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2004-04-15 - 9:11 a.m.

I decided that Stephen Lewis' Speech obviously ought to replace anything else I have to say. This is the first half of it:

Speech at London Microbicides Conference

There is, I will admit, a touch of amiable irrationality in racing across the ocean for a half hour speech. I want to assure you that I don’t do it as a matter of course. But in this instance, it seemed to me that your kind invitation to address the Conference could not possibly be forfeited. I’m here because I think the work in which you’re collectively engaged … the discovery and availability of microbicides … is one of the great causes of this era, and I want to be a part of it. It is in this room that morality and science will join together.

I’ve been in the Envoy job for nearly three years. If there is one constant throughout that time, a large part of which has been spent traversing the African continent, it is the thus-far irreversible vulnerability of women. It goes without saying that the virus has targeted women with a raging and twisted Darwinian ferocity. It goes equally without saying that gender inequality is what sustains and nurtures the virus, ultimately causing women to be infected in ever greater disproportionate numbers.

And the numbers tell a story. It was the report issued by UNAIDS on the eve of the International AIDS Conference in Barcelona in 2002, that identified the startling percentages of infected women. And it was during a panel, at the same conference, when Carol Bellamy of UNICEF used a phrase --- for the first time in my hearing --- that was to become a repetitive mantra: “AIDS has a woman’s face”.

But the problem is that the phenomenon of women’s acute vulnerability did not happen overnight. It grew relentlessly over the twenty years of the pandemic. What should shock us all, what should stop us in our tracks, is how long it took to focus the world on what was happening. Why wasn’t the trend identified so much earlier? Why, when it emerged in cold statistical print did not the emergency alarm bells ring out in the narrative text which accompanied the numbers? Why has it taken to 2004 --- more than twenty years down the epidemiological road --- to put in place a Global Coalition on Women and AIDS? Why was it only in 2003 that a UN Task Force on the plight of women in Southern Africa was appointed to do substantive work? Why have we allowed a continuing pattern of sexual carnage among young women so grave as to lose an entire generation of women and girls?

Ponder this set of figures if you will: in 2003, Botswana did a new sentinel site study to establish HIV prevalence, male and female, amongst all age groups. In urban areas, for young women and girls, ages 15 to 19, the prevalence rate was 15.4%. For young men and boys of the same age, it was 1.2%. For young women between 20 and 24, the rate was 29.7%. For young men of that age it was 8.4%. For young women between the ages of 25 and 29, the rate was 54.1% (it boggles the mind); for young men of the same age, it was 29.7%.

Have I not addressed the fundamental question? The reason we have observed --- and still observe without taking decisive action --- this wanton attack on women is because it’s women. You know it and I know it. The African countries themselves, the major external powers, the influential bilateral donors, even my beloved United Nations … no one shouted from the rhetorical rooftops, no one called an international conference and said what in God’s name is going on, even though it felt in the 1990s that all we ever had time for were international conferences? It amounts to the ultimate vindication of the feminist analysis. When the rights of women are involved, the world goes into reverse.

For more than twenty years, the numbers of infected women grew exponentially, so that now virtually half the infections in the world are amongst women, and in Africa it stands at 58%, rising to 67% between the ages of 15 and 24. This is a cataclysm, plain and simple. We are depopulating parts of the continent of its women.

And while finally, after the doomsday clock has passed midnight, we’re starting to be engaged and agitated, very little is changing. Please believe me: on the ground, where women live and die, very little is changing. Everything takes so excruciatingly long when we’re responding to the needs and rights of women.

Between three and four years ago, I visited the well-known pre-natal health clinic in Kigali, Rwanda. I met with three women who had decided to take a course of nevirapine; they were excited and hopeful, but they asked a poignant question which haunts me to this day: they said “We’ll do anything to save our babies, but what about us?” Back then, more than four years after antiretrovirals were in widespread use in the west, we simply watched the mothers die.

Well, thanks to the Columbia School of Public Health, funded by several Foundations and USAID, and working with the Elizabeth Glazer Foundation, UNICEF and governments, the strategy of PMTCT PLUS (Prevention of Mother to Child Transmission Plus) has been carefully put into place in several countries, where the “Plus” represents treatment of the mothers and partners; indeed, of the entire family. But it’s a slow process, and though Columbia will roll it out as quickly as possible, it is necessarily incremental. In principle, the majority of such women will one day fall under the rubric of public antiretroviral treatment, through Ministries of Health, when it’s finally introduced in most countries. But there’s no clear guarantee of when that day will dawn, or that women will get the treatment to which they’re entitled. It’s entirely possible that the men will be at the front of the bus.

Everything proceeds at glacial speed for women, if it proceeds at all, in the face of this global health emergency.

And that’s what I want to drive home. We deplore the patterns of sexual violence against women, violence which transmits the virus, but all you have to do is read the remarkable monographs by Human Rights Watch to know that for all the earnest blather, the same malevolent patterns continue. We lament the use of rape as an instrument of war, passing the virus, one hideous assault upon another, but in Eastern Congo and Western Sudan, possibly the worst episodes of sexual cruelty and mutilation are taking place on a daily basis as anywhere in the world, and the world is raising barely a finger. We have the women victims of Rwanda, now suffering full-blown AIDS, to show the ending of that story. We talk ad nauseam of amending property rights and introducing laws on inheritance rights, but I’ve yet to see marked progress. We speak of empowering women, and paying women for unacknowledged and uncompensated work, and ushering in a cornucopia of income generating activities ... and in tiny pockets it’s happening, especially where an indigenous local women’s leadership is strong enough to take hold ... but for the most part, in Churchill’s phrase, it’s all “Jaw, Jaw, Jaw”.

For much of my adult life, I have felt that the struggle for gender equality is the toughest struggle of all, and never have I felt it more keenly than in the battle against HIV/AIDS. The women of Africa and beyond: they run the household, they grow the food, they assume virtually the entire burden of care, they look after the orphans, they do it all with an almost unimaginable stoicism, and as recompense for a life of almost supernatural hardship and devotion, they die agonizing deaths.

Undoubtedly --- and I must acknowledge this --- with the sudden growing awareness internationally of what the virus hath wrought, we will all make increasing efforts to rally to the side of women. It’s entirely possible that we will make more progress over the next five years than we have made in the past twenty. But I cannot emphasize strongly enough that the inertia and sexism which plague our response are incredibly, almost indelibly engrained, and in this desperate race against time we will continue to lose vast numbers of women. That is not to suggest for a moment that we shouldn’t make every conceivable effort to turn the tide; it is only to acknowledge the terrible reality of what we’re up against.

People say to me, Stephen what about the men? We have to work with the men. Of course we do. But please recognize that it’s going to take generations to change predatory male sexual behaviour, and the women of Africa don’t have generations. They’re dying today, now, day in and day out. Something dramatic has to happen which turns the talk of generations into mere moments in the passage of time.

And that, ladies and gentlemen, is where all of you come in. I’m not pretending that microbicides are a magic bullet. Microbicides aren’t a vaccine. Nor do I dispute the powerful point made by Geeta Rao Gupta at the opening of the conference, that we can neither forget nor diminish the structural cultural changes so urgently required. But when so many interventions have failed, when the landscape for women is so bleak, the prospect of a microbicide in five to ten years is positively intoxicating.

The idea that women will have a way of re-asserting control over their own sexuality, the idea that they will be able to defend their bodily health, the idea that women will have a course of prevention to follow which results in saving their lives, the idea that women may have a microbicide which prevents infection but allows for conception, the idea that women can use microbicides without bowing to male dictates --- indeed the idea that men will not even know the microbicide is in use … these are ideas whose time has come.

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