Interview with Stephen Lewis, by Sheila Marunga Coutinho

Submitted by Amber Phalen (amber) about 1 year ago

Sheila Marunga Coutinho interviews Steve Lewis on Thursday 7th August 2008 during the XVII International AIDS Conference held in Mexico.

Sheila: Good afternoon Mr.  Lewis, it’s a great pleasure to be with you. As one of my role models I just want to express how happy I am to have this chance to talk to you. Let us begin from the basics; you are so passionate about HIV/AIDS and in particular women and children in HIV/AIDS. What exactly brought this about?
Mr. Lewis: Two thing; first when I was the Deputy at UNICEF from 1995 -99 every time we thought we were making progressive on things like infant mortality rate in Africa, we realized that the AIDS virus was turning us back. AIDS was always sabotaging what we hoped to achieve. So towards the end of my time at UNICEF, I could have stayed on much longer, but I felt I wanted to do more on HIV/AIDS because I saw the carnage that was occurring amongst children. I left UNICEF and I became Peter Piot’s advisor, and then unexpectedly Koffi Annan asked me to be the HIV/AIDS special envoy role. When I started doing the envoy role in 2001 and travelled through the high prevalence countries between 2002- 05, I realized that the greatest price being paid in the pandemic was the women and I could not get over it. Now I am a feminist, I live in a feminist family; I love it and believe in the feminist analysis of social issues. It was heartbreaking to see how the male hegemony in the world was resulting in terrible disproportionate vulnerability amongst women and the absence of gender equality and sexual tolerance. I therefore felt I was spending my days watching people die and the people I was watching die were women.

Sheila: So after that revelation, what do you think are some of the things that we can proudly say we have taken a few steps to rectify the status quo?
Mr. Lewis: I think there is very little to be proud about there, I really do. I don’t think we have made much progress at all as far as the status of women is concerned. I think that at the moment, there is a very real possibility that the United Nations will create a new international agency for women. My organization, AIDS Free World, has been fighting for that strongly especially in the last two years. If that happens, I think progress can be measured because there will be a vital and energetic force in the field which will support the women in what they want to do. But all the other interventions, you know we are way behind on the prevention of vertical transmission, it is an outrage, an unconscionable outrage that in the year 2008 only 34% of the HIV positive women in Africa have access to any form of antiretroviral treatment. Frankly the treatment tends to be purely single dose nevirapine rather than full HARRT, so we are still losing tens of thousands of children every year unnecessarily, not to mention the inadequate treatment of their mothers. The treatment of women generally is terribly slow. We have a couple of million of people in treatment in Africa but there is another six million who need treatment today. The majority of them women and we do not know if the roll out of treatment will be fast enough to save their lives. The situation for women continues to be appalling. On every front, the young girls do not have the correct knowledge and facts of HIV. This in itself is excruciating because of what it might mean. We are failing in prevention, we are failing in treatment, the women are doing all the work in the community, they are doing all the home based care. They do it uncompensated, unacknowledged, we call it voluntary labour, its really conscripted labour. Women carry the societies. I have to say to you that the one thing that didn’t change very much between June of 2001, when I started on the envoy role, and today is the situation of women, we simply have not taken it serious enough.
Sheila: In your opinion, do you think what is those advocating for the family being the centre for provision of support to vulnerable people is the right way to go? If so why has it taken us so long to reach this conclusion?
Mr. Lewis: Everything has taken us so long to reach obvious conclusions. We are 26 years into the pandemic and we are still taking forever to reach conclusions. It is as though people do not understand that there are people out there who are dying on a daily basis while we tinker intellectually with what we should do. Of course the family should be the centerpiece of the response particularly for orphaned children. However the family has been so decimated by the virus in so many high prevalence countries. Remember there are seven countries that have prevalence rates of over 15 % and that’s called hyperpandemic prevalence and that means that there is no one in those countries who has not been affected or infected. Therefore the family should be the centre. When it is hard to find the resources to support all the needs of the family and to find mechanisms to get out medication out fast enough to the family several consequences are seen even when there is one person ill in the family.  The women, who do most of the agricultural production, spend more time caring for the sick and with time everything grinds down. It is a terribly difficult situation of course. I am filled with optimism for one reason and one reason only, because at the grassroots of Africa there is tremendous resilience and strength. The sophistication and intelligence and generosity of spirit in Africa, largely amongst the women of Africa at the community level, is what will one day defeat the pandemic and turn things back. If I had to rely on the international community or the United Nations I would be waiting forever.
Sheila: Unfortunately the gap between the international community and the United Nations and the people who you think are going to be the real agents of change is quite wide. What interventions can be put to narrow that gap so that we can really achieve your vision of hope?
Mr. Lewis: That gap will narrow slowly I admit to you. It will not narrow overnight. I think that the incumbent who has just taken up his post as the head of the Global fund. Michel Kazatchkine, brings hope in that regard because he is very direct to a community level role for the Global Fund which it has not had before now. I think the emergence of a new executive director of UNAIDS with a recognition to have to get down to community level is hopeful. I think that the Clinton foundation is beginning to understand the community level is the answer. So as all these things occur and governments realize that as you work with the Global Fund the country coordinating mechanism must be a reflection of the grass roots. This is all very promising I am not going to pretend that it is going to happen tomorrow but it will happen.
Sheila: On the global arena, what are some of the things that we can do really to catalyze the implementation of the interventions you talked about that will bring about lasting change?
Mr. Lewis: We know what to do, this is not a mystery. At this conference, it has been kind of interesting, there been a lot of talk about prevention. I want to tell you that none of it is new, none of it! It is a little more intellectual, it is a little more analytic, it is a little more academic, it is a little more thoughtful, but it is not new. It is the old pattern of forever publishing papers when you already know what to do and you should damn well do it and get down to the ground and do it. And this tendency to procrastinate is unconscionable, what is really required therefore is not so much how do you scale up, because we know how to scale up but nobody is doing it. The question is where is the leadership? What has been lacking in all of this and what no one fully understand is that with the right leadership you can move mountains. When Jim Grant was the executive director of UNICEF we moved mountains. We had the child revival and growth revolution and whether it was oral rehydration therapy or whether it was immunization by needles we moved mountains because you had the leadership. Leadership has been lacking at agency level and governmental level. PEPFAR may sound great but has several limitations like over emphasis on abstinence before marriage to the exclusion of every thing else and the excluding sexual and reproductive health from family planning from work on HIV and AIDS. Even the money invested through PEPFAR, though it sounds large, is not large compared to what the United States should be giving relative to the Global World National Product.
Sheila: To be fair to the Americans they have put far more money in the HIV/AIDS response then many countries with comparatively vast amounts of money in their national coffers. For instance, how do we bring countries with large oil reserves to also contribute mitigating the impact of HIV/AIDS globally?
Mr. Lewis: The truth is that the Middle Eastern countries with large oil reserves have never before played a very major role in the official development assistance at the international level.
Sheila: I know the plight of the girl child in the developing world is extremely dear to your heart and often at times you link that to education. Can you comment about the interrelatedness between girl child, education and the HIV/AIDS?
Mr. Lewis: They interrelate because increase in comprehensive knowledge will defend young girls against HIV. If you go back to the UNGASS Declaration of Commitment in 2001, it says by 2010, 95% of young girls and boys, between ages 15 and 24 would have comprehensive HIV/AIDS knowledge. At the moment 38% of young women and girls have comprehensive knowledge. So clearly we are failing because the education system is not adequately responding. You know, as I know that there are almost no jurisdictions in Africa which provide free and universal secondary education. We are getting more and more free and universal primary education but in the age range of adolescents and the teenagers, who must understand the meaning of AIDS and how to protect themselves we are not getting the large numbers accessing education. This is because they can not afford secondary school fees. So one of the objectives must be, and it is one the objectives of my organization, AIDS Free World, to advocated and lobby for free and universal secondary education. At the moment, the last figure that I saw about Africa when you take the whole continent is roughly 16-20% of those enrolled are girls. Now how do you expect to have knowledge against HIV when you have such a small portion of those who are eligible?
Sheila: Well I come from Uganda, as you already know, and we have free primary education and we started free secondary education. We have a high enrollment rates, but retention of girls is low even at primary education.
Mr. Lewis: Retention is low because families are poor. Girls are taken out of school to help families. If there is HIV in the family, girls are first to be withdrawn from the education system. They are taken out to look after sick people. There are close to 2 million orphans in Uganda, higher than almost any other country. It puts tremendous strain on grandmothers looking after the orphaned kids, strain on food, strain on health and obviously you have got to provide uniforms and text books. There are still a lot of hidden costs still even if you do not have to pay the school fees. What Uganda has done, in terms of free primary education is exemplary, but you know and I know that there are parts of Uganda, especially in the North, where there is not widespread enrollment and there is a lot of dropout because of the two decade conflict by Lord’s Resistance Army and its destabilization on the provision of the basic social services.
Sheila: A lot has been said about strengthening systems in particular health systems, and nothing has been said about strengthening the other systems. For instance one, of the things that is causing the high dropout rate is that we do not have the systems to monitor and make sure that the children are in school and take people to book when children do not go to school. When we compare with the developed world, I know for a fact, that when a child is not going to school somehow the social worker will come knocking on your door.
Mr. Lewis: Oh yes, there are follow-ups, but you know it is a difference between an economy that has wealth and can employ people to do those jobs, and an economy which is relatively impoverished. I mean as well as Uganda has done, the number of people living under a dollar a day is probably close I’m sure it is between 30 -50 % of the population
Sheila:    Officially it has reduced to 39%.
Mr. Lewis: 39%, so putting that in place is very difficult when you have a very poor economy and you cannot monitor and chronicle the people who are not there let alone sending someone after them. Its one thing to register the data and it’s another thing to make sure they get into school.
Sheila: Now that brings me to another thing, when we do get funding for support obviously it is limited and it cannot be stretched to take care of all the poor people living below the poverty line. Therefore choices have to be made, hard choices. What selection criteria does your organization use to identify beneficiaries?
Mr. Lewis: Now the criteria for selection are to have the G8 countries fulfill their promises. The problem lies in the refusal of the rich world, to raise their official development assistance to 0.7% of Gross National Product, which they have always promised to do. We have only a fraction of it, we’re about 0.3% average across all of the G8 countries. Jeffrey Sachs points out that if we reach 0.7% we would have enough money to meet most of the basic needs in the developing countries. These countries would be enabled to reach many of the developmental goals and do away with the tremendous scourge of hunger, child poverty in particular and poverty generally through the society. I am not asking for a new neocolonialism, I am asking only that Africa be given the resources it was promised, no more than that, and the refusal to honor the promises is what makes life so difficult in Africa.
Sheila: But in the meantime before the G8 come together, what criteria should we use to use the little resources?
Mr. Lewis: I can’t dictate the criteria. The normal criterion is to reinforce your social sectors first, to invest your money in health, education, nutrition, sanitation, all of these areas. The social sectors are where the investments pay off for getting rid of poverty. Young women who remain in school know better how to handle their families and deal with poverty than anyone else.
Sheila: What is your view on giving families cash transfers?
Mr. Lewis: That is what I was going to come to, then your next situation to eradicate poverty, once you’ve got all the social sectors in place, is to a social security safety net. We are learning cash transfers are tremendously useful as a tool to do that. I am not sure if cash transfers are enough, I’m not sure they adequate, I’m not sure whether governments have enough money to do offer them despite their percentages of Gross National Products are very tiny. However there are certainly different safety nets modalities that would be considered looked at as cash transfers. For instance social security apparatus, not just old age pension, but mothers’ allowances and welfare, are all different forms of the crash transfers that are possible. That pre conference Children Symposium meeting on children and AIDS in Mexico made the point that even the elimination of school fees is in effect a cash transfer so one has to look at innovative ways of doing this.
Sheila:     The cash transfers and all these other systems are many a time linked to some legal requirement of documents which we do not have in Africa
Mr. Lewis:    You know when I was at UNICEF one of my jobs was to get the Convention on the Rights of Children ratified. I travelled all over the world speaking to governments, urging them to ratify it. One of my closest colleagues was Marta Santos Pais who now heads UNICEF Innocenti Research Centre in Florence in Italy. Marta made the argument to me that what was most important about the convention was child registration to give children documents that would enable them provide the legal proof required to access many services both as children or adults. I said, “Come on Marta, what’s important is the health cause, the education clause, the disability clause and all the other things.”  She insisted that with no registration papers the children would be discriminated against. As you can see I was wrong and she was right and we are paying the price for it now.
Sheila: Mr. Lewis, I’d like to thank you very much for your time. 

Keywords: AIDS children HIV IAC 2008 Stephen Lewis vulnerable women

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