The death toll from HIV/Aids is continuing to rise despite medical advances, says Fr Michael Kelly
The World Aids Campaign has adopted accountability as the global theme for the 2006 World Aids Day, with the slogan "Stop Aids: Keep the Promises".
The world has committed itself to universal access to treatment, care and prevention by 2010 - but unless it keeps its promises it will not succeed in doing so. And the signs are that the problem is growing larger day by day.
The statistical update on the epidemic released 10 days ago shows that there were more cases of HIV in every region of the world in 2006 than in 2004. The total number of people living with HIV now stands at 39.5 million, an increase of 2.6 million on 2004. In western and central Europe, the figure is 740,000, up from 700,000 at the end of 2004.
Despite the more widespread availability of life-preserving anti-retroviral drugs, an estimated 2.9 million persons died in 2006, compared with 2.7 million in 2004.
The epidemic clearly forges ahead, outwitting best efforts to respond to it. The UN secretary general speaks of the global Aids response standing at a crossroads. Possibly this is so, but those working in the field see the epidemic confidently marching along its own predetermined road, with the response timidly and uncertainly following after.
The reasons are simple: massive concentration on responding immediately and directly to the virus, but much less attention to the social, cultural, and economic environments within which HIV transmission flourishes; responding to the epidemic primarily as a medical condition instead of as a multi-faceted development problem; making promises but not keeping them; and doing little to develop the human resources needed to design, implement and deepen the types of responses.
The virus - this strange entity that wreaks its destruction so quietly on the body's defence system - has mesmerised the world into exceptionalising HIV and Aids.
Resources have been dedicated to setting up sophisticated medical systems to respond to the medical impacts of the epidemic, even in situations where the simplest of medical services may not be available. In remote parts of the worst affected countries in southern Africa, for instance, a clinic may stock costly antiretroviral drugs but lack Panadol or other simple medications.
Similarly, the world has ring-fenced HIV with a whole battery of human rights and confidentiality restrictions that do not apply in the case of other life-threatening conditions. Doing so has contributed significantly to the stigma associated with HIV and Aids and in practical terms has made it difficult for the medical profession to confront the disease.
In exceptionalising HIV and Aids, the world has treated the epidemic as if it were an isolated event. But it is not. It is something that occurs within the total environment within which people live. And for the majority of people that environment is one of struggling economies, insecure food systems, and inadequate investment in water, sanitation, health care, and education. These set the scene for any infectious disease to flourish. Hence, when HIV came along in the 1970s, it found the terrain well prepared for its advent.
The disease quickly took hold and deepened its grip because policies dealt with its surface manifestations and did not try to excise the roots going deep down into a rich supportive soil of poverty, gender inequalities, and structural inequities within global society. Globalisation processes hastened its development while economic structural adjustment programmes undermined the health and education systems that could have been mustered to provide some of the social protection.
Even after more than a quarter of a century of experience, the global effort still focuses narrowly on managing the virus almost in isolation. Few of the global Aids resources go to improving food security, transforming the situation of women, promoting livelihoods, improving basic health services, or developing education.
In effect this means that there is insufficient focus on the long-term drivers of the epidemic. Instead, the bulk of resources goes to responding to the epidemic, for the provision of treatment and the mitigation of some of its worst impacts (on children, for instance); a small proportion goes to narrowly conceived prevention efforts that have had very limited success; and remarkably little goes to addressing the underlying factors that maintain the vigour of the epidemic.
Such an approach will not solve the global problem of the Aids epidemic. Rather it is a recipe for its long-term continuation.
The years of this millennium have been years of many promises, some kept and several broken. Those that have been kept, such as extending antiretroviral treatment in resource-poor settings, have seen deaths averted and lives saved - possibly up to 350,000 in 2005 alone. But there is a long sad history of promise after promise being consigned to the dust heap of what might have been. Those made most recently, at the June meeting of the UN General Assembly, ring hollow when they commit to some $20 billion by 2010 to combat HIV and Aids, yet fail to muster $7 billion for 2006.
Martin Luther King spoke of the founding fathers of the United States signing a promissory note to which every American was to fall heir. But her citizens of colour found that America had given them a dud cheque that came back marked "insufficient funds". So it occurs only too often in the world of Aids - commitments given, promises made, and promissory notes coming back from the world's wealthiest countries marked "insufficient funds".
The UN Secretary General said that while some countries reached key targets and milestones, set by the UN General Assembly, many countries failed to fulfil the specified pledges. It is heartening to note the better scenario emerging within Ireland. The Taoiseach has committed Ireland to reaching the UN target for spending 0.7 per cent of GNP on Official Development Assistance (ODA) in 2012. In line with that commitment, the Minister of Foreign Affairs stated two weeks ago that the 2007 ODA allocation would reach €813 million or 0.5 per cent of GNP. At least €100 million of this allocation will be spent combating HIV and other communicable diseases in developing countries. So far, Ireland is keeping its promises.
Ireland's recent White Paper on Aid is realistic in stressing the urgency of ensuring adequate staffing levels to plan, implement, monitor, audit and account for the increased ODA spending. More money is important. Increased capacity to use the additional resources efficiently, effectively and in an accountable manner is equally important. This is one aspect of ensuring the human resources needed for combating HIV and Aids.
But there is a strange anomaly. Countries that are badly HIV affected find their ability to manage the epidemic severely constrained because so many of their medical, paramedical, education, technical and other personnel have been attracted away to serve in more prosperous countries. It is reported, for instance, that over the past five years, Malawi has lost 53 per cent of its health administrators, 64 per cent of its nurses and 85 per cent of its physicians.
HIV undermines the immune system that should defend the body, but in a similar fashion this global pull appears to be undermining the ability of social systems, already hard hit by Aids-related illnesses and deaths, to defend the body politic. At the same time that the developed world pours in funds, costly drugs and even more costly personnel to assist poorer countries respond to the epidemic, it bleeds away the local personnel who can best lead the local response.
This is bizarre and accounts in considerable measure for the weakness of the Aids response in many places.
World Aids Day is an occasion for reflection on this and other anomalies in the global response. No matter what steps are taken, the epidemic will be with us for another quarter century or more. But its days will be lengthened if the vision does not extend beyond the virus to the environment in which the epidemic prospers, if promises are made and not kept, and if imaginative steps are not taken to develop and retain the local human resources needed for combating the epidemic.
• Father Michael Kelly, who comes from Ireland, is professor of education at the University of Zambia. He has worked extensively on Aids in Africa with the Department of Foreign Affairs, several UN bodies and the World Bank.
The first Irish Aid/Father Michael Kelly Lecture on HIV/Aids will be delivered this evening at the Royal Irish Academy in Dublin by Stephen Lewis, the UN Special Envoy for HIV/Aids in Africa