Race Against Time: Searching for Hope in AIDS-Ravaged Africa

• Introduction
• Remarks
• Questions and Answers

JOANNE MYERS: Good morning. I'm Joanne Myers, Director of Public Affairs Programs at the Carnegie Council. I would like to welcome our members and guests, and thank you all for joining us today.

Before we begin, I would like to take a moment to thank the Canadian Consulate, especially Jennifer Kay, for her assistance in arranging this breakfast program.

It is a great pleasure to host Stephen Lewis, especially on the day that the United Nations is to launch the progress report on global HIV treatment. Mr. Lewis, as many of you know, is the UN Secretary-General's Special Envoy for HIV/AIDS in Africa. He will be discussing his book, Race against Time, in which he talks about what AIDS has done to the African continent and what needs to be done to eradicate this disease. AIDS is no ordinary pandemic, as it not only threatens individual lives, but its tentacles reach into the very core of society, destroying everything it touches in its path.

As someone who has known our guest for a very long time, I have asked Pamela Wallin, the Consul General of Canada in New York, to formally introduce Mr. Lewis.

Before taking up her first diplomatic posting in our city four years ago, Pamela was one of Canada's most accomplished and respected journalists and broadcasters. In fact, in recognition of her achievements, in 2002 she was named to the Canadian Broadcasting Hall of Fame. Knowing of her vast experience, first as a reporter for the Toronto Star, as a commentator for CBC Radio, and, later, anchoring the nightly network newscast for CTV and CBA, I know she is more than qualified to anchor our breakfast program this morning.

Please join me in welcoming Pamela Wallin and Stephen Lewis.

PAMELA WALLIN: Thank you, Joanne, for this opportunity. A lovely introduction. I have appreciated working with you over the last four years. You do a superb job in putting the right people in front of us to listen to.

I have the extraordinary pleasure of introducing a man who is an icon and a hero in Canada. He works tirelessly on behalf of all of us, and I don't exaggerate when I say, on behalf of humanity.

Stephen is currently the UN Secretary-General's Special Envoy for HIV/AIDS in Africa, a post which he has held since 2001. He is also a senior adviser to the Mailman School of Public Health at Columbia University, and chair of the board of the Stephen Lewis Foundation, an organization which is dedicated to helping those living with HIV/AIDS in Africa.

To risk understatement, I will warn you that Stephen is passionate. He is determined. He is a true humanitarian. He has spent a lifetime working on these issues abroad, going to Africa first when he was just a boy, and continuing this work throughout his life, as Canada's Ambassador to the United Nations and as the Deputy Executive Director of UNICEF. He has also served as a member of the International Panel of Eminent Personalities to investigate the 1994 genocide in Rwanda.

Stephen has been named a Companion of the Order of Canada, our highest honor in the country. In April 2005, Stephen was named by Time magazine as one of the 100 Most Influential People in the World, along with the Dalai Lama, Bill Gates, Oprah Winfrey, and Nelson Mandela.

Race against Time was published last fall in Canada. It has held the number-one spot on the bestseller list for months, not only in Canada, but internationally. Reviewers of Stephen's book have called it "a verbal shelling from inside the tent."

Stephen argues very forcefully that the world, including his very own organization, the United Nations, needs a completely different approach to Africa, and indeed to the whole question of values as it surrounds the way the West deals with some of these issues. The ongoing plight of Africa forces him into perpetual rage, that it is all so unnecessary that hundreds of millions of people should be so abandoned.

Please welcome Ambassador Stephen Lewis.

STEPHEN LEWIS: I am delighted to be here. I very much appreciate having the Canadian Ambassador to the United Nations, Allan Rock, with me to fortify my anxieties about being part of a lecture series which is truly auspicious. Even to be on the same page as Joe Stiglitz and Wole Soyinka and, above all, Amartya Sen is almost more than my frail psyche can endure.

I believe that Americans should have to endure a Canadian speaker from time to time. After all, in an act of almost supernatural generosity, we signed the Free Trade Agreement with the United States, thereby rescuing your economy and engaging in a degree of self-immolation with our own.

I get a kick out of speaking in the United States, because I'm always introduced as "Ambassador Lewis." It's a delicious encomium. In Canada, when you have finished your diplomatic tenure, you lose your title and you revert to mortal obscurity. It's only in the United States where once an ambassador, always an ambassador; once a governor, always a governor; once a senator, always a senator; once a president, always a president. The entire country is sustained by titular self-aggrandizement which Canadians look upon with a bemused affection.

HIV/AIDS is the ultimate ethical issue. It is a coincidence that the World Health Organization and UNAIDS are issuing a document today to examine the results of the 3 by 5 Initiative, the program launched around World AIDS Day, December 1, 2003, to attempt to put 3 million people into treatment by the end of 2005. We have reached only 1,300,000 people. We are less than halfway there.

There will be a lot of caterwauling about failure. From my own point of view, WHO, in an entirely visionary way, broke through the paralysis which was infecting the response of the international community, and multilateralism generally, and has now unleashed a momentum which is irreversible. Country after country is moving heaven and earth to put people into treatment. Although it is sad and lamentable that we are only 20 percent along the way, it is nonetheless a significant and important 20 percent.

The point of departure for me today will therefore be the question of ethics, on the one hand, and what we have achieved thus far in these areas of the pandemic, on the other. I would like to ask a series of questions, which speak to the ethical conduct of international affairs, and frame the issues, perhaps, slightly differently than would otherwise have been the case.

1) Why are there only 1,300,000 people by 2006 whose lives will be prolonged and sustained by antiretroviral treatment?

We have the drugs, at very low cost, generic compositions largely coming out of India—fixed-dose combinations, three drugs in one pill, taken twice a day. In the next few months the brand-name pharmaceuticals may well have a fixed-dose combination which will require only one pill a day.

We have regimens which are easy to follow, and the adherence to the regimen in Africa is often better than in the United States. Why are we only 20 percent along the way?

Matters of infrastructure and capacity in Africa lie at the heart of the problem. But there is also no question that the sustained flow of resources and the contribution of technical assistance where it is most needed from the Western world, from the industrial community, would undoubtedly have facilitated much larger numbers of people in treatment. Whatever deficiencies there may be on the ground—and I spend my life tramping around the continent—there is still a great deal of room for intervention to save lives. Intervention has been compromised time and time again by an inadequate flow of resources and inadequate technical assistance from the international community.

What kind of ethical default is this? How is it possible for the world to endure millions of unnecessary deaths?

2) Let's talk for a moment about the matter of resources. There is much self-congratulatory rhetoric these days as people note that in 2005 we spent roughly $8.3 billion on AIDS, which is an exponential increase from what we were spending in the late 1990s. But UNAIDS, in a very careful assessment, has indicated that in 2006 we will need $15 billion; in 2007, $18 billion; in 2008, $22 billion. Any straight-line projection gets you to $30 billion by 2010. That is for only one disease. We are nowhere near generating that kind of money.

If we were to approximate internationally the 0.7 percent of GDP upon which the world generally agreed back in the year 1969—orchestrated and fashioned by a Canadian, Lester Pearson, I should note in a spasm of nationalism—all of the Millennium Development Goals could be put in place, and certainly we could subdue the pandemic of HIV/AIDS.

But we are nowhere near it, and we will not reach it based on the commitment which the G8 countries have thus far made.

At Gleneagles in July 2005, there was an orgy of triumphalism about the way in which the world would provide Africa with an additional $25 billion by the year 2010 and the way in which this money would facilitate the recuperation of the continent. We will not get an additional $25 billion in 2010.

The desperate efforts now on the part of superb people, like the Chancellor of the Exchequer in the United Kingdom, Gordon Brown, to introduce the International Financial Facility so there is some significant front-end-loading, and the efforts by the French government to put in place the surtax on airline tickets to generate money for development—all of these are compensatory efforts to make up for what everybody knows will be a significant shortfall in official development assistance from the G8 countries.

Bob Geldof had apoplexy at the G8 meeting. I judge that that is his normal state. He said, "We'll have ten out of ten as a commentary on what we've achieved at this meeting."

But the fact of the matter is that just eight weeks later, the pattern of betrayal which has become systemic in the behavior of the G8 countries towards Africa began again. We had the Global Fund Replenishment Conference in London, in September 2005, chaired by the Secretary-General of the United Nations himself. Even the most jaded skeptics among us felt that the momentum that had been generated, at least rhetorically, at Gleneagles would sweep over the Replenishment Conference and provide the additional dollars that were necessary.

The Global Fund said, "We need $7.1 billion for 2006 and 2007," and they received $3.8 billion. We fell $3.3 billion short, which will be counted in millions of lives.

The Global Fund is not yet in a position to have a new round in 2006 or 2007 to receive the proposals so desperately and urgently needed on behalf of Africa, because they simply cannot guarantee the provision of the funds.

What kind of moral delinquency is that? What kind of ethical conduct is that? If you will forgive the juxtaposition, 2005 was the first year since the end of the Cold War when we spent over $1 trillion on the arms race. I am reminded of Major Barbara and Lazarus and Undershaft, munitions makers to the world, when I see the ever-escalating amounts of money that we spent on the arms race. It is not invidious to point out that we are spending hundreds of billions of dollars to prosecute wars in Afghanistan and in Iraq, and we cannot find a relative smidgen of that amount to intervene to ameliorate the human condition.

Where lies the ethical compass?

3) One of the chief problems is, within the African continent, the fact of capacity, which is eviscerated by so many people who are ill and are dying or are dead. But there is another dimension of the capacity problem which is particularly grievous, and that is the way in which the Western world poaches on the very few professionals which Africa is able to train—taking the doctors, nurses, pharmacists, clinicians, and even some of the community health workers, and pulling them into the orbit of the industrial world. If people were urgently conscripted into the fray, we could break the back of the pandemic.

The United Kingdom has been a leader. Its development agency, DFID, is showing what can be done by providing the budgetary support to Malawi to increase significantly salaries and benefits within the public service, so that for the first time the entire graduating class of nurses in Malawi remained in the country, because they had an adequate income and benefits.

We all understand what can be done in response to these desperate human predicaments. But I ask you, what kind of ethical conduct is it for Western countries to continue to poach on those who can intercede to save lives?

4) What about the children? How is it that it is only in 2006—and 2007 and 2008 thereafter—that we are finally responding to the needs of infected children? We have had treatment available since 1996. We have treated very large numbers of adults, but only a microscopic portion of children who need treatment. We have never had the pediatric formulations to do so.

We take the capsules, break them in half, take out the powder, and try to estimate how much powder a child might require based on age and weight. It doesn't work for doctors, it doesn't work for nurses, it doesn't work for grandmothers who are looking after orphaned kids, it doesn't work for caregivers. We need special pediatric drugs and pediatric formulations.

But 2,300,000 children in this world are infected, 700,000 new infections every year, 570,000 deaths. Why have we come to it so late? Why are children always at the bottom of the social and economic ladder in human priorities? Where is the ethical default?

That leads me to the dimension of it which is even worse, because the vast majority of infections for children occur during the birthing process. If the child emerges HIV-positive, it's likely that 50 percent of children will be dead by the age of two, 80 percent by the age of five. Since when have children become expendable in the international human equation?

We have a wonder drug called nevirapine. A single dose given to the mother during the birthing process, or a liquid equivalent to the child within the first forty-eight or seventy-two hours after birth, and we can reduce the transmission from mother to child by 50 percent.

No one in this room knows of HIV-positive children being born to infected mothers, because it doesn't happen in the Western world. We provide full antiretroviral therapy to the mother for a sufficient number of weeks of the pregnancy so that the child emerges HIV-negative.

We are still losing 50 percent of the children in Africa that we need not lose, hundreds of thousands, millions of children, because of the grotesque disparity between the priorities of the North and the realities of the South.

Only 10 percent of all the pregnant women in Africa even have access to a clinic which provides the prevention of mother-to-child transmission through a single dose of nevirapine. How is that possible in 2006, when this pandemic has raged for over a quarter-century? What is the ethical default?

5) What do we do about the continuing depredations of the international financial institutions? I am probably treading on shaky ground here, but I am too old, impatient, and angry to wrestle my natural maniacal spasms to the ground. What the international financial institutions have done to Africa is utterly unforgivable. The impact of the structural adjustment programs in the late 1980s and early 1990s shredded the social sectors so that Africa today is not in a position to respond adequately, even were it to wish to respond.

One of the aspects which I deal with at length in the book is what has happened to school fees, which tended to be imposed as a condition in return for the loans that were granted by the international financial institutions. Suddenly the requirement of conditionality was user fees—user fees for health, user fees for education. The consequences in the early part of the 21st century are quite direct. Many children who should be in school, and desperately want to be in school, cannot be in school because they cannot afford the fees.

We know what an emancipation it is when the school fees are removed. Look at the example of Kenya. The government under President Kibaki eliminated school fees, and within a matter of weeks, 1,300,000 children turned up who had not been in school before—fully 20 percent of the school-aged population.

We understand what it means when you eliminate school fees and allow children to return to school, which they so determinedly crave. But the consequences of structural adjustment programs have compromised that process, and we are only now beginning to consider seriously again the removal of school fees in those countries which still apply them.

Where have we been over the last several years? How do you abandon so many children to a fate external to the school, when we could have made it possible for them to attend? Where were those of us in the multilateral system who could have intervened?

The World Bank apologizes now, as it always does in ten-year cycles. They say, "We were wrong. Those economic nostrums were mistaken, so we'll impose a new and draconian set of economic nostrums for the next ten years, so that the cycle of apology can rhythmically be repeated."

What happens to the behavior of these international financial institutions even now?

Kenya, for example, has a gifted and talented minister of health, Charity Ngilu. Kenya also has 4,000 retired nurses, and it has a very severe problem with HIV/AIDS. It wants to hire the retired nurses, put them back into the health-care system to respond to the pandemic. But they can't hire the nurses, because were they to do so, they would breach the "macroeconomic framework" imposed by the IMF.

What is wrong with these people? Things shift when you are dealing with the pandemic. You have a tragedy of such intense human toll, such intense human carnage, that it is necessary to abandon the rigidity of economic prescription and to understand what is at stake. To this day, we can't get the international financial institutions to do that.

In case you feel that these are the polemical rantings of the democratic socialist which I am, let me point out that at a recent gathering here at the Carnegie Council, Mary Robinson, a person sober, thoughtful, careful, dispassionate, objective, made exactly the same argument and asked exactly the same questions about the behavior of the international financial institutions.

Where is the ethical compass? Why the ethical default?

6) Women lie at the heart of this pandemic. Women are disproportionately vulnerable in numbers that make the mind reel. I have never in all my adult life imagined that gender inequality should wreak such damage on women. I have never imagined that one communicable disease would exhibit such a ferocious assault on one sex. What is happening to the women of the continent of Africa is perhaps the most distressing dimension of the entire pandemic, and it is beyond me how the world watches it occur without emergency intervention. Of the 7 million or 8 million people between the ages of fifteen and twenty-four living with the virus in Africa, 76 percent are young women and girls.

All of the international human rights conventions and covenants are violated when it comes to the rights of women. Everything we thought we had achieved at the Human Rights Conference in Vienna, the Population Conference in Cairo, and the Women's Conference in Beijing is sabotaged by the force of the virus. What is happening to women—their lack of sexual autonomy and the predatory male sexual behavior which drives the virus and the lack of response from indigenous African states and the international community—is heartbreaking. We need an international women's agency within the United Nations to drive this.

I am an ultimate multilateralist. I am a shameless apologist for the United Nations. But I am not hesitant to identify those areas where it seems not to work. On women's issues, the UN has been curiously diffident, timid, and begrudging.

We have agencies that deal with health, with labor, with education and science and culture, with food. The World Food Programme is doing a particularly good job. We have UNICEF, with a budget of $2 billion a year and over 8,000 employees, which deals with children; the United Nations Development Programme, which deals broadly with questions of governance; the United Nations Fund for Population Activities, which deals with women and men and their sexual and reproductive health in a rather narrow definition, without the broad mandate addressing the whole panoply of issues that involve women.

But we have nothing by way of a significant agency for women, nothing for more than half the world's population. Were there a voice, were there a ceaseless response to the predicament of women in Africa, it would save lives.

When I first took on the envoy role, I thought in terms of abstractions. I thought of 20 million dead, 40 million infections, 5 million new infections a year, 3 million deaths a year, 14 million orphans. Now, almost five years later, all I want to do is save that life, rescue that child, prevent that woman from dying. Your whole Weltanschauung narrows, and you want to overcome this terrible decimation of communities and families and individuals, which is indescribable in its carnage.

And it's happening to young women particularly. They are dying in their twenties and thirties, in hallucinatory numbers. They come up to me with their children in tow, and ask, "What's going to happen to my children when I die?" I have absolutely no way of answering that question.

I have always been taken with the feminist analysis of male authority and power. I have never seen an example of that analysis more riveting and more true than what is happening to women in the presence of gender inequality.

7) Finally, let me say a word about orphans. We have a desperate problem, hardly understood yet in the world, as though no one calculated that when you had so many adults dying, you would inherit a deluge of orphans. Everywhere I go, the numbers of orphans are overwhelming. You are constantly confronted with the realities of the pandemic.

I was just in Swaziland. In the antenatal clinics where the testing takes place, for the women between the ages of twenty-five and twenty-nine, the prevalence rate is 56.3 percent. It's like an apocalypse for women in that age category who happen to be pregnant.

I attended a school outside a community center where the women were doing an income-generating project. There were 350 children singing vigorously, as children in Africa always do for a visitor. The principal, a young woman, took the microphone and said, "Mr. Lewis, I want you to know that while we welcome you enthusiastically, of the 350 children in my school, 251 are orphans." That's 70 percent of the school.

Swaziland is a country where between 10 and 15 percent of the entire population will be orphans by the year 2010—not 10 to 15 percent of the child population, but 10 to 15 percent of the entire population.

The torrent of orphans is absolutely overwhelming to these countries, and they have no idea how to handle it. The communities desperately try to absorb the orphaned children, but extra mouths can push impoverished families right over the edge. The unsung heroes of the continent are the grandmothers. They bury their own adult children and then, at the age of fifty, sixty, seventy, eighty, they begin to parent again. If it weren't for the grandmothers holding the society together, I don't know what would happen in some countries.

Then, the grandmothers die, and you have the phenomenon of child-headed households, where the oldest sibling in the family looks after the younger ones. Sometimes the age of the child heading the household is eight or nine or ten. It defies comprehension.

Children who are orphaned by AIDS go through a particularly excruciating emotional experience. They do not become orphans when their parents die. They become orphans while their parents are dying. You enter hut after hut, and you have a spectral figure lying on the ground, the mother in the last stages of full-blown AIDS, and the children frantically scrambling for an aspirin to reduce the pain of an opportunistic infection or wiping the mother's brow with a cold cloth or, in a mutual experience of humiliation, cleaning up the mother when she is incontinent. Then these kids stand in the hut and they watch their mothers die. The trauma that is part of that, the emotional dismemberment that a child experiences, is something that is not easily repaired.

This pandemic has been going on for a long time. When I am introduced to orphans now in Africa, they are often in their twenties. They are beginning to have children of their own. They have had no experience of parenting. The responses are slow, tentative, and limited. It was only in the fall of 2005 that UNICEF finally fashioned a plan to respond in a significant way to the orphaned children.

Why the ethical default? Why have we taken so long? Why do we move with such limited urgency?

I will not take the continent of Africa off the hook. The long period of denial and silence is absolutely unforgivable. By and large, at the turn of the century, the year 2000 and 2001, Africa came alive to what was happening, and with very few exceptions, those countries are truly engaged and attempting to allow their people to survive.

It's very rare that you have a situation like that of South Africa, where the political leadership is not actively engaged, in an almost obsessive way. One would think or hope that would be true of South Africa because it has 5.5 million to 6.5 million infections, the highest number of absolute infections in the world. There is still tremendous anxiety in the external community about commenting upon it. I regard that as our ethical default.

But most African countries are deeply engaged. The resilience of Africa is truly remarkable. The intelligence, sophistication, generosity, camaraderie, engagement that lie at the grassroots, at the community level, in Africa, particularly amongst the women, are what hold it all together. If the rest of the world responded adequately by way of resources, by way of technical assistance—no neocolonial or neoliberal impulses, just a decent response to the human predicament—Africa has the capacity to turn it around, because of this extraordinary network at the grassroots.

By the year 2012, there will be 100 million people in this world, based on present realities and projections, who will either have died as a result of AIDS or will be living with the virus. There is no excuse for that. There is nothing that can rationalize the indifference of the international community to what has happened.

I was in rural Zambia, traveling with one of the district commissioners to see his income-generating project. We trekked down a number of trails for a very long time and finally came upon an open field. One half of the field was a cabbage patch and in the other half, a group of women, fifteen or twenty of them, stood holding a banner aloft proclaiming their HIV-positive status. They talked to me with enormous animation and feisty pugnacity about what they thought of the men who had infected them.

Then, almost to break the tension, I asked, "This is your income-generating project, this cabbage patch?"

"Oh, yes," they said.

I said, "You eat the cabbages to reinforce your immune system and to allow you to withstand opportunistic infections in AIDS?"

"Oh, yes," they said.

"Do you use all the cabbages?"

"No, no, no. We have many left over."

"What do you do with them?"

"We take them to market."

"Do you sell them all?"

"Yes, we sell them all."

"What do you do with the profits?"

"What do we do with the profits?" they said. "We buy coffins. We never have enough money for coffins."

It is at moments like that that I feel as though the world has gone mad. There is something inexcusable, ethically indefensible about millions of people dying unnecessarily, when the world knows how to intervene. We have lost the moral anchor of the international community, and we must reclaim it.

JOANNE MYERS: Thank you for that extraordinary and moving presentation. I would like to open up the floor to questions.

QUESTION: In the unwillingness of the G8 countries to follow through on their promises, what role do you see in the Christian reconstructionists among them who believe that AIDS is God's punishment and it is moving forward to the coming kingdom by getting rid of those who are sinful?

STEPHEN LEWIS: The construct which assigns sin and guilt to people who have AIDS is not a fashion which is widely shared any longer, internationally or in Africa. Indeed, recently in Africa, a number of clerics in the Protestant world have apologized publicly for attributing sin to the transmission of the virus. There is an ever-greater understanding that this is a sexually transmitted disease, but it's a disease like other diseases and has to be responded to in much the same way, with a great deal of urgency and with appropriate medical interventions.

There is a tremendous focus on prevention, particularly amongst the fifteen-to-twenty-four-year-old group, who move from community to community and school to school, using all of the cultural artifacts of Africa—the drumming, dancing, poetry, song, and particularly drama—speaking with tremendous, almost brazen forthrightness about sexuality and about what must be done.

That awareness-raising and consciousness-raising tends to diminish the views of those who live lives of attributing guilt.

QUESTION: I am straying from your geographical area of expertise, but I've followed the situation in Brazil, which is a country of great income disparity, tremendous poverty. Yet it seems to have broken out of the mold, and refused to follow the established norms of international order, intellectual property protection. It is reputed to have done a rather spectacular job of dealing with its own HIV problem.

Does this represent a model for a poor country?

A second question: Why didn't you mention our last Pope, who ran around the world telling people not to use condoms?

STEPHEN LEWIS: Brazil has about 150,000 people in treatment now. But Brazil is a high-middle-income country, with a great deal of revenue generated through an operational tax system and with a president who recently attacked the international community on exactly the grounds I have disgorged this morning. I wasn't attempting to mirror his views, but he was talking about the default of the international community in areas of resources and in responses to particular pandemics and poverty.

Brazil was blessed with having money and also blessed with having a tough government that was prepared to defy the pharmaceutical industry and the United States and break patents when they had to and indigenously manufacture generic combinations which could be used for their own people.

I was in Rio recently at an international scientific conference, and I was fascinated when the Brazilian exponents of the AIDS experience there talked of how they were going to move to second-line drugs.

Over time, resistance and side effects develop to the first-line drug interventions, which involve roughly 10 percent to 15 percent of the treated population. The second-line drugs are more complicated and expensive, and Brazil is now trying to figure out what to do. In Brazil, it took an average of only four years of treatment for the side effects and the complications to start to show in significant numbers. So, inevitably with AIDS, one has to have a variety of interventions down the road, different clinical diagnoses and medical intervention.

They are an excellent model for a belligerent indifference to intellectual property rights. I'm not sure that Lesotho or Zambia or Malawi or Namibia or Swaziland or Mozambique or many other southern and eastern African countries would have the courage to take on the World Trade Organization and to give the back of its hand to major international powers.

The Catholic Church has an anti-condom position. I don't spend my time fighting with them about that, because it's largely futile. They will not change their position. But they do some remarkable work at parish level with home-based care and raising consciousness and a lot of prevention.

Pamela mentioned my foundation. The Canadian people have been tremendously generous, and we are now supporting over 100 projects in some fourteen countries. Many of those projects are Catholic parishes—Catholic AIDS Action in Namibia, PASADA in Tanzania, Reach Out Mbuya in the heart of the district of Rakai in Uganda. These Catholic groupings are remarkable on the ground. We'll look for condoms elsewhere. We'll go to the UN Population Fund or to USAID or to PSI or a variety of other groups. You deal from strength. You don't spend your time excoriating those who are otherwise doing useful work in other areas.

QUESTION: Martin Meredith, the British author, in his new book, The Fate of Africa, takes issue with all that you have had to say about the optimism of contemporary Africa. He says that, contemporarily, huge amounts of Western money, both government and private, continue to be wasted by the corrupt and inept leadership of African leaders.

David Reiff, Michael Mann, and others have made the same observations.

Robert Root-Bernstein, the epidemiologist, has indicated that hygiene has been the complicating factor in creating conditions in Africa that have led to the deterioration of people's immune systems. So it's not that one silver bullet that we are looking for to offset AIDS; it is a whole range of social and medical problems that come from inadequate conditions in the country. You have blasted the international community, the United States, the institutions. Yet generic research for that silver bullet to offset AIDS is still needed. So if you criticize the pharmaceutical companies, where do you expect all of this research to be done?

STEPHEN LEWIS: Number one, I was extremely gentle with the pharmaceutical industry today. I have a serious representative of the industry sitting in front of me. He had neither apoplexy nor cardiac arrest. He sat through it with equanimity.

Not only have I read Martin Meredith, but I had a long discussion with him on Canadian Public Radio. He has written a remarkable book called The Fate of Africa.

What he said in our discussion was quite unlike what you've said today. He's very tough on the way in which the Western world, from slavery through colonialism to structural adjustment, prejudiced the possibilities of Africa to reform and to endure.

But, in truth, what Meredith argues is not that Africa is inherently or abjectly corrupt, but that the way in which Africa has been manipulated, carved up, exploited, inappropriately used over the centuries has resulted in a situation which is truly grievous. In that context, the Meredith alarums about corruption have a different sensibility.

I don't dispute the corruption, but I also note that there are fifty-three governments in sub-Saharan Africa, not just five or six. There are not just the Zimbabwes. There are not just the Nigerias. Although allegations of corruption occur, many governments, many of whom have been democratically elected now several times, are trying very hard to root out corruption.

I spend my life hoping that we'll discover a vaccine. Merck is in the third-phase trial of something that is relatively optimistic. In fact, it's the one pharmaceutical company which is doing serious research on vaccines. The experts say it may be ten years off.

I, therefore, hope against hope that we'll discover a microbicide so that there is a gel or foam or cream which women can use which will prevent transmission and save millions of lives. That is allegedly four to seven years off, which is more optimistic.

While I may have been unkind to some groups, on balance, what I've said is rooted in truth. The pharmaceutical companies have to be able to have a return on investment sufficient to do the research into their products—although not enough is attributed to the amount of money which is provided by the public sector and by the university community in the process of researching major drug products.

It's not just the pharmaceutical companies. They do some of it, but not all of it. If one looks carefully at their public relations budgets compared to their research budgets, it's an interesting juxtaposition. I notice that Merck joins with Bill Gates in Botswana to provide an important treatment program, with the government of Botswana as well; Pfizer builds a training center in Uganda; Bristol-Myers Squibb has children centers of excellence in Botswana, Swaziland, and Lesotho; Glaxo gives a voluntary license to an indigenous generic firm in South Africa.

The pharmaceutical companies are trying desperately to seek redemption, and they are doing a number of excellent things in the process.

But the rest of the world, particularly the corporate world, must begin contributing more directly to what is happening. I have suggested 0.7 percent of pretax. I'm prepared to take post-tax earnings, in order to help.

QUESTION: In showing great concern for women and women's situation in Africa, and talking about the pharmaceutical companies and the money, I almost jumped out of my seat and asked, "What about men?" In dealing with the ethical issues, with Africa, with all the points that you made about the needs of women, the needs of orphaned children, the problems of pharmaceutical companies, the lack of money from donors, one of the major areas which is conspicuously missing is the role of men in spreading the disease, the role of the ethics of the macho man in Africa that you didn't approach at all.

In many cases, the reason women are an issue is because men are an issue.

STEPHEN LEWIS: In the United Nations and the international community, there is a lot of prevention work done with men, particularly in what we call the high-risk groups, like truck drivers and migrant laborers, who are kept away from families and partners for months on end and naturally turn to commercial sex workers to satisfy sexual yearnings.

However, a number of studies have demonstrated that the sexual activities of African males are not that different from the sexual activities of North American and European males. It's the context of poverty, it's the context of the truck routes across the continent, the context of taking thousands of men from Mozambique, Swaziland, Lesotho, putting them in the mines of South Africa or Botswana, living in male-only communities for months at a time, separated from women.

Some situations for men speak less to the macho and more to the predicament.

That does not mean that the point you make is wrong. The United Nations Population Fund produced a monograph on male sexual attitudes in Zimbabwe. By the time you come to the end of the monograph, you feel, "What hope is there?" The sense of sexual entitlement is absolutely staggering. The prevalence of sexual violence in many countries is desperately worrying.

The whole circumstance of a patriarchal culture and gender inequality produces a worrisome pattern. But one shouldn't diminish the environs and the context within which it occurs. People are trying desperately to get men to focus on prevention, to use condoms, to understand the nature of transmission.

The problem is that the women are dying now. It will take two or three generations to change male sexual behavior. So we have to find a way to change the legislative infrastructure around property rights, inheritance rights, sexual violence—empower women now so that they remain alive and deal directly with the men along the way, both in the terms you have described and in terms of prevention.

But understand that the focus has to be on women, because they are the ones who are dying. Part of the answer surely is to empower them. I have seen some wonderful girls' schools, empowering young women who will not allow themselves to be subjected to predatory sexual assault.

They are trying very hard to educate the young boys in a greater sense of respect and understanding of young girls—not unlike the need for this to be done in Canada or the United States. The same macho culture exists in our societies. The same sense of young boys filling a particular role and young girls filling a particular role continues to exist in North America and Europe. Some countries approximate gender equality a little closer than others, but there isn't a country on the face of the earth where you have real gender equality.

JOANNE MYERS: Thank you for a very extraordinary morning.

Thank you, Pamela, for hosting this.