USAID Administrator Natsios Press Remarks on HIV/AIDS in AfricaAndrew Natsios, USAID Administrator
Press Remarks En Route to South Africa With Secretary Powell
May 24, 2001
Andrew Natsios, Administrator,
MR. NATSIOS: Does anybody have a question?
QUESTION: What can you tell us about what is going to happen at the next stop and about what the AID is doing?
MR. NATSIOS: We are going to meet with the President and delegation. There is going to be a speech by the Secretary. You have the schedule, you know.
We are going to see some HIV/AIDS programs -- how they are structured, what they do. They are all heavily prevention-based. That is the strategy of AID worldwide, and particularly in Africa because of limited infrastructure. That is one area we have achieved the greatest results working with African governments, for example. We know these interventions work. In Uganda, for example, we have been able to drop -- working with the Ugandan Government -- the AIDS infection rate by about fifty percent. So we know these interventions work. And they have to do with individual marketing, social counseling. Almost all Africans know about the epidemic. Ninety-eight percent, including those living in the remotest areas, know that there is a disease. There is, however, a lot of misconception as to what causes it and how to get cured of it.
QUESTION: What is the biggest impediment in your education program? Do you find that a lot of people are concerned? Are there people who just do want to do what you recommend?
MR. NATSIOS: The social structure -- there is still polygamy in many areas, for example. There is an aversion to using condoms in some areas. There is an aversion by some leaders to talk about this. We have found a direct connection between the willingness of the head of state and the success of our social marketing program. The structure of African society looks toward strong leaders, so the leadership, for example of President Museveni in Uganda, has had a profound effect on the success of our social marketing program -- to educate the public, to change behavior, postpone the sexual debut, particularly of young women -- that has a huge effect on the infection rate.
QUESTION: Tell us about President Mbeki and comments that he has made in the past. Tell us that first.
MR. NATSIOS: President Mbeki has unorthodox views on this subject, although he has been cooperative. His Ministry of Health has been very cooperative in working with us on this problem. We have done a lot more in the last six or eight months with the South African Government. The South African infrastructure, as you know, is much better than almost any other area of Africa. But their infection rates are very high. They are twenty percent. And we expect maybe by 2003, 2004, 2005, they may be almost up to twenty-five percent among adults. South Africa along with Botswana -- and I think Zimbabwe -- may have a negative population growth rate which means that the infection rate is extremely high and that more people are dying than are being born. So they may actually have a drop in population within the next few years because of the epidemic.
QUESTION: What have the South Africans failed to do to reduce it, given that they have the infrastructure, given that Uganda is a much less prosperous society and has been able to reduce the levels by half.
MR. NATSIOS: When the infection rate gets past four percent there are geometric increases in the spread of the disease. That is, sort of, the explosion period -- about four percent. They are way, way beyond that right now. I think the question is that if you go back, they reached the four percent period a long time ago. And that is when it got out of control. That was before there was a sense of panic or a sense of real concern on the part of some heads of state in Africa that they really needed to take leadership at the national level.
QUESTION: What would you like Mbeki to say and do, that he has not done?
MR. NATSIOS: What would I like him to say? I would not presume to tell the President of South Africa what to say or do. What would make a difference is any head of state, not just President Mbeki, publicly saying that we have a crisis, that we need people to change their behavior.
QUESTION: Could you talk a little bit about some of the misconceptions that you said are prevalent across Africa.
MR. NATSIOS: I don't want to increase perceptions about Africa. I will give you one story off- the-record however.
QUESTION: (Inaudible) developed areas like in Abidjan where there are condom kiosks on many corners giving out U.S. funding -- you ask people if they use them and they say no. Even though they are all very aware of the AIDS epidemic. There are plenty of billboards about the causes of AIDS -- the cures. They simply refuse to use condoms. Why fund it if they are not going to use it? And why aren't they using them?
MR. NATSIOS: Well, it depends on the culture of the society. Different societies react differently to it. And a lot of people, in fact, are using them. I mean, the fact that some people won't use condoms in the United States -- how can we expect other countries to use them? If you talk to certain at-risk populations in the United States, they refuse to wear condoms. So that exists in any society -- the view that they are going to take their risks. I have to say, among teenagers, that's the big problem. Because teenagers think they are invulnerable. And that is not a function of African society. I have teenagers, and they think it's impossible to die when you are eighteen years old.
We know it is working because the condom distribution in those places where the infection rate has begun to drop has worked. It's just that everybody will never use them. I mean you can't get one hundred percentage usage anywhere.
QUESTION: (Inaudible) refuse to use them are the same ones who have frequent sexual encounters. It's not a case that they are not exposed to the causes of AIDS.
MR. NATSIOS: No, I understand that. It's just that there is always going to be a percentage of people who refuse to use them, and you refuse to take precautions. The question is that: can we raise the rate at which they are used and which -- that the two most important interventions are monogamy and abstinence. They are working. There is an increased awareness among religious leaders -- Moslem and Christian in Africa; they are going to have to take leadership. I met with Muslim leaders in Mali and I asked what their perception is, and they are really panicked about what is happening in Africa generally. And they are using the mosque and the church as ways of advertising the government's Ministry of Health programs and NGO programs. So religious leaders are cooperating now, and that is helping too.
QUESTION: Andrew, can you explain why AID programs are focused so much on prevention? Are you saying that to treat the problem is just too hard and too big and too expensive?
MR. NATSIOS: Well if we can -- just go back to the United States. Forty percent of the people who know that they have HIV/AIDS in the United States are not in a treatment program. And that is not because they cannot afford it. A friend of mine in Boston -- a prominent talk show host [name off the record] -- and the rigor you have to go through to take this medication. It's 17 to 25 pills a day. Every two hours. And you have to change the cocktail -- the mix of drugs -- every three or four months, or you can die from the toxicity of the drugs. And it does not always work. There are some people who are HIV-positive where the drugs simply will not keep you alive. So you have to have a very high level of infrastructure, higher levels of education, levels of education, you have to have a cold (inaudible) because some of the drugs have to be refrigerated. Now if you apply that to Africa, and if we can't get forty percent of the people who are HIV-positive to take the drugs in the United States, how can we expect the people in countries where there are no roads -- there are two doctors per 100,000 people in Ethiopia, for example. Doctors have to supervise this. The average health worker's level of education in Mozambique is the sixth grade. If this were one immunization, we could do it. This is a very complicated treatment regimen. If you have a fixed amount of money -- it's a lot of money. We spend more money in AID and the CDC on AIDS work internationally than all other donor and southern countries combined. Fifty percent of the worldwide total is spent by the US Government, so we are making a big commitment; but the infrastructure problems in Africa are really very severe.
MR. NATSIOS: When I was in South Africa ten years ago, I was negotiating an agreement on humanitarian relief in Angola, and I asked some of the doctors whether they'd been affected by the epidemic -- Zambia and Zimbabwe were bad even ten years ago. They said it's a huge problem; this is before the change in government. It's a huge problem; no one wants to talk about it on any side in the political turmoil in South Africa. It's just not culturally an issue the people want to talk about. The acceptance by the leadership of the country is critical, as I said earlier, in stopping the spread of the disease. I think the fact that South Africa got a late start, when the infection rate had gotten past four percent very early on, is the reason we're facing such a severe crisis in South Africa.
QUESTION: Could I ask a rather perhaps cynical question? Why, besides a humanitarian or charitable impulse, should Americans care about how many people are dying of AIDS in Africa? What are the reasons besides charity?
MR. NATSIOS: It's having a profound effect on every aspect of society. It's affecting economic growth, for example. In Zimbabwe, businessmen told me a few years ago -- these are major business leaders -- that they had a death rate in their work force. This is a better-educated person's disease. The infection rates are higher in the urban areas by a factor of two-to-one than they are in the rural areas. Their educated elite in Africa is dying off from this disease at an alarming rate. It's affecting business in a profound way. They can't keep trained people in the banks, for example, now. American investments in Africa, which are substantial, are being affected by this in a very direct way. That's number one.
Number two: we're seeing incidences of famine-like conditions in Africa that are unrelated to drought or war, which are two other causes of famines. It appears because so many of the ambulatory adults -- the farmers -- are dying from it. The kids can't farm their parents' farms -- they are orphans; there are I think 11 million AIDS orphans in Africa right now -- that food security is deteriorating in those areas, and nutrition is (deteriorating). A lot of these younger people who are orphans are having problems in terms of street violence and that sort of thing.
So it has an effect on the criminal justice system, has an effect on the economy, has an effect on food security, has an effect on food production, has an effect on war. The more young men who are unattached to their villages, their parents, and their tribal and religious leaders, the more instability you have. And I might add that incivility in Africa affects us profoundly because some of the counterfeit rings, some of the drug rings around the world are in societies that have weak national governments, where there are civil wars, or are what we call "failed states." Failed states affect us, the United States, in a very direct way.
QUESTION: Is resistance to the use of contraceptives by either the Catholic Church or Muslim clerics making it difficult to fight this disease? And I want to know whether or not the appointment of Mr. Klink to be in charge of some of our population programs is likely to affect the United States' support for the use of contraceptives overseas?
MR. NATSIOS: I am not aware of any appointments so I can't comment on that.
The American policy on this is determined by the President, the Secretary of State, and me, and it's not going to change. We are committed to family planning programs and to women's reproductive health programs. The Secretary announced an increase in funding for those programs in the budget we proposed for 2002. We can give all the rhetoric we want to; what counts is how much money we're spending, and we're spending more money on that. There has not only been no cut, the United States continues to be a leader in it.
I think when you have a national leader willing to take the risk, people are listening. The Muslim leaders I spoke with last evening are panicked over it, and they are using the mosques to get the information out. In fact, AID is about to -- I don't know if I should be announcing this now -- but we're beginning a program through the mosques and the churches Africa-wide. It's an Africa-wide initiative. We haven't done the contracting on it yet for the NGO grant-making, but it's a new initiative to use religious institutions to get the word out on this subject. Religious leaders preaching abstinence and monogamy actually are helping with the epidemic. Those are the two best interventions. Condoms don't always work. The best thing to do is behave yourself.
QUESTION: How many African leaders have been willing to say that this is a dangerous disease and their citizens need to do something? And secondly, what do you say to groups like Global AIDS Alliance, which criticize the United States for giving only $200 million when proportionally to our economic strength we should be giving $3 billion?
MR. NATSIOS: I come from the NGO community. No matter what you say, my friends will always say it's not enough. Okay?
QUESTION: It's a huge discrepancy.
MR. NATSIOS: To be fair, that's an incremental increase. We were already spending a lot of money on AIDS. AID's budget on AIDS before the President's announcement -- just USAID -- was $343 million; and there's going to be another increase of $25 million unrelated to this trust fund. CDC spends another $100 million with us on AIDS outside the United States, and then the research that's being done at the National Institutes of Health is another couple hundred million dollars. So we're spending on the order of 700 or 800 million dollars, all federal agencies combined, on HIV/AIDS abroad. That is a wad of money. And I have to tell you, I wish that other countries were spending that much.
QUESTION: (Inaudible. How many African leaders are taking leadership roles in countering AIDS?)
MR. NATSIOS: I have never done a count. That's a very interesting question; I will ask the staff. I know a number of African leaders whom I met with at the LDC conference in Brussels last week. I brought the subject up with the President of Tanzania. I had met with the President of Mali. Museveni has been one of the earliest leaders. I had a lunch with President Obasanjo of Nigeria -- he has taken a leadership role on it now. A lot of them are taking leadership roles, but I will get you a count. I haven't actually asked them for the number.
QUESTION: Basically, my question is similar. I wanted to know besides South Africa, what are some of the countries with extremely high rates of AIDS infection?
MR. NATSIOS: The saddest thing is that the country -- South Africa -- is in a different category for a variety of reasons. It has a huge economy and that kind of thing, and a large infrastructure. The African country that was doing the best from a democracy, corruption, civil society, human rights, distribution of wealth, and economic progress was Botswana. It's a little country, but it was the model. Botswana has the highest infection rate in the world; it's 38 percent. I asked the staff how could that be with a country which is fully functional. There is almost no corruption; the government is very competent; it's a very ably led country, a democracy from the start; and they don't have human rights abuses. No predatory state exists. It's a very, very well run and well-led country.
The reason is there is a large mining industry, and the men are away from their wives for a large period of the year, and there are a lot of sex workers. Before it was realized how severe the disease was, the miners were catching the disease and bringing it back to their spouses, unfortunately. We noticed the spread of AIDS in Africa is along the truck routes. You can see along the roads the infection rates are much, much higher because the men who are driving the trucks -- the sex workers are along the road, and that's how it gets spread.
QUESTION: You mentioned USAID getting involved in an initiative to have religious leaders spread the message. What exactly would be your input into a program like that? How would you spend money? Where would the money go?
MR. NATSIOS: I haven't read the document yet. I think it's not going to be a very expensive program. It is going to be to attempt to organize the mosques, the Islamic leaders, and the Catholic and Protestant leaders and Orthodox leaders in Africa to get instructional material out that can be distributed during services on Fridays and Sundays.
Particularly, the thing we are most alarmed by is the younger people. Once again, our public health staff said if we could postpone the sexual debut of younger women -- teenage girls -- until their twenties, we could drop the infection rate substantially. Churches and mosques can play a major role in that. It is consistent with their theology, so we're working in tandem with their own value system where there is no debate over that. That could be very helpful.
QUESTION: (Inaudible) the percentage of teens, 15 or over, in South Africa and how many are dying? And aren't those the ones who get most of the messages? Do you write most of that off to what you said earlier, that teenagers don't think they can die? Or is there something more there that you're looking at?
MR. NATSIOS: What has happened -- I don't know the figures; I can get them for you. But what has happened now is that -- it happened in Uganda. When I was with World Vision, I would talk to the Uganda staff, who were all Ugandans; they are not Westerners. I said, what effect is this having in your society? They said because of the epidemic, a large number of Ugandans, particularly educated people, decided to be celibate and never to marry because even when you get married, you can't be sure who you're marrying. So people have changed. It has had a profound effect on the social structure. When the infection rate gets this high -- at 20 or 25 percent -- and younger people see their friends dying from it, then it begins to infect people. They don't think they're invulnerable any more.
So there is a natural prevention thing that takes place at a certain infection rate, because everybody begins to have family members and relatives and friends who are affected by it, and people listen to the message more. Unfortunately, it's a little too late then sometimes.