While serving as U.N. ambassador from 2000 to 2001, Richard Holbrooke helped redefine AIDS as a worldwide security issue, going so far as to arrange a January 2000 Security Council session, the first such session on a health issue. He is now the president and CEO of the Global Business Coalition, which coordinates the efforts of more than 200 companies in the global fight against AIDS. Here, Holbrooke talks about AIDS' economic impact and explains why testing is the key to effectively preventing the spread of HIV. He commends Botswana's national "opt-out" testing policy and suggests that nations automatically give HIV tests to pregnant women, soldiers, people applying for a marriage license and people admitted to hospitals. "You will never catch up with the spread of AIDS no matter how much money, no matter how many antiretrovirals are put into the system, unless you stop its growth," he says. "And the only way to stop its growth is prevention. And the only way to get prevention going is through a very aggressive system of getting people to test to [learn] their status, to get counseling and treatment. Yet testing is still voluntary. Testing is the least mentioned subject." This is an edited transcript of an interview conducted on March 7, 2005.
- Some highlights from this interview
- Testing is the key to prevention
- Why people don't get tested
- Where will AIDS impact local economies?
- Why AIDS is a business problem
What was your first encounter with HIV/AIDS?
My first personal observation was in Cambodia in 1992 when I went there as a private citizen, and I saw the peacekeepers from the U.N. in Cambodia, and they were doing a good job. But at night I saw them wandering around the street drunk and going into whorehouses and so on and so forth, and I was quite upset about this. It was clear that they were spreading AIDS, and they were going to take AIDS back with them. So I wrote a letter to the head of the U.N. in Cambodia saying, "You've really got to do something about this," and I never got a reply. But it stuck with me, and then when I became ambassador to the U.N. seven years later, that was a seminal memory in my mind.
[Talk about the Security Council's session on HIV/AIDS.]
After a visit I made to Africa in 1999, where I went with my wife, [author and journalist] Kati Marton, to 10 countries, in all of which we worked with the AIDS people, I came up with the idea that we should hold a special session of the Security Council on HIV/AIDS. Now, as it turned out -- and I didn't realize this when I proposed it -- the Security Council had never, since its foundation in 1945, held a meeting on a health issue. So I was told by everyone, including my own staff, "You can't do this; it's not done; it's not in the U.N. charter." And I said, "But AIDS is a security issue, because it's destroying the security, the stability of countries."
We took it to an informal meeting of the Security Council in December of 1999, and we met with them. All the African countries wanted to do it; the British and the French supported us. Our main opposition came from the Russians, who didn't want to violate the standard rules of the Security Council, which is, "But you don't talk about internal issues" -- ironic because Russia has one of the three largest growing AIDS problems in the world, along with Ukraine and Estonia. The Russians were very uncomfortable with this. Finally the Russians yielded and said, "Well, [if] you insist, but we're not going to talk," as though they were punishing us. We couldn't have cared less.
All this led directly to the January 2000 Security Council special session, which we symbolically made the first U.N. Security Council session of the new millennium. Vice President Gore headed the U.S. delegation that day. The United States was in the presidency, and Al Gore did our nation proud by sitting in the seat as president of the Security Council and making a powerful speech, clearly and unambiguously identifying the AIDS problem as a security issue. And the world watched. It was one of the most exciting days we had in the U.N., and I think history shows that it helped redefine the issue.
[Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS)] Peter Piot said the days he spent with you in the Security Council changed his life and rededicated him. Can you tell us about that?
Well, I didn't know Peter Piot very well until the Security Council session, but he was excited by it. He realized that the world was going to pay more attention. We were breaking the issue out of the field of health specialists and into the international consciousness as a security issue. Peter told me later that it was the best day of his first four years as head of the UNAIDS.
Back [up] a minute to your trip in Africa. Do you remember any particular moments on that trip in December '99 that formed your belief about AIDS?
I didn't need the trip to Africa to know AIDS was a huge problem, but you have to see it on the ground firsthand in detail to understand all its dimensions. Watching kids sleep in the gutters in Lusaka, [Zambia], knowing that they will become either prostitutes or rape victims, either getting or spreading the disease, because there's no shelter for them, and that the government is doing nothing about it, makes a powerful impression on you. We saw that firsthand.
My wife and I in Namibia, in Windhoek, the capital of Namibia, met with six or eight very brave women, all of whom were HIV positive who had formed an outreach group. But they came to the meeting in a van with the curtains drawn. The curtains were drawn in the room. It was clear that while they were telling us about their condition, they hadn't told their fellow workers or even their husbands about it, because they would be doubly victimized. If they admitted they were HIV positive, they'd be thrown out of the house. So while it was very brave of them to come forward, it was clear that the stigmatization problem was the most immense.
Finally, it was crystal clear that the South African government was in denial in a very dangerous way. I had a very dispiriting meeting with President Thabo Mbeki who just simply said, "This disease is caused by poverty." And I said: "Well, yes, Mr. President, it's spread by conditions of poverty, but that's not what causes the disease. We need to educate people; we need to try to get treatment to them." He was then in the mode of saying that HIV did not lead to AIDS. He has since backed off that a little bit, but his government's slowness to respond has resulted in an extraordinary number of deaths. The proof of that is that the elite of South Africa, when they get sick, use the very drugs which the government is objecting to. So it was a tragic situation in South Africa.
Do you have any insight into [Mbeki], why he has the view or had that view?
I think that there's no excuse for the position that the South African government took, but its friends and supporters, which include me, think the future of South Africa is critically important to all of us as a successful multiracial, multi-ethnic state. South Africa's friends said that this came partly out of the African National Congress' background as an organization that was always skeptical of outside Western influences, because they hadn't gotten much support from the West during apartheid. That may be true, but it's not good enough.
It may be true that the ANC's feeling that it didn't get enough support led to it being skeptical of Western points of view, but this is a medical and technical and scientific issue, and it shouldn't be reduced to political correctness or symbolism. We're talking about the life and deaths of hundreds and hundreds of thousands of South Africans, and the government owes the people better than the people got from the Mbeki government during that period. To attack people for being racists when they're trying to help doesn't do any good either. Now I think that period is gone to some extent. …
Now, you've also said that [in January of 2000] when you proposed AIDS as an international security issue, a global economic issue, that hard-liners mocked and people left. Can you describe that response?
Well, I remember that weekend on Meet the Press, one of the leading members of the United States Senate criticized it, laughing at it. I was privately told by many people that national security should not be confused with humanitarian issues. I said: "Look at the facts; it's not simply a humanitarian issue. If a country loses so many of its resources in fighting a disease which takes down a third of its population, it's going to be destabilized, so it is a security issue."
Anyway, that was years ago. That issue is over. Everyone now accepts our definition of AIDS as a security issue -- it's self-evident. Anyway, everyone in Africa does, except that I don't know about South Asia. I think the Indian government is still having trouble coming to terms with it. And the Russians, Ukrainians, Estonians, countries which have the fastest growth rate of AIDS in the world, are certainly behind the curve in recognizing the danger to themselves.
What's the cost of that ignorance or that denial?
If a country denies it has AIDS, that country will inevitably become an even greater victim. Ukraine today has an infection rate some 30 times higher than China's, and they've not yet dealt with it adequately.
They have not put into place the programs of testing, treatment, counseling that are required, and prevention.
So you've seen this pattern of denial over and over again. What are the mechanics of that denial?
The male elites that run most countries are exceedingly uncomfortable with the subject of AIDS because it's a sexually transmitted disease. The legacy of the voluntary testing approach, which was a fantastic mistake and grew out of the Angels in America period [the period during mid-1980s depicted in the Tony Kushner play] and the Reagan administration, is still with us. If you don't test people, it doesn't matter what else you do, the disease will continue to spread. ...
You will never catch up with the spread of AIDS no matter how much money, no matter how many antiretrovirals are put into the system, unless you stop its growth. And the only way to stop its growth is prevention. And the only way to get prevention going is through a very aggressive system of getting people to test to [learn] their status, to get counseling and treatment. Yet testing is still voluntary. Testing is the least mentioned subject.
Are you calling for a universal testing?
I'm not calling for universal and mandatory testing because that is not possible in almost any country in the world today, although it is true that certain countries like the United States and Great Britain have widespread testing for government service, for insurance policies, for military troops.
But right now there should be vast categories of people who are automatically tested who aren't. Let's start with marriages. People are tested in many places, including parts of the U.S., for syphilis when they get married. Why aren't they tested for HIV/AIDS? In Uganda, with its famous ABC program [abstain, be faithful, use condoms], the B is for "Be faithful." But you don't know when you come into the marriage if the other person in it is HIV positive, because if they haven't been tested, they could have been carrying the disease for seven or eight years without knowing. If you look at the spread of AIDS in Uganda, you'll find that a good chunk of the married, monogamous marriages still spread AIDS. One person comes into a monogamous marriage infected, doesn't know it, infects the other; the child is infected.
Or number two, when a person is admitted to a hospital, they should be tested immediately for HIV/AIDS. Instead, they're often treated for tuberculosis and released without anyone checking whether the tuberculosis is the opportunistic disease and the underlying cause of his AIDS.
Finally, when a women is pregnant in a hospital, she should automatically [be given an HIV test], because a single pill given at the right time to mother and child can cut the AIDS transmission rate by 50 percent. So I would start with these three areas: marriages, hospital admissions, pregnancies.
Also military troops. United Nations peacekeepers are going all over the world spreading AIDS even while they're trying to bring peace. What a supreme irony. We passed the first Security Council resolution on this in the year 2000, but the administration and the U.N. have failed to implement it adequately. ...
What is your opinion of the ABC strategy, particularly the [portion about] condoms and their use in societies where women don't have the power to negotiate that?
If we're going to stop the spread of HIV/AIDS, we're going to have to find more ways to empower women. Strategies to get their husbands or, if they're prostitutes, their clients to use condoms are very difficult. Microbicides are the most promising thing there, because the woman can protect herself, not force the man to use a condom, which is very difficult to do. …
If you can devise a device, microbicides, that allows the women to protect herself instead of trying to persuade the man to use a condom, what conceivable reason would there be for not developing it and making it easily available to women? … The hard stuff is to stop the spread of AIDS, and you use every device you have. An effective microbicide would have a major immediate effect in stopping the spread, as would more testing.
Let me ask you about PEPFAR [the President's Emergency Plan for AIDS Relief]. Were you surprised at President Bush's announcement of $15 billion?
I was very pleased that President Bush announced that he would make AIDS a high priority for a very specific reason. When a conservative administration adopted a policy like that, working closely with religious groups on the right wing, they ended close to 20 years of the most awful politicization of this problem. In effect, by embracing ABC, the administration said to their own conservatives, "We're going to agree to condoms," and to the liberals, "You've got to agree to abstinence." There's nothing wrong with that, because both condoms and abstinence are important components of a strategy. Nobody would want 13-year-old girls to have sex, which really amounts to rape by your neighbors or your uncles coming back from the mines, so what's wrong with trying teach abstinence strategies?
But also, the opposition to condoms was extremely ill informed. I still encounter opposition to condoms. When I give speeches, very often somebody gets up in the audience says, "How can you support the distribution of condoms?," that they spread AIDS. And I say, "What are you, crazy?" And they say, "Well, condoms encourage promiscuity, and promiscuity spreads AIDS." Well, it's that kind of thinking that spread HIV/AIDS and many other diseases. It's a ridiculous position.
[Can you explain the 3 by 5 initiative and tell us what you think about it?]
The United Nations and the WHO [World Health Organization] set a goal of getting 3 million people on antiretrovirals by the end of 2005. They did this without the slightest idea of whether it was possible or how much it would cost, or what the goal was.
Now, I'm very much in favor of putting as many people on antiretrovirals as possible. It's very important. But in the absence of a comprehensive war on AIDS that attacks prevention, that emphasizes testing, these numbers don't hold up. First of all, they're not going to get 3 million people on antiretrovirals by the end of 2005, so why did they set themselves a goal which was unachievable?
Secondly, if in fact 12,000 to 15,000 people are being infected per day all over the world, which is the U.N. and WHO's own figure, you can do the math yourself. That means a minimum of 4.1 million people are being infected every year. So what we've got here is a tortoise and a hare in which the tortoise will never catch the hare -- the hare is the spread of AIDS; the tortoise is the slow-moving treatment programs. We have to attack HIV/AIDS as we've attacked every other infection disease in the last century and a half. We have to attack it as it spreads, before it spreads, until we can develop a vaccine. And a vaccine is 10 years away.
What's the maximalist approach to AIDS?
We are never going to stop the spread of HIV/AIDS until testing is widespread, until at a minimum people getting married, people entering hospitals and pregnant women are required to have testing. This is not a violation of their human rights, as some people have said. It is a protection of other people's human rights, because when you're getting married it affects your spouse. When you're pregnant it affects the unborn child. And when you enter a hospital and you have tuberculosis, they should test you for the underlying cause, because it could well be AIDS.
Also people in the military, people who travel, it's not a violation of rights to test people. They've been tested for other diseases throughout recent history. People getting married are tested for syphilis in many places. Why aren't they tested for AIDS? If you don't do testing, you're never going to stop its spread.
The reason testing has not gotten the emphasis it should of lies in the Angels in America period, in the wars in San Francisco and New York between the Reagan administration and the gay community. At that time, the Reagan administration and many of its right-wing acolytes said this was God's punishment to homosexuals, and it created a backlash, and so testing became a confidential matter in the States because of the stigma. We moved past that in the States. ... But the legacy of the voluntary testing program went on all over the world.
Now, let's be realistic about this. If you say something's voluntary, it isn't going to happen very much. There's one country in the world that has changed its policies on testing, and that's Botswana. They've moved to the opt-out system, by which they mean you're going to get tested unless you sign a piece of paper saying I don't want to. So you can still avoid testing. Immediately testing jumped from under 10 percent to over 90 percent, and the rate of increase of AIDS has gone down commensurably. The Botswana model, the opt-out model, is essential to adopt elsewhere. So people can still avoid it if they want to, but the pressure is on for testing.
What is the Global Fund [To Fight AIDS, Tuberculosis and Malaria], and what do you think about it?
The Global Fund was a very good idea proposed by [U.N.] Secretary-General Kofi Annan to raise billions of dollars for the effort, and it was the right thing to do. Now, no international fund can ever work unless the United States supplies around 20 percent to 25 percent of the funds, because we have to lead the world, not just because [we're] the world's richest nation, but because of our leveraging effect. That's why President Bush's initiative, in his January of 2003 State of the Union speech, was so historically important.
[Samaritan's Purse President] Franklin Graham criticizes the Global Fund. He says that the money will be wasted, as has been the case with other U.N. programs [and that U.S. money] would have been better spent through PEPFAR, the American contribution. What's your reaction to that?
Let's be clear on what the Global Fund is and is not. It is not an operating agency; it is a collection agency for money which then is disbursed and spent in individual countries. In theory it's a good idea. Where it's run into trouble is because in each country, it has to go through an individual Country Coordinating Mechanism [CCM]. In the first several years of the Global Fund, those Country Coordinating Mechanisms in many countries were, to put it gently, constipated. ...
There was a lot of politics in these Country Coordinating Mechanisms, jealousies between ministries and NGOs [non-governmental organizations]. There were too many people sitting on these committees. The very mechanism the Global Fund had created to accelerate the money turned out to be a bottleneck, and it had to be revised. Nonetheless, the Global Fund is a very valuable idea, and it has collected a great deal of money, and it is making a real difference, and it should not be abandoned. It should be improved.
Originally businesses did not think AIDS was their problem, but it is. First of all, if they operate in a highly affected area, they're going to be affected. They're going to have to hire three workers for two jobs. That's true in South Africa and Botswana; it's going to be true elsewhere. Big companies, like Coca-Cola, which is the largest employer in Africa, realized this early. Under the leadership of [former] CEO Doug Daft and present CEO Neville Isdell, it had a very visionary program where Coca-Cola were paying 90 percent of all the hospital costs for its employees, but it took them a while to get there. ...
The Anglo American mining company, with 100,000 mining workers in South Africa, had to deal with it in an even more dramatic way, and they've finally gotten around to it. Brian Brink, their chief medical officer, is an exceptionally talented person, and played a big role in this area. Other companies should just support the effort because it's generally good for business.
Finally there's this thing called corporate social responsibility, this amorphous concept that great companies should do something for the common good.
So the Global Business Coalition, which I began in 2001, was almost nonexistent with a dozen or so members. We're now up to 190 members, and we're growing. We're a worldwide organization with a British chairman [Mark Moody-Stuart]. I'm the president and CEO, and we have a vice chairman in Paris, Bertrand Collomb of Lafarge, and in Johannesburg Cyril Ramaphosa. We have offices in Paris and Johannesburg. We're going to open in Kiev and I think probably in China and India.
What is corporate social responsibility, and what does it have to do with AIDS?
There are really two different kinds of companies that we're trying to attract to the war. [The first is] companies that work in heavily affected areas and have a direct financial bottom line here: Coca-Cola, Unilever, DaimlerChrysler, Anglo American mining corporation, Ford, Volkswagen. These are companies that really are employing people in heavily affected areas and have a lot to contribute by educating their workers, giving out free condoms, providing free treatment, which Coca-Cola, Anglo American and others are moving towards as rapidly as possible after a slow start.
The second group of companies are the companies that aren't on the ground in the area in any significant way but have a larger responsibility to the social environment they work in. Examples of that are American Express, which is a very strong member of the National Basketball Association, which sends great players like Yao Ming and Magic Johnson and its Basketball Without Borders program to Africa to work on the problem; Citicorp; Goldman Sachs; Lehman Brothers. These are all examples of financial institutions which are heavily involved in the fight, even though they don't have many people on the ground.
How will AIDS affect the global economy?
The greatest tragedy to me about HIV/AIDS is that we are now required by the horrific danger it poses to societies to spend billions of dollars -- and we have no choice -- simply to prevent something, when those millions of dollars could have been and should have been spent on education, on roads and on overall health care for areas which were already heavily effected by malaria, tuberculosis ... and other endemic diseases. This is a tragedy, but we have no choice.
I believe that while AIDS is a problem in China, it's not going to have a material economic impact in China. It will definitely have an economic impact in Ukraine and Estonia without any question if it isn't checked very fast. And in India it will have a localized impact in those states like West Bengal, Calcutta, where it's well over 1 percent already. But it is true that with these huge population bases, it will have less of an impact in China and India than elsewhere. But anywhere it hits, once it takes off, it is devastating.
Now, one more thing which must always be understood by everyone who says, "Well, AIDS is a problem, but so is malaria or tuberculosis or some other disease, or even dysentery for children": It must always be understood why AIDS is a uniquely dangerous disease. ... In many parts of Africa, when you talk to somebody about AIDS, they say, "Why should I worry about AIDS when all around me people are dying of malaria, or children under 5 are dying of dysentery?" Fair point. The answer is because AIDS uniquely is incubating in a person for seven to nine years, and during that period it's being spread, and it's got to be stopped, and the only way to really stop it is with education, testing and aggressive follow-up for people who test positive.
That leads me back to a question I was going to ask earlier about Africa. You said people have two responses to Africa. One is that we can never do enough, and [then] there's this other group of people who at a cocktail party will say to you, "[If in] Africa they all die of AIDS, so what?"
After they've had a few drinks.
Explain that. ...
Many people say Africa is hopeless. Some people, especially after they had a drink or two, start saying, "Well, you know, it's overpopulated; this is the solution." They're completely wrong. It destroys the social and political, economic infrastructure of a country when a disease runs rampant, particularly this one, because of that long incubation period. So the idea that it's some form of Malthusian triage is complete nonsense.
Does Africa matter to the rest of the world? Obviously it does, not just as a humanitarian issue, [but] because it's an economic and political and strategic issue as well. The instability in Africa, which already exists for other reasons and will increase because of AIDS in countries that are hit hard, is a calamity the rest of the world can't ignore. Countries of great potential like South Africa and Botswana are being decimated by it, and they need to turn it around. Only they can do it. They'll need outside help, but the leadership must come from within.
[What is the lesson of AIDS?]
There's a possibility that we're entering into an age where new diseases are beginning to break out, like avian flu, SARS, Legionnaires' disease; that the old diseases like smallpox, pneumonia are under control, but there's always some new disease. If that's true -- and a lot of friends of mine in the field think it is true -- the first lesson is you've got to move really fast. The second lesson is you have to get away from mythology, stigmatization and all these other things that created such a slow, slow reaction to AIDS.
But we have to also recognize one thing about AIDS. There's a unique quality about it, and the unique quality is twofold: First, it's spread sexually, not entirely but primarily, and therefore it's very stigmatized; and secondly, it incubates in the body for so many years undetected. Those two factors make HIV/AIDS the most single serious threat, from a health point of view, in human history.
How important was it that [former Sen.] Jesse Helms [R-N.C.] and Franklin Graham got onboard the war or got engaged in the battle?
From the 1980s until 2002, 2003, the war against AIDS was severely hamstrung by its politicization with the right wing, and particularly Christian conservatives saying it was somehow the Almighty's punishment of the homosexual community, and the gay community fighting back by saying that testing had to be voluntary in fighting the stigma.
When Sen. Helms, [Tennessee] Sen. [Bill] Frist and Rev. Franklin Graham and others began to realize, based on their experience -- and Sen. Frist being a doctor was very important -- that this was not an appropriate response, and that they had to do something to break through, it made a big difference.
Sen. Helms' famous articles in 2002 saying he was wrong on AIDS and proposing a large funding effort, which he did with [Massachusetts] Sen. John Kerry, it was a very important moment, and it preceded President Bush's speech. I don't think President Bush could have made that speech without the support of people like Rev. Graham.
I work closely with Rev. Graham on this. He in fact gives the invocation each year at our annual dinner for the Global Business Coalition. The first year he did this here in New York, 2002, people were really upset in the audience: What is Rev. Graham doing here? Why is he preaching to us? But I don't apologize for a second. I talked to President Clinton about it beforehand, since he was the main speaker that year, and President Clinton said: "You're absolutely right to bring in the Rev. Graham. We have to depoliticize this issue. We have to create a bipartisan front." So Franklin Graham and Bill Clinton sat next to each other at the dinner, and they both spoke. And each year, in Washington and Berlin last year, and New York two years ago, Rev. Graham has always been there as part of it, and that's what you have to do to create a bipartisan effort.
It doesn't trouble you that they make a distinction between innocent victims and culpable victims?
I have many differences with those points of view. But we are in a war, and in a war you find your allies, and you work out your disagreements. I don't want to sit around having arguments while people are dying, when we can work together and work out our disagreements as we go along. And I believe that's what [Global AIDS Coordinator] Randy Tobias is trying to do as President Bush's ambassador.
I like to work with Randall Tobias because he is a no-bullshit problem solver out of the business community who understands that you have to solve problems now and have your philosophical and theological discussions separate. I don't like to sit around having theological arguments while people are dying. Let's work on the problem and simultaneously have the debate. …