This is the second interview in an oral history with Dr. Peter Piot, Executive Director of the joint United Nations Program on HIV/AIDS (UNAIDS), and Under Secretary-General of the United Nations, on April 8, 2009 at the Bill and Melinda Gates Foundation in Washington D.C. The interviewer is Victoria A. Harden
Harden: Dr. Piot, when we stopped at the end of our first interview, you had traced your involvement with AIDS through 1992, when you joined the World Health Organization’s Global Programme on AIDS (GPA). Looking back at the WHO response between 1981 and 1992, I am struck by how slow WHO was to get involved, to appreciate the impact of AIDS. WHO’s Director General [Halfdan T. Mahler] admitted this. Would you comment in a general way on WHO’s involvement during the first ten years of AIDS from 1981 to 1992?
Piot: Where to start? I think in general, like most huge institutions, the WHO is slow to take on new issues, because it has a complicated planning process, budgetary process, and governance process. In terms of specifics, it is indeed in the mid ‘80s, 1986 I think, when Jonathan Mann moved to Geneva and created what was initially called a Special Programme on AIDS, which would become the Global Programme on AIDS. That was like five years after the first cases of AIDS were described, and WHO Director General Mahler thought that this was an issue only for high income countries, for the U.S., North America, and Europe, and he said “That’s not our business.” And let’s not forget that in these days we were counting the AIDS numbers by a few thousand, which is something people tend to forget today. It is not always obvious whether something is going to become a big epidemic or not, and some people--the catastrophic types--have a tendency to believe that if you have two cases, it’s going to wipe out the world. Other people play it down. Of course, in the case of AIDS, it has become much bigger than any of us could imagine.
I remember that I was at the first donor meeting that Jonathan Mann hosted for the Special Programme on AIDS, trying to raise money. The US was there, and I don’t remember who represented it, but I represented Belgium, which was a bit of an accident because I didn’t work for the government. There had been talk about a lack of interest from the Belgian government, but they had been invited, and so they asked me, “Why don’t you go there, you know about AIDS in Africa,” and so on. I had agreed with Jonathan Mann that I would state that Belgium was fully supportive of the Special Programme on AIDS. I had no mandate to do that, but I said Belgium would contribute money and so on. It was calculated to start the process so that other donors would come in. The US came in, because Jonathan Mann made this his own work, being American, and coming from CDC, from the government.
Mahler started the meeting in a way that really made me angry. He said “Here we are having a meeting on AIDS yet so many more people were dying from malaria, from TB”--a story which we are still hearing today. In those days it was true, but today it’s not true, there are more people dying from AIDS than from malaria, but there is no need for this kind of competition. I stood up and I said--in more diplomatic terms, but not that many--I said that you don’t know what you’re talking about. There’s a huge epidemic going on in Africa and WHO must address it. Later, I had a discussion with Mahler and he recognized that he had underestimated AIDS. I think he has probably been the best Director General that WHO has ever had, so I’m saying I admire him enormously, but on that one he was wrong. Then Jonathan Mann came on with his incredible energy. He mobilized money and put together teams with the goal that each developing country would have some plan on AIDS, which was called a short term plan, STP--you know everything gets an acronym. NIH is the same, WHO is the same.
I participated in the STP for Ghana. There was actually a meeting that was planned to set up the second generation programs, but what Jonathan actually did was send some money and some people to all African countries, and then to several of the others. His main challenge was an internal bureaucratic one. In the WHO, at the headquarters in Geneva, the Director General has basically no say over the country offices. The Director General in the WHO controls about 25% of the resources in terms of people and money in the organization. The rest is controlled by the Regional Directors who are elected by their Ministers of Health. Take PAHO (Pan American Health Organization [the western hemisphere branch of WHO]): The PAHO Director is elected by the Ministers of Health of the region, of Latin America and North America, and the Caribbean. This was why the regional directors have a political legitimacy, and they’re the kings in their region, and don’t you dare to come here from Geneva to tell them what to do. This is not specific for AIDS. This is a general rule and even today it’s still the case. That’s the fundamental problem of the WHO, because it prevents a coherent approach. When you have to come up with a global program for a new epidemic, cutting through that bureaucracy became Jonathan Mann’s daily fight. That’s also why he resigned at some point, because he was daily undermined by the new Director General Hiroshi Nakajima and the Regional Directors. Some regional directors, such Dr. Gottlieb Lobe Monekosso, who was the head of the regional office for Africa, believed that all the threat about AIDS was exaggerated.
UNAIDS doesn’t have that problem. And at that time, there wasn’t much AIDS outside Africa, except in the Americas and in Western Europe, but the governments there said, “We’ll do this ourselves, we don’t need you.”
Raising money and awareness for AIDS was a constant fight, and the situation at WHO undermined Jonathan Mann's work. In the beginning he could work directly with the countries without going through major offices and that. The new Director General, Hiroshi Nakajima, stopped that practice and so it became a huge problem—power of the periphery of the WHO regions that typically tried to stop any initiative coming from the center. That's the basic rule in WHO, as a matter of principle.
Harden: In 1992, after Jonathan Mann resigned, there was a report that suggesting that some new entity needed to be created to address AIDS. I'm trying to get a handle on some of the definitions that you all used and how the UNAIDS project emerged. As you tell me about it, would you please define terms like “civil society” and tell me what we need to know about your Program Coordinating Board (PCB), and about how you raised the necessary money.
Piot: First of all, when Jonathan Mann left, Michael Merson took over the Special Programme on AIDS. He was a UN functionary – I mean, a WHO one--specialized in diarrheal disease. And I think that he did a good job. I mean, he's not always appreciated, particularly in the AIDS world, because Jonathan Mann was elevated to some kind of sainthood. But Mike Merson brought some order, some sound management into the program. I worked with him for two years and learned a lot from him. But he came at a time when some people were already looking beyond WHO.
First maybe I will give you some definitions and then go into your question on how UNAIDS came about. “Donors” are defined as the governments of high-income countries.
Harden: Only governments, not private?
Piot: Only governments, not private. There have been private donors, but it's marginal. The main donors of UNAIDS are the Netherlands--the number one donor--then the US, Sweden, Norway, and the UK. These are the top donors. And then we have the equivalent of either the USAID [United States Agency for International Development] or in the UK the Department for International Development or Ministry of Foreign Affairs. And eight donors sit on the program coordination board. They are elected in the Economic and Social Council of the United Nations, in their respective regional groupings. Because these are high-income countries, they have a grouping name. It's called the Western and Other Group, “other” to designate Australia and New Zealand, because they're Western countries but they're not in the West. Japan's in that group, also.
What is “civil society”? These are individuals or organizations that represent not the governments, but nongovernmental organizations by the people of a country. Here we go into a new paradigm in international relations. I recently read some political scientist calling it a post-modern failure in international governance. The Treaty of Westphalia in 1648 marked the recognition that it was the state (civil government) and only the state that represented the nation. With AIDS, and we see that also now with environmental movement, we see activist groups, like People Living With HIV, we see religious organizations, we see women's organizations, we see business –multi-national business has always been influencing politics, at least underground. But now it's more the voice of those without a voice, and they are now playing a role and also putting pressure on international relations. A lot of this is thanks to internet that the AIDS groups in South Africa, China, and Brazil and the US stay connected. Before the internet, this didn't exist. I think the AIDS movement is probably pioneering for other globalized civil society movements.
I don't know much about the political science of that, but I got quite interested in it, because for example, in the UN General Assembly, when normally only states are recognized players, we brought in people living with HIV, we brought in sex workers. A gay man addressed the General Assembly. I mean, for us it's normal, but in these circles that was shocking, unusual. The problem we are facing is that when it comes to negotiating a document and a resolution, at the end of the day, only states can engage to represent countries, because there are commitments for money, and so on. Community groups in, for example, Burkina Faso or the Netherlands, cannot engage on behalf of their governments. There's also no accountability for civil society groups. So we have now individuals and groups from civil society interact with governments on the international scene. In a democratic country, at least, with the next elections groups can change their governments. In a dictatorship, however, that mechanism doesn't exist. I don't know how it works, for example, in China.
So that's civil society, and there are five representatives on the UNAIDS Program Coordination Board. How are they elected, or selected? It's close to a mystery, and you don't want to ask too many questions. The International Council for AIDS Service Organizations organizes consultations, and there's one from North America, and they fight it out among themselves, and then the board approves. They say, “We propose so-and-so,” and the board says, “Yes.” There are thousands and thousands of organizations--and it's not only AIDS organizations but also groups such as the Zambian Christian Medical Association and the Red Cross of Mozambique. It's broader than AIDS activists. People living with HIV are sitting on the board, and I found it a very positive experiment. I fought for that when I came on as Executive Director, because I was very concerned about how I was going to explain all these difficult things if all I had on the board were diplomats with no clue about AIDS because they were not scientists or people from the community living with AIDS.
Harden: Which brings me to the question that as the UN looking for a leader for what became UNAIDS, it was tough. Someone said you were selected because you had fewer enemies than anybody else.
Piot: Yes, that's true.
Harden: But my question is that if you were never particularly interested in being a bureaucrat, why did you let your name be put into nomination, and what did you think you could do, in terms of dealing with this massive bureaucracy, which, in the past you didn't want to be a part of?
Piot: To be honest, I didn't really think it through very hard, because if you think too much about these sorts of things, I don't think you'll ever do it. It's like jumping in the water and swimming. I became interested in it for a positive reason and a negative reason. I started with the negative reason. When I saw the candidates for that job, with the exception of Helene Gale, now director of Care International, who was a friend of mine, I realized that they were all UN bureaucrats. And if any of these people lead this new effort, it will be dead in the water at the beginning. I was always hoping that somebody would come up who would be a candidate, who had international experience, who was more senior than me, and who would know AIDS in the developing world. But that didn't happen. So I became more and more determined to be a candidate. And then there is also the positive reason. I had a year and a half experience in WHO during which I had learned how the system functions. I had also worked on AIDS and had a good knowledge of several African countries, how they function. They were the most severely hit. I saw an opportunity to translate into practice ideas I'd been developing. For example, on the one hand, AIDS work should have a strong scientific base. But on the other hand, we also needed to involve the people. I got really irritated when I was in WHO when they would call in a few experts sitting in a room in Geneva, usually a room without windows like this one, and define policy for the rest of the world and try to shovel it down people's throats. And then they would be surprised that the policy didn't work. So I believed that we need to involve the people. And that's my interest in bringing in these civil society groups.
I was approached to be a candidate, actually, not by my own country, but by the Netherlands. It was the Netherlands who campaigned for me. We speak the same language; Dutch is my mother tongue. For some reason they all decided I was the best person to lead UNAIDS. Hans Moerkerk was then the chair of the governing board of WHO’s GPA. He approached me, and I had to convince my own government and my own Prime Minister that they should support me. In the beginning, I was not that interested in the idea, because I was going to go back to Antwerp and be the dean and continue my scientific career.
But what had been driving this reform effort was a few things that all came together at the same time. There were some positive elements and some negative. Some push and some pull factors. On the negative side, is a generalized dissatisfaction with the performance of the WHO. Not with the global program on AIDS, but with WHO, for the reasons I mentioned, and also Director General Nakajima, who was not very popular and had been accused of many things. The Nordic countries were particularly dissatisfied. That was one factor. A second factor--a more positive one--was the growing understanding that AIDS was becoming a big epidemic, with implications for social and economic development, and that we needed more than a medical approach. And that was pushed by countries like Uganda, but also by Sweden. A Swedish diplomat called Nils Kastberg came up with that vision. Another negative factor was also the growing concern, irritation with the fact that various UN agencies were spending more time fighting each other than doing something about AIDS.
Harden: Let’s step aside here, and say that this is a very depressing picture of the UN as a whole. Is it the only way that we can do things in this world? Is there any way to make things happen better?
Piot: Yes, in general I’m pretty optimistic, but I think that is one dynamic that afflicts bureaucracies. I think it's actually unethical, because the net result is that we spend energy on something negative, on turf, fighting each other, instead of something positive, helping people, doing better research, doing better programs, joining forces. And I was never able to accept that. I think maybe it's very naïve, what I'm saying, but I try to do something about that. In terms of the UN system, what is needed is an absolutely radical cultural revolution, but is is not going to happen. But it is much better now than it used to be.
Harden: Let’s talk about the major debates about what this new program on AIDS was going to be. Was the secretariat going to be strong or weak? Was it going to be an organization that provided funds or not? And to whom would you report? To whom were you accountable, the member countries, or the UN agencies? I think this must have been your first big fight.
Piot: Yes. They were debates in the corridor, but there was never a conclusion, because initially there was no leader to – to say, well, this is what I stand for. I fought for two things. During the session in which I was appointed by the Committee of Co-Sponsoring Organizations, where the various heads of the then six agencies involved met, they started discussing limits on UNAIDS literally ten minutes after having selected me and before I was presented to Secretary General Boutros-Ghali, who officially appointed me. I fought them for two things, and I was ready to resign if they refused. One was, who has the right to hire and fire, and two, who was my boss? I wanted an answer to these two questions. I wanted the right to hire and fire. I didn’t want to have to go ask Nakajima and the other guys to recruit staff, because what they wanted to do was to impose staff on me, and it's extremely rare in the world that then you would get their best people, and ones that would help you.
The second question was, who's my boss? It was not a trivial question, and it's about governance. The proposal from within the UN was that I would report to the agency heads in the UN. And I said that for me is unacceptable. The reason is not so much my ego but for two practical reasons. One, that would have de facto reduced me to one of their staff, and I would not have the liberty to work. Secondly, a fundamental philosophical position for the United Nations is that the UN systems should be accountable to the countries, to the people of the world through their countries, and not to themselves. Because of this, there was no accountability, and I thought that was unacceptable. That had to go.
I discussed this with Richard Butler, Australian ambassador and president of the Economic and Social Council at the UN (afterwards he became the famous weapon inspector in – in Iraq). He was a bulldozer. I mean he really pushed me hard when I went to see him to discuss why I wanted this accountability arrangement. When I convinced him that it was not just for my ego, he was very brutal with all these agencies and said, “This is unacceptable, UNAIDS should be accountable to member states.” That debate is still going on, and there are still people in the UN system who believe that we are not accountable.. Member states have sometimes mutually exclusive positions. For example, if you have Israel and Syria in the same room, don't expect any agreement on anything. The second thing was whether the secretariat would be strong or weak. Evidently, the UN agencies wanted a secretariat that was as weak as possible, one that would only coordinate activities, not initiate them. I was not interested in being the coordinator.
Harden: But that would also relate to who your boss was, would it not?
Piot: Indeed, yes. It was related to that, who was my boss. But also, I thought, we need – and this was the metaphor I used in the beginning, the early days--to play judo. And by that I meant that on the one hand, we need to use the weight of the opponent, in this case the weight of big organizations, to push them into the direction that would get them to do more on AIDS. That was my idea.
We also needed a champion group. I thought a lot about issues like gender, because I'm very interested in gender equality. The two extremes in dealing with that is that you have a group of champions, the Office for Gender Equality or something like that. And most other people will say, “Oh, they're dealing with gender, so I don't have to do it.” The other extreme is we mainstream it, and so – and it's everywhere, but then nothing happens. So it's nowhere. So you need a “champions” group that is responsible for coordination, for the advocacy, making noise about it, but also for policy involvement, and for policy guidance.
And then I thought we needed a similar structure at the country level. I fought hard. That was particularly against the wishes of the UK, which wanted some kind of global center of excellence coordinating UNAIDS activities, and then nothing at country level. The US wanted the strong secretariat, with offices in countries that would run programs. So we had differences of opinions not only within the UN between, for example, the agency heads and the co-sponsors and myself, but also among the donor nations. What we came up with was some kind of hybrid. It was not at one extreme prevailed or another one. We went more towards a strong secretariat over the years, in part because the rest of the UN is so weak. Another reason was because I always thought we need to control the data and the policies and information. We needed to have a good team of epidemiologists, to have the information systems under our control.
Harden: After you weathered this first storm of getting everything organized, you withdrew for a weekend retreat to Bellagio. I was quite interested in seeing the picture in the first 10 years history of UNAIDS and want to find out why you selected the people to come and – for example, why Jim Curran from the US and nobody else? And then the name – you came up with UNAIDS while you were there. Why this, and apparently your daughter designed the logo. Tell me about this retreat.
Piot: My daughter would have been 15 or so at that time. I needed a sounding board, because very early I saw that this was going to be a lonely job. I couldn't go to many people in the system, particularly not the ones who said “I'm going to help you,” which basically meant “I'll stab you in the back at the first opportunity.” I actually invited a group of friends to a non-meeting. There are no records of that meeting, which I now regret, I must say. And I can't find my notes. The attendees were friends who were available to come on that short notice to Bellagio. Dr. Seth Berkley, who was then working for the Rockefeller Foundation, made their center at Bellagio available for free and paid for the meeting because I didn’t have a budget. Jim Curran was somebody I had been working with in Projet Sida in Kinshasa, Zaire, with Jonathan Mann. I have the greatest respect for him. And he was willing to come to Bellagio in a personal capacity, because she was still at CDC and it was not an official meeting. The retreat was extremely useful, because we had an open discussion, which you can rarely have in the system itself because everything then acquires a meaning, and people think you have an agenda. It's the same in any political and bureaucratic system.
One of the questions we addressed was what to name the new organization. This happened during a dinner, a late dinner with a lot of wine--and Bellagio had good wine, I remember. Somebody said that we had a number of options. I said, “it's about AIDS and it's in the UN.” Then somebody, I think it was Rob Moodie from Australia, said, “UNAIDS.” And that was it. The official name was Joint and Co-Sponsored Programme on HIV/AIDS, and I said, nobody can pronounce that kind of thing, so an acronym that says something is what we want. And then of course, we needed a logo, and my daughter, you know, is a wise girl.
Harden: Is she an artist too, or is she –
Piot: She works at MTV. She has some artistic tendencies, but she said, now that it will be called UNAIDS, the AIDS symbol is the red ribbon, and you already have the UN logo, so UNAIDS’ logo should be a combination of them.
Harden: But the red ribbon in the UNAIDS logo is wound within the UN logo, rather than sitting on top of it. I think that's very interesting.
Piot: Yes, it is indeed. And because the idea came from my daughter, it saved us some $10,000 that it would have cost to get the logo from a design firm, and UNAIDS didn’t have theses dollars. Afterwards, at a meeting of the Committee of Co-Sponsoring Organizations, I was under attack because we had chosen a name and a logo. I said, “You can't have an organization if you don't have a name.” But this illustrates that every single thing required a fight. Everything. And I had no money then.
Harden: I've been trying to figure out how you plan and implement programs when you don't know how much is coming, and where it's coming from, and when it's coming. How did your funding develop? I know you had to fight for the initial budget.
Piot: In the early days, particularly, the money came from the Clinton Administration in the US. Now in UNAIDS there is a savings account that serves as buffer for late payment by donors. Most donors pay at the end of their fiscal year, so generally, there's hardly any income at the beginning of the year. If you don't have that kind of reserve, you have to close the doors.
Harden: The US budget process often operates the same way.
Piot: Yes, but the US government can borrow money. UNAIDS can't borrow money. I accumulated that reserve money through conservative fiscal policies, trying to be a bit thrifty, and good management. But it was often guesswork.
Harden: In March 1995 you set up a preparatory team of 10-12 people to work out a detailed strategy. One participant described this as a very non-hierarchical structure, and somebody else called it anarchical. I would like for you to describe your vision: what you wanted out of this, what sort of strategic plan emerged, and, finally, whether you found that size group to be the right-sized group to help you plan.
Piot: For a few months, I was literally the only employee UNAIDS, and I was supposed to create a new organization, with no money in one year. Then I got some money from the US, from France, from Sweden, from UK, some starter money, or seed money, so I could hire people. WHO, the Global Program on AIDS, also gave me money. Mike Merson had left and Stefano Bertozzi, who was then the acting director of the Global Program. He and I were very close friends, which Nakajima and other people didn't know, fortunately, because otherwise Stafano wouldn't have been put there. We worked together, and he provided some of the initial administrative support.
Was this the ideal size? I don't know. If I were to do it again, I would start certainly with a bigger team. But I couldn't get the people, I didn't have the money. I particularly was disappointed from the beginning that our co-sponsoring agencies were really not helpful. The idealistic approach was that WHO would second somebody, and then UNICEF, and we would all be brothers and sisters, and we would work together for this common purpose. The agencies did second some people, but they were more spies who served to make sure UNAIDS didn't develop too fast or not at all. For example, in WHO, Nakajima was convinced that UNAIDS would never see the light of day. That was a bad mistake, because I kept a low profile. As they say in Seattle, where I trained, the first whale to surface is the first to be harpooned. So I kept a low profile.
We had to do everything. I wrote job descriptions. It was indeed non-hierarchal. Our challenge was to focus on where we wanted to be in June, because we would have a first program coordination board meeting at that time. That would be a big test, so I had to come up with a strategic plan, and with the budget. That was our absolute deadline, because if we failed there, we couldn't start on the first of January of 1996.
Harden: Tell me who these 10-12 people were in terms of their backgrounds and training.
Piot: It was a combination. The person who served as my chief of staff was Purnima Mane, who is now the Deputy Executive Director of the UNFPA, the UN Funding Planning Organization. She is a social worker by background, with a PhD in social work from the Tata Institute in Bombay. She is also a great singer. I mean she was a professional singer. She did the Indian version of “Jesus Christ, Superstar.” So I mean, we have really talented people. Who else was with me? Elizabeth Manipoud. She's French, and she came from UNICEF, and had a legal background. She was a lawyer, so that was very useful. We had people who came from WHO, Nina Ferencic, a communicator, who came from the Annenberg School in Pittsburgh. I didn't go for technical people, because that was not my problem. Plus, I knew that I didn't know how to organize something. Rob Moodie, was also there, a public health physician from Melbourne with Africa experience. These were people who were totally dedicated to the AIDS cause, but were not AIDS scientists. Scientists would have been pretty useless.
Harden: Tell me about your strategic plan. How far down the road were you looking, here at the beginning? Certainly one would like to see everybody who is ill be treated, a vaccine developed so that it would end the threat, and discrimination be ended and what have you. But those are such big goals that they would have been impossible to measure at the outset.
Piot: Yes, on the one hand we had big goals, but for example, no treatment was available.
Harden: In the initial strategy.
Piot: In '95, there was no proven effective treatment. And that came only exactly a year later, in July '96 in Vancouver, at the international AIDS conference. Then we added that, and I even spoke in the opening ceremony in Vancouver, and I said, “This is great news. But I am really concerned that the majority of people who need this therapy live in poor countries. Will they have access?” And it took eight, nine years before that materialized.
So the strategic plan included some of the broad picture, but it focused really on how to get the various components of the UN system to work together, and to do something about AIDS. It was I think quite explicit on stigma, discrimination, and on – on bringing those with HIV to the table. I honestly can't remember exactly what was in the original strategic plan. I would have to go back to our records for that one.
Harden: When you presented your budget to the PCB, it countered with about a third of what you thought you needed. Eventually you got the money increased, and you were ready to launch then on World AIDS Day 1995, December 1st, but the launch turned out to be a bust. Would you tell me about this?
Piot: First, the debate on money in the PCB was where we had a major conflict. On the one hand you had the donor countries, who wanted to pay as little as possible. I mean, I understand all that. I think the proposed budget was $40 million for two years. Can you imagine that they believed that amount would defeat AIDS epidemic? It didn't pass the laugh test. I was really angry. The developing countries and the AIDS activists—representatives from civil society--wanted to go for the bigger budget of $140 million that I had proposed. At some point, I saw that the donors were putting pressure on developing countries to vote for the lower budget, the lowest budget, and twisting arms. These developing countries depend on many things and so can be pressured. When I started seeing that, I asked for a time-out. And so it became politics in the corridor. I said that if the higher budget was not approved, I would resign. I didn’t want to set myself up for failure. It was difficult enough without failing at the start. I nearly got into a physical argument with some of the representatives. In UN governing bodies you don't do these kinds of things. But I was really angry, and I'm not an aggressive type of person. I've never physically fought in my life. We finally got the support. We turned it around. And the lesson for me was that at crucial moments you really have to put your foot down and use your capital when it really matters.
We were then approved to launch on the first of January '96. That date was part of a resolution of the UN Economic and Social Council. But we wanted to launch on World AIDS Day, the first of December. It turned out to be a total fiasco. This was caused by a combination of inexperience from our side. Sally Cowal was then the Executive Director. She was an American diplomatic – career diplomat from the State Department, and ambassador in the Caribbean and Assistant Secretary of State and so on. She was a really great woman to work with, and also an entrepreneur, but she didn't know the UN system either. I think that was a problem. None of us knew enough. On the one hand it was an advantage that I didn't know the system, because I didn't see all the bullets and all the knives that were waiting to attack our program. I just went for it. On the other hand, the lack of experience made us miss some opportunities. For example, we hadn't thought about the fact that people needed to pass through security at the UN. Going into the UN is a pain. Anywhere with security is a problem--I mean, I'm going to NIH tomorrow morning.
Harden: NIH security is a pain.
Piot: I know, and as a foreigner, I know I need my passport. Before—in my previous life, when I was getting NIH money--I went jogging at NIH, on the campus. But no longer.
Harden: Before 9/11. Everything changed after the attacks. And then NIH got the fence.
Piot: When we started UNAIDS, it was before 9/11 at the UN, but still security was tight. We also hadn't prepared the field. We should have systematically gone and visited ambassadors and this and that. So anyway, we learned a lesson. We learned a lot of the things the hard way. It was like a child growing up.
Harden: You did become operational the first of January, 1996. You had a staff of 91 in Geneva and 10 in other countries around the world. It appeared to me that your first real task was to get people's attention, to understand that AIDS really was a problem. Tell me more about how you started at UNAIDS.
Piot: I set three goals for myself when I got into the job. The first one was to put AIDS on the political agendas in the world. I had come to the conclusion without that we would never get the money necessary. Secondly I wanted to build a large coalition. I wanted UNAIDS to get out of the ghetto of AIDS doctors and AIDS activists, who sometimes fought with each other, sometimes worked together. Finally, I wanted to mobilize the money, not so much for UNAIDS, but for developing countries. Those were my personal goals. But, indeed, the first one was to get attention for the issue.
The first thing we did was try to get better figures, to review completely the estimates of HIV. How many people are infected, and so on. Why was that important? Because I felt that before this, WHO really hadn't gathered statistics very systematically.
Harden: Yes, I'm very interested in this.
Piot: The original estimates from Jonathan Mann’s time were often called Delphi surveys. Jim Chin did that. He would interview a few people and ask, “What do you think is the number of cases are in Asia, Africa, and so on?” I participated in that when I was a professor of microbiology in Antwerp and chair of WHO’s Committee on HIV Epidemiology. That method’s fine when there's a total unknown, when you need a Delphi method, like the oracle. But what we needed now was more a systematic analysis of the data that started being published. Many data points collected in a systematic way.
Harden: Did the World Health Organization collect any kind of infectious disease data systematically at this time?
Piot: WHO data was mostly based on the reporting by ministries of health of their member states. And some didn't want to recognize that they had an AIDS problem, so it became a political issue. Two, the quality was really poor. There was no quality assurance. And three, the data were often very old. They would report data from four years ago, and in an epidemic, by definition, cases go up. You need real-time data if possible. Mike Merson had started to improve that system. So it's thanks to that initial investment that we could do our work. But we never saw the fruit of this work, because these things take time to set up. What was then was launched was called sentinel surveillance. It was a systematic approach. Pregnant women who came to antenatal clinics had blood drawn and tested for HIV. They were thought to provide a representative sample of the population. In the developing countries, most women get pregnant, so by definition they're sexually active. That's still probably the most practical approach, although it is not 100% accurate, as we know today. We didn't know that in these days. It's accurate enough for us to follow trends, which is important. Is infection going up, is it going down, is it remaining the same?
Merson had invested through the WHO system in this with mixed success. What I wanted to do was to bring it all together, to try to estimate, country by country, how many people are infected with HIV in Zambia, in Nicaragua, in Cambodia, in Belgium? The stuff that CDC had done, although it had not done this for many years. It took so long before CDC published its recent new estimates.
Harden: Right, but even there, the CDC estimates were limited to the US.
Piot: Yes, to the US. And not every country has a CDC. Some have them, but they are not of the high quality as in the US. And so that is where UNAIDS invested a lot of our energy in the beginning, learning about the size of the problem.
Harden: How did this end up with the US Census Bureau tallying this information, instead of the World Health Organization?
Piot: The US Census Bureau was a very important player because they had a systematic database of anything that was published on HIV prevalence surveys. It was Peter Way and Karen Stenucki who were doing this. They would take pictures, they would go to every conference on AIDS you can think of, and collect all the information.
Harden: And they were working for the Census Bureau, the US
Piot: Yes, for the US Census Bureau.
Harden: And how... This just doesn't register with me, why they were going – why the US Census Bureau was doing this around the world, when it, like the CDC, is an agency of the US government. You'd think there would be – it would be limited to the US. This is why I was surprised about this. And were they using World Health Organization statistics?
Piot: Yes, but WHO was grossly underreporting. They were using official government statistics, and nearly always that meant AIDS cases, not the number of people with HIV. Big difference. The US Census deals with population issues in the world, I think as part of its mandate, because that's a strategic issue for the US. So we worked with them. WHO would not work with them, but I said, we work with the people who have the information. We are agnostic about why they gather it. That collaboration resulted in the first estimates on HIV infection in the world. I can't remember when we published it, but that's in the chronicle. And that was the work of Bernhard Schwartlander and his colleagues. They worked really hard, and in some cases these estimates retrospectively turned out to be very accurate, while others were exaggerated. Particularly for Asia, we had overestimated. For example, in India, the estimates were based on nearly exclusively urban figures. We had hardly any figures from rural populations. And it turned out 10 years later that rural populations had a far lower incidence and prevalence.
Harden: In 1996, at the 11th International AIDS Conference in Vancouver, the epidemic reached a turning point with the introduction of the protease inhibitors, and HAART (Highly Active Anti-Retroviral Therapy]. Do you see this date as a turning point because something could now actually be done to keep people alive who were infected with HIV? Has funding and activity increased because once AIDS could be treated, political entities were more willing to admit that it was a problem in their countries?
Piot: That's right. My political approach has always been one of, it's not enough to bring on a problem. You need to bring on a solution. Decision makers, big politicians, confront so many problems. I thought that treatment was some kind of solution. It's not the solution for the epidemic, but at least you could do something about it in 1996. And therapy also meant that politicians didn’t have to deal with sex and drugs, which is a problem with doing HIV prevention. Many politicians don't want to have to deal with that. I think that the availability of treatment not only changed the nature of the epidemic, because AIDS could be treated now, but it also brought a sea change in what was possible, in terms of putting it on the map. I was very fortunate that that happened. But also, it took so long before the therapy became available. Think of it.
Harden: And one other philosophical issue, if I may just go on here. With respect to questions about whether HIV caused AIDS, I have become very interested in what convinces people that the cause of a disease has been found. For scientists, there is Koch’s Postulates. In 1882, when the famous version of Koch's postulates were published about the cause of tuberculosis, it may have convinced the scientific world that a single germ caused this disease, but it was not until 1894 when diphtheria antitoxin was introduced, that the lay public was persuaded about the correctness of the germ theory. When physicians could actually intervene to stop a disease, when a child who was dying was suddenly getting well instead, the lay public began to trust this new medicine. I wonder if the introduction of HAART had the same effect. Although scientists had been convinced by data in 1984 that the cause of AIDS had been found, AIDS denialists gathered support until the introduction of HAART and seemed to lose steam after 1996.
Piot: I fully, fully agree. We call it the Lazarus effect: people essentially stand up out of the grave.
Harden: Did you see a decline in the opposition to belief that HIV caused AIDS?
Piot: Not immediately, no.
Harden: It took a while.
Piot: It took a while, and for example, in 2001, when we had the UN Special Session– the General Assembly Session on AIDS-- when you read the Declaration of Commitment, which is the document that came out of it, a kind of a road map for the whole world to deal with AIDS, one thing is not in it. I think that session was a tipping point in the international response to AIDS. Forty-five presidents and prime ministers unanimously endorsed this road map. But there is one thing that is not in there, and it's treatment. There are targets for knowledge by young people about AIDS, and targetrs for reducing new infections and mother-to-child transmission. All that is in there, but agreement could not be reached on access to treatment. And all the donor countries, including the US and except for France and Luxemburg, were against any mention about access to treatment. Latin American and Caribbean countries lobbied hard to have a treatment access target, but failed. The African governments were against it, even though their people were dying. So were Asian governments. And I think the reason was money. The donor countries said, “This is not possible, it's too expensive, the money's not there.” They were concerned with cost containment, resource containment. The African ministers of health were concerned that if this resolution includes access to therapy, I will be asked to do this in my country. I can’t pay for that. They knew the health systems were not functioning well and that health services were lacking. They didn’t have enough healthcare workers. All that was true. But I always thought that this may be true, but let's do something about it. I'm so glad that we started with antiretroviral therapy. I mean, by we, I don't mean UNAIDS, although we were the first ones in Africa to introduce antiretroviral therapy into private projects, one in Uganda, one in Ivory Coast. I'm so glad we didn't wait until the health systems were fixed, because now there are 4 million people in treatment in the developing world. Without treatment, most of them would be dead. So I believe we shouldn’t wait until the system is fixed before acting but try to fix it while you are taking action.
Harden: Following the 1996 meeting, you started trying to do something, as you said, even though the systems weren't fixed, and trying to – to work with the business people and the religious people, and the military services. Will you tell me about the different approaches you took with each one of those, to get support?
Piot: Basically, in many countries, the ministries of health and the public health community did not want to deal with AIDS, so I had to go around them. I was looking for alliances, and I wanted to build these alliances. Working with the military was an important one. It was triggered off my suspicion that UN peacekeepers had possibly spread HIV in Cambodia. Probably some of that is true. I met Kofi Annan, because he was then in charge of peacekeeping operations, and he asked me, what should we do? How do you deal with this? And so that was – so we – we focused first on missions that provide peacekeeping troops. The Ukraine, Zambia, Bangladesh, Sweden, the Netherlands, Ireland--they're big providers of peacekeeping troops. The military, in my experience, is very pragmatic once you convince them of something. They go for it. No discussions, no debates about condoms, they just implement a policy.
I also knew from my experience in Africa that religious organizations, particularly Christian organizations, play an enormous role in providing health care. There, we had a few problems, particularly when it came to HIV prevention. But what I found, also, is that the higher you go up in the hierarchy, the more rigid people become, and more ideological. But the people on the ground are more flexible. You would find condoms in Catholic hospitals, run by sisters who, did not want to talk about condoms but let them be available. They were better than the Pope, both the previous one and the current one.
In the business community, I was also looking for allies. I was talking to the pharmaceutical industry, but they were very suspicious, because they knew that I was calling for lower prices, and they didn't like that. For them, Africa is not a market. I think it represents about 2% of the global pharmaceutical market. That's all. So I had to work really hard on them. I used mostly moral arguments. I said, “Look, this is a global epidemic. Do you want to be like tobacco companies, or do you want to be heroes?
Harden: Oh, that's interesting.
Piot: In the end, it worked to a certain extent. For example, Merck, with Ray Gilmartin and Jeff Sterchio, was already there. They were the first ones – though Richard Sykes from Glaxo Wellcome had also decreased the price of AZT a few years before. Merck broke the solidarity front within the pharmaceutical industry, and went for tiered pricing. But that was only in 2000. It took several years.
Harden: How did it take you to get the business community to realize that AIDS was bad for business?
Piot: That took several years, and is still going on, and there Richard Sykes from Glaxo Wellcome, and Bill Roedy from MTV International were really instrumental. I must say, this was primarily an idea of Sally Cowal, my deputy, who had a business background also, besides being a diplomat. And she was married to a businessman. So they started with the Global Business Coalition on AIDS, which was launched at the Commonwealth Summit by Nelson Mandela. It was in Edinburgh. I don't know exactly how we got him on board, because he had not been outspoken about AIDS in his own country. But we brought him to Davos to speak at the World Economic Forum. In those days big pharma had sued Nelson Mandela in South Africa for wanting to introduce generic medicines—this was a PR disaster, of course, so they were looking for a way to get out of bad publicity. Richard Sykes, Nelson Mandela, and myself spoke in a big plenary session at the World Economic Forum, so they could have some direct dialogue.
Harden: And what year was that?
Piot: That was in – I think it was 2000, or it was maybe '98. I'm not certain.
Harden: And this brings us to the – the other question, big question here. Nelson Mandela was a very traditional man, and you were asking him to speak about sex, which is a taboo subject in every culture on Earth. How did he respond, and what got him finally to speak up?
Piot: I discussed this later on with him, because I asked him long before he spoke up about AIDS even though his country was so heavily affected. The first time he spoke about AIDS was not in South Africa, interestingly, but it was in Davos, Switzerland, in an Alpine village for the wealthiest people in the world. He spoke about AIDS and business rationale. But by then he was convinced. In December, in his last World AIDS Day as President of South Africa, he addressed the nation on TV, live, about AIDS. But it was out of a military camp, so the audience was mostly soldiers. I was there next to him. He said that one, he had underestimated the problem, which I accept. In the ANC [African National Congress] there was a strong health constituency, and they had prepared a good plan on AIDS before the liberation from apartheid. He said also that they were concerned about this for electoral reasons, during the first free elections in South Africa. There was a discussion on this apparently within the leadership of the ANC. The conclusion was that too much attention would go to AIDS that could be used against the black majority. He acknowledged that it had been a mistake to ignore AIDS, but he took responsibility for that. That’s why he was not dealing with it. But then the facts and figures came out and his family was also personally affected. One of his sons died from AIDS. Since then, he's been a courageous and great spokesperson for AIDS. Also, at the personal level, he said, “I made a mistake.” Not too many politicians do that.
Harden: This is true.
Piot: Nelson Mandela is the person I admire the most in the world, and he has an incredible charisma, and a great combination of natural authority, but also humility, and that's a unique combination. South Africa was liberated from apartheid, and then comes AIDS. That's really bad luck. It put such a strain on the country.
Harden: This will be a good place to stop, because we need to shift gears here. We'll stop today, and pick up next time. Thank you.