Keynote by Stephen Lewis, UN Special Envoy on HIV/AIDS in Africa, to the “Microbicides 2004” conference in London, March 2004.

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.

For me, while microbicides are not a salvation, they come as close to salvation as anything else I’ve heard about. I pray that everyone at this conference understands that the women of Africa and many other parts of the world are counting on you. It is impossible to overstate how vital is the discovery of a microbicide. If we were making progress on several other fronts, microbicides would pale. But we’re not making progress, or we are making progress in such painfully minute installments, that it feels as though we’re moving from paralysis to immobility. The resources of the international community should flow, torrentially, into the hands of the scientists and researchers and advocates and activists assembled here who fight the good fight, because in those hands lies life.

I admit: I have a proclivity for hyperbole. It’s a molecular disability, with one exception. This subject is the exception. I don’t know how to convey to you what’s happening out there. I move from country to country, from rural hinterland to rural hinterland, from project to project, and everywhere I go the lives of women are compromised. And it’s not changing. How do you get governments and international financial institutions and bilateral development donors to understand? It’s not changing. Three merciless years, and women face today exactly what they faced in yesteryear and yesteryear before that.

I travel and absorb incidents and moments that sear themselves into the mind. Some of the following anecdotes I’ve used before, but I cannot shake them.

I meet a grandmother of 73 in Alexandra Township in Johannesburg. She lost all five of her children between 2001 and 2003. She’s looking after four orphans, all of them HIV positive. Her life is in ruins. She stands for the legion of grandmothers on the continent who bury their children in a perverse reversal of the rhythm of life, and then, heroically, look after the grandchildren. How has it come to this?

I travel with Graça Machel to ground zero of the pandemic in Uganda, to visit a child headed household. … a young girl of 14, looking after two sisters of 12 and 10, and two brothers of 11 and 8. Graça and I sit on the floor of the hut; I have the two boys on my left and Graça has the three girls on her right. She shoos everyone out of the hut except for one translator. And then she turns to the two older girls and in a gentle voice asks: “Have you started to menstruate yet?” And shyly, oh so shyly, in whispered fragments, the little girls say yes. And then Graça asks a series of questions: Do you know what it means? Do you talk to your teacher about it? Do you talk to the other kids at school. Do you talk to the villagers? Does anyone ever give you any pads? And as I sat there listening, I realized that these girls were receiving the first act of mothering around an experience that must surely be one of the most important moments of a young girl’s life. And I thought to myself: this is what’s happening across the continent: the mothers and fathers are gone. The mothers especially are gone. The transfer of knowledge, love and care from one generation to the next is going. How has it come to this?

I stand outside a clinic in Lusaka, Zambia, where mothers have come for testing, and the possible use of nevirapine during birth. The mothers approach me: “Mr. Lewis, you have drugs in your country to keep your people alive, why can’t we have the drugs to keep ourselves alive”. I cannot tell you how often women have asked me that question. Their sense of collective dismay and vulnerability, their panic-stricken tremors at the prospect of leaving their children as orphans is palpable. I don’t know how to answer the question. How do you explain that we’re dealing with one of the ugliest chasms between the developing and developed world on the face of the planet. How did it come to this? How is it that we can’t seem to get the world to understand that if you want to reduce the deluge of orphans, with which deluge no country can cope, you keep the mothers alive. Treatment is one way. Microbicides are the preferred way.

Just ten days ago, with my colleague Anurita Bains, who is here at the conference, I traveled to Swaziland. On a Thursday afternoon, we trekked into the hinterland to visit a small community of women living with AIDS, looking after hordes of orphan children. They led us along a narrow footpath, for what seemed an eternity, into the surrounding brush, until we’d reached the home of a woman who lay dying. I’ve spent a lot of time in huts where women lie dying; I don’t know why this particular encounter had such a profound effect on me, but I haven’t been able to get the image out of my head. I guess I’ve never seen anyone quite so ill before, the face a mask of death; a young woman in her twenties --- they’re always in their twenties --- valiantly raising her head a few inches to acknowledge the visitors. You touch her hand; utter soothing words; she’s unaware. Sometimes I think I make such gestures more for my own benefit than for the person who’s so desperately ill. And around her were children, watching her die. That’s what children in Africa do: they don’t become orphans after their parents die; they become orphans while their parents are dying; and then they watch the death itself; and then they attend the funeral.

How has it come to this?

For myself, I’m filled with rage. I can barely contain it. I know it reduces my effectiveness, but there’s nothing I can do about it. The madness of what is happening, the fact that it is so completely unnecessary, the fact that we could subdue this pandemic if the world put its mind to it … all of that renders me almost incoherent with the roiling blood of anger. We must find a way to bring this nightmare to an end. Africans and the world will obviously work with every instrument at our collective command to reduce the heart-breaking decimation of individuals, families and communities. But the women, certainly the women of Africa need huge quotients of additional help, and that help lies, in significant extent, in the discovery of a microbicide.

I don’t have to tell anyone here --- God knows, I’m way out of my depth --- about the science and the trials and the timetable and the resources. I’ve read the materials, and as much as a layperson can grasp such things, I have grasped them. I ask only that you see microbicides, not merely as one of the great scientific pursuits of the age, but as a significant emancipation for women whose cultural and social and economic inheritance have put them so gravely at risk.

Never in human history have so many died for so little reason. You have a chance to alter the course of that history. Can there be any task more noble?

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For more information about the Microbicides Conference, please see: http://www.microbicides2004.org.uk