth, in Zambia, more than anywhere else I have yet seen, the model for pMTCT 'Plus" is working wonders. It was initiated by the Columbia School of Public Health at the Chelstone Clinic in Lusaka, and the collaboration has led to 6,000 people in treatment as of this moment. The 'Plus' factor involves not only preventing HIV in newborns, but also treating the mother, her partner and any HIV-positive children as soon as treatment becomes necessary. The fascinating wrinkle at Chelstone is the way in which pMTCT Plus appears to have hastened the evolution from exceptional to universal treatment.
Now, as the country begins providing ARVs to all who need them, pregnant women and their families can be referred from pMTCT programmes to Government treatment facilities, freeing up the experts and resources involved in pMTCT to focus on expanding those programmes far and wide. It stands to reason: first you begin treating the entire family because the mother, through her participation in pMTCT, is the obvious entry point for treatment.
But when treatment is universal, the special programme can be gradually phased out. That's not to suggest any cessation in the expansion of pMTCT Plus. To the contrary, it becomes the linchpin of the process. It is gratifying to see hard evidence of the logical progression from prototype to scale-up.
Fifth, when I visited Zambia two years ago, in January of 2003, in the company of James Morris, Executive Director of the World Food Programme (WFP), the country was starving. Everywhere we went, the desolate face of hunger haunted us. Today, astonishingly, the country is on the verge of becoming the breadbasket of the immediate sub-region, and the WFP last year bought 84 thousand metric tons of locally-produced food from Zambia at a price of US$17 million, all of which was plowed back into the local economy.
There are still parts of the country to which food must be distributed, but the coming of the rains has transformed everything. Sadly, if interestingly, it was the opinion of the Minister of Agriculture, and everyone else I spoke to, that the level of agricultural production would even have been two or three times higher had so many farmers (ie women) not died from or taken ill with AIDS.
Sixth, the political leadership is engaged as never before. When I met with the President, he opened the session with a lengthy, all-encompassing review of every crucial aspect of government public policy on AIDS. It allowed us, in unusual fashion, to deal issue by issue, and again at length, with the various components of the pandemic. It was in fact at that meeting that I learned of the about-to-be-announced free treatment policy (In a totally unexpected high point of the Envoy job, I got to unveil the free treatment decision at an 'expanded theme group' meeting the next day. I mention it only because it will doubtless never happen again!).
The political leadership of the President is mirrored in the encyclopedic grasp of issues, and the force and lucidity of comment, on the part of the Minister of Health. More, his Permanent Secretary and senior officials are all equally committed. So, too, it would appear, are other members of the cabinet. But most heartening of all is the way in which this commitment has filtered down to the local levels.
Time and again, our delegation was treated to a review of realities and problems on the ground by regional and district officials who had a most surprising grip on the nature of the pandemic. It's hard to convey how encouraging that was. So often the top political layer provides the sonorous rhetoric, and the elected or appointed bureaucrats at the bottom provide the pettifogging maunderings of
irrelevance. But not in Zambia.
Seventh, that truth now permeates the country. No matter where we went, the
level of awareness of the pandemic was intense. To be sure, it was largely focused on the urgent need for treatment, but it also came through in conversation after conversation at the grass-roots, about prevention and care and orphans and the special plight of women. Once a country has reached such all-embracing public dialogue, the winds of change are irreversible.
Eighth, the response to the pandemic is of course accelerated when there is significant external support. And that's happening. The roles of the Global Fund and the World Health Organization and, in part, the World Bank, cannot be underestimated. Neither can support from governments like the United States (through the Presidential initiative) and the United Kingdom, which has just made a very large contribution to government coffers, much of the money bound to address critical problems of capacity in the social sectors.
The beauty of the UK money is the way so much of it is going to direct budgetary support, so that the Zambian government makes the decisions as to its use. What's more, Zambia has just met the IMF conditions imposed on debt relief, so that the excruciating debt service (tallied at US$290.5 million owing to the International Financial Institutions in 2003) may now (although it's never certain) be alleviated. If the G7 countries and the 'IFIs' can be brought to realize that a cosmic life and death struggle is taking place in Southern Africa, then the pandemic might one day be subdued.
Ninth, the situation of the advocates for People Living with AIDS, almost always people who are themselves HIV-positive, has significantly improved. I can remember sitting down with this same group in December of 2002, and a more wretched scene, shorn of hope, would be hard to imagine. Later still, I recall meeting with the leadership of PLWAs when they couldn't even find an office space within which to pursue their work.
Now they seem much more confident, much more energetic, much more focused, housed at present in the town hall municipal offices, with the President promising even larger space when a government building is vacated. And the organization - they call it NZP+ - is now a going concern, with 190 support groups in many country districts: it's quite a transformation.
Finally, the role of the UN family has proved to be indispensable. I have to be careful here, lest it appear to be a case of special pleading. But the unvarnished truth is that the UN agencies, impressively coordinated by UNAIDS and impressively led by the Resident Coordinator, are working hand in glove with government to confront and overcome the pandemic.
There is, inevitably, in the midst of such a human maelstrom, the occasional glitch, as happened in the case of drug procurement. But the overall sense is one of such collaborative good will that every exigency, small or large, can be overcome. I want to hand it to my UN colleagues: like most of us, they do not yet approximate sublime perfection, but boy, are they good. They recognize - and not everyone does - that we're in the midst of an emergency in Southern Africa which threatens the very survival of nation states. It is the ultimate measure of multilateralism to be at the centre of the response, employing every instrument at our command. Nothing less will do.
Now having said all of that and enumerated the reasons for my modest optimism, let me insist that I'm not given to self-delusion. The balance sheet is still in deficit.
There are huge problems of capacity in every sector, often with crippling effect in the health sector: this is without question the toughest problem the Government faces. The situation of women, disproportionately infected in Zambia, as everywhere else, is appalling, and the growing contagion of sexual assault induces a sense of desperation.
The situation of orphans has not begun to be addressed: this verges on the unconscionable. Some 23% of children are already orphaned, and the numbers are expected to rise to over 30%, one in every three, by 2010! In both the instance of women and of vulnerable children, there are extensive, complex, intricate plans of action which lie, forlorn and unfunded, on the pages of reports, documents, monographs and dossiers, proliferating in endless numbers.
The gap between the printed page and human life has seldom been more abject. The treatment of children is still wanting; the paediatric formulations are still missing. The availability of counselling and testing centres is still insufficient. People Living with AIDS are still struggling with opportunistic infections and the absence of treatment. The rural areas are still battling for recognition. The Government has yet to embody HIV/AIDS policy in formal legislation. The Government has yet to appoint a permanent Director of the National AIDS Council.
I could go on. And on. Zambia, as with every other country, has made progress in halting, incremental fashion. But there is a fundamental difference: the progress is now sustainable and continuous. The obstacles may from time to time seem insuperable, but the determination to overcome them seems equal to the task.
I'm left with three anecdotes which rest uneasily in the mind. In the little rural community of Chibombo, we met with a group of women who were either living with AIDS, or looking after orphans. We assembled beside a vast cabbage patch which the women were using both for food and for income. What did they do with the money they made, we asked? "We use it to buy coffins". The women were incredibly spunky and demanding. They spoke with earthy eloquence about the trials of life, the orphan kids, the struggle to survive. Why, they wanted to know, should they be abandoned to such a desolate fate?
At a luncheon seminar on agriculture, the Minister of Agriculture said: "Hardly a day passes without receiving a note of the death of one of my colleagues. These are post-graduates we are losing. How many are dying? How will we replace them?"
At two hospices, one in Ndola and one in Lusaka, both of them bright, airy, caring and loving, we were confronted, yet again, with young men and women, mostly women, who were dying, unnecessarily, in the absence of drugs. It's a scene, common to every country in Southern Africa, and it wrenches the heart from one's body. I looked around me, and couldn't get out of my mind the figures in the UN report released just this last week, showing that expenditures on armaments, world-wide, had now reached one trillion dollars a year.
The Global Fund is asking for less than 3/10ths of 1% of that, and can't seem to get it. I wonder if anything would change if the G8 Summit were held in Lusaka?
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