Examination of Witness (Questions 160
- 180)
TUESDAY 20 JUNE 2000
MR JEFF
O'MALLEY
Mr Worthington
160. On the stigma attached to HIV/AIDS and
the willingness or otherwise to discuss sexual matters, in this
country we have seen AIDS through the prism of who does it affect?
It affects drug addicts and homosexuals, two stigmatised groups.
We are not used to seeing this issue in relation to heterosexual
couples. What is the form of the difficulty that people have in
talking about these sexual matters in African society? We tend
to talk about Africa and not to take into account that Africa
consists of very different countries. Can you help us to understand
why people find it difficult to get community activity going,
given the stigma associated with this subject?
(Mr O'Malley) In one way or another I have been involved
in responses to AIDS in about 20 countries and there is no country
to which I have gone where people have not sat me down and said,
"One thing you have to understand is that it is very hard
for us to talk about sex here". That is not even talking
about AIDS. I am from Canada, but other than in the United States,
where people are quite proud of their ability to talk about sex
in some ways, it is a fairly common assumption that in almost
every culture people do not talk about sex very well. Only an
outsider can see, but that appears to be the case everywhere.
However, it varies a lot and I do not think that talking about
sex per se is necessarily a barrier because, if you will
excuse the broad generalisation, many countries in Asia seem to
have more difficulty, at least with the public discussion of sexuality,
than many countries in Africa and Latin America. I know generalisations
are dangerous but I think there is something in that. How people
talk about sex, with whom they talk about sex, and what they say
varies a lot and creates problems. There are a couple of particular
problems with AIDS. One is the early association of homosexuality—more
than injection drug use—and the amount of fear and discrimination
and hatred of homosexual behaviour around the world is quite remarkable.
President Museveni, not excepted, in one of his less helpful remarks,
has contributed in that regard. That association is slowly fading
away now, but it is remarkable how long it has persisted. It is
absolutely remarkable how long the association between homosexual
sex and AIDS has persisted. That is not just among political leaders,
but at a really broad level. Even more than sex, a big taboo in
most societies is talking about death. In many parts of the world,
there is a taboo about talking about death and a strong persistence
of influence around ideas about things like witchcraft. It is
important not to dismiss that out of hand. It is also important
not to exaggerate it. When you put together homosexuality, sex
and death in one equation and add to it the suspicion that supernatural
forces may be at work, that is a difficult combination. I think
that is where political leadership is so important, not community
response. Recently, in Mozambique the president talked about a
member of his family dying of AIDS and by connection he was talking
about sex. In 1988 or 1989 President Kaunda of Zambia talked about
his son dying of AIDS. Those are incredibly important opportunities.
Unfortunately, recently in Zambia a woman was arrested, charged
and for a short time jailed for possession of a vibrator as a
sex toy. The fact that people are not able to own and talk about
sex in that way does not cause AIDS but it reflects something
in the society. Any discussion about using a vibrator being safer
than having sex with men cannot happen if you can be put in jail
for it. Does that help?
161. It helps enormously. You are saying that
for some people in Africa now AIDS may be associated with the
fact that that person has been associated with homosexual activity
or that there is a witchcraft issue and that person has been picked
out as morally inferior or as having done something wrong. Can
you take that a little further? In order to turn things around,
these points are enormously important.
(Mr O'Malley) The homosexual association is slowly
fading. It has been incredibly disruptive over time, but it is
slowly fading. The only way in which to do something about that
is to talk openly about sex. Even though the vast majority of
infections around the world are caused by heterosexual sex, talking
about homosexual sex is part of the way in which to talk about
heterosexual sex. If we cannot talk about sex we shall not be
able to talk about changing behaviour that puts people at risk.
The association with witchcraft is patchy and I do not want to
exaggerate it, but it is particularly dangerous now because often
it also causes enormous harm to children and survivors of those
who have died of AIDS. It is not necessarily just the negative
association with an individual, but it can also be seen as a negative
association with the family or household. Again, there is concern
about the surviving partners or children. I do not believe that
there is an easy answer. We have some political leaders, but far
too few, who talk about people in their families dying of AIDS.
We still do not have political leaders who talk about the fact
that they are living with HIV. We have far too few sports or entertainment
figures who talk about it. The brother of one of the members of
my board of directors was one of the most famous musicians in
Nigeria. He knew he had AIDS for several years and despite the
fact that his brother was a former minister of health and was
on the board of directors of an AIDS charity, Fela Ransone-Kuti
while living did not come out publicly and say that he had AIDS.
After he died his family made a decision to say to the public
that Fela Ransone-Kuti died of AIDS. Every Nigerian you talk to
will point to that as the turning point of public discussion about
AIDS in Nigeria. A musician, whom everyone knew, whom not everyone
loved — the government did not like him — but many
people loved him, died of AIDS. If we can get to the point where
those people say they have HIV while they are living, then we
shall really start to see some success. But in relation to things
like human rights, people are not willing to do that. If there
is not an environment that protects people when they talk about
having HIV and which encourages them to be involved, of course
they will stay discreet about it.
Mr Khabra
162. Would you agree that various communities
in the world have different attitudes because of their traditions,
cultures and religions? You will find it difficult to get co-operation
in some communities—Asia in particular. How do you overcome
such difficulties and convince those communities to participate
in your programme?
(Mr O'Malley) Everywhere it is a challenge. In Tanzania
a catholic diocese developed a simple education intervention that
has spread around the world. It is called the "three boats".
Essentially it is a message that there is a sea of risk out there
and there is a boat for "mutual fidelity", a boat for
"celibacy" and a boat for "condom use". They
say that in their religion they believe that people should stay
in one of the first two boats, but the most important thing is
not to fall into the sea and that they would rather people did
not use condoms but it is better that people are in the condom
boat than in the sea. At a grass roots level that approach has
spread to places like Burkina Faso and Senegal. Outside Christian
communities, that approach has been developed for use in an Islamic
context, as in Bangladesh. That very simple logic tends to be
very powerful at a grass roots level. I believe that there are
problems in the hierarchies of certain denominations, particularly
around condom use and it is very important to challenge that.
It is not just the hierarchies in religious organisations, but
there are hierarchies in institutions around the world that do
not mention condoms enough. I am concerned that UNICEF does not
pay nearly enough attention to condom promotion. As Carol Bellamy
is to come before your Committee, you may want to explore that
point.
163. In that situation do you consider the intervention
or the co-operation of the government to be essential?
(Mr O'Malley) If you are to have an effective impact
at a national level all stakeholders need to be involved: the
Government, religious leaders, community groups, the private sector,
the media and others. That does not mean that you cannot do anything
in the absence of one of those sectors. There is good work going
on where religious authorities are hostile and government authorities
are indifferent, but turning to the evidence that we have, when
there is clear hostility and indifference from an important stakeholder,
we do not see the kind of impact at a national level that we see
otherwise. That goes for most of the world.
Chairman
164. Is the morale of communities affected by
HIV/AIDS in such a way that it makes it more difficult for the
community to respond because of their low morale?
(Mr O'Malley) Yes. Morale is being undermined in certain
places where the epidemic is far advanced.
165. That is when AIDS has set in and there
are deaths?
(Mr O'Malley) Yes, large numbers of deaths. Even there,
there is an incredible potential around the issue of children
affected by AIDS to renew community concern and action. You may
have heard from other testimony or in your reading that often
links are made between prevention and care in the sense that there
is a wide consensus now among professionals responding to AIDS
that if you do not provide any care you will not be effective
in preventing HIV. If you would like, I can talk about that later.
I would go one step further and say that there are tremendous
opportunities to make individuals and communities concerned about
children. People will mobilise and do something about what will
happen to their children and their neighbours' children but it
is much harder to mobilise them around an abstract virus that
may make them sick or kill them in many years' time. Not only
do they do something for the children, but once people become
involved in something like that that allows you to explore why
the families are falling apart. That is an important opportunity.
I also think that your question points to talking about hope and
creating hope. The particular data that Alan talked about are
in cities or states. Even in the worst affected countries 60 or
70 per cent of the population do not have HIV. Of course, we have
to be concerned about the people who do have it, but in many places
people are now convinced that they have HIV because they have
heard so much about how badly infected their country is, so they
say, "Why bother using condoms? We are all going to die anyway".
If that is their attitude how will you change behaviour? We have
to emphasise that even in the worst affected countries most people
do not have HIV. Another point is that most of the world has nowhere
near these infection levels. Even in Africa the extremes are that
there are about 15 countries with very severe epidemics and that
is less than half of the countries of Africa. The risks of more
severe epidemics elsewhere in Africa, in Asia and in parts of
Latin America are very real, but there the challenge is not the
despondency of the impact, but the challenge is, "This is
not my issue". That is the challenge for most of the world
today.
166. The message must be that this can be and
should be managed?
(Mr O'Malley) Yes.
Chairman: Mr Worthington, would you like
to ask the question on funding?
Mr Worthington
167. There is a general issue around more money
being needed. There is no question about the fact that community
interventions will take a lot more money to be effective. Have
you thought about the most effective ways of doing that funding?
Obviously, there is central government, local government, NGOs,
direct community involvement and so on. Have you any thoughts
on that?
(Mr O'Malley) Yes, on a few different levels. I agree
with what the Secretary of State said at South Africa House. Most
of the resources for the response to AIDS anywhere have to come
from local communities and countries in most of the world. The
overall scale of development assistance, as this Committee knows
full well, is so small in comparison to development challenges
in the world that we should not lull ourselves into thinking that
a doubling or tripling of international development assistance
for AIDS will solve the problem. We have to reinforce that message.
That does not mean that I do not think that international development
assistance has a key role to play. I believe it has a key role;
I believe that it should be increased and we have to talk about
what it is spent on and how it is spent. I expect we shall get
back to that. Within a country I believe very strongly, and evidence
of association points to the importance of multiple channels of
dispersement. Even the strongest governments can play important
key roles, but many of the crucial parts of an effective response
to AIDS cannot be implemented by governments. Governments with
a functioning health service can offer health services. Politicians
can, for free, make a tremendous impact. Governments through the
education sector and a whole range of other sectors can do very
important work. A lot of the work has to happen outside government.
Relatively few governments effectively move money from themselves
out to the community sector or the private sector. In a number
of countries where there have been fairly successful responses,
the governments have encouraged separate streams of funding to
support community action and private sector action on AIDS parallel
to government. My big concern about India—I am disappointed
that your colleague has left—was that DFID has perhaps put
too much faith in the ability of the government of India to put
money in at the top that will flow down through many levels and
get out to the communities. There are states in India where that
is happening—Andhra Pradesh and Tamil Nadu are good examples—but
in more states that does not happen effectively. Even where that
does happen, governments will never be very good, for example,
in funding projects for injection drug users. In Asia injection
drug users are a very important flashpoint in the epidemic. The
most effective work with those populations will always be funded
outside government.
168. On the Indian point, we concentrate on
particular states, instead of the whole of India. It is an act
of faith that the other states are picked up by other countries.
I think at South Africa House you said that you have had enough
pilots?
(Mr O'Malley) Yes.
169. And that what we now need is replications.
Have you written down a list of principles for replication?
(Mr O'Malley) I have not written those down at the
moment. I have some notes and I could go on at length about it.
At the moment we are involved in a multi-centre project that is
attempting to consolidate all the evidence. In the United Kingdom
in September we shall be having a seminar to put all that together.
There are some simple ideas that are obvious. One is to focus
on what works. The second is not to have a gold standard. When
the evidence points strongly towards something, we should not
wait for everything to be wrong before we improve it; we should
not have all our eggs in that particular basket. Another point
is that there is an association between scale and quality and
if you bring something to a large scale and replicate broadly,
you will see a decline in quality so you should expect that and
do not point to the fact that one or two things have collapsed
or that, as Alan said, 10 per cent of the money has been diverted.
That will happen. What matters is whether, overall, 80 or 90 per
cent is effective, whether it is getting to where its supposed
to go and whether it is happening? It is much easier in a small
pilot project to pay attention to everything so that not a penny
will be misspent and the quality of everything will be very high.
We will not bring things to scale that way so we have to be willing
to make some compromises.
Chairman
170. Is it sensible of DFID to concentrate some
of their effort in the brothels of India and Bangladesh?
(Mr O'Malley) Absolutely. Most countries in Asia have
either what you would call a concentrated epidemic or a low epidemic.
India has a concentrated epidemic; Bangladesh has virtually no
epidemic at all. In places where the epidemic is not generalised,
there is a strong argument that most resources should be focussed
on the populations that are most vulnerable, but also the populations
that are most likely not only to be infected, but to play a role
in infecting others. In large parts of Asia that brings us back
to the stigma question. It means that efforts in brothels, with
people who exchange sex for money or drugs outside brothels, drug
injectors and indeed men who have sex with men in much of Asia
are very important. Those are all politically and socially sensitive
areas. I commend a number of governments in Asia for discreetly
allowing and encouraging such actions, including in Bangladesh
where the political risk of working on issues like men who have
sex with men, drug users and sex is probably quite high. At this
point the government is being remarkably open to not paying close
attention, knowing that somebody needs to do that work.
Chairman: I shall ask Mr Khabra to ask
the question on international community.
Mr Khabra
171. In your opinion, in what area should the
international community concentrate research funding?
(Mr O'Malley) I think that different international
institutions and international funders have different value added
aspects in terms of where to invest their research funding. I
believe that by and large it is important to have an approach
that looks at the needs for today, tomorrow and the day after.
That is not my line—it is someone else's—but it is
a good line. In the past few years I have welcomed the increased
attention to the development of an HIV preventive vaccine, but
I fear that the sexiness of a magic bullet is such that perhaps
there has been inadequate attention paid to funding what can make
a difference today and tomorrow. I point to a couple of particular
points. On the technological side, we need better diagnostics,
both for the infections that people with HIV are susceptible to
and die from, but importantly for sexually transmitted diseases.
I am sure that you all now know of the association between sexually
transmitted diseases and HIV. The diagnostics that exist are difficult
to use outside laboratory settings and expensive. An easy to use
and cheap STD diagnostics system would make a huge difference
and would be easy to develop. Technologically for tomorrow, we
should look at things like microbicides, at better condoms, condoms
that men are happier to use and condoms that women are happier
to use. There is something called an invisible condom, which is
a gel that can turn into something like a condom-like substance
that is under development. Those are all very important things.
That is not to say that we should not invest in a vaccine, but
these things are more likely to come on stream sooner. Finally,
I believe that there is a lot of important research outside the
realm of technology. I shall point to two examples. Right now
in Thailand an insurance company is involved in a scheme where
it lowers group premiums for companies that are willing to implement
HIV prevention and care activities in the workplace. They have
a graduated steps system, where the more the company will do in
the workplace, the lower the group premium goes. That is a very
innovative response, which is obviously driven by profit, but
if it works it is the kind of thing that probably should be promoted
all over the world. Somebody should be—and indeed in that
example someone is—assessing whether that is working and
promoting the results of that research to other insurance companies.
Similarly, there is a lot of rhetoric about involving people with
AIDS in the response. It is important to look at how to do that
most effectively and to promote those results so that people can
do it more effectively. That is what we call operations research.
I think different people have different labels for it. It is important
not to focus just on technology. We have to look at how to do
a better job with what we have.
172. Do you consider that there should be an
international forum for such work?
(Mr O'Malley) That may be a good idea. I have not
thought about it. Creating a new fund with a new bureaucracy and
administration is not necessarily the highest priority. A lot
of mechanisms already exist. Critical thinking about how to invest
those resources and having some kind of forum whereby international
actors can better share information about what they are doing
would be useful. In recent years the UK and the US have improved
their sharing of information and within the EU there is a reasonable
amount of sharing. So the UK is actually a very important bridge
between Europe and the United States. Nevertheless, there is a
remarkable lack of attention to research efforts, for example,
in South Africa, Japan, Brazil or India, in that type of sharing
of information.
Chairman: Barbara Follett will now ask
about DFID's programmes.
Barbara Follett
173. In your work you have criticised DFID's
strategy. Would you like to respond with details of your reservations
about the strategy?
(Mr O'Malley) I do not believe that DFID has had a
strategy for some while. I did not mean to criticise the strategy
so much as to point out its absence.
174. That is why I hesitated over the word.
(Mr O'Malley) Certainly I attempted in my submission
to note that DFID has been involved in funding some very important
work. I believe that. I also believe that within the past couple
of years DFID has improved remarkably. I shall come to that in
a moment. Overall, for most of the past decade, from my perspective—you
may hear different things from officials in the department—DFID's
functional strategy has come out of the Cairo conference on population
development about six or seven years ago in which there was an
attitude that HIV should be integrated into other sexual and reproductive
health concerns and that in addressing other sexual and reproductive
health concerns somehow HIV would take care of itself. That, as
far as I know, was never put out in a strategy paper, but if I
look at where funds went and where staff resources went, that
seemed to be the functional strategy. I believe very strongly
that that is an important part of any strategy, but I also believe
very strongly—and what has happened in the epidemic backs
me up—that that is clearly inadequate. Even now, in 2000,
17 years into the epidemic, DFID is now preparing a draft AIDS
strategy. I am pleased. I am pleased they are preparing it. I
do not know where it has been. Although there has not been a formal
and public consultation process, I have informally seen drafts
of the paper which is under preparation. I continue to have concerns
that within that draft strategy some of the shortcomings of the
Better Health for Poor People paper which came out earlier
in the year are reflected again in the HIV/AIDS strategy. As I
noted in my submission, I am particularly concerned that DFID
seems to refer to civil society as an amorphous mass. If DFID
chooses to use a definition of "civil society" which
includes everything from the media to the for-profit private sector,
to NGOs, to community groups, that is fine, but it is essential,
with limited resources, to say "What roles do different parts
of society play?" and, with limited resources and limited
administrative and human resources, "Where do we invest our
funds to make the most difference?" I believe strongly that
there has been too much generalisation within civil society. If
I were to reduce it to a soundbite, I believe that its informed
thinking seems to be informed by contracting-out culture, in the
sense that there is an acknowledgement that governments may wish—and,
indeed, it may be a good idea for governments—to contract
out certain elements of governmental responsibility to an NGO,
or a for-profit firm or a church. I agree with that, I think that
might be a responsible thing for a government to do, but I strongly
believe that there is a role for different parts of civil society
and a need for a strategy for different parts of civil society
beyond contracting out. I shall give two examples, if I may (and
I know I am going on at length here). First, private sector providers.
In Cambodia poor people—not people with AIDS, poor people
in general—spend over 25 per cent of their disposable income
on healthcare. A large part of that expenditure is on a mixture
of things—on traditional remedies and on "Western"
and modern medicine, often drugs. People with AIDS and households
affected by AIDS spend much more than that. Clearly that can put
the family that is on the borderline of poverty into destitution.
Much of that spending is bad spending; people are buying drugs
or buying products which do not even help them. There is a need
in Cambodia and most of the world to educate people about how
to invest their own private resources rationally, about why not
to buy products which do not work and about why they should concentrate
on products which work and which are cheap. That is just a very
small part, but that is part of what one has to think about in
talking about civil society and AIDS. Quite separately, back to
this question of community mobilisation, NGOs, international NGOs,
capital city NGOs and capital city consultant firms, donors, governments
can have a role in supporting community organisations and churches,
but none of us outsiders are effectively going to be able to change
community norms. As our role—and here I would lump together
people like me, an international NGO, from a consulting firm,
from somebody at DFID—all we can do is that we can encourage
and support effective responses within the community, but if we
go in directly as outsiders we are not going to be able to change
those norms. If you lump all NGOs together and act as if the local
farmers association or youth group is the same as an NGO like
the International HIV/AIDS Alliance, you are not going to have
a very good strategy.
Chairman: Now Mr Colman wants to ask
about the European Community.
Mr Colman
175. Yes, I want to ask about that and the UN.
In your written evidence to us you made a statement saying that
"the Commission"—that is, the European Commission—"seems
to lack the necessary political will, bureaucratic structures
and technical expertise to effectively support community and civil
society responses to AIDS." That is a direct quote from your
submission to us. What exactly is the problem which is causing
this?
(Mr O'Malley) It has changed over time. I should underline
that the European Commission has individuals with strong technical
capacity in AIDS. However, if you look at the entire Brussels
machinery, there are a couple of people whose full-time responsibility—it
is not even their full-time responsibility—whose primary
responsibility includes technical advice on AIDS. This is from
one of the largest donor agencies in the world, which draws on
a couple of individuals who have responsibilities including AIDS,
but other things as well. There was a period of several years
where one of those individuals who has been there a long time
was supported by something called an AIDS task force. That helped
to some degree, because although officially it showed up in the
accounts as grant-giving, basically it was a grant to an organisation
to set up an office in Brussels and provide her with support,
but at least it meant that there were half a dozen people —
I must say, I do not know how many people, but there was a little
team of people—who could critique proposals, provide technical
advice, provide insight and also do some advocacy about why to
pay attention to HIV and how to pay attention to HIV. There is
no way that one or two people are going to be able properly to
advocate for, and advise on, how to spend the amount of resources
which the EU should be spending on AIDS, and that is with a very
narrow definition of the spending which is called AIDS spending.
Again, to go back to Professor Whiteside's testimony, if you then
want to talk about how to make agriculture, education and health
sector reform more appropriate in the context of AIDS, those one
or two individuals do not have a chance. At a country level, there
are a different set of problems—which again I expect you
are largely familiar with—which are not necessarily problems
about AIDS but they affect AIDS, but they are problems which are
broader problems of how the Commission administers and manages
its development assistance budget. Those problems affect AIDS
as they affect other things.
176. We are, of course, going to Brussels on
6 July. Obviously we shall be following up these points at that
time. Perhaps I can then take you on to the wider situation. Do
you have any comments you wish to make about the response of the
multilaterals, particularly the UN family and the international
financial institutions, and whether their work could be improved?
You may want to talk about UNAIDS, as you are part of that network.
(Mr O'Malley) Yes. I believe that UNAIDS, which was
created three or three-and-a-half years or so ago, maybe four
now, has, in a couple of ways, in a fairly short period of time,
I believe, been a significant success. The two ways in which I
believe it has been a significant success are that I believe that
the fact that you are having these hearings, the fact that there
has been so much attention to AIDS recently, after a period of
many years of lull, reflects the success of UNAIDS in its advocacy
role. Again, in terms of causality and evidence, I cannot prove
that UNAIDS has contributed to AIDS going up the public agenda,
but what I do see is that UNAIDS has been at many levels trying
to engage in advocacy work, and that there is now more public
discussion in many fora about AIDS. I believe that UNAIDS has
contributed to that. I also believe that UNAIDS in many countries
is beginning to have real success at fostering collaboration,
co-operation amongst the different international organisations
working on AIDS. That is particularly important as an increasing
number of the international organisations become increasingly
involved in AIDS. The two which I would point to, which in the
last three or four years have really dramatically increased their
engagement, are the World Bank and UNICEF. UNICEF has had some
involvement in AIDS from the mid 1980s, but it was a very, very
small level of involvement until very recently. The World Bank,
as far as I know, had very little involvement even in financing
health until 1993, and only a very small number of loans associated
with AIDS or reproductive health since then, but of course the
President of the Bank has made many proclamations recently about
AIDS being on the Bank's agenda and, indeed, is obviously encouraging
further at least lending for AIDS. I am not sure what the mix
between IDA funds and other funds is. I think it is incredibly
important that UNAIDS helps to co-ordinate and provide technical
backup to those efforts. I have a concern that the Bank particularly
is putting large sums of money into stuff called HIV/AIDS without
necessarily having strategic or technical resources either to
inform the allocation decisions or to support the implementation
of those activities. There are places where different mechanisms
have been developed, and which seem to be working, but I would
say that they are few and far between, with Brazil being a notable
success story for the Bank, but that is largely because the Brazilian
Government had such large and impressive existing capacity. When
the Bank starts loaning to governments which do not have technical
capacity, the question of how to support implementation responsibly
is incredibly important, and the Bank is not well structured to
address that. Overall, I think that the UN family and other international
institutions do have a very, very important role; the Bank because
they are the one institution which has real money outside of governments,
and several of the others because of their fully co-ordinated
role and their technical capacity.
177. We asked Professor Whiteside a question
in terms of the extent to which HIV/AIDS had affected the internationally
agreed development targets. The Social Summit Copenhagen plus
5 is next week. Is UNAIDS going to be represented there? Will
the concerns about the effects of HIV/AIDS be taken into account,
just as an example of how the UN family should be seeing HIV/AIDS
as something which is affecting everything that they are doing?
(Mr O'Malley) The draft text going to Copenhagen has
a great deal—
178. To Geneva.
(Mr O'Malley) Yes, for the Copenhagen plus 5 activity.
The draft text has a great deal of language about AIDS. Indeed,
that is a big change from five years ago. ICPD plus 5—Cairo
plus 5—which happened in New York (I am not very good with
dates) a year-and-a-half or so ago, similarly saw an increase
in attention to AIDS. I was on the UNAIDS delegation to ICPD plus
5. I am not going to Copenhagen plus 5. So I do think that that
has been taken into account to some degree. On the question about
whether the targets have to be revised, you have heard from Alan,
you have heard from others and, no doubt, DFID. Certainly in many
countries who are worst affected by AIDS the broad international
development targets are no longer realistic. In other parts of
the world they are. I also want to point to the importance reflected
from Copenhagen plus 5 and Cairo plus 5 of some kind of specialist
HIV advocacy and technical capacity. Effective responses to AIDS
are not going to be implemented around the world at community
level by AIDS organisations and AIDS programmes. AIDS has to be
connected to people's lives in other ways. Similarly, again government
welfare systems, healthcare systems, education systems have had
broad remits. There is a need for specialist HIV action to make
sure that community organisations, churches, government departments
are paying attention to AIDS and to help them to figure out how
to do it. Most of the implementation—whether that is an
implementation of community responses or delivery of services
or government policy—should be integrated. I actually think
that one of the weaknesses of the Southern African response has
been that the NGO response has been predominantly led by what
are called AIDS service organisations which are specialist AIDS
NGOs. That has meant that the women's groups, the youth groups
and the family planning groups have said, "Okay, that's their
business. We do something else." As long as that segregation
is there, it is not going to work and the AIDS specialist groups
are never going to reach many people. They might provide a very
good service to a very small number of people. One of the things
that excites me so much in Uganda is that TASO went from being
an AIDS service organisation to becoming really an international
intermediary organisation which is a training and advocacy service
to both local government and local community organisations and
other civil society organisations.
179. UNAIDS were involved in that transformation?
(Mr O'Malley) I think that particular transformation
really pre-dated UNAIDS, but it just points, I think, to the problem
with any discussion which says that AIDS should be integrated
or AIDS should be specialised. We need both. We need those specialist
AIDS organisations, including UNAIDS, doing that advocacy, but
UNAIDS is not, I think, doing a very good job of implementing
anything. I think UNAIDS strengthens the advocacy and that technical
backup to other people who can implement it. In the NGO sector
I believe the same; I believe that those of us who are essentially
AIDS specialists must concentrate on advocating for, and supporting,
integration, rather than setting up a bunch of vertical specialised
AIDS interventions.
Chairman
180. You would not be in favour of just putting
money for AIDS into the Department of Health in Uganda, though,
would you?
(Mr O'Malley) Absolutely not. Once again, to give
credit to the Department of Health in Uganda, something which
is interesting is that they themselves started to call for funding
to go to more than themselves. Again, having some specialist AIDS
resources, but also funding elsewhere, absolutely. There are additional
costs associated with making your programme, whether that is an
education programme, or an economic development programme or a
broad primary healthcare programme; there are additional marginal
costs associated with making those programmes AIDS-responsive.
Somehow we have to figure out how those marginal costs will be
met, but I tell you, it is a lot more efficient to pay the marginal
costs of making those programmes responsive to AIDS than it is
to set up stand-alone AIDS services.
Chairman: That is very clear. I think
we would like to thank you very much indeed for coming this morning
and talking to us on this subject about which we have heard from
you before. We value your written evidence, but it has been most
important actually to talk through these questions, and I think
we have gained considerably from it. Thank you very much indeed.
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