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The Global Fight Against HIV/AIDS

Ambassador Mark R. Dybul
U.S. Global AIDS Coordinator

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MR. MCCORMACK: Ambassador Mark Dybul, U.S. Global AIDS Coordinator. Thanks for coming back. I think this is our second time on the policy podcast.

AMBASSADOR DYBUL: Yeah, good to be here again.

MR. MCCORMACK: I just want to talk a little bit at the end of this Bush Administration. Where do you see things stand now in the fight against AIDS? You know, if you could look back a little bit for us and kind of bring us up to date where we are and then maybe we can a little bit about some of the challenges going forward.

AMBASSADOR DYBUL: Sure. You know, if we look back, it’s a completely different world than it was eight years ago, because of the intervention of President Bush and the American people. As the head of UN AIDS has said, before President Bush launched the Emergency Plan for AIDS relief, people talked about millions of dollars in the fight against HIV/AIDS. And now we talk about billions. When President Bush announced this initiative, 50,000 people in Sub-Saharan Africa were receiving antiretroviral therapy.

Now, through the American people, support two million people – two million people – in five years are receiving antiretroviral therapy, care for ten million HIV-positive people, orphans and vulnerable children, 240,000 children born HIV-free because of interventions of the American people. So it’s night and day. And it’s not just us. The President led the world in a response that has radically changed where we were.

So five years ago was a new, different world, and we are in a new era, and President Bush talks about the new era in development in his launch. And it’s not just about the money, it’s not just about the programs; it’s fundamentally about the lives saved. It’s also about a new way of doing development. We’re now focused on results. We’re now focused on lifting people up in countries and giving them the responsibility and opportunity to control their lives – country ownership. And that’s what this is all about.

We’re shifting from donors and recipients to partnership, believing in, trusting in the people on the ground to do the work. That’s a fundamentally new way of doing development -- principles of good governance, principles of all sectors being involved. It’s not just about governments; it’s about people. We’re not going to have fundamental development. You can’t respond to HIV/AIDS in a village if everyone is not involved. And this is really getting down to that grassroots country ownership, everyone being involved, pitching in, and believing in people to do the work – a completely new way of doing development. So it’s not only AIDS, but it’s actually fundamentally shifted how we do development.

MR. MCCORMACK: Right, right. Let me – and I want to explore that a little bit. But let me first ask you, you say this is a whole new world, President Bush led this fight. What was the moment? I mean, what caused a Republican President of the United States to take this up as, frankly, one of his signature issues in terms of foreign policy and development? It’s -- I think for a lot of people listening, they think that’s counterintuitive.

AMBASSADOR DYBUL: Yeah.

MR. MCCORMACK: So give us a little insight.

AMBASSADOR DYBUL: Yeah, it’s a -- Bush announced it a little like Nixon in China. It’s not what many people expected. But as you’ve gotten to know him and what drives him and -- he says always when he talks about this development work, to much whom is given, much is required. I mean, we just had a conversation on World AIDS Day when he announced that we’d met our goals and the red ribbon for the second time hung in front of the White House -- the first time ever a White House has hung a red ribbon on World AIDS Day under this President.

And he talked about how his own faith and belief in people, belief in the dignity and worth of every human life, belief in lifting people up, to whom much is given, much is required. If we have a lot, we have a responsibility to give. So there’s a strong sense of moral responsibility. But he also talked about the bigger picture that there’s also enlightened self-interest engaged -- involved here. Hopelessness creates despair, and despair can create fanaticism.

The UN General Assembly had their only special session ever on a single disease -- it was on HIV/AIDS. They talked about the security threat to the globe of HIV/AIDS. And the reason is HIV/AIDS, unlike most diseases that kill very young and very old, killed 15-50 year olds. So we’re knocking out a generation of parents, teachers, healthcare workers, peacekeepers, people that are productive in their lives. And that knocks out the social fabric of the society. And as you tear the social fabric apart, you create the breeding ground for instability. So there is a security issue.

It’s also, however -- and these last couple of weeks have taught us, months have taught us, that we are interconnected globally. And so not just AIDS, but his big development vision tripling development overall, quadrupling in Africa, doubling in Latin America, is very much tied to our future --

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: -- to our own interests. And so economic – and economic stability globally, future marketplaces, the opportunity for us to be invested in and get from the people where we are investing now in the future. Our future is Africa’s future and Africa’s future is our future. So there’s very much that long-term vision for a stable world in which we play a role and have a role. And it’s in our self-interest. The other piece, and I think we’re learning this more and more, is these programs have changed how people view America.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: You know, people know what we stand for when we stand with them.

And eight of ten of the countries in the world with the highest approval rating of the United States, sometimes higher than the United States itself, are in Africa. You know, the two are Israel and the United States, and that’s not an accident. These programs touch lives.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: And when you touch lives on that very real level, when the American people are reaching out and touching people at a village level, it has a huge impact on how people live.

AMBASSADOR DYBUL: So that all fits together, too.

It’s not too dissimilar from the Marshall Plan. This is the largest investment since the Marshall Plan in development in economically constrained times. In an environment of isolationism, people still reached out and rebuilt Europe. There was a lot of moral responsibility there, but it was also very strong in our own self-interest. Same thing here. So it’s deep moral responsibility, but also a sense of, this is in our own enlightened self-interest and important for the American people to pursue.

MR. MCCORMACK: Let me ask you a question about if there was any effect whatsoever, any linkage between the fact of the program, the fact of devoting the kind of resources that the United States has to this fight with the attitudes towards AIDS and those affected with AIDS in Africa? I mean, has – is there any linkage or interplay between those two things?

AMBASSADOR DYBUL: Well, I think what you’re getting at is a stigma against people with HIV/AIDS.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: And you know, we have a lot in this country too. When I was a young physician --

MR. MCCORMACK: Right, right.

AMBASSADOR DYBUL: -- we were suing* doctors and dentists who touched HIV-positive people.

MR. MCCORMACK: Yeah, absolutely.

AMBASSADOR DYBUL: And we had to get over that by understanding the disease, how -- understand how it’s transmitted. And that’s occurring right now. In Sub-Saharan Africa, they’re going through the same kind of learning process about what the disease is. And these programs help a lot. Presidents of countries now talk about HIV/AIDS –

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: -- and talk about the medical aspects of it and the fact that this isn’t a curse from anyone.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: And these are people who happen to encounter a disease, a chronic disease.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: And so it’s radically changing the stigma.

Now there's still a stigma –

MR. MCCORMACK: Right, right.

AMBASSADOR DYBUL: -- but the shift from five years ago is extraordinary. And a lot of it has to do, to some degree, when the President of the United States says --

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: -- you know, this is something we care about -- people suffering from HIV/AIDS -- it begins to make a change.

But we’ve also had great leaders on the continent of Africa, presidents of countries, ministers of health, down to the village level, faith leaders. There’s been a real shift. But a lot of it has led from the leadership that says this is an issue we’re going to tackle globally.

MR. MCCORMACK: Mm-hmm. I’ve seen in some commentaries, some view the fight against AIDS and tropical diseases – we’ve linked the two in these programs. They see that as a national security issue. Do you see it that way?

AMBASSADOR DYBUL: Absolutely. And you know, I’ll just mention briefly that there is – disease affects people at the deepest level of their lives and in the presence of significant disease. I mean, we were seeing 30 percent of adult populations dying. People for their social lives were going to funerals.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: It creates a sense of despair and hopelessness. And one of the fundamental aspects of this program and what President Bush has done on development as a whole is created hope, given people a sense that they control and own their lives. And that changes a lot in terms of how a community views itself and views its future. And if you view a future and if you view opportunity, if you have hope for life, liberty, and opportunity, you’re less inclined to fall prey to fanaticism or rebellion –

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: -- out of hopelessness.

You know, the incoming National Security Advisor, General Jones, has talked about this. General Wald, the four-star general who worked under General Jones overseeing Africa said the three greatest threats to global security are weapons of mass destruction, terrorism, and HIV/AIDS. That’s why the UN General Assembly talked about it because it tears apart the social fabric.

MR. MCCORMACK: Right, right.

AMBASSADOR DYBUL: And what we’re trying to do is put the social fabric back together. But it’s not us. And that’s the key.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: That’s the real shift in development. We will never have the resources or ability to go in and change even a community, let alone a country. What we’re doing is supporting them to lift themselves up to create their hope and opportunity for their belief in life, liberty, and opportunity. When you do that, you transform everything. And that has huge implications for moral responsibility, our role in the world, but it also has extraordinary implications for our own national security.

MR. MCCORMACK: Let me – let me ask you one last question. You’ve talked a lot about the fight against AIDS, with your policymaker hat. Let me ask you to shift just a little bit towards looking at the scientific aspects of the fight against AIDS. Where’s the future of this fight? You know, it seems as though we have taken steps to help prevent, to help improve the quality of life and extend people’s lives that have the AIDS virus. What’s the future, though? What does the future look like in this fight?

AMBASSADOR DYBUL: Well, there are probably a couple different areas. One is in the area of treatment, the life extension, which is a big part of this program. Two million people in care right now. And the future of that is, at the moment, treating it like a chronic disease, so that it’s like hypertension –

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: -- or diabetes, so that people will live with it for decades.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: -- and then, we hope, die from some other cause as they get old.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: And that’s our hope right now for treatment. We don’t have any evidence that we’ll have a cure. There could be a technological breakthrough which allows us to do that.

MR. MCCORMACK: Let me ask you just quickly, is that just because of the nature of the virus?

AMBASSADOR DYBUL: It is. And it’s complicated scientifically, but this virus is actually like cancer. Unlike most infections that live outside of our own cells, HIV lives in our cells, which means to kill the virus we kill our own cells --

MR. MCCORMACK: -- our own cells.

AMBASSADOR DYBUL: -- which is very much like cancer.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: -- and so it is a very different type of infection than the types of infections most people are used to. But you do hope for a technological breakthrough that will allow us to view things in a different way. It’s the same in prevention. We do have very effective ways to change people’s behavior, but this is very difficult. It’s human sexual behavior, and that’s not that easy to modify. But we have successful programs and we’re seeing tremendous success. Just recently, Namibia reported a 50 percent reduction in their HIV prevalence in young people from 15 to 24 years old. And we’ve seen that in other countries as well.

But again, we are hoping for technological breakthroughs that allow us to have a microbicide, which women can use to protect themselves from the virus, or a vaccine. We’re a ways away from both of those. Hopefully, we will have a – hopefully, we’ll have a microbicide first. There are a couple other new technological interventions. Medical male circumcision is an intervention which is highly effective that the American people are supporting, as well.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: So it’s a package.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: We’re going to have a package going forward.

MR. MCCORMACK: Right. Right.

AMBASSADOR DYBUL: But it’s a very optimistic time. No one talked about any of the – five years ago, no one even talked about the possibility --

MR. MCCORMACK: No, it’s quite – it’s quite – it’s quite striking.

AMBASSADOR DYBUL: It’s a new world.

MR. MCCORMACK: All right, I lied. I have one last question for you.

AMBASSADOR DYBUL: Okay.

MR. MCCORMACK: And to look a little bit beyond Africa, you read a lot now about the issue of fighting AIDS elsewhere around the world. But there’s been a lot of focus, rightly so, on Africa. Do you – and you also read a lot about issues of underreporting or non-reporting. Is that – is that going to be – is that an issue we’re tackling in some way with governments? Because a lot of times, this gets down to the – I mean, the governments not wanting to talk about this.

AMBASSADOR DYBUL: I think that has been an issue, although there’s been a huge change, as well. You know, Africa still has two-thirds of the disease in the world.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: And we’re engaged in countries, 120 countries around the world, not just Africa, but all over the world. We’re involved in Eastern Europe and Asia, Latin America, the Caribbean, and our own backyard. But Africa is where we’ve had a lot of focus, cause that’s where two-thirds of the disease is.

But looking to the future, we’re very concerned about growth rates in Eastern Europe, in particular. But some of the great fears that people thought – were worried about, like India or China -- were proved to be wrong. In fact, their rates are much less than we thought they were. We just found out India had half as many infections as we had thought. So rather than underreporting, they’d actually been over reporting.

MR. MCCORMACK: Right, right.

AMBASSADOR DYBUL: So it’s a process, as our – one of the things we’re trying to do is support countries to build a monitoring and evaluation infrastructure so that we have a better handle on the disease and they can respond in a better way. But there are concerning parts of the world. Intravenous drug use is spreading the virus in Eastern Europe, and we don’t have a handle on that yet. The countries there, some of them are moving aggressively; some are not.

MR. MCCORMACK: Right.

AMBASSADOR DYBUL: But there’s a lot of hope now, because people are talking about it in ways they didn’t before. But we definitely need to be focused beyond Africa. And we are. We’ve got programs all over the world. We also are – I think this is important too, because President Bush really got this thing going. At present, we are the largest contributor to the global fund to fight AIDS, tuberculosis, and malaria -- multilateral organization. We give out 30 percent of the resources.

President Bush gave the first gift. Until he gave that gift --

MR. MCCORMACK: Yeah. I remember.

AMBASSADOR DYBUL: -- it wasn’t getting started. He gave the first – second gift of any country. We’re by far the largest contributor. So we are involved globally beyond our bilateral programs all over the world, including in Eastern Europe and some of these other areas we’re worried about.

MR. MCCORMACK: Right. Ambassador Dybul, thanks very much. It’s been –

AMBASSADOR DYBUL: Good to be with you, yeah.

MR. MCCORMACK: -- very interesting talking with you.

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