AIDS HAS A WOMAN'S FACE
by STEPHEN LEWIS
word "microbicides" refers to a range
of different products that share one common characteristic:
the ability to prevent the sexual transmission of HIV and other
sexually transmitted diseases (STDs) when applied topically.
A microbicide could be produced in many forms, including: gels,
creams, suppositories, films, or as a sponge or ring that releases
the active ingredient over time. Microbicides are not yet available.
are currently testing many substances to see whether they help
protect against HIV and/or other STDs, but no safe and effective
microbicide is currently available to the public. However, scientists
are seriously pursuing almost 60 product leads, including at
least eleven that have proven safe and effective in animals
and are now being tested in people. If one of these leads proves
successful and investment is sufficient, a microbicide could
be available in five to seven years.
would be the most important innovation in reproductive health
since the Pill.
The following speech was delivered by Stephen Lewis,
the UN Secretary-General's Special Envoy for HIV/AIDS in Africa
* * * * * * * * * *
is, I will admit, a touch of amiable irrationality in racing across
the ocean for a half hour speech. I want to assure you that I
don't do it as a matter of course. But in this instance, it seemed
to me that your kind invitation to address the Conference could
not possibly be forfeited. I'm here because I think the work in
which you're collectively engaged -- the discovery and availability
of microbicides -- is one of the great causes of this era, and
I want to be a part of it. It is in this room that morality and
science will join together.
been in the Envoy job for nearly three years. If there is one
constant throughout that time, a large part of which has been
spent traversing the African continent, it is the thus-far irreversible
vulnerability of women. It goes without saying that the virus
has targeted women with a raging and twisted Darwinian ferocity.
It goes equally without saying that gender inequality is what
sustains and nurtures the virus, ultimately causing women to be
infected in ever greater disproportionate numbers.
the numbers tell a story. It was the report issued by UNAIDS on
the eve of the International AIDS Conference in Barcelona in 2002,
that identified the startling percentages of infected women. And
it was during a panel, at the same conference, when Carol Bellamy
of UNICEF used a phrase -- for the first time in my hearing --
that was to become a repetitive mantra: "AIDS has a woman's
problem is that the phenomenon of women's acute vulnerability
did not happen overnight. It grew relentlessly over the twenty
years of the pandemic. What should shock us all, what should stop
us in our tracks, is how long it took to focus the world on what
was happening. Why wasn't the trend identified so much earlier?
Why, when it emerged in cold statistical print did not the emergency
alarm bells ring out in the narrative text which accompanied the
numbers? Why has it taken to 2004 -- more than twenty years down
the epidemiological road -- to put in place a Global Coalition
on Women and AIDS? Why was it only in 2003 that a UN Task Force
on the plight of women in Southern Africa was appointed to do
substantive work? Why have we allowed a continuing pattern of
sexual carnage among young women so as to lose an entire generation
of women and girls?
this set of figures if you will: in 2003, Botswana did a new
sentinel site study to establish HIV prevalence, male and female,
amongst all age groups. In urban areas, for young women and
girls, ages 15 to 19, the prevalence rate was 15.4%. For young
men and boys of the same age, it was 1.2%. For young women between
20 and 24, the rate was 29.7%. For young men of that age it
was 8.4%. For young women between the ages of 25 and 29, the
rate was 54.1% (it boggles the mind); for young men of the same
age, it was 29.7%.
I not addressed the fundamental question? The reason we have observed
-- and still observe without taking decisive action -- this wanton
attack on women is because it's women. You know it and I know
it. The African countries themselves, the major external powers,
the influential bilateral donors, even my beloved United Nations.
No one shouted from the rhetorical rooftops, no one called an
international conference and said what in God's name is going
on, even though it felt in the 1990s that all we ever had time
for were international conferences? It amounts to the ultimate
vindication of the feminist analysis. When the rights of women
are involved, the world goes into reverse.
than twenty years, the numbers of infected women grew exponentially,
so that now virtually half the infections in the world are amongst
women, and in Africa it stands at 58%, rising to 67% between the
ages of 15 and 24. This is a cataclysm, plain and simple. We are
depopulating parts of the continent of its women.
finally, after the doomsday clock has passed midnight, we're starting
to be engaged and agitated, but please believe me: on the ground,
where women live and die, very little is changing. Everything
takes so excruciatingly long when we're responding to the needs
and rights of women.
three and four years ago, I visited the well-known pre-natal health
clinic in Kigali, Rwanda. I met with three women who had decided
to take a course of nevirapine; they were excited and hopeful,
but they asked a poignant question which haunts me to this day:
they said "We'll do anything to save our babies, but what
about us?" Back then, more than four years after antiretrovirals
were in widespread use in the west, we simply watched the mothers
thanks to the Columbia School of Public Health, funded by several
Foundations and USAID, and working with the Elizabeth Glazer Foundation,
UNICEF and governments, the strategy of PMTCT PLUS (Prevention
of Mother to Child Transmission Plus) has been carefully put into
place in several countries, where the ‘Plus’ represents
treatment of the mothers and partners; indeed, of the entire family.
But it's a slow process, and though Columbia will roll it out
as quickly as possible, it is necessarily incremental. In principle,
the majority of such women will one day fall under the rubric
of public antiretroviral treatment, through Ministries of Health,
when it's finally introduced in most countries. But there's no
clear guarantee of when that day will dawn, or that women will
get the treatment to which they're entitled. It's entirely possible
that the men will be at the front of the bus.
proceeds at glacial speed for women, if it proceeds at all, in
the face of this global health emergency. We deplore the patterns
of sexual violence against women, violence which transmits the
virus, but all you have to do is read the remarkable monographs
by Human Rights Watch to know that for all the earnest blather,
the same malevolent patterns continue. We lament the use of rape
as an instrument of war, passing the virus, one hideous assault
upon another, but in Eastern Congo and Western Sudan, possibly
the worst episodes of sexual cruelty and mutilation are taking
place on a daily basis as anywhere in the world, and the world
is raising barely a finger. We have the women victims of Rwanda,
now suffering full-blown AIDS, to show the ending of that story.
We talk ad nauseam of amending property rights and introducing
laws on inheritance rights, but I've yet to see marked progress.
We speak of empowering women, and paying women for unacknowledged
and uncompensated work, and ushering in a cornucopia of income
generating activities -- and in tiny pockets it's happening, especially
where an indigenous local women's leadership is strong enough
to take hold. But for the most part, in Churchill's phrase, it's
all "Jaw, Jaw, Jaw."
of my adult life, I have felt that the struggle for gender equality
is the toughest struggle of all, and never have I felt it more
keenly than in the battle against HIV/AIDS. The women of Africa
and beyond: they run the household, they grow the food, they assume
virtually the entire burden of care, they look after the orphans,
they do it all with an almost unimaginable stoicism, and as recompense
for a life of almost supernatural hardship and devotion, they
die agonizing deaths.
-- and I must acknowledge this -- with the sudden growing awareness
internationally of what the virus hath wrought, we will all make
increasing efforts to rally to the side of women. It's entirely
possible that we will make more progress over the next five years
than we have made in the past twenty. But I cannot emphasize strongly
enough that the inertia and sexism which plague our response are
incredibly, almost indelibly engrained, and in this desperate
race against time we will continue to lose vast numbers of women.
That is not to suggest for a moment that we shouldn't make every
conceivable effort to turn the tide; it is only to acknowledge
the terrible reality of what we're up against.
say to me, what about the men? We have to work with the men. Of
course we do. But please recognize that it's going to take generations
to change predatory male sexual behaviour, and the women of Africa
don't have generations. They're dying today, now, day in and day
out. Something dramatic has to happen which turns the talk of
generations into mere moments in the passage of time.
is where all of you come in. I'm not pretending that microbicides
are a magic bullet. Microbicides aren't a vaccine. Nor do I dispute
the powerful point made by Geeta Rao Gupta at the opening of the
conference, that we can neither forget nor diminish the structural
cultural changes so urgently required. But when so many interventions
have failed, when the landscape for women is so bleak, the prospect
of a microbicide in five to ten years is positively intoxicating.
that women will have a way of re-asserting control over their
own sexuality, the idea that they will be able to defend their
bodily health, the idea that women will have a course of prevention
to follow which results in saving their lives, the idea that women
may have a microbicide which prevents infection but allows for
conception, the idea that women can use microbicides without bowing
to male dictates -- indeed the idea that men will not even know
the microbicide is in use -- these are ideas whose time has come.
while microbicides are not a salvation, they come as close to
salvation as anything else I've heard about. I pray that everyone
at this conference understands that the women of Africa and many
other parts of the world are counting on you. It is impossible
to overstate how vital is the discovery of a microbicide. If we
were making progress on several other fronts, microbicides would
pale. But we're not making progress, or we are making progress
in such painfully minute installments, that it feels as though
we're moving from paralysis to immobility. The resources of the
international community should flow, torrentially, into the hands
of the scientists and researchers and advocates and activists
assembled here who fight the good fight, because in those hands
I have a proclivity for hyperbole. It's a molecular disability,
with one exception. This subject is the exception. I don't know
how to convey to you what's happening out there. I move from country
to country, from rural hinterland to rural hinterland, from project
to project, and everywhere I go the lives of women are compromised.
And it's not changing. How do you get governments and international
financial institutions and bilateral development donors to understand?
It's not changing. Three merciless years, and women face today
exactly what they faced in yesteryear and yesteryear before that.
and absorb incidents and moments that sear themselves into the
mind. Some of the following anecdotes I've used before, but I
cannot shake them. I meet a grandmother of 73 in Alexandra Township
in Johannesburg. She lost all five of her children between 2001
and 2003. She's looking after four orphans, all of them HIV positive.
Her life is in ruins. She stands for the legion of grandmothers
on the continent who bury their children in a perverse reversal
of the rhythm of life, and then, heroically, look after the grandchildren.
How has it come to this?
with Graça Machel to ground zero of the pandemic in Uganda,
to visit a child headed household -- a young girl of 14, looking
after two sisters of 12 and 10, and two brothers of 11 and 8.
Graça and I sit on the floor of the hut; I have the two
boys on my left and Graça has the three girls on her right.
She shoos everyone out of the hut except for one translator. And
then she turns to the two older girls and in a gentle voice asks:
"Have you started to menstruate yet?" And shyly, oh
so shyly, in whispered fragments, the little girls say yes. And
then Graça asks a series of questions: Do you know what
it means? Do you talk to your teacher about it? Do you talk to
the other kids at school. Do you talk to the villagers? Does anyone
ever give you any pads? And as I sat there listening, I realized
that these girls were receiving the first act of mothering around
an experience that must surely be one of the most important moments
of a young girl's life. And I thought to myself: this is what's
happening across the continent: the mothers and fathers are gone.
The mothers especially are gone. The transfer of knowledge, love
and care from one generation to the next is going. How has it
come to this?
outside a clinic in Lusaka, Zambia, where mothers have come for
testing, and the possible use of nevirapine during birth. The
mothers approach me: "Mr. Lewis, you have drugs in your country
to keep your people alive, why can't we have the drugs to keep
ourselves alive?" I cannot tell you how often women have
asked me that question. Their sense of collective dismay and vulnerability,
their panic-stricken tremors at the prospect of leaving their
children as orphans is palpable. I don't know how to answer the
question. How do you explain that we're dealing with one of the
ugliest chasms between the developing and developed world on the
face of the planet. How did it come to this? How is it that we
can't seem to get the world to understand that if you want to
reduce the deluge of orphans, with which deluge no country can
cope, you keep the mothers alive. Treatment is one way. Microbicides
are the preferred way.
ten days ago, with my colleague Anurita Bains, who is here at
the conference, I traveled to Swaziland. On a Thursday afternoon,
we trekked into the hinterland to visit a small community of women
living with AIDS, looking after hordes of orphan children. They
led us along a narrow footpath, for what seemed an eternity, into
the surrounding brush, until we'd reached the home of a woman
who lay dying. I've spent a lot of time in huts where women lie
dying; I don't know why this particular encounter had such a profound
effect on me, but I haven't been able to get the image out of
my head. I guess I've never seen anyone quite so ill before, the
face a mask of death; a young woman in her twenties -- they're
always in their twenties -- valiantly raising her head a few inches
to acknowledge the visitors. You touch her hand; utter soothing
words; she's unaware. Sometimes I think I make such gestures more
for my own benefit than for the person who's so desperately ill.
And around her were children, watching her die. That's what children
in Africa do: they don't become orphans after their parents die;
they become orphans while their parents are dying; and then they
watch the death itself; and then they attend the funeral.
IT COME TO THIS?
with rage. I can barely contain it. I know it reduces my effectiveness,
but there's nothing I can do about it. The madness of what is
happening, the fact that it is so completely unnecessary, the
fact that we could subdue this pandemic if the world put its mind
to it -- all of that renders me almost incoherent with the roiling
blood of anger. We must find a way to bring this nightmare to
an end. Africans and the world will obviously work with every
instrument at our collective command to reduce the heart-breaking
decimation of individuals, families and communities. But the women,
certainly the women of Africa need huge quotients of additional
help, and that help lies, in significant extent, in the discovery
of a microbicide.
have to tell anyone here -- God knows, I'm way out of my depth
-- about the science and the trials and the timetable and the
resources. I've read the materials, and as much as a layperson
can grasp such things, I have grasped them. I ask only that you
see microbicides, not merely as one of the great scientific pursuits
of the age, but as a significant emancipation for women whose
cultural and social and economic inheritance have put them so
gravely at risk.
in human history have so many died for so little reason. You have
a chance to alter the course of that history. Can there be any
task more noble?