Speech delivered at the University of Pennsylvania's Summit on Global Issues in Women's Health
Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa, Philadelphia, USA, 26 April 2005

I well realize that this is a conference on women's global health, and everything I'm about to say will apply to that generic definition. But the more I thought of the subject matter, the more I want to use HIV/AIDS in Africa as a surrogate for every international issue of women's health, partly because it's what I know best; partly because it's an accurate reflection of reality.

I've been in the Envoy role for four years. Things are changing in an incremental, if painfully glacial way. It's now possible to feel merely catastrophic rather than apocalyptic. Initiatives on treatment, resources, training, capacity, infrastructure and prevention are underway. But one factor is largely impervious to change: the situation of women. On the ground, where it counts, where the wily words confront reality, the lives of women are as mercilessly desperate as they have always been in the last twenty plus years of the pandemic.

Just a few weeks ago, I was in Zambia, visiting a district well outside of Lusaka. We were taken to a rural village to see an "income generating project" run by a group of Women Living With AIDS. They were gathered under a large banner proclaiming their identity, some fifteen or twenty women, all living with the virus, all looking after orphans. They were standing proudly beside the income generating project ... a bountiful cabbage patch. After they had spoken volubly and eloquently about their needs and the needs of their children (as always, hunger led the litany), I asked about the cabbages. I assumed it supplemented their diet? Yes, they chorused. And you sell the surplus at market? An energetic nodding of heads. And I take it you make a profit? Yes again. What do you do with the profit? And this time there was an almost quizzical response as if to say what kind of ridiculous question is that ... surely you knew the answer before you asked: "We buy coffins of course; we never have enough coffins".

It's at moments like that when I feel the world has gone mad. That's no existential spasm on my part. I simply don't know how otherwise to characterize what we're doing to half of humankind.

I want to remind you that it took until the Bangkok AIDS conference in 2004 --- more than twenty years into the pandemic --- before the definitive report from UNAIDS disaggregated the statistics and commented, extensively, upon the devastating vulnerability of women. The phrase "AIDS has a woman's face" actually gained currency at the AIDS conference in Barcelona two years earlier, in 2002, and even then it was years late. Perhaps we should stop using it now as though it has a revelatory dimension. The women of Africa have always known whose face it is that's withered and aching from the virus.

I want to remind you that when the Millennium Development Goals were launched, there was no goal on sexual and reproductive health. How was that possible? Everyone is now scrambling to find a way to make sexual and reproductive health fit comfortably into HIV/AIDS or women's empowerment or maternal mortality. But it surely should have had a category, a goal, of its own. Interestingly, the primacy of women is rescued (albeit there's still no goal) in the Millennium Project document, authored by Jeffrey Sachs.

And while mentioning maternal mortality, allow me to point out that this issue has been haunting the lives of women for generations. I can remember back in the late 90s, when I was overseeing the publication of State of the World's Children for UNICEF, and we did a major piece on maternal mortality and realized that the same number of annual deaths --- between 500 and 600 hundred thousand --- had not changed for twenty years. And now it's thirty years. You can bet that if there was something called paternal mortality, the numbers wouldn't be frozen in time for three decades.

I want to remind you that within the UN system, there's something called the Task Force on Women and AIDS in Southern Africa. Permit me to tell you how it came about, and where it appears to be headed ... and I beg you to see this as descriptive rather than self-indulgent.
In January of 2003, I traveled with the Executive Director of the World Food Programme, James Morris, to four African countries beset by a combination of famine and AIDS: Zimbabwe, Zambia, Malawi and Lesotho. We had surmised, at the outset, that we would be dealing primarily with drought and erratic rainfall, but in the field it became apparent that to a devastating extent, agricultural productivity and household food security were being clobbered by AIDS. We were shocked by the human toll, the numbers of orphans, and the pervasive death amongst the female population. In fact, so distressed were we about the decimation of women, that we appealed to the Secretary-General of the United Nations to personally intervene.

And he did. He summoned a high level meeting on the 38th floor of the UN Secretariat, with TV conferencing outreach to James Morris in Rome and to the various UN agencies in Geneva, and after several agitated interventions, the Secretary-General struck a Task Force on Gender and AIDS in Southern Africa, to be chaired by Carol Bellamy of UNICEF.

If memory serves me, Carol Bellamy determined to focus on seven of the highest prevalence rate countries: studies were done, recommendations were made, costs of implementation were estimated, monographs were published. And here's what festers in the craw: the funding for implementation is not yet available. The needs and rights of women never command singular urgency.

There's an odd footnote to this. Within the last two months, a number of senior students at the University of Toronto Law School, compiled papers dealing with potential legal interventions on a number of issues related to HIV/AIDS in Africa. One of the issues was, predictably, gender. Not a single student, over the course of several weeks, whether on the internet or wider personal reading, came across the Secretary-General's Task Force (although one student said that she had a vague recollection that such a thing existed). The Task Force findings are clearly not something the UN promotes with messianic fervour.

I want to remind you that as recently as March, there was tabled, internationally, the Commission on Africa, chaired by Prime Minister Tony Blair ... indeed established by Tony Blair. It has received nothing but accolades, particularly for the analysis and recommendations on Official Development Assistance, on trade and on debt. The tributes are deserved. The document goes further down a progressive road than any other contemporary international compilation.

With one exception. I want it to be known --- because it's not known --- that the one aspect of this prestigious report which fails, lamentably, is the way in which it deals with women. There is the occasional obligatory paragraph which signals that the Commission recognizes that there are two sexes in the world, but by and large, given that women are absolutely central to the very integrity and survival of the African continent, they are dealt with as they are always dealt with in these auspicious studies: at the margins, in passing, pro forma. And it's not just HIV/AIDS; it's everything, from trade to agriculture to conflict to peace-building.

Maybe we should have guessed what was coming when there were only three women appointed out of seventeen commissioners. They had the whole world to choose from, and they could find only three women ... it doesn't even begin to meet the Beijing minimum target of thirty percent. We're not just climbing uphill; we might as well be facing the Himalayas.

I want to remind you, finally, of the arrangements we've made within the United Nations itself. HIV/AIDS is the worst plague this world is facing; it wrecks havoc on women and girls, and within the multilateral system, best-placed to confront the pandemic, we have absolutely no agency of power to promote women's development, to offer advice and technical assistance to governments on their behalf, and to oversee programmes, as well as representing the rights of women. We have no agency of authority to intervene on behalf of half the human race. Despite the mantra of 'Women's Rights are Human Rights', intoned at the International Conference on Human Rights in Vienna in 1993; despite the pugnacious assertion of the rights of women advanced at the Cairo International conference in 1994; despite the Beijing Conference on women in 1995; despite the existence of the Convention on the Elimination of Discrimination against Women, now ratified by over 150 countries; we have only UNIFEM, the UN Development Fund for Women, with an annual core budget in the vicinity of $20 million dollars, to represent the women of the world. There are several UNICEF offices in individual developing countries where the annual budget is greater than that of UNIFEM.

More, UNIFEM isn't even a free-standing entity. It's a department of the UNDP (the United Nations Development Programme). Its Executive Director ranks lower in grade than over a dozen of her colleagues within UNDP, and lower in rank than the vast majority of the Secretary-General's Special Representatives.

More still, because UNIFEM is so marginalized, there's nobody to represent women adequately on the group of co-sponsors convened by UNAIDS. You see, UNAIDS is a coordinating body: it coordinates the AIDS activities of UNICEF, UNDP, the World Bank, UNESCO, UNFPA, WHO, UNDCP (the Drug Agency), ILO and WFP. UNIFEM asked to be a co-sponsor, but it was denied that privilege.

So who, I ask, speaks for women at the heart of the pandemic? Well, UNFPA in part. And UNICEF, in part (a smaller part). And ostensibly UNDP (although from my observations in the field, "ostensible" is the operative word).

Let me be clear: what we have here is the most ferocious assault ever made by a communicable disease on women's health, and there is just no concerted coalition of forces to go to the barricades on women's behalf. We do have the Global Coalition on Women and AIDS, launched almost by way of desperation, by some international women leaders ... like Mary Robinson, like Geeta Rao Gupta, but they're struggling for significant sustainable funding, and their presence on the ground is inevitably peripheral.

I was listening to the presentations at the dinner last night, and thinking to myself, when in heaven's name does it end? Obstetric fistula causes such awful misery, and isn't it symptomatic that one of the largest --- perhaps the largest --- contributions to addressing this appalling condition has come not from a government but from Oprah Winfrey?

I was noting, just in the last 48 hours, that Save the Children in the UK has released a report pointing out that fully half of the three hundred thousand child soldiers in the world are girls. And if that isn't a maiming of health --- in this case emotional and psychological health --- then I don't know what is. And perhaps you notice the rancid irony: women have achieved parity on the receiving end of conflict and AIDS, but nowhere else.

Female genital mutilation, the contagion of violence against women, sexual violence in particular, rape as a weapon of war --- Rwanda, Darfur, Northern Uganda, Eastern Congo --- marital rape, child defilement, as it is called in Zambia, sexual trafficking, maternal mortality, early marriage ... I pause to point out that studies now show that in parts of Africa, the prevalence rates of HIV in marriage are often higher than they are for sexually active single women in the surrounding community; who would have thought that possible? ...

The overall subject matters you're tackling at this conference strike to the heart of the human condition. All my adult life I have accepted the feminist analysis of male power and authority. But perhaps because of an acute naiveté, I never imagined that the analysis would be overwhelmed by the objective historical realities. Of course the women's movement has had great successes, but the contemporary global struggle to secure women's health seems to me to be a challenge of almost insuperable dimension.

And because I believe that, and because I see the evidence month after month, week after week, day after day, in the unremitting carnage of women and AIDS --- God it tears the heart from the body ... I just don't know how to convey it ... these young, young women, who crave so desperately to live, who suddenly face a pox, a scourge which tears their life from them before they have a life ... who can't even get treatment because the men are first in line, or the treatment rolls out at such a paralytic snail's pace ... who are part of the 90% of pregnant women who have no access to the prevention of Mother to Child Transmission and so their infants are born positive ... who carry the entire burden of care even while they're sick, tending to the family, carrying the water, tilling the fields, looking after the orphans ... the women who lose their property, and have no inheritance rights, and no legal or jurisprudential infrastructure which will guarantee those rights ... no criminal code which will stop the violence ... because I have observed all of that, and have observed it for four years, and am driven to distraction by the recognition that it will continue, I want a kind of revolution in the world's response, not another stab at institutional reform, but a virtual revolution.

Let me, therefore, put before the conference, two quite pragmatic responses which will make a world of difference to women, and then a much more fundamental proposal.

Many at the conference will not know this, but the Kingdom of Swaziland recently made history when it received from the Global Fund on AIDS, Tuberculosis and Malaria, money to pay a stipend --- modest of course, but of huge impact --- to ten thousand caregivers, looking after orphans, the vast majority being women. The Swaziland National AIDS Commission (that may not be the precise name), reeling from the exploding orphan population, made the proposal for payment to the Global Fund, and it swept through the review process with nary a word. The amount is roughly $30/month, or a dollar a day ... not a lot to be sure, but clearly enough to make a great difference.

My recommendation is that this conference orchestrate the writing of a letter, to be signed by people like Mary Robinson, Geeta Rao Gupta, and prominent women from academia, and have that letter sent to every African Head of State and Minister of Health, urging them to ask for compensation for caregivers, using the Swaziland precedent.

And the second pragmatic proposal? I would recommend, with every fibre of persuasion at my command, that the conference collaborate directly with the International Partnership on Microbicides, whose remarkably effective Executive Director, Dr. Zeda Rosenberg, will be here on campus on Thursday. She will tell you what she needs and how to go about getting it. The prospect of a microbicide, in the form of a gel or cream or ring, which will prevent infection, while permitting conception --- the partner need not even know of its presence --- can save the lives of millions of women. The head of UNAIDS, Dr. Peter Piot, who will be known to many of you, recently suggested that the discovery of a microbicide may be only three to four years off. That's almost miraculous: short of a vaccine --- and we must never stop the indefatigable hunt for a vaccine --- a microbicide can transform the lives of women, and dramatically reduce their disproportionate vulnerability. What's needed is science and money. You can help with both.

On the more fundamental front, I want to suggest that the process of UN reform, now urgently underway, be confronted with arguments that spare no impatience.

I have heard the President of Botswana use the word extermination when he described what the country is battling. I have heard the Prime Minister of Lesotho use the word annihilation when he described what the country is battling. I sat with the President of Zambia and members of his cabinet not long ago, when he used the word holocaust to describe what the country is battling.

The words are true; there's no hyperbole. The words apply, overwhelmingly, to women. That being the case, there has to be a proportionate response. It seems to me that the response should proceed on two simultaneous fronts.

First, let me say that I was thrilled by the suggestion from Mary Robinson, and others, that Penn State act as a kind of coordinator for the surprising numbers of initiatives, unrelated one to the other, occurring under the auspices of many universities. The practice of twinning, the practice of using various Faculties as training centres, the practice of American and Canadian universities bridging the gap in capacity until the developing country can take over ... all of that is to the good, and it needs coordination. But there's more, I would submit, for you to do. Within multilateralism, that is within the UN system, wherein lies the best hope for leadership, there must be a change in the representation of women. There must emerge, for Women's Global Health, and certainly for HIV/AIDS, an agency, an organization, a powerful Think Tank, whatever the entity --- it can start on the outside, and then claim equal presence amongst the co-sponsors of UNAIDS, and thrust its advocacy upon the Secretariat, the Agencies, the member states, in unprecedented volume and urgency. Nor does this entity confine itself solely to women's global health, although that is the entry point. It insists on the 50% rule ... just start your evidence-gathering by identifying the numbers of senior women, agency by agency, secretariat department by secretariat department, diplomatic mission by diplomatic mission, and when you've recovered from the shock of learning that the multilateral citadel knows nothing of affirmative action, then begin your unrelenting advocacy. This must become a movement for social change. It needs leadership. Why not this University, why not this conference? And let me emphasize; there's nothing limiting about this concept. We're looking towards the day when governments are finally made to understand that women constitute half of everything that affects humankind, and must therefore be engaged in absolutely everything. Why would it not be possible to build a movement, committed to the rights of women, in the first instance amongst nursing and medical faculties across the world, and take the world by storm? You have resources, knowledge and influence available to no others. The terrible problem is that you've never marshalled your collective capacities.

Second, a similar movement must be directed, I would submit, to Africa itself. I'm hesitant here, because there are enough neo-colonial impulses around without my being presumptuous in making recommendations for Africa, and indeed for women. But I must bring myself to say what I know to be true: the African leadership, at the highest level, is not engaged when it comes to women's health. There's so much lip service; there's so much patronizing gobble-de-gook. The political leadership of Africa has to be lobbied with an almost maniacal intensity on the issues of this conference, or nothing will change for women.

That, too, will take a monumental effort. In my fantasies, I see a group of African women, moving country to country, President to President, identifying violations of women's health specific to that country, and demanding a change so profound that it shakes to the root the gender relationships of the society. I know that African women leaders like Wangari Matthai and Graça Machel and many prominent cabinet ministers, committed activists and professionals think in those terms; what is needed is a massive outpouring of international support from their sisters and brothers on the planet.

I'm 67 years old. I'm a man. I've spent time in politics, diplomacy and multilateralism. I know a little of how this man's world works, but I still find much of it inexplicable. I don't really care anymore about whom I might offend or what line I cross: that's what's useful about inching into one's dotage.

I know only that this world is off its rocker when it comes to women. I must admit that I live in such a state of perpetual rage at what I see happening to women in the pandemic, that I would like to throttle those responsible, those who've waited so unendurably long to act, those who can find infinite resources for war but never sufficient resources to ameliorate the human condition.

I'm excited of course about the Millennium Development Goals, and I'm equally excited that with the leadership of the British, this next G8 Summit in the summer might just possibly spawn a breakthrough. And there are countless numbers of people working to that end.

But I have to say that I can't get the images of women I've met, unbearably ill, out of my mind. And I don't have it in me either to forgive or to forget. I have it in me only to join with all of you in the greatest liberation struggle there is: the struggle on behalf of the women of the world.