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Remarks by Stephen Lewis delivered at the 2016 Global Fund Replenishment Conference side event

Remarks by Stephen Lewis delivered at the Global Fund Replenishment Conference side event, Sharpening our Focus: Human Rights and Key Populations in the Global Response to HIV, TB and Malaria
September 15, 2016, Montreal, Quebec

This is a tale that starts well, but ends not so well.

I vividly remember sitting in a little ante-chamber, outside a boardroom in the UN secretariat in New York in early 2002, with Kofi Annan and Richard Feachem, the first Executive Director of the Global Fund. We were fantasizing at the prospective triumphs of the Fund in confounding HIV, TB and malaria.

History now shows that the fantasies became realities: the Global Fund has made a monumental contribution to the fight against the pandemics of AIDS, tuberculosis and malaria. It was a brave, unique, astonishingly inspired creation. I don’t have to rhyme off the catalogue of its achievements: they’re well-known; they enliven the chatter in the halls of this replenishment conference.

But the Global Fund is now at a crossroads, only partly of its own making. I can’t begin to reconnoitre the details in a mere fifteen minutes or so, but let me try some broad strokes, and forgive me for what is missing.

Take HIV/AIDS. The grand plan for 90-90-90 by 2020 is faltering. The chanted slogan “The End of AIDS” by 2030 is attracting as much derision as it evokes applause. A recent Lancet study suggests that there are two million new infections every year, a greater number than posited by UNAIDS, and worse, a number that has remained stable since 2010. In fact, some 74 countries have experienced an increase in infections over the last decade. The scorched terrain of the disease in the lives of adolescent girls is the stuff of nightmares, and the fact that AIDS is the greatest killer of women in their reproductive years is a hideous testament to gender inequality.

And for all of us, who embraced treatment as prevention as the ultimate mantra, the revelation, raised in Durban, that test and treat may be flawed, was a cardiac moment. I still have religious fervor for Treatment as Prevention, it will always be a brilliant scientific intuition, but it may not be the holy grail.

Further, in 2015, there was more than a billion-dollar drop in funding for AIDS from donor nations as compared to 2014; the first time in five years that this has happened. And whether the analysis comes from UNAIDS, or the Lancet, or academic studies, or analytic NGOs, we need a minimum of nine billion dollars more than we currently have between now and 2020. Where is the money to come from? And in the midst of it all, there are still twenty million people requiring treatment.

Something, somewhere, went wrong. Very wrong. Donors started losing interest, extravagant claims of success were counterproductive, the world turned its hearts and budgets to terrorism and refugees and climate change, and the most debilitating infectious disease on the planet is in danger of making a comeback.

Michel Sidibé, the Executive Director of UNAIDS says he’s scared. We should all be scared.

But that’s only the half of it—and if I were to include malaria in these remarks, which I’m not competent to do, it would only be the third of it.

What is happening with tuberculosis is mind-numbing. There’s been a sudden surge of interest, a kind of frenzy of concern related, no doubt, to the fact that TB, for the first time, exceeded AIDS in the total number of deaths last year: a total of one and a half million.

I’ve said it before, and I’ll say it again, I could happily self-immolate for failing to respond to the TB plague when I first encountered it. When I was the UN Envoy mid-2001 to 2007, the co-infection rates of HIV and TB were steadily rising. I knew it, I saw it, I heard it. But I failed to act. And alas, I was not alone; it was a prevailing truth.

We were all—the entire world—so preoccupied with the carnage of HIV/AIDS that a kind of paralytic myopia set in: we couldn’t see what was happening in parallel. The Global Fund was similarly afflicted, giving only some 18% of its funding over the years to tuberculosis (which is not to diminish the value: the overwhelming external funding for TB comes from the Global Fund, but it’s just not enough, not nearly enough). WHO, in the early days, kept clamouring for a stronger response, but it didn’t happen.

Now in the wake of a clear global health disaster, including lethal levels of MDR- and XDR-TB, the arsenal of engagement is building exponentially. And so it should. STOP-TB, WHO, The Union, UNAIDS, Pepfar, RESULTS, MSF, Partners in Health, TAG, UNDP, the World Bank, the Global TB Caucus, powerful voices … from Dr. Aaron Motsoaledi, Minister of Health in South Africa to Dr. Eric Goosby, the UN Special Envoy, have all come together in an herculean effort to turn the world’s attention to tuberculosis, and remove it, demolish it, extirpate it from the planet.

It can be beaten. It can be treated. It can be cured. There is no reason on this earth for such a toll of human misery. Tuberculosis now exacts a greater swath of death than all of the sordid international conflicts combined. It’s sheer madness to allow it to continue.

But problems abound. The shortfall in funding is astronomic … additional billions are needed, a minimum of $3 billion in this coming year alone. There are new drugs available to treat MDR-TB, but the applicable pharmaceutical companies are recalcitrant in both price and availability. Some BRICS countries with large TB burdens—India is the best example—are indifferent to the appalling conditions of their citizens and insufferably slow to respond. And the aching mystery is why it has been so difficult to integrate the treatment of TB with that of AIDS since they are inextricable and can never be overcome separately. As Dr. Motsoaledi has said “We will not end AIDS without ending TB. We will succeed or fail together, so walking alone is not an option.” And at a panel earlier today, Dr. Motsoaledi told the audience that 80% of the deaths of people living with AIDS was attributable to TB.

I mentioned the financial shortfall.  Take just one example: research and development. It is universally agreed that new drugs, new diagnostics, new vaccines are all desperately needed. But the excellent NGO, the Treatment Action Group, that expertly chronicles what is in the R&D pipeline, has shown in 2014, and it will be worse in 2015, that there is a staggering gap between the global plan targets and the actual funds at hand.

Taking into account Basic Science, Diagnostics, Drugs, Vaccines, Operational Research, Infrastructure and Pediatrics, it’s possible, authoritatively, to predict a shortfall of nearly one and a half billion. And that’s R&D alone!

Something has to give. I’m not sure what the answer is, but somehow the world has to recognize that in tuberculosis it has a growing menace of terrifying proportions.

For some people, the answer is obvious. The answer is the Global Fund. Would it were true. I’m not going to dwell on the arithmetic; I’m simply going to say, and happy to debate it, that the $13 billion target is ridiculous. Do you remember that in the previous replenishment in 2013 it was $15 billion? We’ve certainly lowered our sights at precisely the wrong moment. And I’m prepared to bet that before this week is out we’ll have the $13 billion in the bank. It’s just not that hard to reach. 

But mark this. At a conference in Tokyo last December, it was agreed that during this next replenishment period, 2017-2019 inclusive, an overall total of $97 billion would be needed for Global Fund eligible countries. It was felt that domestic resources and other international sources could provide $64 billion which, with the $13 billion from the Global Fund would bring the total to about $77 billion. That’s a shortfall of $20 billion or 20%. Now why in God’s name you would plan for a shortfall of 20% is reprehensible in the extreme, and it demonstrates, incontrovertibly, that the Global Fund should be asking for much more money.

But the Fund’s target is a combination of the calculus worked out between the Fund’s Secretariat and the members of the Board … and with the new funding formula, based on disease burden and income level, they obviously feel that $13 billion is the best they can do: You don’t want to alienate the donors by asking for too much.

I, for one, will never accept that argument. You can talk till doomsday about innovative financing, but you’ll never put an end to AIDS, tuberculosis and malaria unless the major donors pull their weight … unless the major donors decide that expenditure on public health is as important as expenditure on drones. I listen to all the arguments ad nauseam. I’m old in the tooth; I’ve heard them all.

I say to you as colleagues and friends that one of the great mistakes we’ve made, as activists and advocates, is to have largely given up on the battle for official development assistance.

Everyone is crowing about Canada’s contribution to the Global Fund. We went up by 20%. But what’s really at work here is the colossal relief attendant on everything the new government does, having replaced the fossilized reactionaries of yesteryear. In truth, a 20% increase in our contribution doesn’t mean that much when the previous contribution was far lower than it should have been.  And there are other reasons not to get carried away. Until 2010 when the Tories decimated ODA, we were giving $5 million annually to both the Partnership for Microbicides and the International AIDS Vaccine Initiative (extremely important if you believe, as many do, that only a vaccine will end AIDS once and for all). We’ve yet to restore those grants, and if we backdated the restoration, as we should, to make up for what was lost, it would be $50 million. So the 20% increase looks rather less robust.

But that’s not all. There’s something called TB REACH, an international program that focuses on new technologies for case detection. Canada is an exemplary supporter, but we just reduced our contribution. That, too, somewhat erodes the 20%. But above all, as I said, there’s ODA. A new government, a new budget, and ODA remains at 0.28% of GNP, well below the OECD average. Were we to increase ODA as everyone expected and hoped, our contribution to the Global Fund could be dramatically improved.

We just can’t give up on the primary source of humanitarian aid: rich western governments. The Global Fund would do well to re-evaluate its target. If the target went up, so too, presumably, would, for example, the dollars for tuberculosis.

But the current crux for the Global Fund, and the crux for the excellent Panel that follows, is to address key populations with a sense of almost intemperate urgency.

As it happens, I participated in a couple of panels at the High-Level meeting on HIV/AIDS in New York in June. There was nothing particularly noteworthy at the meeting by way of content or declaration, with one revolting exception: the contempt for key populations—the entire gamut of key populations: men who have sex with men, sex workers, injecting drug users, prisoners, migrants, the disabled, aboriginal peoples—the contempt manifested by a host of governments was palpable. And these are the very key populations on whom the response to HIV must now concentrate. These are the very populations where the rates are rising; they represent 35% of new infections. These are the populations subjected to a merciless pattern of criminalization. We all know that.

But we have a truly vexing problem. The casual, reckless laceration of human rights will undermine everything we want to achieve, everything the Global Fund wants to achieve. If we want to defeat the forces of darkness—honestly, it’s like having a world of reprobates as moronic and dangerous as Trump—if we want to get past the ugly prejudice, the demonic hatred, the biblical rationalizations, the indefensible cultural relativism, then the answer lies in the strength and voice of civil society.

But civil society is also under assault, sometimes mindless, more often premeditated, in country after country. If the Global Fund wants to be seen as something more than a purse of gold, it must find a way to finance civil society activism significantly, as well as to funnel money to the entire panoply of key populations, if necessary in resolute defiance of governments.

There’s a particular conundrum here that we’re increasingly aware of. The transition in middle-income countries from the Global Fund to domestic resources means that some of the very countries where discrimination is most extreme, are deprived even of the modest emoluments of funding devoted to key populations. And you can be darn sure that domestic resources will not be found for key populations where the views of the state are incompatible with fundamental human rights.

Permit me a personal note: I detest this middle-income rationale. It’s a straight, malicious hangover from the days of structural adjustment policies imposed by the international financial institutions in the eighties and nineties. It is preposterous to pretend that poverty and inequality don’t stalk the landscape of middle-income countries, and it’s the poor and the marginalized who are the victims of transition. It poses a huge challenge for the Global Fund.

And that leads, organically, to one other matter I must address. The financial cut-backs by bilateral and Foundation donors are playing havoc at the grassroots. Community-based organizations are struggling, are starving, are closing. It’s crazy that at this most crucial moment in time, the grassroots organizations are under financial siege. It almost feels conspiratorial that we would shred superb community-based initiatives when they’re most needed … communities that live with dignity and embrace social justice. My own Foundation in Canada watches projects unraveling in several countries as external resources evaporate. It’s as though vulnerable human beings no longer matter in the equation of geopolitics; that lives are gratuitously expendable.

What a world we inhabit. It’s a world that the Global Fund must confront.

And let me say in closing that the greatest number of those expendable lives are women and girls. In all the thirty-five years of HIV, now pulverized further by tuberculosis, we’ve never come to grips with the gender inequality that drives so much of the pandemics, from an absence of sexual autonomy to the presence of sexual violence. Misogyny and AIDS go hand in hand. Of all the key populations, women and girls are front and centre. The Global Fund notes that girls account for 80% of new infections among adolescents; and women and girls overall account for 56% of new infections. It never ends.

I realize that this Replenishment Conference is meant to be a celebratory jamboree. And there is a lot to celebrate. But I’ve never been able to get my mind around the tens of millions who have died, unnecessarily, of AIDS, tuberculosis and malaria, and the millions who are still locked in a life-and-death struggle. When you remember the countries that resembled cavernous graveyards just ten years ago, the thought of even one more unnecessary death scars the soul.

The Global Fund is helping to bring this scourge to an end. But it has to do more. And the doing is in our hands.