World Bank - November 20, 2003

Please allow me extend my thanks to you and your colleagues here at the World Bank for inviting me to deliver this lecture. This is a particular honour for me because of the enormous leadership you have personally provided in the fight against AIDS. Today, of course, AIDS is an important part of the global agenda, but your leadership on AIDS began long before this was the case.

At the outset, I would also like to pay tribute to Debrework Zewdie and all her colleagues of the Global HIV/AIDS Program of the World Bank Group and the Multi-Country HIV/AIDS Program (MAP) for their groundbreaking work on AIDS in the Bank, and for ensuring that the collaboration between the UNAIDS Secretariat and our Cosponsor the World Bank is a mutually beneficial one.

It is exactly 20 years ago that I started investigating AIDS in Kinshasa, Zaire. I can recall the exact moment I realized what we were confronting. Watching young, emaciated men and women die in Mama Yemo Hospital, I became convinced that this disease would be predominantly heterosexually transmitted, that it would spread rapidly, that Africa and the world were in peril, and that the disease would change my life.

A few years later, in 1987, my relationship with the Bank started. I was determined to convince the Bank to confront AIDS. It had become clear to me that without the Bank's financial and intellectual muscle, African countries could lack the resources to address the emerging crisis.

I made my case with the Bank, but I did not succeed. In retrospect, I realize I used both the wrong vocabulary and the wrong arguments, and did not know how to push an agenda inside the institution.

In the last several years, the global fight against AIDS has been transformed. Notwithstanding my inability 16 years ago to convince the Bank to come on board, the Bank has played a critical role in ushering in a new era of determination and commitment on AIDS. It is therefore profoundly significant for me and a great honour that I have the privilege of addressing you today in this Presidential lecture.

Where are we?

I will not inundate you with the latest numbers on AIDS. The magnitude and depth of this global crisis is well known. Fundamentally, this crisis is not about numbers; it is about human suffering and about the failure of development to prevent this human catastrophe from unfolding.

Let me describe the situation:

- HIV infection is not leveling off: New infections continue to grow as prevention efforts remain small-scale and as treatment remains beyond the reach of all but a small percentage of people with HIV. Rapid globalization of the epidemic is also evident. The fastest growing epidemic is in Eastern Europe. Particularly worrisome is the AIDS situation in Russia. The Caribbean is still experiencing high levels of infection. There is potential for the epidemic to explode in China, India and Indonesia. Even in western Africa, where infection rates were relatively low, there is now a sharp increase, such as in Burkina Faso, Cameroon and Nigeria.

- Increased feminization of the epidemic: Every year brings an increase in the number and proportion of women infected with HIV. Globally, more than half of all persons infected between the ages of 15 to 49 are women. In Africa, the proportion is reaching 60%. Because of gender inequality, women living with HIV/AIDS often experience greater stigma and discrimination. And since women are the main care-givers and source of household labour, their illness means the collapse of family structures and community care networks. At the same time, society needs to increase its efforts in preventing infection among women, which would then also prevent mothers from being infected and eventually prevent countless children from being orphaned.

- AIDS is having enormous impact on societies: We are already beginning to see the profound impacts these enormous demographic shifts are having on the fabric of societies. Consider those left behind when adults die from AIDS: the millions of orphans-they will account for 15% of all children in the worst affected countries by 2010, adding to the growing number of street children and child-headed households.

Most worrisome is the impact of AIDS on the capacity of the state and private sector to deliver services because of illness and death among service providers. This in turn contributes to failings of development. AIDS creates economic insecurity, which in turn causes growing local, national and international instability. This includes an increasing threat to the services provided by police and military forces. This is why it was so appropriate that the UN Security Council in January 2000 took the unprecedented step in debating AIDS.

A time of great opportunity

There are three clear signs the global response to AIDS is entering a new phase-a time of great opportunity to defeat this epidemic. The Millennium Development Goals, adopted by the international community in 2000, envision that by 2015 the epidemic will be halted and begun to be reversed. This ambitious goal may have seemed somewhat fanciful to some when it was adopted at the dawn of our new century. We know today, though, that it is eminently achievable-if we put into place the policies and programmes that have proven effective in rolling back the epidemic in diverse countries throughout the world.

First, there is growing political momentum to respond to AIDS-never before seen at such a high level for a health problem, and indeed rarely for any international development issue.

Today, when global leaders meet, AIDS is high on their agenda. As a matter of fact, this afternoon in London, President George W. Bush and Prime Minister Tony Blair announced they will greatly intensify their collaboration on AIDS.

While we applaud this growing political momentum, we must also face reality.

Many countries, particularly outside sub-Saharan Africa and the Caribbean- and many international institutions - still do not take AIDS as seriously as they should. Too often, political leadership on AIDS remains confined to political rhetoric. If words would do it, AIDS would be gone by now! Yet real leadership requires the courage and vision for governments to go against the stream of public opinion if that is what is needed in this epidemic associated with sex, drug use, stigma and shame.

Second, there is a discernable momentum of evidence. The hope that we can bring the epidemic under control is being bolstered by growing evidence it is feasible. We are seeing more and more instances of prevention success on all continents. With the fall in prices of antiretroviral medicines, the scaling up of effective HIV treatment is now a real possibility, driving a number of national and international initiatives forward, including the campaign by the World Health Organization and UNAIDS to provide 3 million people with antiretroviral treatment by 2005. We must not underestimate the extent to which these efforts are bringing hope amid the despair AIDS has caused.

Third, there is a real momentum in greatly increased resources going to AIDS from both donors and from the governments of developing countries.

The World Bank has shown the way, together with several of the major donor countries. The Bank has played a leading role in the financing of AIDS programmes and in advocacy on AIDS as a development issue. In addition, the Bank's innovative Multi-Country HIV/AIDS Programme has pioneered new mechanisms to support local authorities and NGOs in Africa and the Caribbean. I saw it with my own eyes this year in Kenya and Ethiopia. It may surprise even you to learn that there are more than a thousand community groups in Kenya and 5,000 villages in Ethiopia receiving World Bank support.

The Bank has developed the disbursement and accountability mechanisms through existing national structures that make this possible.

Mr President,

UNAIDS is proud to have the World Bank as one of its nine Cosponsors.

Together, we are spearheading UN reform, demonstrating that the UN system is new, more effective, and more efficient means when global emergencies arise. UNAIDS-comprised of a Secretariat and its Cosponsors-delivers five key functions:

- Leadership and advocacy for effective action, - Strategic information needed to guide the efforts of partners, - Tracking, monitoring and evaluating the epidemic and the response, - Engagement of civil society and businesses in the response to AIDS, and - Mobilization of sufficient financial, technical and political resources.

This week's decision by the US Congress to allocate US$2.4 billion to international AIDS activities in the coming budget year follows the commitment of President Bush in his 2003 State of the Union address to provide $15 billion over the next five years. South Africa, the country with the largest number of people living with HIV/AIDS in the world, has not only tripled its budget for AIDS, but yesterday it unveiled a plan to ensure universal access to treatment.

However, we are still far falling short of the minimum $10 billion needed annually to mount an effective, comprehensive response in low- and middleincome countries. But let's also recall that when UNAIDS started in 1996, barely $200 million was being spent on global AIDS efforts. This year, we estimate that expenditures on HIV/AIDS programmes in developing countries will total $4.7 billion, including resources from the Global Fund to fight AIDS, TB and Malaria and the World Bank.

What we have learned from the response so far

AIDS is undoubtedly a major problem-one of the pre-eminent challenges of our era -but it is a problem with a solution. Worldwide experience in responding to AIDS has been accumulated over the last 20 years, resulting in a body of effective strategies against AIDS.

Some developing nations have shown real success in the response to AIDS- particularly in preventing new HIV infections among adolescents and young adults, although less success in offering antiretroviral therapy. Most notable are Uganda, Senegal, Brazil, Cambodia, Thailand, and a growing number of cities in East Africa, such as Kigali and Addis Ababa. However, these few successes need to be sustained and expanded.

When infection rates and AIDS deaths are mounting in so many parts of the world, what accounts for these successes? There are, I believe, five key elements that are present in every effective response to date. These elements should inform and underpin our efforts to expand worldwide our success against the epidemic.

First, leadership. No money can replace courageous leadership at all levels. The response to AIDS must be led from the highest level in the state.

Second, comprehensiveness. Success comes from sustained and comprehensive approaches on prevention, care, treatment and impact mitigation. A commitment by all states in the world to accelerate and scale up implementation of a comprehensive response was forged at the UN General Assembly Special Session on AIDS in June 2001, when 189 member states endorsed the Declaration of Commitment on HIV/AIDS. This new UN initiative to reach 3 million people with HIV treatments by 2005 is but an outgrowth of this global commitment to a comprehensive response.

Third, multisectorality and inclusiveness. The epidemic cannot be brought under control by the health sector alone-we need the broad engagement of all sectors and people of all walks of life including people living with HIV/AIDS and religious leaders.

Fourth, breaking down stigma and discrimination. Stigma and discrimination are major obstacles in encouraging people to take advantage of prevention and care services. As Mary Robinson put it so forcefully in her Presidential lecture two years ago, AIDS clearly demonstrates that promoting human rights in development is cost-effective.

Finally, act now, or pay later. Africa has learned this lesson the hard way. Denial and ignorance do not reverse this epidemic. It is a lesson that the countries of Asia and Eastern Europe must immediately take to heart.

We still have much to learn on the ever changing challenges in AIDS: how best to respond to the enormous and growing numbers of orphans, how to reverse AIDS-induced food insecurity, how to implement antiretroviral therapy programmes on an unprecedented scale, how massive foreign aid will affect macroeconomic and fiscal policies, and how we can reverse the crippling effect of AIDS on countries' abilities to govern themselves effectively.

What are the key challenges?

More money for AIDS programmes is vital, but money alone will solve little. If we are to succeed, we must come to grips with three overriding challenges that have the potential to frustrate even the best-funded initiatives.

The first is capacity. One way in which the epidemic drives a vicious circle is by striking hardest at those countries with the weakest capacity for implementation. In many nations, AIDS is now depleting capacity faster than it can be replenished-a macabre mirror of what it does to the immune system. Already we face an unparalleled crisis in human resources, and it is only going to get worse. We cannot possibly keep pace by relying on traditional tools. Many private firms have figured this out and are taking unprecedented steps to safeguard their human investments. AIDS programmes must do the same. We need to broaden our vision of how we approach capacity, combining vital short-term measures with long-term capacity development. How can we do this?

We can begin by preserving existing capacity. In other words, keep people alive. This is why providing HIV treatment is so critical. In the hard-hit countries, nothing else-nothing-will so directly or quickly arrest the plunge in public capacity as this single measure. Antiretroviral therapy has reduced mortality by 80% in Brazil-what other capacity-building measure can show such a return?

We must then call in reinforcements. In many countries, there are vast cadres of trained specialists who are sitting idle in the struggle against HIV/AIDS.

Kenya, for instance, is said to have 4,000 nurses who are no longer practicing. Can there be any higher priority for the nation than to lure these front-line workers back into service?

We can also expand our concept of capacity. In times of crisis, many countries have developed non-conventional capacity to compensate for formal skills gaps. The simple knowledge and services they can provide have helped countries make far faster gains in health and education than they would have by waiting for specialized human capacity to develop. In HIV/AIDS, so much of what makes for good practice requires little or no technical knowledge. Enlisting and empowering a wider range of talents and untapped resources in the community-particularly people living with HIV/AIDS -would both swell our numbers and help break the silence on AIDS.

Over the long term, we must help countries build strong foundations to sustain capacity. That is a long-standing challenge of development, but it has taken on new urgency in the age of AIDS. We in the donor community bear much of the blame for insufficient national institutional capacity to initiate and sustain effective programmes. In truth, most forms of AIDS assistance over the last 20 years have made little effort to build durable national institutions. If we are to halt and reverse the global epidemic, we cannot continue repeating this mistake. In high-prevalence countries, AIDS calls for a complete re-thinking of how skills will be built, retained, and sustained. In low-prevalence countries, it underlines the importance of aggressive prevention efforts, to preserve the vast investments in human and institutional development.

Aren't we paying the price now for decades of development donor practice?

In my view, any donor AIDS programme that neglects the capacity dimension should be discontinued. The long-term challenges posed by AIDS cannot be addressed by flying in experts from rich countries, or by focusing only on hardware. Such approaches simply undermine capacity even more.

The second overriding challenge is harmonization and joint accountability. This, too, is fast becoming a development cliche, but it is no less true for that.

In AIDS as elsewhere, programme managers are often little more than data processors for donors, spending obscene amounts of time trying to satisfy dozens of duplicative reporting requirements, and hosting repetitive review missions month after month. Donor-driven agendas are raising transaction costs and reducing programme effectiveness. There has been much discussion of late of the "absorptive capacity" in countries, but little action to address the fact that it is donors who are absorbing much of the overstretched capacity that presently exists.

It is time for donors of all types-multilateral, bilateral, philanthropic-to formally agree to work together under national leadership. I call this the "three ones." One national AIDS strategy that drives alignment of all partners; one national AIDS authority to coordinate it, and one nationally-owned monitoring and evaluation system to serve the needs of all. Although we have far to go, there are signs of progress in this regard. Kenya, for example, now hosts regular joint programme reviews, in which all donors take part. In Malawi, eight donors are supporting the national AIDS programme in a unified way, and four of them are even pooling their funds, including the World Bank. We need to make such common cause in every country, so the officials entrusted with AIDS can spend their time contending with the pandemic, not paperwork.

This is not just important for practical reasons. It is also a means of acknowledging and enforcing the joint accountability that all of us share for what happens on our watch. What on earth can donors be thinking when they report that "their" project succeeded in a country where the national programme simultaneously fell apart? Where a country fails, all of us have failed. We must stop planting flags and set aside childish hopes of instant gratification, such as producing remarkable results by the end of the next fiscal quarter. This is a generation-long struggle, not an invitation to a quick fix. We must instead take on the politically difficult challenge of improving our modalities of support, as this year's World Development Report so persuasively shows. Let us think programmes, not projects. Let us act as seamlessly as possible. And let us take the long view.

If we succeed, there will be plenty of credit to go around. In the river blindness control programme, dozens of organizations joined forces, and all of them today deservedly share the glory of having saved millions.

If we fail-especially by tripping over ourselves-we and our institutions will all be held accountable, and history will rightly consign us to disgrace. And what happens to our reputation will pale beside what will happen to tens of millions of people around the globe.

The third great challenge-and the most daunting-is the exceptionalism of AIDS. I don't normally use such words, but "exceptional" is the only word that fits. AIDS stands almost alone in human experience. Many diseases and natural disasters create their own brutal equilibrium, a self-regulating mechanism that eventually enables society to cope, if not to overcome. AIDS, thus far, seems different. Virtually all its impacts serve to weaken our defences and accelerate its spread, not to limit it. By selectively killing young adults, AIDS removes the cornerstone of developing societies. Children whose parents are lost to AIDS are less likely to be well-nourished, in school, or properly socialized, in turn making them even more susceptible to the very situations that enable HIV to spread. Moreover, because it preys on the most private human behaviour and stays invisible for years, it has silenced us from acting. In short, AIDS has rewritten the rules.

After long reflection, I have concluded that to prevail, we, too, must rewrite the rules. I once believed that it would be enough for us simply to do more, or do it better. I now believe we have to act differently as well. An exceptional threat demands exceptional actions. As Abraham Lincoln once remarked, "The dogmas of the quiet past will not work in the turbulent future. As our cause is new, so we must think and act anew."

I believe the time has come to take exceptional action in the way we finance the response to HIV/AIDS. For example, when I hear that countries are choosing to comply with medium-term expenditure ceilings at the expense of adequately funding AIDS programmes, it strikes me that someone isn't looking hard enough for sound alternatives. I recognize that such principles are in place for good reason, and by no means am I urging countries to act in ways that would merely deepen their economic woes. But surely there must be means of accommodating vast new inflows without stirring economic demons. The Bank must agree, since you have been arguing so eloquently for a dramatic increase in development aid. And this is the one institution- along with your sister across the street-that can show a new way on issues such as this. For countries emerging from conflict, the Bank has pioneered a careful programme of exceptions, running a calculated risk on the grounds that inaction would be riskier still. Let us now do something similar for AIDS, a risk far greater than conflict for many countries.

Above all, every community and every country needs to rewrite the rules of how it deals with those sensitive issues at the heart of the epidemic-sex, adultery, homosexuality, prostitution, drug use, blood sales, rape, stigma, gender, inequality. Each community needs to find its own language for addressing these painful truths. This is already happening in many places around the world, with encouraging results. But what is now exceptional needs to become commonplace. Nothing spreads HIV faster than silence.

Where do we go from here?

How can we come to grips with the greatest natural challenge ever to confront humanity? I would propose that we look to the future. Twenty years from now, what can we expect from the epidemic, and what should we expect from ourselves?

From AIDS, I can only say that we should expect the unexpected. Frankly, the virus has made fools of us at every turn. Ten years ago, the World Development Report forecast a worst-case scenario for Africa of two million new HIV infections per year by 2000. But by 1999, it had already hit four million. Globally, this year the number of new infections will be greater than the total number of HIV/AIDS cases worldwide in 1987, the year of the first World AIDS Day. Almost no predictions have proven too pessimistic in practice. What the epidemic will do next is beyond our power to say.

What lies entirely within our power is how we respond. At first glance, AIDS seems to create a dilemma of managing under uncertainty for the vast part of the developing world, where the epidemic is only now getting started. If you don't know how much risk you face, it's hard to know how much to invest in guarding against it.

But I would argue the opposite. This is not a dilemma-it's an opportunity.

For AIDS is, more than anything else, an invitation to redouble our efforts in development. Poverty, ignorance, unemployment, and inequality are the handmaidens of the epidemic. They help spread HIV, and AIDS, and, in turn, undermine development. Already in Africa, hopes of reaching most of the Millennium Development Goals have been dashed because of AIDS.

By the same token, however, most of what is good for development is good for defeating HIV/AIDS, and vice versa. Children who stay in school are at lower risk of becoming infected. A vibrant rural sector creates local jobs that keep families intact. Gender equality creates security and opportunity for women, reducing the number who must resort to commercial sex work for survival. Twenty years on, if we have helped the developing world to achieve these goals, I can assure you that AIDS will be in retreat. In reality, the epidemic has prompted visionary, innovative thinking to improve development efforts. In Africa, AIDS inspired a commitment by leaders two years ago to devote 15% of their national budgets to health-a far greater portion than most had ever spent before. Globally, AIDS has given rise to a new Global Fund, which addresses other mass killers as well. And the outcomes of AIDS programmes are serving the development cause more broadly. For instance, community-driven AIDS efforts have helped nourish social capital that is now having beneficial effects in areas far beyond the epidemic.

This great institution, and the larger UN family which we serve, are living reminders of the vision of those who resolved half a century ago to prevent another world war by eradicating the causes that would give rise to it. They recognized the international system was irrevocably broken, and proceeded to rewrite the rules of trade, of aid, and of collective security forever.

Today, with more people already infected than died in both world wars, and no end in sight, it should be clear to all that the challenge confronting us is no less compelling. As a virus, HIV is likely to be with us for a very long time.

But how far it spreads and how much damage it does are entirely up to us.

Let us recognize the root causes of this tragedy, let us treat those already afflicted, let us prevent new infections, and let us reject what is no longer valid in the global system of our own era and replace it with new approaches that will stand the test of time. Twenty years from now, let it be said of us that we not only saved a second generation from this scourge, but that we planted the seeds for a world where nothing like AIDS could ever run rampant again.

Let me conclude, Mr President, by quoting from your speech in Dubai: "It's time to take a cold, hard look at the future."

That future will look much bleaker certainly in Africa and the Caribbean, but also in countries in Asia and Eastern Europe if we do not take exceptional actions immediately.

The stakes are high.

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