Remarks by Andrew S. Natsios
Administrator, USAID
HIV Prevention Symposium
Academy for Educational Development
January 14, 2004
Thank you, Steve and Greg, my old friends. I am pleased to be here at the Academy for Educational Development and have the chance to discuss what the Bush Administration and the United States Agency for International Development are doing to fight HIV/AIDS.
The scope of the HIV/AIDS pandemic is of terrifying proportion. Every six seconds another person becomes infected. Some 8,500 people a day die. That is almost three 9/11s every single day.
I have compared the HIV/AIDS pandemic to only three other events: great famines, in which a very large portion of the population dies in a great famine; genocides; and wars. The pandemic is of that proportion.
The absolute urgency of containing and ultimately defeating the HIV/AIDS pandemic is one of the defining issues of our era. It is, as President Bush has said, "a moral imperative."
I quote him here: "Fighting HIV/ AIDS on a global scale is a massive and complicated undertaking. Yet, this cause is rooted in the simplest of moral duties. When we see this kind of preventable suffering, when we see a plague leaving graves and orphans across a continent, we must act. When we see the wounded traveler on the road to Jericho, we will not--America will not pass to the other side of the road."
But it's not only a question of being a good Samaritan, important as that is to a country such as ours whose traditions of public and private humanitarian assistance go back to the earliest days of the Republic. It's also a question of clear and overwhelming national interest, even national security interest, when one considers the potential impact of HIV/AIDS in such places as India, China, and Russia. In the case of Russia and India, as you know, the infection rates are rising the most rapidly of any area in the world. Even though the infections rates are now higher in Africa than any other area of the world, the fact is that those two countries have the highest growth rates.
We are seeing countries in Africa now, some countries, where more than a third of the adults are infected. That means huge numbers of the most productive people these countries have are either sick or obliged to care for those who are. This leaves children and elderly to tend the fields, grow the food and run the shops, and do whatever else they must do to keep their families together.
We can only assume that the prospects for sustainable economic growth under these circumstances are greatly compromised. And we know the only way to reduce poverty is through sustained rates of economic growth.
We have a growing concern, too, that in the displacement, chaos, and disruption of the wars in Sudan and Liberia, the disease may spread more rapidly. I have a deep personal interest and commitment to the people of Sudan. We believe we are on the verge of the signing of a peace agreement after 20 years of bloodshed where two and a half million people have died.
My good friend, John Garang, the leader of the rebellion in the South, who negotiated this with the northern government and I had lunch recently in southern Sudan. And I said: "John, you know what's going to happen if the disease is spreading in Sudan. It's going to get worse once the roads are built to connect Sudan in the south to the rest of Africa because the truck routes, traditionally in Africa, have been a means by which the disease is spread. So the opening of Sudan to the rest of Africa, in fact, may spread the disease, which would be an enormous tragedy.
And, so, we -- Anne Peterson, my good friend and Connie Newman, the head of the Africa Bureau, and Roger Winter, the head of the Humanitarian Bureau -- have all been talking about how we can design a program for the peace and reconstruction of Sudan that will avoid this tragedy being spread into Sudan once the peace agreement is implemented.
We now have the right leadership; an enormous increase in funding, thanks to the President; the right organizational structure in this new office in the State Department; and the right strategy, which is field-driven and technically based. I am more optimistic now that the conditions are right to slow the pandemic's spread. I believe the President has made an inspired choice in Randy Tobias, as the United States government's HIV/AIDS coordinator to lead this effort.
The technical leader within USAID on this massive effort is Dr. Anne Peterson, who is here today, the head of our Global Health Bureau. Anne's understanding of the complex medical and social issues facing the developing world and her experience in Africa at the grass-roots level with faith-based and community approaches have made her a genuine asset to the United States government and to our agency in this great battle.
Our regional bureaus, particularly Africa, are exceptionally well led. Connie Newman, according to the career people I speak with privately, is arguably the best manager and leader the Africa Bureau has had in years. I've actually had career people tell me that. So we have an unusual situation where, in the critical bureaus that deal with this pandemic, we have exceptionally able leaders right now.
I would like to turn now to the focus of my remarks and make three points: First, is to discuss the President's emergency plan; secondly, to discuss AID's role in it; and then, third, to talk about the focus and direction of the prevention activities supported by AID within and outside the emergency plan's focus countries.
When President Bush took office, U.S. spending on international HIV/AIDS was about $400 million. This was far more than any other country was doing but, clearly, unequal to the task of containing, let alone defeating the pandemic. Nobody saw that more clearly than the President and Secretary Powell.
I should tell you a little story. I took Barbara Turner, some of you know, to go brief Colin Powell just after--in fact it was even before I was confirmed--I shouldn't admit this that I was briefing the Secretary before I was confirmed by the Senate--but we did--on the HIV/AIDS pandemic. And I can tell now, particularly knowing Colin Powell as well as I do, when he was a little impatient.
And I said, "Mr. Secretary, is there something wrong? Is this repetitive to you?" And he said, "Well, I knew most of this already; can you move on with the briefing?" And I said--this was highly technical stuff-"Mr. Secretary, where did you get this information from?" And he said "the Internet." And I said, "Were you reading popular articles?" He said, "No, I read the journals, public health journals." So he knew the data, personally. This was in early 2001, this was in April of 2001, when Barbara and I briefed him. He had an understanding of the data in detail--in detail.
So that we had to reorganize very rapidly the briefing to ramp it up, as though he were a public health officer because his technical skills in this area are far beyond anything that any of us had expected, I mean, in a Secretary, who is primarily a diplomat and military leader.
As the Secretary said at the United Nations General Assembly in June of 2001, and I quote: "I know of no enemy in war more insidious or vicious than HIV/AIDS, an enemy that poses a clear and present danger to the world. The war against AIDS has no front line; we must wage it on every front. And only an integrated approach makes sense, an approach that emphasizes prevention and public education, but also must include treatment; care for orphans; measures to stop mother-to-child transmission; affordable drugs; delivery systems; and infrastructure; medical training. And, of course, it must include research into vaccines and a cure." End quote.
Doing that is a tall order. That is, however, precisely what the Administration has done. The President and the Congress has given us the resources to do it.
By fiscal 2002, the Administration was putting more than $1.2 billion into the fight against HIV/AIDS. That figure rose again in '03 to $1.629 billion. And in '04, we expect it to be well over $2 billion, although the budget has not passed yet, it's still in the Congress. No other country in the world comes even close to that level of commitment and that is hardly the full extent of it.
From day one, the United States has been the largest donor to the Global Fund to Fight AIDS, Tuberculosis, and Malaria that President Bush and Kofi Annan announced at the Rose Garden in 2001.
In June of 2002, the President took another bold and compassionate step with the International Mother and Child HIV/AIDS Prevention Initiative. This was focused on two areas: preventing the transmission of AIDS from mothers to their babies; and care to keep the mothers alive and reduce the number of orphans. This includes expanding drug treatment and building stronger healthcare systems so that as many women as possible can be reached.
Then last year the President went further, launching the Emergency Plan for AIDS Relief; a visionary program to increase HIV/AIDS spending to $3 billion annually by '08. The commitment was for a $15 billion program aggregated over several years.
As you know, the President's Emergency Plan focuses on 14 countries that, together, are home to 50 percent of those with HIV/AIDS. It has three goals: provide ARV (anti-retroviral) treatment to 2 million people; prevent 7 million new infections; and, provide care for 10 million people suffering with AIDS or who are affected by it, including orphans and other vulnerable children.
USAID has a major role to play in each of these presidential initiatives. Thanks to the resources the President and the Congress have made available, we have expanded our programs and pioneered a number of new ideas. Accordingly, our budget for HIV/AIDS has grown from $433 million in Fiscal Year '01 to $510 million in '02 and $795 million in '03.
At the same time, we will continue to be an implementing agency facilitating the work of the Global AIDS Coordinator's Office. We are very pleased that the Coordinator is following a field-based approach within the technical frame work established in the legislation and by the coordinator's office, leadership has been delegated. This is very important to the field missions, where interagency collaboration among all U.S. actors is encouraged and is flourishing.
We in USAID have always considered the field to be our particular strength. And, I might add, we know that each country is slightly different. The disease may be the same, but the way to approach it differs from country to country, depending on the social structure; religious institutions; the national leadership.
There are countries, like Uganda, where President Museveni, of course, is probably the leading figure in the developing world, in terms of this fight, where he mentions this every single day in every single speech. And there are other countries where the heads of state will not even talk about the subject, no matter how much we may encourage them. And that means different approaches in different countries. That's why a field-based approach makes the greatest sense.
There have been many aspects to our work since we began our programs in 1986. Many of you in the audience have worked with us and deserve considerable credit for what we have achieved. Still, the threat the virus poses is such that we are always seeking new partners: companies, foundations, NGOs, colleges and universities with whom we can work and share expertise, experience, and resources.
I have made, with Colin Powell, the Global Development Alliance, a new model for doing business in AID, the way in which AID is headed, not just in this area, but in every area. But it is particularly important in a crisis like this, where we need the networks and the outreach and the institutional capacity of other private institutions through which we can work.
The point of these partnerships, as Randy Tobias recently said, and I quote, is "to engender new leadership and commitment and to leverage that competitive strengths of different partners." Close quote.
One of USAID's new partners is Coca-Cola--and I'm not making an advertisement here--one of the largest employers in Africa, with whom we are working in 56 African countries to ensure that their staff and their families are fully aware of the resources available for prevention, care, and treatment.
Another partnership is with Catholic Relief Services, CARE and other NGOs to provide food assistance to 29,000 people a month in Rwanda. Among the key recipients are child-headed households; children orphaned by AIDS; and families with HIV-positive members. This food aid is also tied with other education and income-generating activities.
I might add here that there is a clear relationship, as the clinical people here know, between good nutrition and the onset of the disease. You can postpone the onset of the disease if people drink clean water; they are properly nourished; and they do not get other communicable diseases. And, so, there are other things we need to do ensuring food security. I'm focused on food security as a central focus of what AID does in the developing world through different means. But it's particularly important in fighting the pandemic.
The topic of this meeting, is the Next Phase of HIV Prevention. What we have learned from our many years of support to the HIV/AIDS prevention programs, I'd like to go over here.
First, we have learned that behavior change is possible and that we can reduce, if not completely eliminate, high-risk behavior in all groups: youth, adults, high-risk groups. And, second, we have learned how to design effective messages to address these groups. Let me just mention one thing that I think we need to work on. Western Europe and the other developed countries and the United States are fundamentally secular societies. Africa is not a secular society, for those of you who have traveled as widely as I have for 15 years; people are either Muslim or they're Christian or they're animists. One way or the other, they've accepted a particular religious world view.
If we ignore the world view out of which they come, we will not succeed in stopping the spread of the disease. There is a reluctance in the West, I think, to deal with faith-based institutions -- I don't mean American faith-based institutions; I mean the faith-based institutions in Africa, at the village level. And I think we all need to put our own philosophic world views aside and deal with the reality that we face in Africa, which is a profoundly religious continent.
When I went recently to Ethiopia to meet with Prime Minister Meles about food security issues and the famine, we also discussed them with the Patriarch of the Orthodox Church -- I'm Eastern Orthodox, myself - and with the Imam, who is leader of the Islamic Council of Ethiopia. About 40 percent -- these are debatable figures, of course -- of Ethiopia is Orthodox and about 40 percent is Muslim. So that's 80 percent of the people in one of the largest countries in Africa.
And I asked them what they were doing to deal with this. Of course, the staff in AID knows that I have a little obsession with trying to build bridges to the religious community around the world, regardless of the faith tradition, because I think religious leaders, actually, in some ways have more influence than political or NGO leaders do. And I was intrigued by what both of them told me: that we are providing funding to the NGOs that are associated with the church and the mosque in Ethiopia to get the message out.
Now, between the two of them, they have several hundred thousand priests and mullahs in the mosques and the churches. And to have that as a network through which these messages can be moved is very, very important. The most powerful force for changing behavior in any society is religious institutions. To ignore them is to ignore an enormous resource that we need to make available.
Now, the Patriarch did tell me he's taken three patriarchal tours. And when he goes, he does not go to the church in the village to speak, he goes to a soccer stadium, so the Muslims can come, because in Ethiopia, there is a lot more harmony between the Orthodox church and the Muslim community than there is in other countries. When the patriarch speaks, the Muslims will come, too, and the mullahs. And vice versa, I might add. And so, he gives a lecture on abstinence and faithfulness. He asks what are your children doing? What are they doing in the evening? How are they behaving? How are you behaving? And that's the message he gave.
Now he did not tell me that AID provided the truck to take him around to his patriarchal tour. And, in fact, we plotted the course of the tour with his staff. We can't speak for him, of course, he needs to speak out of his own tradition. But this is a powerful way of getting the message out and of influencing people's values and lifestyle.
It is widely perceived that USAID promotes condom use to the exclusion of other behavior-change approaches. This is not true. Balance is the key to our behavior-change approach -- or as it is commonly known and has been for 20 years -- the ABC strategy.
Our strategy, in large part, evolved from our long and pioneering work with President Museveni and the government of Uganda. I was particularly struck by a comment he made on one of his recent trips to Washington: that behavior-change approaches were the only way he could empower his people to address the catastrophic impact of HIV/AIDS that was wreaking itself on Uganda, in the absence of other available resources like, drugs or diagnostics or condoms. This was at the beginning of the fight, in the late 1980s. My first trip to Uganda, in fact, was in 1989.
According to U.S. Census Bureau and UNAID's estimates, Uganda's HIV/AIDS prevalence rate peaked during the early 1990s at around 15 percent. But by 2001, it had dropped to 5 percent. Why? The evidence suggests, empirical evidence, that this precipitous drop has been due to a major positive behavior change in all three ABC categories.
First, is increased abstinence, including deferral and considerably reduced levels of sexual activity among youth. Second, is increased faithfulness and a reduction in the number of partners among the adult population, sometimes known as "zero grazing." As well as increased condom use by casual partners.
As a recent USAID report states, quote, "the most significant of these appear to be faithfulness or partner-reduction behaviors by Ugandan men and women, whose reported casual sex encounters declined" -- I'm quoting from the report -- "by over 50 percent between 1989 and 1995."
"Uganda's successful combination of ABC strategies was rooted in a community-based, national response, in which both the government and NGO actors, including faith-based women's groups and grass-roots organizations, succeeded at reaching different population groups with different messages and interventions appropriate to their need and ability to respond."
Stigma reduction and active and effective political leadership are also key elements in Uganda's success story. And we're beginning to see similar results in Zambia.
Condoms clearly need to be a part of the equation, especially for high-risk populations, which is where we're now focusing our condom efforts on, instead of just to the general population. So, we are increasingly making condoms available through our programming. Shipments from AID of condoms increased from 233 million in 2002 to 480 million condoms in 2003.
There are 5 million new cases of HIV every year. According to the National Institute for Health, it could take at least 20 years before we have an effective vaccine available. So it is imperative that we build solid strategies based on experience, good science, and best practices.
I would like to conclude by pointing to some other ideas we've been working on. Because of their effectiveness, we are scaling up our ABC programs to national levels wherever possible. Scale is essential. Having small, community-based programs stand alone as islands in a sea of misery does not work. We need to take the community-based approach and nationalize it.
- Putting more emphasis on youth and expanding our abstinence and behavior-change programs: To this effect, we put a request for proposals in December. The response has been overwhelming and we hope to have a new program finalized within the month.
- Developing new technologies, such a microbicides to empower women and to prevent HIV/AIDS transmission and new technologies that facilitate prevention and treatment, like simple blister packets to administer ARVs or to use blister packs to administer drugs to newborns in the mother-to-child transmission programs.
- Reinvigorating programs to prevent the medical transmission of HIV; improved blood banking and improved medical protocols.
- Continuing active operations research, which AID has been doing for decades; we continue to determine best practices in all aspects of HIV/AIDS programming, including prevention, ARV treatment, links to nutrition, food and water, and programs for particularly vulnerable populations.
The scope of the pandemic and the strength of the President's response are such that we will continue to need to count on strong partners, like AED and all of you assembled here today; as well as to look to new partnerships we are forming.
We look forward to working with you in the future. Thank you all, very much.
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