by Kofi Annan
Responsibility for reform lies with the people on the ground, the politicians and leaders within their own countries. But the failure of donor countries to provide the necessary financial aid when these kinds of reforms are being pursued is perhaps made even more unforgivable by this dynamic. The reformers need to be given every chance. The MDGs are a partnership in the truest sense between the rich and poor. The people within developing countries are responsible, but everyone has a role to play.
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Of the countless components to the MDGs campaign and our battle with poverty, one issue—HIV/AIDS—demands special focus. In turning to this challenge, we drew on many of the innovations of the Millennium Declaration, applying them in an intensive form to face down one of the most serious crises of my secretary-generalship.
At 8:50 a.m. New York time, on December 7, 1999, the phone rang. It was Richard Holbrooke, the U.S. ambassador to the United Nations, on the line:
“We should raise HIV/AIDS as an issue at the Security Council in January.”
When I heard this I couldn’t help but pause in satisfaction at this news. For HIV/AIDS to obtain the attention that it deserved, and of the right kind, I had believed for some time that it had to be understood as a security issue. It was not just a problem to be packaged away under the label of “health.” It was a fundamental security threat of global proportions: just the sort of world issue that the UN, and particularly the Security Council, existed to deal with. But its nature as a disease meant it was of a type never brought to the Security Council before. This was a foolish reason not to act against a threat that had required concerted global attention for years. An obstinate layer of ambivalence in the corridors of power had made leaders apparently impervious to the colossal evidence that mounted every day.
“Well, we have a problem, Richard. You do realize HIV/AIDS isn’t seen as a peace and security issue don’t you?” I was deliberately baiting him. I needed to establish the level of his ambition. Was this going to be a side issue, a distracting footnote at the Security Council, or was this going to be an opportunity to bring HIV/AIDS into the center of international diplomacy? It would all depend on how the powerful would represent it.
“You know full well that you told me over a year ago that it is a security issue!” Richard replied. “If we take it to the Security Council now, then it’s finally going to get the emphasis that it deserves. This is going to be a priority for the U.S. presidency of the Security Council.”
The idea was finally in the head of one of the permanent five. A crack in the wall had opened. Better than that, we had Holbrooke leading the charge. I thought the other members of the Council might not be ready to accept this change. But Holbrooke had the force and personality and moral courage, in a manner like no one else, to push the other governments into unfamiliar territory. With the Security Council as a rhetorical partner, there was now a chance for a change in the trajectory of the HIV/AIDS agenda. Holbrooke had been speaking to Nelson Mandela that day, and I remembered my own lesson from Mandela’s achievements: you have to have a sense of opportunity.
A year later, a new global level of awareness and willingness to respond to calls to tackle the HIV/AIDS issue had been reached. At this stage, in early 2001, I decided to make this issue a core priority of my office. We were now in a position to make a genuine, life-saving difference. But as with the MDGs, here, too, I realized that the only way to have any hope of pushing forward the HIV/AIDS agenda was through the formation of a global alliance.
The UN had its own agencies tasked with taking on this problem, with excellent leaders who would prove integral to our later achievements against the disease. UNAIDS, run by Peter Piot, was one. With UNAIDS we established the first interagency organization tasked with the essential coordination of all our programs and funding in this area. Another was the World Health Organization, headed by Gro Harlem Brundtland. But our agencies alone were never going to be enough. It was only through a raft of partnerships with NGOs and other advocacy organizations that this campaign could be successfully fought. This was not only because of the scale of the scourge of HIV in the world but also the multiheaded nature of the problem. First, we needed to pursue prevention: to halt and reverse the spread of the virus, requiring education on precautions; information campaigns to raise awareness and the mobilization of young people; and, in particular, measures that would enable mothers to know that they were infected, allowing them to avoid passing the virus to their children through breast-feeding. Second, we had to endeavor to put care and treatment within the reach of the millions of living victims of the disease, to enable access to the drugs and treatments that could totally transform the impact of infection. Third, we needed to pursue scientific breakthroughs, with investment in research for treatments and preventative measures, and, most important, a vaccine against HIV. Given the complexity of the tasks at hand, the solutions were going to have to come from a large number of partners from various sectors. It had to be a truly global alliance.
Just as we sought to build a civil society network for the MDGs, we did so here, but in a more targeted way. The general effort to reach out to partners in business and international civil society in the preceding years meant we had the foundations to be able to do this. With this expanding network, in the following months and years, through a sustained and concerted effort, we were able to achieve two important things: first, in the establishment of a war chest to sustain the complex fight against the disease, in the form of what was called the Global Fund; and second, in the successful campaign to cajole the biggest pharmaceutical companies into dramatically reducing the prices of drugs for HIV/AIDS victims in the developing world.
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On April 26, 2001, I gave a speech at the African Union summit in Abuja, Nigeria, dedicated to the subject of HIV/AIDS. In that speech, I issued a public call for the creation of a fund that would form the basis for waging the war against HIV/AIDS. This was the outcome of weeks and months of discussions and suggestions between many parties: NGOs, private foundations, governments, and academics. The overriding call was for a war chest dedicated to sustaining the worldwide campaign against HIV/AIDS, as a lack of resources specifically dedicated to tackling the disease and its effects was considered the chief obstacle to progress. I proposed that there had to be, at a minimum and over a ten-year period, between $7 billion and $10 billion deposited into that fund.
Not long after, we saw the establishment of the Global Fund, designed to finance large-scale prevention, treatment, and care programs in the developing world for HIV/AIDS, tuberculosis, and malaria. The other diseases were included because they ranked on a par with HIV/AIDS in their impact: those with AIDS often died of tuberculosis, and the impact of malaria remained a deep scar across prospects for development in much of the world, particularly Africa.
The Global Fund was perhaps the most important international financing facility for aid established in the last twenty years. Its prominence mobilized donors, and it pooled their contributions, concentrating them into a central, coordinated, and global strategy. It also started a snowball of attention that began to make the subject of HIV/AIDS a reputable one for open and public discussion. That same year, in September 2001, the General Assembly even held a special session to debate the HIV/AIDS pandemic for the first time. This attention was not something the HIV/AIDS agenda had enjoyed before in many public circles, largely due to the sense of embarrassment incurred by the subject’s sexual connotations. Finally, this was beginning to change.
The fund immediately attracted philanthropists. Early on, the Bill Gates Foundation stepped forward to donate $100 million. Bill Gates and his wife, Melinda, and I became acquainted over the HIV/AIDS campaign, and they remain some of the strongest supporters of the fight. This is in addition to their uniquely generous contributions to international development as a whole. The fund attracted the support of governments, too. Regardless of the disagreeme
nts that would later grow between the UN and the Bush administration on other issues, the U.S. government and George W. Bush in particular became resolute supporters of the campaign. The president immediately pledged $200 million for the fund, while Congress started proceedings to approve $700 million for the next year’s budget. Other governments followed, and as early as July the German parliament had already approved a donation of $130 million and the United Kingdom a further $200 million.
Bush would then go further still. He created the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). With $5 billion in funding per year, this was the biggest financial commitment by any country in history to fight a single disease. I spoke to Bill Clinton about the new U.S. agenda on HIV/AIDS at that time. He shared with me a telling insight: “You know what, Kofi? This may be the most important thing he does in his entire presidency.” He was right. And by the look on his face, Clinton seemed to signal he wished he could go back and seize the same chance.
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In a 2001 speech in Abuja, I addressed the African heads of state and government as directly as I could on this challenge:
“You must take the lead in breaking the wall of silence and embarrassment that still surrounds this issue in too many African societies, and in removing the abuse, discrimination, and stigma that is still attached to those infected. The epidemic can be stopped, if people are not afraid to talk about it.”
This wall of silence had been immensely destructive. Mugabe was one of those leaders who remained obstinate in the face of the rational arguments for measures to prevent HIV, partly on religious grounds but largely in embarrassment. Across Africa, methods had emerged to avoid talking about and recognizing the issue. In Uganda, for example, it was covered over with the unpleasant pseudonym “the slim disease.”
I was told of one occasion when it was suggested to the then president of Kenya, Daniel arap Moi, that he speak publicly about the use of condoms. His response was: “I am father of a nation. My duty is to keep the people moral and upright. I can’t talk to them about being promiscuous!” It was deeply disturbing for me, even to the point of shame, to know my fellow African leaders were so irresponsibly obstinate on so deadly a matter.
Thabo Mbeki, the president of South Africa, was particularly obstructive. Successor to the most impressive of Africans, Nelson Mandela, Mbeki was always going to have a hard time filling those shoes. He made some impressive contributions to life and politics in South Africa and Africa as a whole, providing effective management of the South African economy and playing a proactive role in the conflict-resolution endeavors of the African Union. But he proved incapable of exerting anything like the kind of leadership that was urgently required of him on the issue of HIV/AIDS, and with terrible results. On one occasion, before traveling to South Africa for a conference, I spoke to Mbeki to tell him that Mandela and I thought the three of us should make a public visit to an HIV/AIDS clinic in South Africa to raise awareness of the disease. At first he agreed. But when I arrived in South Africa, it became clear he had no intention of fulfilling this promise. “I don’t think we should distract ourselves from the conference” was his only explanation.
At first it just seemed too much for Mbeki. But his position, as head of state of a leading African country, meant that he should not have considered such a reaction a luxury available to him. Worst of all, he refused to recognize the mainstream scientific conclusions about HIV/AIDS: namely, that AIDS is caused by the HIV virus and could therefore be helped through antiretroviral drugs, which he also claimed were toxic. In correspondence to me, he cloaked his reasoning—based on the flimsiest of scientific advice—in postcolonial arguments, alleging racism in the debates surrounding the issue. At a time when neighboring countries were budgeting to provide their populations with antiretroviral drugs—with, for instance, Namibia treating 71 percent of its infected population by 2005—Mbeki was refusing to do the same in South Africa. A team of Harvard researchers later investigated the likely impact of this policy. They found that, at a conservative estimate, Mbeki and the South African government could have prevented at least 365,000 premature deaths if they had not taken this position.
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In the buildup to the launch of the Global Fund, the public campaign began to turn our way as we received more and more endorsements from a variety of governments, organizations, and prominent figures around the world. This brought the pharmaceutical companies under the spotlight to a new degree. There was a growing rejection of the big companies’ refusal to make their drugs available at affordable prices in the developing world, and this view was now entering the mainstream. In early 2001, my senior staff and I agreed that the time was right to push for significant cuts in drug prices. We had a better chance than ever before for a receptive audience with the drug companies.
This was a very big step. The cost of antiretroviral treatment was such that, at that time, the conventional wisdom in the development community was that the pursuit of antiretroviral therapy for poor countries would never be possible based on simple economics. In this view, prevention and research into a vaccine was the only real hope. But our high-profile advocacy and lobbying for the right of access to treatment in the developing world changed this. We proposed that this was simply a question of will, not economics. Would we help the millions dying when we had the science to do so, or would we not? It was under the shadow of this lingering and hopelessly simple question that Peter Piot, Gro Brundtland, and I arranged a series of meetings with the top pharmaceutical manufacturers, the first in March 2001 in Amsterdam.
As a result of these meetings and the collective process of pressure and engagement worldwide, the pharmaceutical companies began to compromise. This led to a dramatic reduction in the cost of treatment for victims in the developing world. The cost of drugs fell from $15,000 a year to, eventually, just $150 a year, or fifty cents per day. The impact was enormous. As a result of this step, by 2005 countries like Botswana were now able to afford to extend HIV/AIDS treatment to 85 percent of those in need, a dramatic transformation in the life prospects for millions of victims.
Important improvements have been made in the vast struggle to contain and reverse the impact of HIV/AIDS since those early years. In 2010, for the first time, the number of new HIV infections in sub-Saharan Africa began to drop. By the same year, eight developing countries had begun providing universal access to antiretroviral drug therapy across their populations. More lives are being saved from HIV/AIDS now than ever before. Unprecedented advances have also been made recently in research into producing a vaccine, with the possibility of an effective vaccine for humans finally established and, particularly promisingly, the identification of neutralizing antibodies against HIV.
But all this progress, in infection rates, treatment, and scientific research, is under threat from a global fall in funding for the HIV/AIDS campaign. It is estimated that there is currently a shortfall of around $10 billion if these successes are to be sustained. All this hard-won progress depends utterly on the continued supply of major donations, as otherwise it stands to be reversed. By one estimate in the Lancet, the British medical journal, new HIV infections could reach a rate of 3.2 million a year if funding is not now increased, as just the activity of keeping the pandemic under control will cost between $397 billion and $733 billion over the next twenty years. The impact of the financial crisis has led to tough economic times and a tightening on donations, but HIV/AIDS is surely an area that we cannot afford to abandon.
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Those who argue the MDGs divert resources from the real interests of donor states are sorely mistaken. Such a view reflects a blindness to the world we live in. The walls have come down. The threats faced are those that no single country has the capacity to tackle alone. This is because of the intricate and complex relationship between development and security.
Others have claimed that the MDGs represent little more than a rheto
rical flourish that does no good. One activist once even referred to the MDGs as a “Major Distraction Gimmick,” and I have heard them referred to elsewhere as nothing more than a useless form of “cheerleading.” The implication is that they should be done away with. That would be a mistake.
First, at the diplomatic level, I personally witnessed how the MDGs served to transform the agenda of the world’s leaders. Before 2000, social, economic, and development issues had long been a major part of the UN’s work. But they were always considered and debated in distinct separation from the other pressing political issues of the times and were never to be expected on the agenda during any urgent negotiations with the secretary-general. By the time I left the UN, this had all changed. Development was at the top of the pile, an entirely appropriate feature of high-level meetings and pressing telephone conversations with heads of state and government. Most important, this has been sustained. The 2010 world summit saw every country justifying its role and charting its progress in pursuit of the MDGs, and all under the gaze of intense international media attention and scrutiny.
The second impact has been in accountability. The MDGs, and their standardized rating system for evaluating progress in development contained in their simple and universally accessible aspirations, have provided a mechanism for civil society in all parts of the world to hold governments to account. This did not exist before, and the universal standard set by the goals has allowed an international community to emerge in transnational solidarity, further empowering people to raise their voices and demand results. The outcome has been a new momentum for good governance in the developing world, with, as Jeff Sachs put it, dozens of governments now forced to “watch themselves in the mirror” of poverty, hunger, disease, infrastructure, and education.
