Text of Key-Note Address
Callisto Madavo
Vice President, Africa Region
The World Bank
Durban, July 8, 2000
Thank you very much, Dr. Karim, for that kind introduction. I am deeply honored to be addressing this symposium today. As an African, I have seen first-hand the ruin that AIDS has visited on our communities and our countries. As a World Bank Vice President, I have seen the progress of the past half-century put in peril. And from both perspectives, I have seen the new century dawn under ominous skies. I do not exaggerate when I say that in Africa—and increasingly across the developing world—AIDS has quite literally put the future at stake.
Yet I have also seen the difference that leadership, empowerment, community action, and respect for human rights of those infected and affected can make. By bringing us together in the continent most affected, this gathering to learn from success symbolizes our surest hope for sparing the generations to come from what we have had to endure. And so I am honored to play a part, both on my own behalf and on behalf of my institution.
Honored as I am to speak here today, let me say forthrightly that the time is long overdue to move beyond talk to action. Yes, we must continue advancing knowledge about the epidemic, its nature, its impact, and effective ways to prevent it and halt it. But we must, above all, act now on the basis of mainstream science and the broad base of successful experience. I will speak primarily of Africa today, because that is where the epidemic is most severe. But the Bank is equally concerned with all other developing regions, where HIV/AIDS could follow the same destructive path it has across Africa. There is still time to prevent further outbreaks. But the cost of any further delay could be the future itself.
Madame Chair, I will spend no time reiterating the numbers that we all know too well. I will begin instead by focusing on the threat AIDS poses to development. Three months ago, the World Bank presented findings on AIDS and development to a meeting of the world's finance ministers. We stressed the key pathways by which the epidemic endangers the future.
Specifically, AIDS directly undermines five of the foundations of development. These include economic growth, good governance, development of human capital, the investment climate, and labor productivity.
The latest growth evidence is especially striking. A decade of data from 75 countries suggests that AIDS is costing the typical African country more than half a percent of per capita growth every year. In the hardest-hit countries, the price is far higher—perhaps as much as two percent per person per year. Considering that annual per capita growth in Africa has recently been 1.2 percent, this is a loss Africa simply cannot afford. It wipes out any gains.
The impact of AIDS on the labor force is hitting both the public and private sectors. The epidemic is eroding productivity at just the time that developing countries need to become more competitive to cope with rapid globalization. In the private sector, this raises the costs of doing business and deters investment. In the public sector, it depletes the already small corps of policy makers and managers on which developing countries critically depend. The loss of such key officials is further reducing scarce capacity, which is weakening the prospects for good governance.
AIDS also targets the poor. It has overwhelmingly hit the world's poorest countries and those with the greatest disparities in income. People of all classes are vulnerable to HIV, but it is the poor who have suffered the most economically. The epidemic has had a severe impact on health and education, which are the most important assets people can use to bring themselves from poverty to prosperity. As one African health minister remarked recently, "We no longer even dare to dream."
It should come as no surprise that AIDS destabilizes development. After all, the disease takes its greatest toll among young adults. And what happens when, say, a typical African woman dies at 30? All at once a mother, a daughter, a wife, a farmer, a teacher, a housekeeper, a community caregiver, and a micro-entrepreneur are gone. And the "orphans" she leaves behind are not only her children, but the hundreds of people in the community and the workforce with whom her life is intertwined. Multiply that impact tens of thousands of times, and the knots in the social fabric begin to uncoil.
For this reason, we can no longer regard investing in HIV/AIDS programs as just one among many policy choices. That is a false choice. In the worst-hit countries, otherwise sound investments are already proving uneconomic and unsustainable because of the epidemic. Investing adequately in AIDS is therefore a precondition to virtually any other investment a developing country may wish to make. This is especially true of public investments. That is why immediate action is essential.
Fortunately, this symposium is correct: prevention works. Although there is still no vaccine, we have seen time and again that a "social vaccine" can be highly potent. Behavior change has been very effective in reducing HIV transmission and changing the course of the epidemic. We will hear many examples of this during this symposium.
Prevention also pays. Not only does it prevent great suffering and loss of life, it also pays vast dividends in savings to households and society. A cost-effective program can avert one HIV infection for as little as eight U.S. dollars, compared to the hundreds that each case of AIDS costs to treat in health care alone.
But prevention alone is not enough. With 34 million people already living with HIV/AIDS, we must also step up our efforts in care and treatment.
I am delighted to see more and more leaders rallying to the AIDS cause. In his New Year's address, President Moi of Kenya summed up the spirit of this new awareness. Declaring AIDS a national emergency, he urged: "Anything that can be said or done to halt the progress of the disease must be said and done."
Madame Chair, that is also the approach of the World Bank.
Two years ago at Geneva, we pledged that the Bank would adopt a sweeping new strategy to address HIV/AIDS more forcefully in Africa. Last September in Lusaka, I launched that strategy. At the same time, we committed the Bank to mainstream HIV/AIDS into all areas of our work and all aspects of our dialogue. AIDS is strong because it strikes on many fronts at once. That means we can strike back on just as many fronts. Today, nine months later, let me report to you what we have done:
We started with the tools at hand. Our existing portfolio of projects offered dozens of opportunities to act at once. By retrofitting parts of these projects, we have supported fast action on AIDS in a host of countries and a broad range of sectors—including agriculture, energy, water, social development, roads and education.
In new projects, we have built in HIV/AIDS components wherever possible. This work, too, has spanned all sectors. Let me cite just a few examples:
In Senegal, a community-based infrastructure project includes IEC, community capacity-building, and resources for community care and prevention activities.
In Tanzania, a social action fund will put resources directly in community hands to support locally-designed HIV/AIDS projects.
With the Chad/Cameroon Pipeline Project, the Bank is supporting IEC, capacity-building, and workplace interventions along the pipeline route, both for workers and for the affected communities.
In a number of countries including Benin, Guinea and Nigeria, the Bank has helped integrate HIV/AIDS into the training and activities of thousands of agricultural extension workers.
To help accelerate this mainstreaming, we have assembled teams of our AIDS specialists and our sector specialists. Together, they are developing concrete guidelines for how to integrate HIV/AIDS into projects of all types. Draft guidelines have been completed for the transport sector and are in progress for mining, water and education.
In other regions, the Bank is funding pre-emptive programs that will prevent HIV from taking off in countries with early epidemics, such as Bangladesh and China, and we are reinforcing programs in countries with concentrated epidemics, such as Brazil and India.
Besides these specific steps, we have also built in general safeguards against HIV/AIDS. Soon, all Bank-supported projects in Africa will undergo an HIV/AIDS impact assessment as part of the standard environmental assessment. All Bank-supported civil works contracts will require construction firms to include prevention and mitigation measures.
We are also integrating AIDS into debt relief programs. As you know, the Bank and the IMF are helping process billions in debt relief under the HIPC initiative. Many of the countries which will benefit are heavily affected by the epidemic. We are helping ensure that some of the debt relief goes to increase funding for HIV/AIDS efforts.
Recognizing the vicious circle between AIDS and poverty, we are requiring attention to HIV/AIDS in all poverty reduction strategies. Only by addressing the socioeconomic factors that make people vulnerable can we help communities overcome the epidemic sustainably.
The long run dream is to have an HIV vaccine for all the world. But such a vaccine is unlikely to come to market without concerted action by both the public and private sector. The Bank has therefore been a co-founder, a sponsor and an active member of the International AIDS Vaccine Initiative (IAVI). Over the page 18 months, the Bank's AIDS Vaccine Task Force has worked with IAVI to find innovative strategies to accelerate the development of an AIDS vaccine targeted at the needs of developing countries. The resulting recommendations will be available at this week's conference. The Bank has also worked closely with the Global Alliance for Vaccines and Immunizations. We plan to provide similar support for the development of female-controlled protection methods, such as microbicides.
Life-prolonging drugs exist already, of course. The Bank has existed substantially in drugs to treat TB and other opportunistic infections, as well as STDs. But even now, far too few people have access to these inexpensive and essential tools. We are beefing up our efforts to improve availability.
Another class of drugs are the ARV "cocktails." These remain expensive and sensitive, and so out of reach for the vast majority of the developing world. The Bank has been part of the UNAIDS task force which recently reached agreement with drug manufacturers to cut ARV prices dramatically for the developing world. This is only one step down a long road, but a vital one. The Bank will support countries in strengthening their health infrastructures to make use of these drugs safe and effective.
We have also used our policy influence to raise the profile of HIV/AIDS as a development and security issue. James Wolfensohn, the Bank's president, has addressed the UN Security Council on the issue—the first time a Bank president had ever appeared before that body. We have, as I said, briefed the world's finance ministers on the threat. We put the epidemic at the center of our Annual Meetings discussions with country delegations. To expand knowledge, we have undertaken new economic work both at a global level and in several of the worst-hit countries. And we will be underscoring the development aspects in several sessions over the coming week.
Now I am sure you are all thinking, "Very well, Madavo, but what about the money?" A fair question. Money is still an issue. We estimate that a basic program of prevention, care and treatment in every African country would cost about three billion dollars each year. Current investment in HIV/AIDS in Africa is nowhere near that figure.
The World Bank recognizes its unique responsibility to lead in bridging this gap. Since Lusaka, we have been designing a vast new initiative to that end. Before this year is out, we will present to our Board a Multisectoral AIDS Program for Africa. This program would set aside 500 million dollars from the Bank's soft-loan window, IDA, to fund HIV/AIDS programs. Because IDA funds come on highly concessional terms and usually catalyze substantial cofinancing, they could greatly expand a country's resources for HIV/AIDS with a minimal impact on debt. Nearly every country in Africa would be able to access these funds. All that would be needed is a sound national AIDS strategy developed in a participatory way, backed by serious government commitment.
This program would come with streamlined procedures to permit faster preparation. Funds would be available for all activities authorized by national plans—whether in prevention, care or treatment. And funds would be channeled to all actors in the struggle, including national AIDS programs, sector ministries, NGOs, communities, and the private sector.
The central goal of the program is to help achieve truly national coverage. One of the key tools would be a mechanism to ensure that a large share of the money flows directly to communities to support their own local responses. We know now that empowering communities is a core element of successful programs.
The program would also support efforts in two other realms where AIDS poses a special threat—in cross-border areas and in countries beset by conflict. The Bank is designing ways to support both subregional bodies and countries in conflict or post-conflict.
This would be no unilateral action. The Bank is developing this program in full collaboration with its fellow UNAIDS cosponsors, with its partners in the International Partnership Against AIDS in Africa, and with all others. In the ideal situation, a country would convene all potential sponsors to make contributions to a common plan. This would ensure a broad base of support and prevent gaps in support. Malawi recently conducted an HIV/AIDS roundtable on precisely these lines, and raised 70 percent of its needed funds in a single go.
Let me highlight two additional points. First, the 500 million would be only the first phase of a long-term commitment by the Bank. Consider it a down payment. As Mr. Wolfensohn pledged in April, we are resolved that no sensible program will be stopped for lack of money. However quickly countries make claims on this fund, we would replenish it with new resources. For as long as AIDS remains the foremost threat to development in Africa, it will remain at the forefront of our agenda.
Second, as I have often underlined, money alone is not the answer. AIDS is, above all, an issue of commitment, political will, and leadership. Only where governments show commitment can international support be effective. But we are now seeing an upsurge of just such leadership. One African health minister recently noted, "We may be poor, but we see it as our duty to convince our own minister of finance and head of state to fund our efforts before asking outsiders for help." As that type of ownership expands, it is incumbent on us external agencies to be prepared to help at once.
Yet Madame Chair, although global attention to HIV/AIDS is swelling, serious challenges remain. I fear that if we do not address these, even our best efforts will fall short. Let me focus on four in particular:
First and foremost, the renewed rhetoric must be matched by action. For every country that has declared AIDS an emergency, some other country has not. And even those that have sounded the alarm have yet to muster a full brigade. Let me be blunt. Not one country has mounted an effort on the scale required. More leaders need to be bold in helping people change high-risk sexual and drug use behaviors without stigmatizing them. Likewise, not one partner—the World Bank included—has yet done its utmost to support such efforts in full. All of us in the international community must do more—and not just with money. For the countries hardest-hit, we need to factor AIDS into development planning to help them maintain capacity and mitigate the impact on the poor. For countries that have so far been spared the worst, we must work against complacency and underscore the importance of early, aggressive action.
Second, as I have said, we must devote greater attention to care and treatment. While prevention is central, it cannot be achieved without caring for the tens of millions already infected and affected by AIDS. Indeed, care is often indispensable to prevention.
Third, we must set a collective goal of achieving national coverage in as many countries as possible. Africans, in particular, are people in perpetual motion. Truckers, traders, armies, farmers, teachers, miners, builders and tourists bring new contacts to communities every day. Until every community is AIDS-competent, no community is safe for long. This calls above all for putting resources directly in the hands of communities.
Fourth, we must strengthen our efforts to reduce mother-to-child transmission. This does not mean merely the provision of drugs. It means a full program of voluntary counseling and testing and advice for breastfeeding alternatives.
Madame Chair, let me close by taking the longer view. We have run out of analogues for AIDS. The most common parallel one hears is to the bubonic plague of the 14th century. But HIV is more insidious, more invisible, and far more enduring. This modern plague is truly without precedent.
Yet I believe there is a powerful lesson to be drawn from that earlier catastrophe. As everyone knows, the plague swept across Europe like a wildfire. Within a few years, one-third of all Europeans were dead, and life on that continent changed forever.
What is less often remembered is that the human family lived side-by-side with plague for at least a thousand years. Plague never disappeared, but disasters like the Black Death were the exception. How was this possible? Because prevention worked. For centuries before antibiotics were invented, communities around the globe developed customs and behaviors to minimize risk while still caring for the afflicted. They then handed them down unfailingly from one generation to the next.
In short, it was not the plague that changed. It was people. So it can be with HIV/AIDS. Like all of you, I long for the day when modern medicine delivers us a vaccine. But we need no laboratory miracle to begin protecting ourselves, caring for those living with the virus, and reclaiming the future for our children. In the words of former Tanzanian President Mwinyi, who now heads the national advisory board on AIDS, "All we need to do is empower and entrust."
Let us be as opportunistic as the virus. Let us empower and entrust and exploit every opportunity within our collective reach. Let us mount strong programs of prevention, care and treatment and fund them in full. And let us act so fast that a generation from now, AIDS will seem like a fading remnant of the troubled 20th century—a tale from history, a spent force, another challenge of nature overcome by the indomitable human spirit.
Thank you.
|
RSS