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FOR FURTHER INFORMATION: Helen K. Chang, 650-723-3358, Fax: 650-725-6750
Keynote Address: Dr. Debrework Zewdie
Director, Global HIV/AIDS Program
The World Bank
International Development Conference
February 26, 2005
Thank you and good morning. It's a pleasure for me to be here. Despite my busy schedule one of the things I never say no to is an invitation by students, because I have a strong belief that you are the generation who will go out and change the world. I was very grateful that the organizers didn't impose a title on me and they told me to choose what I wanted to talk about. I am going to take HIV/AIDS as an example to show the consequences of what we have been doing wrong all this time.
In doing this I'll try to do two things. One, I'll try to show you what we see in the area of HIV/AIDS is a result of the many issues that we have neglected for many years and also the way we have been doing development. The second one would be to impress upon you that HIV/AIDS is an exceptional epidemic that requires an exceptional response. I'll start with some of these neglected issues and then show you a few things about the epidemic and its consequences, and at the end I'll try to come up with a few issues as to how we move forward.
What are some of the neglected issues? This is a map that shows you where the HIV/AIDS epidemic is today. As most of you know, the epidemic started simultaneously in the north and in the south, but if you look at this graph, look at Sub-Saharan Africa with 25.4 million people living with HIV/AIDS compared with 1 million in North America, and this is not without a reason. There are a number of issues. The first one would be health services. If you look at how Sub-Saharan African countries especially and developing countries in general deal with the healthcare system, in most countries the per capita expenditure for all health issues is $10 per capita. The cheapest way to deal with a patient with HIV/AIDS in one of the developing countries today is about $300 per person per year. This is the context with which we need to see the HIV/AIDS epidemic. On top of that, the health personnel—for that matter, managers and other people who need to be on top of this epidemic—are very few, and the epidemic disproportionately affects them.
The scarce resources that are available in these countries are used inefficiently in most cases. It's very common to go to developing countries where you see 60 percent to 80 percent of the health expenditure is spent in capital cities—which serves only about 10 percent of the population. Under circumstances such as these, new epidemics such as HIV/AIDS would flourish, and this is a no-brainer. There are also economic constraints. We didn't deal with the underdevelopment issues before the HIV/AIDS epidemic came, and as a result we are paying for it. If you take Cameroon as an example, there is only one health professional per 400 people in urban areas and per 4,000 people in rural areas. These are the kinds of things that we see. Cambodia—85 percent of the population lives only with 13 percent of health workers. These are the kinds of neglected issues that have been with us before the HIV/AIDS epidemic came up.
Gender discrimination contributes to fueling epidemics. Girls in many of these countries are less likely than boys to attend schools, and there is a massive socioeconomic burden. Almost 70 percent of the 1.2 billion people living in extreme poverty are women. The HIV/AIDS epidemic has now a feminine face.
In many of the countries more women than men are infected and affected, and these are some of the reasons why we see more women than men.
This shows you the density of the health workforce in the world. I will follow this slide with a slide to show you the prevalence of HIV/AIDS, and you will be able to see where there is low density of health workers you see a very high density of infant mortality, maternal mortality, and HIV/AIDS. If you looked at the earlier graph and you look at this and if you focus on Sub-Saharan Africa, the darker colors are the ones which show you prevalence rates of more than 10 percent. In southern Africa, which is darkest, we have countries like Swaziland where the prevalence rate in the general population is 38.8 percent.
This is also another example which will show you where the HIV/AIDS prevalence rate compares to the measures of development—which is GDP per capita and life expectancy. You look at Zimbabwe plus the U.S., Italy, and Egypt, and it would be easy for you to see where we are when we are dealing with this epidemic.
These are some of the issues which perpetuate the problems that the world faces today. The consequences are obvious. When an epidemic hits a certain population, school enrollment decreases; when school enrollment decreases, the country's development slows, the education standard falls, there will be less trained people, and that is what creates underdevelopment and a vicious cycle of poverty.
This is one of the slides which shows what this epidemic is doing to many of the countries in Sub-Saharan Africa. If you take Zimbabwe, South Africa, and Botswana, these were countries that were showing good economic development before the onset of HIV/AIDS. What has happened because of HIV/AIDS now is that life expectancy in these countries has decreased by anywhere between 17 to 28 years. Zimbabwe's life expectancy has decreased now by 28 years. Where it should have been around 60 or 65, it is less than 35 now. On the other hand, if you look at Madagascar, Senegal, and Mali, their lifespans are going up. These are countries where the HIV/AIDS prevalence is very low at the moment and their life expectancy has not been affected. Our responsibility is to see that these countries do not become the Zimbabwes and the South Africas of this world tomorrow.
This is a very tragic pyramid. For any population you should see a perfect pyramid. Botswana without HIV/AIDS would have a normal population pyramid. Because of HIV/AIDS it has been reduced into what we call a population chimney; it's no longer a pyramid. Generally somewhere between the ages of 55 and 40 there is knowledge and experience. That is the population that's being wiped out in these countries. You can look at this from the point of view of how can a country develop, how can it maintain its culture, its development through the generations when an epidemic which does this to the demographics of populations is happening. That is why HIV/AIDS is exceptional. Yes, malaria kills people; yes, road accidents kill people; but you haven't heard that 15 million malaria orphans or tobacco orphans exist. For HIV/AIDS, currently we have 15 million orphans and 13 million of them are in Sub-Saharan Africa.
The World Bank, being a development agency, we try to help countries to look into what they need to do to mitigate this epidemic. Although I personally am a health professional, we are 10,000-strong economists in the institution. The biggest impact we have is to show countries, and especially policymakers, what the impact of this epidemic is on development. This is something we did for South Africa. If South Africa does not do something to mitigate this epidemic, by 2010 the GDP will be lower by about 17 percent, GDP per capita will be lower by about 8 percent, and the other sectors, the non-health and the food consumption sectors, will be lower by about 17 percent. This will put South Africa in a very dire position where it is a downward spiral rather than development upward.
I did mention a little bit about increasingly the face of this epidemic becoming feminine. This is what you see happening to women all over the world. Most women are affected and infected in Sub-Saharan Africa. If you look at the picture of HIV/AIDS all over the world, including Asia, what you see is more and more women getting infected by this epidemic.
If countries do not do something about this epidemic, this is what is going to happen to their workforce. This was a study done by the International Labor Organization. If you focus on the countries which are highly populated in Africa, especially Ethiopia and Nigeria (we have 140 million people in Nigeria and about 70 million in Ethiopia), they will be losing 7 percent to 10 percent of their population. Botswana is a small country, which is going to lose about 30 percent of its workforce. This is what is happening to the hardest-hit continent because of HIV/AIDS and because of the issues which I told you earlier by which the epidemic has been flourishing.
If you look into the different public sectors, you see a tremendous impact of this epidemic. In 1999 over 869 pupils lost their teachers, and you can imagine what happens. They don't get schooled properly, so then you don't have trained manpower and development doesn't happen. The civil service security is also at high risk in many of these countries. The health sector and the education sector are hit hardest by this epidemic. Fiscal capacity in many of these countries is weakened and you see what some of the consequences are. This leads to underinvestment and underdevelopment. As I said earlier, the health and education sectors are hit hardest by this epidemic. If you look at the teachers, Zambia today, the number of teachers that die are more than the number of teachers that the country has. Girls are taken out of school. This is what adds to the feminization of this epidemic. Not only are they disproportionately infected and affected, they are also the bearers of care in most cases. It is young girls who are taking care of the sick parents. It's also young girls who become heads of households when the parents are dead.
Coming back to the density of health workers vis-à-vis HIV/AIDS prevalence, it's very clear that if you compare Europe and North America to where Sub-Saharan Africa is today, one of the reasons we could contain the epidemic in the north and we couldn't contain this epidemic in the south is because of this discrepancy. This is an epidemic which could be dealt with if you have the right things in the right place.
On top of HIV/AIDS undermining training, on top of the people dying, there is something else adding to the problem in Africa—the migration of the trained health and education workforce to the northern countries. Today you find more Malawian nurses in London than you find in Malawi itself. There are a number of reasons for this, one of which is the trained manpower looking for something better somewhere else and abandoning their countries.
In addition, before the advent of the HIV/AIDS epidemic, we inherited a dilapidated health system. Most of these developing countries could not deal with childhood diseases, malaria, tuberculosis, and it is on top of that that we have epidemics such as this. There is a lack of basic drugs and this has significance as we are trying to roll out treatment for HIV/AIDS patients in these parts of the world. There is very little coverage. To give you a few examples, 47 percent of hospitals and 33 percent of health centers and 47 percent of health stations need major repair in Africa. Now, if Africa has most of the HIV/AIDS people living with the disease, then you can imagine the challenge that we face. Only 65 percent of hospitals and 28 percent of health centers and 57 percent of health stations have at least 75 percent of the recommended supplies of the basic drugs. If you don't have aspirin and painkillers in these institutions, then you can imagine the problem that the world is facing as we try to deal with the HIV/AIDS issue.
We must address the ratio of physicians and nurses to populations in countries that have been highly affected—those with rates of HIV anywhere from 10 percent to 35 percent in Botswana. If you look at the size of the population with the number of physicians and nurses, then it's very easy to see why epidemics perpetuate in these kinds of countries. In addition to this, at any given time most of the countries in Africa are in conflict. That is a fertile ground for epidemics. People move, people get dislocated and displaced, people become impoverished. These are the situations that perpetuate an epidemic such as HIV/AIDS.
So what are the challenges? There are health problems in general and HIV/AIDS in particular as a short-term crisis. If you look into the way donor governments or donor agencies are looking into this epidemic and the way development is done in these countries, it's always short term, especially for HIV/AIDS. It has always been seen as a crisis. We are in the middle of the second decade of this epidemic and we still look at it as a three-year problem, a five-year problem. This is very difficult for countries to plan for the long term, especially dealing with an epidemic that is wiping out the very same people that are supposed to plan for development.
We are not coordinated at the country level. The three major donors for dealing with HIV/AIDS issues or building health systems in developing countries today are the World Bank; the Global Fund for Tuberculosis, AIDS, and Malaria; and the President's Initiative, which is $15 billion for five years. None of these programs is coordinated, so in a typical scenario countries are dealing with entertaining these different donor agencies that come with different requirements instead of dealing with the problem they have at hand.
Most of the programs that deal with HIV/AIDS or with health systems are not evidence-based. It is almost a cookie-cutter approach, where donor agencies impose and countries accept that the funding should go to A, B, C, despite the fact that maybe B is not as important in Country A as it is in Country B.
The weakening of the health systems and the neglect of health systems for a very long time would make it very difficult for scaling up treatment. We have over 62 million people in the world who are living with HIV/AIDS today. The only way we can keep them alive is by scaling up treatment. In order to scale up treatment you need a functioning health system, which most of these developing countries do not have. HIV/AIDS has become a chronic disease because of the availability of drugs, but this has a number of consequences. One, you won't be able to reach these people to treat them on time. On the other hand, there are the treatable diseases which will not get a chance to get access to health systems because the health system is inundated with the current epidemic. And there is the shortage of human resources especially in healthcare.
The number of people receiving treatment currently for HIV/AIDS is a litmus test for you to see how inefficient health systems are. In Sub-Saharan Africa the unmet need—and this is an underestimate—is about 72 percent. If you have this and if you have a nonfunctioning health system, then you can imagine the magnitude of the problem.
The World Health Organization last year declared it will be able to treat 3 million people by the end of December 2005. Currently this need will not be met for a number of reasons. First of all, there is a huge resource glut. Secondly, it's very difficult to ensure equitable access. You hear horror stories where families are sharing dosages of treatment, which has very bad consequences. You also hear stories where the needy people to whom the drug is meant to be do not get it, whereas the people who can afford to buy it are exploiting that. The most worrying thing about the rollout for treatment is that prevention is taking second place. The hardest hit country is Botswana, with 38.8 percent of its population affected by this epidemic. Still there are 62 percent of [Botswanans] who need to be protected from new infections, but because of the focus on treatment and because it is an easy fix, it's very simple for policymakers to talk about treatment than to talk about sex, about behavior, about condoms, about injecting drug use. As a result, people are moving their attention toward treatment and prevention is taking second place, which should be worrisome to all of us.
Looking beyond 2005, we must accept the fact that HIV/AIDS is a problem which will stay with us for generations. If we find a drug tomorrow and if we find a vaccine tomorrow, we still have 62 million people to deal with. That is not something that is in the face of policymakers in either the north or the south, who look at this epidemic only in a three- to five-year horizon. The most important point is coordination. Let me give you a very simple example. The amount of resources that are needed to mitigate this epidemic globally is between $10 billion and $12 billion per year. The best year we have had is this year, where the amount of money received globally is about $6 billion. However, if you go to a number of countries you will see that the money is not being spent. There are a number of reasons for this, but the major one is lack of coordination. We pull countries in 10 different places by 10 different demands from 10 different donors and they don't have the capacity or the time to deal with the issue. They spend more time catering to our needs.
This is a real example; this is Tanzania. This is what we do to them. There is the Bank, there is USAID, and there is the Global Fund. You can imagine a small local government or a small national program catering to all these in different ways 365 days of the year. When do they get to deal with the epidemic? When do they build health systems? That is the major challenge. Yes, we haven't had adequate resources to deal with this epidemic or to build health systems; however, it is impossible to even utilize existing resources if we are pulling countries in millions of directions.
This became a problem both to the receiving countries and to the donor agencies and governments and a new approach has come up and it's known as the 3-1's. What are the 3-1's? The first one is for all donor governments and donor agencies to work under one action framework that is being articulated by the country. In many cases many countries have strategy plans and we all claim now that we follow the strategy plans. It's not true. We go and impose our own rules and regulations and the strategy plan is just a plan, a piece of paper which is sitting somewhere. What we are trying to do with the 3-1's is to adhere to one strategy plan [that] all of us would work under.
The second is one national authority. When we say one national authority we do not mean government dominance. We mean a broad-based, multi-sectoral entity in-country, which is coordinated so that it will tell the external aid to either conform to one strategy or stay away. Mozambique is a wonderful example where, as I told you earlier, the World Bank, the Global Fund, and the President's Initiative are working. Each one of us has different requirements on Mozambique. Well, the government said, "This is our strategy; this is what we want you to do. If you don't want to do this, don't come to our country. We don't need your money." Guess what? All three of us said yes, and we are working together in Mozambique and we want each and every developing country to be like that.
The last and the most important one is having one monitoring and evaluation system. Currently, if you remember the slide I showed you earlier, each one of these require their own monitoring and evaluation system because they have a constituency to respond to. The President's Initiative has a requirement to go back to Congress and say we have done A, B, C, D with the money you gave us, and they go with their own sets of indicators. The World Bank has a board to respond to. We have our own set of indicators and so on and so forth. The tragedy is most of these indicators are similar. If we sit together and say these are the requirements, the countries would do these for a number of reasons—the most important being to see for themselves that they are doing something to solve a problem. Then each one of us will get whatever we want to respond to our constituencies, and this is not happening currently. These are the 3-1's and this is what we are moving toward.
Currently we are at this side of the triangle where we merely exchange information. The World Bank will say, "Oh, we will be in Zambia next month," and if the Global Fund happens to be there or if [the President's Initiative] happens to be there, we'll be together. If not, then we go our own way. Where we want to be is at the end of this pyramid, where we will have comprehensive coordination, where we will not inundate countries with 10,000 missions and 5,000 indicators but we consolidate this together. If the 3-1's work on HIV/AIDS, it will change the way development has been done in most of these countries and we will see some results.
It takes all of us to change what needs to be changed and it can be changed. It is people who make it very difficult for countries to develop and for countries to respond. It's not done for malicious reasons. It's done because that is the way we have been doing development for years. So what do we do? Where do we go from here? As I said earlier, AIDS is an exceptional epidemic. We haven't seen anything like this before, and hopefully we won't see anything like it in the future. Because it is exceptional it requires exceptional activism, and this is where you come in.
This is the generation which should question the way we do development, the way we have been dealing with issues. That would help to make governments responsible. In countries where there are bad governments there are multiple problems. It is this generation that could change this and advocate the fact that unless we deal with this epidemic then there will be no development, because it is undermining everything we have done in development for the past many decades.
Developing countries need adequate financing and the money is there. You can imagine the money that we spend on wars. The tiniest and the poorest country has a huge budget for defense and a tiny budget for health. This has to change if the world is to become a better place to live. Debt sustainability, debt consolation needs to be changed from a slogan to something that is implementable, otherwise these poor countries are in a vicious cycle of poverty if they are not allowed to sustain their debt.
There are other cultural subsidies which happen in the north which are killing the production in developing countries. The world has talked about it for many years; we haven't had a solution yet, and this is where exceptional activism comes in. Unless these things are curtailed now there will be no development. Trade barriers are another issue which from time to time you see activist groups shouting about and it's not without a reason. It is because development cannot happen unless these trade barriers are removed.
There are drugs. HIV/AIDS is a very good example. There are very effective drugs, which if people have access to them they would have a chance to lead a normal life, but they are not accessible to 98 percent of the population that needs these drugs, and this has to change. If this doesn't change, then we won't get there. We need to come up with exceptional implementation mechanisms to use the resources that are on the ground currently, for two reasons. One, the diseases require us to act now and the resources are available. The second reason is there are skeptics who say developing countries cannot use money anyway, so let's move to whatever is sexier and a better reason currently. This is very dangerous. If the world abandons developing countries imagining that it is their fault and it's not our fault, then we will be in a worse position than we are now.
We should reverse the depletion of human and institutional capacity. It is poor developing countries that are training their workforce only for this workforce to end up in better places. The world needs to reconcile this. It is a human rights issue. You cannot prevent a nurse from Malawi going to London and practicing what she needs to practice. What you can do is to deal with the issues that make her go to London in the first place. Unless we deal with this, then we won't even be able to deal with the simplest epidemics, let alone HIV/AIDS.
Improved harmonization and coordination is something that I can't emphasize enough, because I see it in all countries. Last year alone the government of Malawi has entertained 500 missions on HIV/AIDS. When do people get to work? This needs to be dealt with. We need to look at HIV/AIDS and health systems and health problems in developing countries as a long-term political commitment, both from the north and the south. We need to stop governments from investing more money in killing one another and not saving lives or making children grow up. It is critical that we strengthen health systems in poor countries. That is where the basic problem is. If you don't strengthen health systems, you get sick children and on and on. Evidence-based strategy planning and programming is critical. Currently in many countries, as I said before, it's a cookie-cutter approach. Money is dumped on issues that are less important when more important problems do not have enough resources. Implementing the 3-1's, as I said before, would be a breakthrough in the way we do development in many of these countries.
Before I finish I would like to say a few words as to where you come in. You are the generation who will be able to translate the concept of global solidarity into action. Because you are in an institution such as this, because you care about the world and you're not boxed into looking in your surroundings you will be able to change this. You should be able to challenge policymakers, both in the north and in the south. You should challenge inequity. If something doesn't make sense to you, then it means it doesn't make sense to the poor child in Burkina Faso or in Nigeria or in Cambodia. You should question these things: Why is this happening? Are we using taxpayers' resources appropriately? In one way or another you contribute to all these things that are happening in the world. The reason why I'm here is for you to see the problems and to challenge you to make the world a better place to live for all of us. I thank you.
Questions and Answers
Q. I have two questions. They relate to the long-term impact of antiretroviral therapy. You had mentioned that a lot of the organizations, Global Fund, [the President's Initiative], perhaps the World Bank as well, have been in the mode of crisis planning. Right now the emphasis seems to be just to get drugs in people's mouths. The two questions I have concern the long-term effects of resistance to antiretroviral therapy and also to the impact on the actual spread of the epidemic. Regarding resistance, if we follow the [First World] example, we expect that over about three years resistance is going to emerge to most of the antiretroviral regimens. Is there a plan to manage that resistance, or are they just going to continue to spend money on rolling out drugs even when the population has developed widespread resistance? The second question is since nobody really knows what concentration of viral load is necessary to actually transmit AIDS and it's very difficult to conduct studies on whether people who are under antiretroviral therapy are still transmitting the disease, is there any initiative under way to try to understand whether ART is really slowing the spread of the epidemic or whether it doesn't have the wide-scale impact on slowing spread? Thank you.
Zewdie: Let me take one more.
Q. The question I had was in strengthening the health system by itself: What are the major initiatives that could be taken? Is it just educating the doctors and nurses and creating a more effective link between them to cooperate and to help them be more effective, or are we trying to implement a new system that is adapted in different places or is there a better example that we could take?
Zewdie: OK, thank you. The first one, where is the leverage? It can happen in two places. One is with the donor agencies and donor governments. If we are truly concerned about underdevelopment or mitigating the HIV/AIDS epidemic, then we should not put a lot of strings on the kind of aid that we give. That's one.
The second one comes from the country governments. I have run national programs. I come from Ethiopia; I'm an Ethiopian. When you are on the receiving end you very rarely say no, even when you know that what is imposed on you is something stupid. You end up saying, "Yes, sir. No, sir. Three bags full, sir." That is why we have very little to show for the 50, 60 years of development. It has to happen from the two ends, and this is where maybe I'm very naïve and maybe I'm very tired, because I've been working on this epidemic since 1984. I have a lot of hope on the 3-1's, because it is both donor governments and recipient governments who have seen the problem and who have said that unless we do this nothing is going to happen. The leverage point is both from the receiving end and the donor agencies.
Antiretroviral issue, the long-term effect of resistance. There are two things about resistance. The first one was there was skepticism, as you know, at the beginning of the advent of treatment, where the issue of resistance was taken as the major issue for not providing antiretroviral treatment in developing countries. Fortunately, we have broken that cycle and we have seen a number of studies in many places where adherence in developing countries is as good as or better than it is in the northern countries.
That is one set of problems which we have dealt with. What we have not dealt with and what is contentious, is the issue between the brand drugs and the generic drugs. Who is taking care of providing, coming up with the new generation of ARVs because resistance is inevitable? That is the deadlock the world is in today. On the one hand, we want cheap treatment to cover the population which I showed you earlier. On the other hand, we want innovation and science to happen so that we come up with new drugs. Is something being done? Yes. Is it done in a scale which is useful? No. That is where we are, and hopefully this will change as people understand the magnitude of this problem and the long-term effect instead of looking at it only as bringing drugs and putting it in the mouths of people. What are the consequences and what can we do to mitigate this?
It's the same thing for the spread of the epidemic and understanding. There are studies which show where infectivity happens from the day the person is infected and the person is put on antiretroviral therapy and on. It is difficult to tell people this is what is happening in this epidemic. You have to realize we are in a world where we didn't manage to effectively control malaria and we didn't manage to effectively use contraceptive pills. That is where the fundamental issue comes in, and unfortunately the answer is we do know a little bit, but it will be a long time—that's what I meant by evidence-based programming for example—before we use the results that are happening in research in institutions to impact and enforce programs.
Health systems, are we inventing a new thing? No. When we talk about strengthening health systems it's very simple. The first thing is the infrastructure. In many of the developing countries you don't find essential drugs, you don't find the basic elements of health systems. This needs to be built. The second one is training. It is both enhancing the knowledge of the health professionals that are already trained and also training more. I don't know, and my own institution is one of the culprits. We have been saying, for example, in Zambia more teachers die than are being trained, but I haven't seen a plan which says in order for Zambia to be able to have X number of teachers and X number of doctors and nurses, this is what Zambia should be doing. We haven't seen that. This is what I mean by the long-term planning.
These are the kinds of things that should happen, and it can be done. It can be done if instead of giving a nurse $10 to work in Malawi, donor institutions and donor governments subsidize salaries so we can keep these nurses and doctors in their countries. It's not only for want of money that people flee their countries. It is also lack of democracy. Nobody wants to live in a country where you are not safe or where your children are not safe. These are doable things which should happen, and that's where activism comes. The world should be standing up and putting a stop to this, and it can be done.
—Theresa Johnston
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2005 International Development Conference