A Critical New Juncture

Editor's Note: The following remarks were delivered by José M. Zuniga, President of the International Association of Physicians in AIDS Care (IAPAC), at the opening of the 6th International Conference on Healthcare Resource Allocation for HIV/AIDS, which was held October 13-15, 2003, in Washington, DC.

It is with slightly mixed emotions that I open the sixth of these annual conferences dedicated to convening partners from the broad spectrum of constituencies engaged in the battle against AIDS. As some of you may know, this conference holds a very dear place in my heart since it was under the close tutelage and through the pioneering vision of the late Jonathan Mann that it was first launched in 1997. As I stand here today, therefore, front and center in my thoughts is one philosophical question: To what extent have we truly embraced the spirit of Jonathan Mann's message, placing the fundamental human rights to health and dignity at the core of what we do?

Clearly some progress has been made. Those of us fortunate enough to have known Jonathan Mann before his tragic passing will recall a time when the funding mechanisms that currently exist to harness the collective might of the global community; the array of medicines now available to treat HIV disease; and the political will necessary to effect change were but the imagined columns of a home that he and the earliest advocates in this fight sought to erect.

Several years later, with that home now largely built, it behooves us to examine the mood that has come to reside within that household -- one that we loosely refer to as the global AIDS community -- and to determine what is required if its economy is to be enhanced.

In presenting some brief reflections that might set a tone for the next three days, I want to first recognize the contributions made by so many individuals in this room to our collective struggle. There are many selfless acts that deserve a word of praise -- from the grassroots and community efforts of patient, advocacy, and healthcare provider groups the world over; to the technical assistance and review provided by the World Health Organization, Joint United Nations Programme on HIV/AIDS, and other United Nations and government agencies; to the dedicated individuals who have joined us here out of sheer concern for the alarming spread of HIV throughout the world.

With that said, these very victories, and the web of agencies, organizations, and mechanisms that have been woven as a result, have added layers of complexity to our efforts that deserve critical reflection. We must always ask:

• Is what we are doing merely maintaining the structures of the status quo?

• Or are our actions truly being carried forward in the best interest of those communities that stand to benefit?

We must ask these questions even if the implication of our honest answers is that some structures require renovation.

While my analogy of our global AIDS community to a home and the possibility that we may need to renovate could be inferred as a criticism of the past, this is not what I would intend. Rather, I would like to argue that it is not in looking backward that we should be concerned, but in what decisions we make at this point of the struggle, as we stand at a critical new juncture on the road to eradicating HIV disease and redressing the human devastation wrought by AIDS.

Despite the long road ahead, we should not simply dismiss past successes. Against significant odds:

• we have established robust advocacy, care, and treatment institutions which have propelled forward our efforts in clinical and social research and program delivery;

• we have developed multilateral funding mechanisms which seek to ensure the resources necessary to provide care and treatment to those in need;

• we have achieved consensus around processes and tools necessary to expand access to therapy in the developing world including treatment guidelines, trade agreements, and leading public-private partnerships; and

• we have succeeded in placing this disease on the political agenda in most countries of the world.

These are no small feats, even if they were 20-plus years in the making.

But with these hard-fought battles having been won, and with all of the essential elements of an expanded response to the global threat of AIDS in place -- perhaps with the exception of adequate funding -- the course of action that we assume from this moment forward will speak to the spirit that resides within our home. The critical juncture at which we find ourselves is defined by the successes that I have referenced as well as the unprecedented potential that we now have to truly turn the tides of this pandemic. The emphasis now must be on cooperation.

Whether as leaders and officers from disparate organizations and governments we coalesce around the mechanisms that we now have at our disposal, and cooperate to make most efficient use of funding pledges that may soon be realized, or whether we fragment into a community of competitors may very well be the most important test of our commitment. Signs of funding that are appearing before our very eyes signal an opportunity to alleviate the suffering and despair of countless millions whose fate is in our hands. Thus, the "business as usual" approach to our activities cannot remain. Instead, we must cross both geographic and philosophical borders; forge innovative, logical, and meaningful partnerships; and comport ourselves with ultimate concern for those in whose service we operate, and on a scale that is unprecedented.

In addition to the need to cooperate around the disbursement of scarce resources and in delivery of technical assistance, care, and treatment in regions that are eagerly anticipating rejuvenation, it is imperative that we examine the manner in which we expect countries to cope with the influx of assistance. Where we have a variety of sources of bilateral and multilateral funding for national efforts, cooperation among funders must exist in order to ensure that we are not establishing or perpetuating parallel structures that place an unnecessary and avoidable administrative burden on governments and organizations that are already overwhelmed. Critical in this regard -- and this must touch upon all of our transfers of wealth, technology, and expertise from the North to the South -- we must place countries in positions where they may set the agenda for national efforts based on what is locally appropriate. Of course, it goes without saying that accountancy and evidence-based practice must predominate.

A respect for the technical capacity that exists within countries and commitment to expanding that national capacity should be seen as a logical extension of our respect for the dignity and human rights that must be at the core of our commitment. We must not for one second believe that making available antiretroviral drugs in resource-poor areas constitutes an adequate response, in and of itself, to the AIDS pandemic. Rather, we must ensure quality care for patients along a continuum of support and services. And, we must remain cognizant that a spirit of empowerment and sustainable development must guide our engagement with individuals and institutions on the front lines of this pitched battle.

In our effort to ensure that support reaches every child, woman, and man that requires care and treatment for HIV, we must at the same time cooperate with all agents of social change seeking to ensure access to education, healthcare, and economic opportunity for marginalized groups so that we empower individuals and communities to rise out of spirals of poverty and inequity. As we refocus our attention on the goals which lie in our immediate future -- for example, expanding access to antiretroviral therapy for 3 million people by 2005 -- we cannot lose sight of what lies beyond the horizon. In fact, 3 million people represents a fraction of those who will require care and treatment in the near future, and both our ability to prevent and treat HIV will depend upon the extent to which we appreciate and approach HIV disease from within a perspective of broader development assistance.

All of this, through a spirit of compassion and cooperation, must be the substance of our intentions and our actions as we -- the global AIDS community -- embark upon the next steps of our common journey.

As we prepare for the next stage of our journey, let us remain ever cognizant that not only must our first steps in the battle against this pandemic be taken out of concern for the dignity which it all too often strips from individuals, communities, and nations, but that in carrying forth our efforts we must very conscientiously suffuse them with the premise of dignity and human rights which lie at the heart of our collective dilemma. In so doing we shall be constantly reminded that the needs of those who suffer must come before institutional ego and advancement, and we shall be rewarded in our time by knowing that we have contributed to the preservation and renaissance of communities and nations.

José M. Zuniga is President/CEO of the International Association of Physicians in AIDS Care, and Editor-in-Chief of the IAPAC Monthly.