July 16, 2004
Jackie Judd: Jon Cohen of Science magazine, welcome back one last time.
Jon Cohen: Thanks so much, glad to be more back one more time.
Jackie Judd: The final day of the conference, I think there's general consensus that one of the things this week, is it put the spotlight of AIDS on Asia.
Jon Cohen: Yeah.
Jackie Judd: What difference does that make?
Jon Cohen: It makes a huge a difference for these Asian countries. For one thing a lot of the scientists in these countries, they know what to do but they can't convince their leaders to do it. So to have others saying to them do it, do it, do it ...
Jackie Judd: And saying it to them literally in their faces ...
Jon Cohen: In their faces, right. And to see world leaders doing it in their faces, that really makes a huge difference.
But there's another thing that is really the power of this conference being in a certain locale. You have Asians mixing with Asians in a way that they don't normally mix. They're meeting each other, and they're meeting the people from other countries as well, you know you walk around the halls here and it's like an international airport mixed with sex workers and injecting drug users who are prominent about the fact that that's what they do. And it's a fabulous colorful array of people from every nation. And the monks in their saffron robes and the African tribal leaders in their headdress, it's just a beautiful sight, to me, of the diversity of the world. When it's in your continent and you're the host it makes a huge difference.
Jackie Judd: And is it true then that some of the ideas that were exchanged here among those from Asia, it couldn't have happened in any other way? It wouldn't have happened?
Jon Cohen: You know it's really weird Jackie, because in a lot of Asian countries even though they're bordering, they just don't cross the borders. They don't visit each other. They need to talk to each other; they need to learn from each other. That's the big challenge right now is people don't know how to do this, they know that drugs exist, they know that they can now even get them from their governments, but they don't really know how best to run a national roll-out program and they need to talk to each other. They need to talk to each other. They need to learn from each other's failures, from each other's successes and the same is true with prevention. If you look around Asia the prevention campaigns in each country are remarkably different. They need to say, "Who's having success? Who's failing? Can I call you up, can I email you?" That kind of stuff. And the main thing you see here when people meet is a business card.
Jackie Judd: In the closing ceremony every leader who spoke had a slightly different take, a slightly different emphasis about what occurred here in Bangkok. Helen Gayle, from The Gates Foundation, who is the incoming President of the International AIDS Society, said that one of the great lessons was one size does not fit all. What does she mean by that?
Jon Cohen: The epidemic is extremely different in each place, in each country, within each country, within regions. And you have tailor make both treatment and prevention plans for the place.
I'll give you very quick example. Asia has injecting drug users. Heroin doesn't exist very much in Africa. Africa has very high prevalence rates in many countries. You can't target a high-risk group when 50% of the women in a pregnancy clinic are infected. What's the high-risk group? So, your strategies completely change. And that's what one size doesn't fit all means, ultimately. You can't have one response to this.
Jackie Judd: And is that really something that until Bangkok wasn't as thoroughly understood by as many people as it may now be?
Jon Cohen: That's a big change, I really think so. I think the epidemiology has become clearer of how the spread is occurring and the differences between places. I think the notion of how best to proceed with this new pile of money has forced people to see that. And what it talked about earlier about activism becoming more fractionalized. Activists all used to have the exact same agenda, "We're dying, get us drugs, act up fight back, you're not doing enough." Well that's not the world here any longer.
Jackie Judd: You mentioned a pile of money. And one of the biggest piles of money is the Global Fund, which this week seems to have emerged as something as a star, really. This new funding mechanism to get money out to countries, to communities, in a way that was different from other funding mechanisms. And it also seems to mirror Helene Gayle's idea, "One size doesn't fit all."
Jon Cohen: That's right, it moved to center stage here. In a way that it hadn't the week before the conference. And that's one of transforming things about this conference, it can put that stamp of validation on something. There's a round consensus here that the Global Fund should be the centerpiece of how to distribute money. And the reason gets at the "one size doesn't fit all" because the way you get money from the Global Fund, is you tell them what you need, you tell them how you're going to spend it.
Jackie Judd: It's not imposed from the outside in.
Jon Cohen: Exactly and it's a radical shift. In the history of public health, there's been nothing like this, we've always had rich countries helping poor countries, or some foundations doing prominent things but it wasn't a complete program where you know, if you want money for South Africa you've got to get, all the activists on board, you've got to get the doctors and nurses, you've got to get the whole thing together first before you ask for it.
Jackie Judd: And along with the emergence of the Global Fund came the reemergence I should probably say, of criticism directed at the United States. Which under the Bush Administration is a significant donor to the Global Fund but more significant amounts of money are being spent unilaterally to these countries. Does that help explain the degree of criticism that we heard?
Jon Cohen: It does, I mean I think there's a big rage and anger at the United States for things that have nothing to do with AIDS.
Jackie Judd: Right, you and I both heard this discussion and some of its anger towards Iraq.
Jon Cohen: Yeah, and it gets mapped over. It's anger towards Iraq and this is an international community. You know the United States every loved everywhere for what it's doing in Iraq. And people are angry about that. And so when they see the Bush Administration doing anything they're highly critical. Now on the other hand, scientists are highly critical whenever politicians steer things away from the data. And politicians in each country do that, it is certainly happening with the Bush Administration, they have been heavily criticized for that. So that's another part of the anger. So there are these two things that meshed here that make things explosive, that otherwise I think the tenor would be somewhat different.
Jackie Judd: Also at the closing ceremony, Jon, Graca Machel, Nelson Mandela's wife and activist in her own right read the Leader's Closing Declaration. It seemed to me that they really fell on their swords here. "We have failed you," and "we hope not to lose credibility in the future." "Bangkok has to be an end of promises made, promises broken." What is that tone about?
Jon Cohen: There's been a lot of apologizing this week by leaders. And we have to think for a moment about when rich people got access to good treatment. It was in 1995, 1996, well we're in 2004 that was eight goes. Most of the HIV-infected people in the world still don't have access to good care. So the community of leaders and scientists and researchers -- medical researchers -- who want to do good and make pronouncements about how they are doing good, has failed. The people most in need don't have what they most need.
Jackie Judd: But is this a tone that has been struck at other conferences or is this something unique?
Jon Cohen: It has, but it's growing louder as time passes. You know, people are watching the watch now.
Jackie Judd: Uh-huh.
Jon Cohen: And they're saying "Come on. We've had something now in our rich countries for eight years." I mean how long does this have to go on? What's it going to take?
Now I can't blame, I'm not blaming the rich countries and I'm not blaming the doctors and the leaders. The countries themselves have failed as well, the developing countries that need help, their leaderships have failed. But we've seen massive change in the last year, especially in Asia. I mean China really has completely changed their tone. India has changed. Both countries announced roll-out programs this last year. So, we have to look at, I think, everyone being responsible for the failure.
Jackie Judd: And one of the promises made was through the World Health Organization last year when they announced 3 by 5, three million people on ARVs by 2005, at this moment they estimate that about only 440,000 are on ARVs and to my mind there seems to be an unspoken acceptance that that goal, in fact, is not going to be met by the end of next year.
Jon Cohen: Public health has a tradition of setting targets that they don't hit. And at the end of the day they say to themselves, the leaders in public health, well we brought in more people because we set the target so high. I think it's going to be remarkable if they get that target. It seems to me that ...
Jackie Judd: But does it further undermine the credibility of public health leaders if they set this goal and they don't meet it?
Jon Cohen: It doesn't do anything for their credibility. And on the other hand maybe they'll hit it. Who are we to judge right now? It doesn't look like it's going to happen. And when I've been in countries in the last year in Asia that have new big national roll-out programs, things aren't going so well, because it's really tough to train the doctors you need to train. You know, it's really tough to get the equipment to monitor people's immune systems and to teach people how to that and how to fix the machine when it breaks. The logistics of this stuff are really scary and when you start treating people they have side effects. And then dealing with that issue, just takes people completely by surprise. Even though those of us who followed it for awhile can expect these things, they don't in the rural village Hunan Prop.
Jackie Judd: Right.
Jon Cohen: It doesn't happen that way.
Jackie Judd: Jon, a final question. And I'm going to ask you to do a little bit of predicting, two years from now, when this conference is held in Toronto, Canada, how do you think the AIDS epidemic will be different than it is at this moment?
Jon Cohen: One of the things, I've been covering AIDS now for about 15 years, and one of the things I've learned is that every time I try to do that game, try to make that prediction, I'm wrong. The world's moving too quickly with AIDS, it's an exceptional disease. Huge things happen that come out of nowhere like the Global Fund or The Gates Foundation. The time that I've covered this disease, those two things have come to existence. They've completely changed the world. I suspect in the next two years, my prediction is something else will pop up that none of us here can think of right now, that will completely change the equation. That's my prediction.
Jackie Judd: On that note, I'll thank you for a really wonderful week. Thank you so much everything.
Jon Cohen: Jackie, it's been great pleasure doing this with you.
Jackie Judd: Jon Cohen of Science magazine, thanks.
Jon Cohen: Thank you.
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