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Speech: Remarks at XVI International AIDS Conference
August 15, 2006
Toronto, Canada
Thank you very much. Thank you. I'm very fine, thank you for asking.
Thank you very much. Thank you for the warm welcome. Thank you, Helene
Gayle. Thank you, Stephen Lewis.
I owe a great deal to Helene Gayle for her dedication to the Centers
of Disease Control. She was a valued member of my administration. She
was great at the Gates Foundation and at CARE, and she has been great
as President of the International AIDS Society.
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I always love the sharing the stage with Stephen Lewis, though he is a hard
act to follow. I thank him for a lifetime of public service. He was Canada's
ambassador to the United Nations. An important leader at UNICEF before he took
on his current role and, I must say, all over the world, whenever people grow
lax in this fight, Stephen's passion, his demand and his no-nonsense approach
always wake the rest of us up and put people back to work. The world is in your
debt and the people at this conference are in your debt. Thank you, Stephen.
I had a great time here yesterday in my conversation
with Bill Gates, and I think that maybe the most important thing I can do
today is to simply thank all of you who are devoting your lives to this fight.
You feel the plight of others, and find freedom in their release. I urge you
to continue to do this, and I hope that this week, we will all have learned
a lot from one another, the researchers, the fundraisers, the advocates, the
health care professionals, the volunteers, the people living with HIV and AIDS.
There was a time when we needed these meetings to call the world's attention
to the problem of AIDS. Today we need them to learn from each other. To leave
smarter, as well as more dedicated. Four years ago, when Nelson Mandela and
I closed the conference
in Barcelona, the world was radically different. Today I want mostly to
talk about the future, but it's worth taking a moment to realize how much has
changed in those four years.
Four years ago, there were 6 million in the developing world in desperate need
of treatment to stay alive. Outside of Brazil, fewer than 70,000 were getting
the medicines they needed. All of China, all of India, all of Southeast Asia,
all of the Caribbean, Eastern Europe and Central Asia, infection rates were
rapidly increasing.
Today, more than 1.3 million people are receiving treatment. We didn't make
it to 3 million in 2005, but soon we will and go beyond. Last year, many nations
achieved a drop in infections among young people. Southeast Asia has seen steady
declines in overall prevalence. China, once in a state of denial, deserves all
of our respect for turning on a dime and acknowledging the problem and approaching
it systematically. Over 20 countries are providing ARVs to 50-percent or more
of their populations. Some states in India have achieved declining prevalence
rates. And next year, I believe Rwanda can achieve universal access to treatment,
as children and people in rural areas begin to receive the care and services
they deserve.
Of course, there is a long, long way to go, but there is some good news too,
and we should not forget it. When I made a commitment as a private citizen leaving
the White House to help countries scale up their care and treatment efforts,
I actually had no idea where to begin. I just had a reunion with Prime Minister
Denzil Douglas of St. Kitts and Nevis, who asked me in Barcelona four years
ago to help him, and he said, "We don't have a denial problem, we have
a money problem and an organization and resource problem." I had done a
lot of work in the Caribbean when I was president, and I said, "Well, Denzil,
what do you want me to do about it?" He said, "I want you to fix it."
I said, "Okay." I didn't have a clue what I was agreeing to. I had
a total of 12 people working in my foundation in Harlem. It was all we could
do to answer the mail, but I knew that something had to be done. I began by
calling my old friend, Ira Magaziner, who worked with me on health care and
electronic commerce in the White House. I asked him what we could do to have
the biggest impact in the shortest amount of time. Whatever progress we had
made in the last four years is a result of his efforts and those who have come
to our aid, who have worked with us all over the world, both as paid employees
and partners, and as volunteers. They now number about 500.
We knew in the beginning something had to be done about the prohibitive costs
of medicine and tests. Four years ago, first-line generics cost about $500 a
person a year. So we set out to organize a drug market to shift it from a high-margin,
low-volume, uncertain-payment process to a low-margin, high-volume, certain-payment
process. We worked with the generic drug companies, and with donor nations beginning
with Canada and Ireland. Eventually, including Norway, Sweden, and in the Caribbean,
the United Kingdom and France, and the Asia Pacific region, now Australia, to
guarantee that prompt payment. We were able to lower the price to just under
$140 a person a year in the beginning.
We then worked to reduce the cost of CD4 and viral load testing, and equipment,
and reduced the price by over 80 percent. We have achieved further reductions
of over 50 percent on second-line drugs, although we don't have enough of them
in the agreement yet, and on pediatric formulations as well as rapid tests,
which can now be had for between 50 cents and 65 cents apiece.
Today the adult formulations cost about just less than $120 a person a year.
Children's medicines have gone from $600 to less than $200. Almost 60 nations
are now accessing these prices, and about 30-percent of the people on ARVs.
More than 400,000 of them are getting the medicine under these agreements. I
am very grateful to the more than 500 staff and volunteers in 25 countries who
are helping governments at their request to scale up AIDS care and treatment
programs.
This is just part of the good work being done by the Global Fund, by the United
States effort and by other countries’ bilateral programs, the Gates Foundation,
UNICEF, and so many others involved in all aspects in the fight against HIV
and AIDS. And it's worth taking some time to say not everything has gone wrong.
Despite the progress, however, there is still too much bad news and too many
blind alleys, too many unanswered questions. Since Barcelona, millions more
have died. Millions more have been affected. The vaccine still seems a decade
away. We see that prevention efforts are sporadic and some have produced mixed
results. We know that Stephen must still persist, unbelievably, after all this
time in too many places, and also unbelievably, 90-percent of those who are
infected do not know their status. It is no wonder that millions of more people
are infected every year.
I have people all the time coming to me in the States and say, "Aren't
you fighting a losing battle? Think of all these irresponsible people out there
infecting millions more people every year." And I'd say, "You're only
irresponsible if you know you are positive and you infect someone." Ninety-percent
of the people do not know their status. That's what I would say to them.
Actually, to you, I would modify it and say, "If you know you are in a
high-risk group, and you take a chance, you are also being irresponsible, even
if you don't know your status." But I have to be more categorical when
I'm out there trying to sell the rest of the world and build more allies.
Here's the bottom line. We know how to overcome AIDS. We know how to prevent
millions of needless deaths. We know it can be done with urgent sustained and
strategic action. First there must be enough money, of course, to fund effective
prevention efforts and to treat all those who need it, and to continue the important
research work on vaccines, microbicides, and all the other areas that need the
research.
I am profoundly grateful for all Bill and Melinda Gates have done through their
foundations, but especially for their recent half-a-billion commitment to the
Global Fund over the next five years. There is no better mechanism to channel
the funds needed to beat AIDS, and I say that as someone who respects the bilateral
programs, and without the bilateral programs in the beginning, I could not have
even begun my work. But no bilateral program, no matter how impactful, can take
the place of the Global Fund, and we have to make sure that it's properly funded.
I also think it's important that every one of us, before he leaves, thanks Dr.
Richard Fitchum [misspelled?] for his leadership to the Fund overall these years.
He's done a tremendous job on helping those helping those affected with AIDS,
TB and malaria. Countless people are alive today because of Richard's work,
and I wish him well in the future.
Second point I want to make is while more money is necessary, it is nowhere
near sufficient. It is our moral obligation to ensure that the enormous contributions
already made and those that will be made are used most efficiently. Every single
wasted dollar puts a life at risk. A few days ago, my foundation unveiled our
consortium for strategic operation research here in Toronto. It's an initiative
designed to help ensure that this huge investment of resources results in the
highest quality care, most efficiently delivered for as many HIV infected people
as possible. We want to apply the same planning methods that Fortune 500 companies
use to manage their operations, so that we can make the most effective use of
what will always be scarce resources until the number of people who are HIV
positive begins to drop dramatically. Using simple open-source computer models,
we'll be able to help governments save more lives with the same human and financial
resources.
The third thing we have to do is to intensify and re-double [misspelled?] effective
prevention. Last year, as I said, there were over four million new infections,
90-percent of the people not knowing their status. Alarming trends can be observed
all over the world. Now, for the last four years, I have focused mostly on expanding
access to care and treatment, with a view toward obtaining universal access
by the end of the decade. We will not succeed through scaled-up care and treatment
alone. Prevention efforts also have to be scaled up simultaneously. They will
not be successful, however, without the treatment options, so we can't do one
without the other. Just as no government organization can run the fight against
AIDS alone, prevention care and treatment are intertwined, and we cannot realize
universal treatment - I'll say it again - let alone stop AIDS, unless we also
see prevention as a part of a mutually dependent strategy.
I salute the efforts of UNAIDS, Civil Society, the treatment activists, the
private sector and all those committed to unite for prevention. Prevention can
work. We've seen it in prevalence reduction in South India, Cambodia, and Thailand.
We've seen several African countries with reductions of over 25-percent in young
people between the ages of 15 and 24.
Last month, I visited a microbicide test site in Durbin with Bill and Melinda
Gates, and was heartened to talk to trial participants, and learned the exciting
gains being made there. Our foundation is now partnering with the International
Partnership for Microbicides to help accelerate their work by guaranteeing proper
care and treatment for all the participants in the test trials, just as PEPFAR
is doing for the Gates Foundation in Durbin.
Empowering women to protect themselves seems so elemental, and yet when I hear
people pontificating about AIDS, and acting as if we can do everything through
abstinence, I think they don't know what most women are up against in too many
parts of the world today.
I also want to say a word about the recent promising study with regard to male
circumcision and its role in reducing the risk of HIV transmission. I know the
scientific jury is still out, and I know a couple of more studies are being
done, but should this be shown to be effective, we will have another means to
prevent the spread of the disease and to save lives. And we will have another
job to do, a big job - first in selling it, and secondly in providing safe,
effective comprehensive and rapid ways of doing it.
So I think it's important that as we leave here, we all be prepared for a green
light that could have a staggering impact on the male population, but will be,
frankly, a lot of trouble to get done. And we have to be prepared to do it.
We keep going around at people all over the world and telling them not to be
queasy about the hard things. If the research shows that this saves lives, we'll
just have to get after it, and deal with it, deal with the cultural inhibitions
and deal with all the other problems. We can't leave here without at least a
commitment to watching it.
I also think we have to not give up on the search for a vaccine. We should continue
to support the International AIDS Vaccine Institute, and all the government
scientist foundations and private citizens who are engaged in this search. I
know it seems like a long way away. When I launched that Millennium Vaccine
Initiative in my last year as president, we thought we could get there within
a decade. Now, we still think we are a decade away. The more we rely on the
biochemistry, the more frustrating it is, but it's hard to imagine a world totally
without AIDS, without a vaccine, if not a cure. So I thank the people that are
not too tired to continue to this work, and not too frustrated who believe there
has to be an answer here and are determined to find it.
Since I waded into the circumcision thicket, I want to say a little bit more
about testing. I just don't believe we can reverse this if we keep having more
people infected every year than we are increasing the number of people on medication.
If we keep having 90-percent of the people not knowing their status, I don't
see how we can do that. The rapid tests now available through my foundation
cost 50 to 65 cents. We have to give it twice to make sure. Results are available
in 15 minutes or so. This epidemic is 100-percent preventable. More people have
to agree to be tested.
I will never forget when my wife and I lost our first friend to AIDS in the
1980s. I watched him, early in the ’80s. I sat in the hospital room as
he was dying with those scabrous marks all over his face, feeling totally helpless.
When all the activists said, "Well, we can't push testing too hard, because
after all, there is no medicines, people are going to be discriminated against
and all that they are going to find out that they are going to die sooner or
later." I felt enormous sympathy. We still need to fight discrimination
and we still need to ensure that treatment options are available to anyone,
and even encouraged to be tested.
But there is a different equation today. That's why I think these universal
voluntary opt out testing programs in countries particularly that have significant
infection rates are terribly important.
Stephen mentioned the government of Lesotho. The WHO has worked there, as well
as our foundation on this Know Your Status program. Other countries are doing
similar things. If it's done right, Lesotho's infection rate will plummet and
more people will live. I was there last month and met with several young people
for whom this Know Your Status campaign was a source of pride. I met with a
couple of people who were working with us, a man, a former boxing coach who
was literally on his deathbed, his CD4 count was so low and is now 750. And
he goes around, obviously still very fit-looking, and tells people that they
have nothing to be ashamed of, they should know their status.
Most remarkably, I met a young woman who works as one of our expert patients
for the foundation, who became infected after she was raped. There are still
societies in this world that are if you are raped, somehow it's your fault and
you are supposed to go around and be ashamed for the rest of your life, and
hide, and not tell people things. This woman was unbelievable. Instead of giving
in to her shame and allowing someone else's oppression to define her life down
forever, she goes out with pride in her communities and says, "Look, what
can I make happen that's good, as a result of this terrible shape that befell
me? Will I spend the rest of my life feeling sorry for myself? I don't think
so." So she goes around saying, "Look, this happened to me. This could
happen to you. This could happen to anybody. We don't need to be ashamed of
this. I'm HIV-positive. I am not ashamed. I am going to get the medicine. My
government tells me I cannot be discriminated against. We have to deal with
this. You need to be tested so you don't wind up positive too."
It's unbelievable. This young woman will be more good, than I ever could, by
standing there and being proud to be a living, breathing human being entitled
to dignity, equal respect and asking people to do the responsible thing for
themselves and all the other people in their community and their nation.
Let me just say another word about stigma. We all know it's really not a problem
for people with HIV. It's a problem for everybody else. Stigma is about a twisted
place in the mind of the stigmatizer. A place of fear, normally, and ignorance.
Last year, the Chinese government, which as I said, it really got after this.
Even asked our foundation to work within the Ministry of Health, jokingly said
to me, "Oh well, I know you think we're a non-democratic country and we're
an authoritarian country, but believe it or not, we can't order people to change
their minds and hearts. So would you please take a tour of rural capitals, and
do media events where people see you playing on the floor with children who
are HIV-positive, and having dinner, having meetings, having conversations with
younger people who are HIV-positive, showing people who have AIDS who are going
to live because they’ve gotten medicine, both children and young adults?
Would you please do that? We think it will help to fight the stigma."
So I did, and it was really an unusual example of foundation and government
cooperation. I felt like I had been sent on a tour of the Chinese countryside
by the government just because people would be surprised if I didn't keel over
after having embraced all these people with HIV and AIDS.
But we can't be too arrogant, patronizing or disdainful about this. All of us
are afraid of the unknown, of what we are previously experienced, and if you
can come to these meetings forever and a day, it may be impossible to imagine,
but until the tainted blood transfusion equipment began to ravage Chinese villages,
there were millions and tens of millions of people in rural China who did not
have a clue what AIDS was. It could have been something from another planet.
So we have to continue this work. This is something that the political leaders
don't have to do alone, and may not even be able to do best. I want to say a
special word of thanks to Richard Gere to all the work he's done in India getting
movie stars, TV personalities, people in the media, people that are looked up
to, and identified with into this business of fighting stigma.
The last time I was in India, a family, a small family tried to commit family
suicide in a rural village because they were being discriminated against by
all their neighbors who still believe that they could all become HIV positive
if they were breathed on by any of these people walking down the street. So
thank you, Richard Gere and thank you, all of you, who are fighting this. We
cannot forget this.
I'm getting to that. These are the same people that were here yesterday. Let
me say one other thing about the status of women that we talked about before.
Stephen Lewis and others, Bill and Melinda Gates talked about addressing gender
and equality. I just want to say this as a philanthropist. I also work on development
issues, climate change issues, other issues in developing countries, and if
the gender equality cause can first surface through the fight against HIV and
AIDS, we will see that all these other problems will be more easily addressed.
We can't really adequately develop poor countries and their economies. We can't
really address any of these other challenges unless we convince people that
they cannot keep throwing away the potential of half of their citizens. We know
the population stabilizes. We know the economy grows. We know the new challenges
are embraced. So there is a way that fighting AIDS can help developing countries
to do all these other things.
The fourth thing we have to do is to keep reaching the hard-to-reach populations.
The children, the people in rural areas and border lines. In Bangkok two years
ago, that was one of the most stunning messages that I had sitting half a world
away. Couple of years ago, only 10,000 children outside of Brazil and Thailand
were getting pediatric antiretrovirals, while over 500,000 a year were dying.
But a little over a year ago, our foundation worked to reduce the price of pediatric
medicine, as I said, by about two-thirds, from about $600 to a little under
$200. We then donated drugs, clinical and programmatic support to double the
number of treatment on in a year.
That sounds so good, until you say we went from 10,000 to 20,000, it sounds
pathetic. It shows you how much young children were worse off, even then the
rest of the population. But by the first quarter of 2007, we think we'll be
supporting another 60,000 children. Now thanks to the leadership of the governments
of France, Norway, Chile, Brazil, the U.K. recently announced their support.
There will be others. UNITAID will be able to provide treatment for all children
who need it. This is important and we have to do it.
We're also making an effort to develop models that can be replicated to provide
health care in rural areas. In July. I was in Rwanda with our partner, my friend,
Dr. Paul Farmer, who is here, and who has done such an astonishing job in developing
health care in Haiti. In Rwanda, the Clinton Foundation and Partners in Health
are working as we are in Lesotho and Malawi and elsewhere to expand the availability
of medical services, not just for HIV and AIDS, but for other things as well.
Rwinkwavu, in eastern Rwanda, was devastated in the genocide. We're partnered
there in a hospital that's just been reopened, making astonishing strides in
establishing good quality care with limited human resources, dealing not only
with a handful of doctors and nurses, but a remarkable number of health care
support workers trained by Paul Farmer's people according the model that has
worked so well in Haiti, and I thank him for that.
In India, we are working to train 150,000 doctors who still provide amazing
services in rural India, but they know very little about AIDS.
In Ethiopia, thanks to Dr. Ted Resses’ [misspelled?] visionary leadership,
and he’s here today, and I thank him for his leadership as a minister
of health Twenty-five-thousand health care workers will soon be deployed across
the nation, where over 80-percent of the people live in rural areas.
Programs like this are absolutely key to our ultimate success. As Bill Gates
said yesterday, "There are lots of places where the absence of health care
infrastructure is more important than the money to buy the medicine." Keeping
people from getting their antiretrovirals. This effort to treat people in remote
rural areas requires both the support of national governments and those doing
the real work. Our ability to empower them by providing systems, infrastructure,
human and financial resources, drugs and tests, will I believe, determine that
course of this epidemic over the next five years.
I really want to say one other thing about this. I'm in Canada. I'm an American.
My daughter was born in a hospital in Little Rock, Arkansas, with the aid of
a nurse from Guyana. I came to love her very much, and unlike most health care
workers who leave their native land, she actually went home, so that when I
went to Guyana as president, Hillary and I were able to have a reunion with
her. All over the world, there are people whose health is better in wealthy
countries because of people who left their own countries to go where they could
earn more money with their great gifts.
My foundation is working hard to reverse this trend in our partner countries
by making sure they have the skilled workers they need to do the job. Kenya,
for example, unlike much of the rest of Africa, is a country with a surplus
of trained nurses. Get this, but for reasons to convoluted to address here,
you'd be here ’til tomorrow morning, the government, believe it or not,
cannot lawfully hire them at this point. So we're hiring them, and training
them to treat the AIDS patients. Hundreds already. They are working through
the National Healthcare Systems in rural areas, and by the end of the year we
will be supporting about 1,000 of them, all of whom will be transitioned onto
the national payroll within the next two years.
As a result, tens of thousands of people in rural Kenya will now have access
to AIDS care and treatment, who otherwise would have died, and hundreds and
hundreds of nurses who otherwise would have come to North America, to Europe
or someplace else, will stay at home and serve their people.
In Ethiopia, through our partnership with the Yale University School of Public
Health and Management, we've recruited 23 experienced hospital administrators
to be based in 13 Ethiopian hospitals for the next year to work with doctors
and administrators not only to help improve the operations of the hospitals,
but to develop standards and systems which can then be applied to more than
100 others over the next three to five years.
These efforts are beginning to bear fruit. In Malawi and other countries in
which I work, with the support of the British government and other partners,
we've just had the first year in recent memory when there was virtually no out-migration
of health care professionals. I think most people want to stay at home, but
they need to be able to make a living to do it, and we need to help them.
There are really practical things that the NGOs can do. For example, my foundation
has a policy of not hiring people away from governments and community based
organizations. We can't expect nations to maintain or increase capacity if the
best people are constantly being lured away by higher salaries. So instead,
what we try to do is attract good people from the private sector and people
from the African and Asia [inaudible], now living in the U.S. and Europe. We
are able to do this and still keep our overhead costs at 2-percent. It has not
been unduly expensive and it has been very good policy. I think it is important
that all of us in the NGO community try to set a good example on this important
issue.
These are the things that I think we have to do as we leave here. Money, money
spent more effectively, prevention, more testing, not compulsory but voluntary
and empowering, lifting the status of women, continuing the search for medical
answers through microbicides and vaccines, reaching the hard to reach population,
developing the infrastructure and getting treatment out to every single soul
who needs it.
In just a few days, I will be 60 years old. I hate it, but it's true. For most
of my working life, I was the youngest person doing whatever I was doing, then
one day I woke up and I was the oldest person in every room. Now that I have
more days behind me than ahead of me, I try to wake up with a discipline of
gratitude every day. I realize that I came from, by American standards, very
humble circumstances when I was born in my home state at the end of World War
II. Our per capita income was barely half the national average, and I had a
totally improbable life, but I know I was not born in a log cabin that I built
myself. I had teachers, a coherent community, a decent health care system. I
knew that there would be some connection between the efforts I made in life
and the results that I achieved. The longer I live and the more I travel, the
more I realize that intelligence and effort and ability and dreams are evenly
distributed across all of humanity in every country across all races, and religions
and cultures.
What is not evenly distributed are the mechanisms to give life to all those
things. The opportunities, the investment, the systematic capacity that establishes
a link between a person's intelligence, ability, effort and dreams, and the
picture of life that emerges. There is no more tragic example of this then HIV
and AIDS, but there are many, many others. If we can turn the tide on this epidemic,
it will unleash a burst of energy and belief in human potential that I think
will spill over into TB, malaria, into economic development, and into meeting
the challenges of climate change, and to anything else you can possibly imagine.
Now, this is a huge conference. There is one person in this conference for every
1,500 HIV-positive people in the world. That's a pretty high ratio. Think of
it. If we pool our efforts, can each of us account for 1,500 lives? I think
we can, if we're organized, persistent and passionate, I think we can. We can
break the back of AIDS and lift the hopes of billions of people. Obligations
and the opportunity to fulfill them are gifts from God. The awful burden of
AIDS is quite a gift. How fortunate we are that we live in a time when we have
the opportunity to meet our obligation, to give many more people back their
lives, and their dreams.
Thank you very much.
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