sexta-feira, janeiro 20, 2006

Acesso universal em 2010?!

Gregg Gonsalves, GHMC

Last week, UNAIDS and the UK's Department for International Development sponsored the first of three meetings of the Global Steering Committee of the Universal Access initiative, the "sequel" to WHO's 3x5 program, which sought to get 3 million people on antiretroviral treatment by the end of last year. The Universal Access initiative extends the promise of 3x5 targeting "universal" access to treatment, care and prevention, by 2010. (Well, we all should get busy if we're going to have heaven on earth in just four years' time!).

I attended the first meeting as a member of the committee with my community colleagues, Rodrigo Pascal from Chile, Susan Chong from Malaysia, Anandi Yuvaraj from India, Elizabeth Mataka from Zambia, Lillian Moreko from Uganda and Bob Vitillo from the faith-based organization, Caritas International (Raminta Stuikyte from Lithuania was unable to be there).

Let's say things did not start off well. The first night of the meeting began with a "working" dinner at which everyone in the group of about 30 people was to quickly say a few words about what they expected from the process. Much to my complete horror, the first up at the microphone was none other than garlic-toting, HIV-denying, treatment-hating, TAC-bashing, South African Health Minister Manto Tshabalala-Msimang, who proceeded to ramble on for about 15 minutes about how she was a nice person, but misunderstood, the glories of the South African AIDS response and the need to ensure that the response to AIDS is integrated into larger concerns around human development. I think the idea was to have Manto there to constructively engage the South African government, but it did another thing in my mind: it revealed the deep problems with UNAIDS' calls for the Universal Access initiative to be a "country-led" approach. This "country-led" approach was leading millions of people straight into the grave and no one, except a few of the community members in attendance, challenged a word she said that evening. I am not challenging the need to have an approach to scale-up that is driven by local needs and led by national goverments and civil society-I am challenging an approach that appeases the worst governments and gives them center stage and allows them to seize the agenda. For me, this was the Marie Antoinette moment of the AIDS epidemic-"let them eat garlic, African potato, olive oil and beetroot" instead of cake.

The second day of the meeting split up the participants into five groups: one on predictable and sustainable financing and macroeconomic constraints chaired by Manto and Peter Heller from the International Monetary Fund (please shoot me now I kept thinking, when these two problematic figures are leading this discussion!); the next on human resources capacity and health and social service system constraints chaired by the head of the Nigerian AIDS program, Babatunde Osotimehin and Sigrun Mogedal from Norway's development agency (who is an old-style health systems' advocate and sees scaling up ART as a potential threat to health systems development); the next on affordable commodities and low-cost technologies chaired by the French AIDS Ambassador Michel Kazatchkine and Minghui Ren, Deputy Director-General, China Ministry of Health (but with Merck's Jeff Sturchio among the small working group); the next on human rights, stigma and discrimination and gender equity chaired by Rodrigo Pascal and Edward Greene, Assistant Secretary-General of Caricom, the Caribbean Community; and finally, the last group on Targets and Milestones chaired by Anandi Yurvaraj and former US Ambassador to Uganda Jimmy Kolker from the US' PEPFAR program. Community members were split up between some of the groups, but Anandi, Susan and I were in the targets and milestones group, since it seems important to have targets and milestones for even small tasks, let alone something as grand as “universal access by 2010.”

Anandi, Susan and I were joined in the targets and milestones discussion by Jim Kim, the former head of the WHO’s HIV/AIDS Department (the incoming director, Kevin de Cock was not at the meeting nor was any senior WHO official), Debrework Zewdie from the World Bank, Paul DeLay from UNAIDS, and someone from the South African Ministry of Health. After a long and unconvincing discussion about why “global” targets such as the 3x5 goal were useful only one time in history, the conversation largely focused on the idea of selecting 5-10 key indicators on treatment, care and prevention, for which countries would develop interim 2008 and final 2010 targets—these targets would be developed by the end of 2006 and published and then aggregated for a set of “country-led” global targets. Let’s see how this idea fares in meetings #2 and #3 of the Global Steering Committee.

These working group discussions were short-only a few hours long and then everyone convened back into the larger group for report-backs. Sadly, much of what was said descended into vagueness. In the first working group on sustainable and predictable financing, there was no rallying cry for supporting the Global Fund nor any critique of the IMF and World Bank’s macroeconomic policies; in the group on affordable commodities, no one talked about the crisis around access to second-line therapies such as the new formulation of Kaletra and tenofovir or pediatric formulations or the failure of the current intellectual property framework under TRIPS to provide for any real way for countries to manufacture generic equivalents of pricey ARVs.

So, where are we? Well, we’re in deep shit.

It’s clear that the momentum for scaling-up access to treatment is dissipating. The Universal Access initiative wants to be all things to all people and will end up being nothing for millions infected with HIV/AIDS or at risk of contracting the virus. I’ve made my critique of the initiative in other emails, but the main fact is that without targets for treatment, care and prevention, with milestones, deadlines and consequences for inadequate performance, incentives for achievement, with detailed operational plans from the district level on up in each country, nothing is going to happen. The sad fact is that governments and the UN agencies that do their bidding are happy to let us die, most leaders like Manto have power and privilege that insulate them from the fate that falls upon the rest of their countrymen and women, most UN staff have cushy sinecures which they are unlikely to jeopardize by taking a risk, taking a stand for us.

All of this makes our work together more important than ever. We have to raise our voices locally, with our governments and demand access to treatment and prevention services, we have to hold our leaders accountable. We have to keep the pressure on the UN and donor governments. I’ve said this before, but we’ve got to treat this as a political campaign and fight to win. Right now, lots of us working internationally have tried to be technicians talking about policies on things from health systems, to diagnostics, to TB when we are in no position to get them adopted, or taken on the role of capacity-building again usually on technical subjects, doing trainings and workshops for our peers, when being in more meetings is the last thing we need to be doing. Lots of my work is just like this and my criticism starts with me. Why with all the wonderful people we work with can’t we create a powerful political movement to fight for our right to treatment? Part of our fate lies in ourselves and not in any external factors. In Nairobi, at a meeting of PWLHAs from around the world, we talked about radicalizing the AIDS movement, about conscientização, a critical awakening needed to free us from the NGO-ization, the domestication of our work. We need to have this conversation now, together, and move quickly. It means taking risks and perhaps taking directions that make us uncomfortable, giving up the security of the way we work now, the way we do business.

The UNAIDS/DFID meeting on universal access last week was a wake-up call for me. Access to AIDS treatment, in fact, even the larger fight against the epidemic, is in danger of being swallowed up and treated as just another intractable social ill. They’ve said AIDS needs to be de-exceptionalized, treated like other diseases, we’ve got to stop acting like there is a crisis, like there is something special about this virus that grips our bodies, and quietly jog like pigs to the market.

Well, not this pig. I won’t do it. Not ever.

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