The Crisis at 25: Women and the Fight Against AIDS
To recognize World AIDS Day and the 25th anniversary of the first HIV/AIDS diagnosis, the World Affairs Council welcomes Dr. Helene Gayle, President and CEO of CARE, and one of the world's foremost authorities on the HIV/AIDS pandemic, to discuss the impact of HIV/AIDS on women.
As a doctor with global experience in HIV and AIDS, a woman of color and a well traveled and well informed citizen, Dr. Gayle is in a unique position to speak about the impact of AIDS on women and what must be done to stop this trend. She speaks to how average US citizens can help women around the world overcome these vulnerabilities through a comprehensive response that empowers women. Dr. Gayle argues that women and girls must be at the forefront of preventing and treating the disease, not only because they are disproportionately infected and affected by HIV and AIDS, but also because their potential to bring about social change is powerful. - World Affairs Council of Northern California
The World Affairs Council was founded in 1947 out of the interest generated by the founding of the United Nations in San Francisco in 1945. With over 10,000 members, they are the largest international affairs organization on the west coast.
John Diaz is the Editorial page editor for the San Francisco Chronicle.
Dr. Helene Gayle
Helene D. Gayle is president and CEO of CARE USA. An expert on humanitarian issues, Gayle previously held senior positions with the Centers for Disease Control and the Bill & Melinda Gates Foundation. Gayle serves on several boards, including those of the Rockefeller Foundation, Colgate-Palmolive, and the US Department of State’s Foreign Affairs Policy Board. She is also a member of the Council on Foreign Relations, chaired the Presidential Advisory Council on HIV/AIDS, and currently serves on the President’s Commission on White House Fellowships.
The council is very pleased to welcome Dr. Helene Gayle to discuss the impact of HIV/AIDS onwomen and what we can do to fight the disease with us this evening. Dr. Gayle is the president andCEO of CARE, and responsible for providing overall leadership, management, and direction to one ofthe world's premiere humanitarian organizations.With programs in approximately 70 countries, CARE serves individuals and families in the poorestcommunities in the world to help them expand the control they have over their own lives and toadvance positive, enduring social change. The organization's work fighting poverty reached 48 millionpeople in 2005, helping them gain access to health care, education, safe water, and improved sanitation,and to help them recover from disasters. Regarding HIV/AIDS more specifically, CARE operatesmore than 150 programs addressing the disease in nearly 40 countries, reaching millions of people andhelping to prevent the spread of the disease.Dr. Gayle has been working in the HIV/AIDS and public health field for more than 20 years. She isthe immediate past president of the International AIDS Society, and recently co-chaired the TorontoInternational AIDS Conference. Her experience spans Africa, Asia and the Americas, and includesnumerous high-level positions at the center for disease control, the US Agency for InternationalDevelopment, and the Bill and Melinda Gates Foundation. Dr. Gayle received her MD from theUniversity of Pennsylvania, and is board-certified in pediatrics. She also holds a Master's degree inPublic Health from John Hopkins University, and a Bachelor's degree from Bernard College atColumbia University. Please join me in welcoming Dr. Helene Gayle.Well, believe me, I only tapped the very highlights of Dr. Gayle's extensive resume and biography,she's really had a remarkable career, and in reading some of the background in preparation for thisevening, Dr. Gayle, I was struck by an anecdote in one of the profiles about when you were in medicalschool, and you talked about how during your youth, you had a very strong sense of social activism.And you listened to a speech when you were in medical school that made you decide, "I don't want tojust treat individuals, I want to eradicate poverty off the face of the globe." Tell us about that incident.Well, this is when I was in medical school, and I went to one of my brother's graduations, and thespeaker at that graduation was Dr. D.A. Henderson. He was one of the people who helped lead theworldwide campaign to eradicate smallpox. And at that time I had been toying with the idea of publichealth. I had some sort of a vague notion that public health was in fact the intersection betweenmedicine, the treatment of individuals, and kind of the broader societal look at health, and you know,but I hadn't had a lot of opportunity to be exposed to public health, but when I heard Dr. Hendersonspeak, for me it was one of those "a-ha" moments where you say, wow, this is what I'd like to do, youknow, something where as a result of the collective action of people, you do something as wonderful aseradicate a disease off the face of the earth.And you know, most of us in this room have never seen a case of smallpox, but it was debilitating, itwas humiliating for many people, and it was a cause of a lot of human suffering, and by people comingtogether, they were able to eradicate this disease off the face of the earth. And I think that sort of senseof collective action, and the ability to take a problem and really solve it in that way kind of crystallizedfor me what I wanted to do.Of course you're not the first person in their youth to think about changing the world. Looking back,did you have any idea of either the scope of what you were taking on, or in some ways themanageability. I mean, you look at the work that you do now for CARE,some of these things of eradicating poverty are possible.Well, it's huge, obviously. I've worked in HIV, that's a huge problem, now I've taken on eradicatingpoverty, I mean, that's a huge problem, but I think one of the things that does come, when I wasyounger, you know I think like all of us you have this sense that I'm going to single handedly take onthese issues and make a difference, and I think as you grow older and recognize that change doesn'tcome necessarily in a revolutionary way, change comes in an evolutionary way.And it's really by working together and looking at how do you work smarter and more collaboratively,how do you work in partnerships, and how do you take on bite sized pieces of a problem so you reallycan see the changes occurring and see that you are actually accomplishing something, and recognizingthat it's those steps, step by step, that in fact by cumulating change, ultimately we can make adifference, and I think the work we do at CARE, where we work at the community level and you cango out to the areas that we work and actually see how individual change by giving a woman access tocredit, and being able then to send her children to school because she startsa business, and then those children learn and change that generation.And it's that sort of change that you see you create a virtuous cycle, it really does have an impact onindividuals, ultimately on communities, and that's the only way thatwe're going to have an impact on nations and ultimately change our world.Of course the theme of tonight's program is tied in with World AIDS Day and much of your career overthe past 25 years or so has been focused on AIDS. You've often said that AIDS chose you. Explain,how did you get involved in working on HIV/AIDS.Well, HIV was just becoming a major problem when I went to the Centers for Disease Control. WhenI first went there, in fact, many people told me to stay away from HIV. They said it was this kind ofstrange disease, and like so many other things, we were going to solve it within a year or so, so whybother, why don't you go do work on something that really is important.Obviously, I didn't take that advice and realized that not only was HIV an important public healthproblem, but in many ways I think it's one of the defining humanitarian issues of my generation, of ourlifetime. I think what we do about HIV and AIDS in many ways will say a lot about who we are as ahuman community. So in many ways, I think it has defined a lot of my thinking about myself, mycareer, and has shaped a lot of what I have ultimately done with my life.I'm interested in the atmosphere that you found in the reaction at the Centers for Disease Control toAIDS, hearing more about that, during that time, there's obviously been a lot written, including my latecolleague from the San Francisco Chronicle, Randy Schultz, about the slow federal response to theAIDS crisis. Maybe you can give us a sense of some of the things that you saw that were eitherfrustrating or possibly heartening, some voices at the Centers for Disease Control at that time.Well, I think the frustration is in fact that this was and still continues to be, to a large degree, a diseasewhose hallmark is shame, stigma, discrimination, and denial in many ways. I think we as a communityin this country and clearly around the world have denied the importance of this disease because itaffects people that we don't want to talk about, or it affects issues that we often don't want to talk about.Drugs, sex, and things that we as a society and people around the globe have a difficult time dealingwith, and so I think the fact that we took too long to really mobilize the resources, mobilize the politicalwill to do something about it, in this country and around the world.By the time you know you have a problem with HIV, it's almost too late to have the kind of impact thatwe could, and now when we think about how long it took to mobilize the resources for the globalepidemic, had we spent even half as much as we spend today, we could have had a huge impact onslowing the spread of HIV around the world, and now we have 40 million people living with thisdisease, and 4 million new infections occurring every year. And the age of people getting HIV isgetting younger, 50% of people acquiring HIV are under the age of 25 years of age, it's becoming, it'sincreasingly affecting women around the world. 50% of new infections are occurring among women.And so we waited too long in this country, and around the world. The flip side of that, and you'd saythe heartening thing, is that what it has done, where people have banded together to make a difference,it's made communities better and stronger. It has made people face their own sense of stigma,discrimination, homophobia, fear of addiction, all of those issues, I think, have really, whencommunities have banded together, they've become stronger communities and better communities, andI see that around the world, and that to me is heartening.When you talk about this lost opportunity, which you do a lot in speeches and as you have tonight, youtalk about how because of the slow response, it's so much more expensive now to be treating thesesymptoms than if it was taken early on. What do you think might have been possible if we collectivelyin the United States or in the world had a more assertive response, is it conceivable that the diseasecould have been eradicated? What is the extent of the loss that you're talking about?Well, I think it's hard to say, you know, it's a hard disease to eradicate. But it is a disease that isessentially 100% preventable. We know how to prevent it. It doesn't run up and snatch you. This is adisease that we know how to make a difference, and we haven't. And in this country, while we have farfewer infections than we had at the height of the epidemic when a range of a hundred, hundred and fiftythousand new infections were occurring every year, you know,now we're down to 40,000 new infections.Well, that's still 40,000 too many infections in a country as rich as ours with the kind of resources thatwe have, and we still have people who go untreated. We're a rich nation that should not happen andwhen increasingly the people who are affected by this epidemic are poor, Black, brown, and woman,there's something wrong with that. And so I think there's a lot that we need to do in this country to getthe information, the programs, the resources out to the people who need them the most, and showleadership here in our country which will go a long way toward helping on the global fight as well.Now you speak of how in this country the changing nature of the disease and the infection rate in termsof the populations that it's hitting has impacted as well. I remember it was what, in the early 1990s, wehad the International AIDS Conference here in San Francisco, which I suspect you probably attended,and it was such a matter of great public attention. One of the words that I hear from folks who workwith HIV/AIDS, is there's a certain AIDS fatigue out there in terms of public concern, in terms ofpublic awareness. Have you seen that? And if so, how do you overcome that?Well, there is, and I think the fact that we have better treatments has been remarkable, the death rates inthis country have gone down dramatically, people's lives have changed dramatically, people whothought that they would never work again are working. So the quality of life, the length of life, hasincreased, but what I think it has also done, unfortunately, has led us into the sense of complacency.And so we think that having HIV is no longer serious, and it is still serious, and it is still better toprevent somebody from getting HIV infection than to treat after the fact.Again, I think the fact that we have better therapies and they are more available to people istremendous. But we can't treat ourselves out of this epidemic, we can't treat the epidemic away, wereally have to look at a comprehensive approach that still focuses on keeping as few people as possiblefrom getting infected with HIV to begin with, and then make sure that we have all treatments and careand support available for people who are infected. And that's what we're not doing. Just like we dowith everything else in this country, where we wait until the disease occurs, we aren't a preventivethinking society, we don't put the focus on keeping people from getting a disease to begin with,whether it's HIV, whether it's heart disease, whether it's obesity, we are not a preventive thinkingsociety, and I think we have become complacent with this disease.Part of it is the focus has shifted to the global epidemic. And that's a good thing, because that's wherethe burden is greatest. 90+%, 95%, of new infections are occurring outside of our borders. But thatdoesn't mean that we shouldn't take the same responsibility to make surethat we continue to keep the focus here in this country.I'm interested in your position as somebody who travels the world a lot and sees the effects of AIDSelsewhere. You mentioned the sense of complacency in the United States and the perception, withsome merit, that HIV infection is not nearly as serious as it would have been before some of theseretro-virals were available. What about going to these places where they're not available? I mean thatmust be a great point of frustration for yourself, but there's also some controversy as to whether that isreally where the emphasis ought to be versus prevention. Whatare some of your thoughts on the international aspect of AIDS?Well I think it's hugely important to get therapies to people around the country. Around the globe.There's a range of 8 10 million people today who need anti-retro-viral therapy and about 2 millionpeople have access to it, so there's still a huge gap. And I think we should do all that we can as a worldcommunity to keep people alive, when we know what we can do to make a difference. You know, Ithink of it as one of the best ways of orphan prevention, if you will, it's still a prevention strategy in thatsense, because there's 16 million children orphaned in Africa today. Those numbers are going tocontinue to increase in Africa, they're going to continue to increase around the world.Economies are suffering because the work force is losing its key workers, HIV hits people in the mostsocially and economically productive years of their lives, so we ought to do all that we can to get lifesaving anti-retro-viral therapy to people who are living with HIV around the globe, and there's a lot ofeffort going into that. On the other hand, it is still, as I said before, the goal ought to be to reduce thenumber of HIV infections to as few as we possibly can, because again, we will never be able to keeppace with the number of people needing treatment if we don't slow the spread of HIV. 4 million newinfections occurring every year. We only have 2 million people on anti-retro-viral therapy, and that'staken us this, almost ten years, to get to that point. So we'll never be able to keep up with the pace ofthe need for treatment, if we don't slow the epidemic to begin with,and ultimately, that ought to be our goal.You mentioned earlier some of the cultural barriers that you need to overcome, some of the economicbarriers, what's your sense, especially on prevention in someof the developing countries, is there progress being made?There is progress being made and I think the good news is that there are more and more countries thatare starting to report slowing of the spread of HIV. In Eastern Africa, for instance, in countries likeKenya, people are, they're now able to start reporting the slowing of new HIV infections. In a countrylike Haiti, that has, in the Western Hemisphere, some of the highest rates of infection, now starting toreport declines in HIV infections, Cambodia, countries in Southeast Asia, so the good news is that inthis disease, there is a clear correlation between resources, programs developed, and the slowing of thespread of HIV, or the slowing of death with access to anti-retro-viral therapy, so there is a clearcorrelation between input and output, and I think that's the good news.On the other hand it is hard, it's tough to change behaviors, it's taken us decades to change smokingbehaviors in this country and around the world, and that's an easier habit to change than sexualbehaviors, so it's tough. Behavior change takes awhile, it's more than just giving people information,and I think it's important to remember that individual behaviors take place in a broader social context.So while people may have information, and may have the desire to make a difference in their behavior,if in fact you end up putting yourself at risk, at a sexual risk as a woman, because the only way that youcan put food on your children's plate is by exchanging sex for food or other commodities and that's thereality of your life, then it doesn't matter if you know that you may put yourself at risk for HIV for adisease that may kill you in ten years if you're preoccupationis putting food on the table of your children today.So we've got to look at what are the underlying causes, why are people at risk, does a woman have theright to say no in the context of a relationship when she knows that her husband may have had outsiderelationships that put her at risk, but she's not in the position to say no to sexual intercourse. So youknow I think we have to think about the fact that individual behavior does take place in broadercontext, and we've got to look at those issues as well as making surethat we support individuals with information and services to change behaviors.We're talking about some of the good work that's being done on the ground. Maybe this is the editorialwriter in me, but I want to know, where is government and people in power getting in the way. Maybewe should start with the United States, actually, and the Bush White House, I mean you've been criticalat some points about some of the emphasis on abstinence or their resistanceto having US funding go toward sex education that might be critical in preventing.Well again, and you know I actually think that what President Bush has done in the initiative to get 15billion dollars into the global fight against HIV has been tremendous. I think the flip side of that,though, is that the policies that went along with it were sometimes narrow. And so a policy that says athird of prevention dollars must go to abstinence programs doesn't necessarily look at the reality ofpeople's lives. If you're not in a position to abstain because you're forced into an early marriage, or youare in a situation where you may be faithful, in fact, increasingly, women around the world, if you lookat the profile, the profile of women who are getting infected with HIV, often is a monogamous womanwho's only had one sexual partner, and that sexual partner happens tobe her husband, but it's the husband's behavior that puts her at risk.So I think that when we look at programs that are narrowly prescriptive and don't look at the reality ofpeople's lives, then we put people's lives at risk. When we have policies that say to countries, "Youcan't make the decision about how you spend the money, you can't develop programs that relate to yourneeds, because we have a particular prescription," I think that takesaway from the effectiveness of the programs.I was interested, you had a comment talking at one point about CARE's mission in a story I read whereyou were talking about, one of your goals is to basically equalize the value of life. Whether we'retalking about here in the United States from inequities in society or around the world, talk about that,because that seems to kind of fit in with your vision of using public health for social justice.Well, I guess if we look at every life as having the same value, then we would be much more generousabout what we do as a nation, I think we would be much more forthcoming about the way we do ourprograms, if we thought about each person, whether they live in this country or around the globe, andthought that their lives had equal value. And so I just think that that is empowering, if you will, torecognize that all life has equal value, and we ought to do whatever wecan as a rich nation to make that a reality.Talking about moving from the Gates Foundation, where you worked for what, 14 years?No no, the Gates Foundation hasn't even been in existence for 14 years!but going from the Gates Foundation to CARE. As you put it,from the other side of the check. Talk about that.It's a phrase that people in philanthropy often make, but my whole career has been as either agovernment donor or as a private donor in philanthropy, so this is my first opportunity to be on the endof raising money. But you know in many ways, I don't find that it's very different from what I've doneall along, where what you do is to talk about the things that matter to you.And whether it's being a government donor and talking to Congress about raising our budget or talkingto, convincing Bill and Melinda Gates about the ideas that we thought were important, or convincing anindividual donor who supports CARE. It's really about talking about the things that you believe in.And so for me it's really continued to be talking about the things that matter to me and that I believe in.Going from the Center for Disease Control to Gates to Care seems almost seamless when you talkabout your philosophy of how health care and poverty are interrelated,how health crises and poverty are interrelated. Talk about that.Well, you know, as I've often said, poor health is both a cause and a consequence of poverty. Thosewho are poor have less good access to health and health services, but if you have poor health that alsohelps to continue the cycle of poverty. If you have poor health and you can't work andyou're absent, you're not able to be as economically productive, in the flip side.So I think they're very interrelated. The reason I went into health to begin with is because I saw it as aconcrete way of helping to address social inequities. So I think they are very interconnected. Many ofthe reasons why people have poor health have as much to do with their economic status as their socialstanding in their community, and other factors, and not alwaysjust that direct causative agent, if you will.You have often said that whether the issue is AIDS, or whether it's poverty, that the key to makingprogress is mobilizing women. Why are women the key here?Well, I think first of all, because women are a huge untapped resource around the world. But alsobecause women, we in many ways have impoverished women. Women make up ÃƒÆ’Ã¢â‚¬Å¡Ãƒâ€šÃ‚Â¾ of the people whoare living in most dire extreme poverty, women have less good access to education make up the largestproportion of those who are illiterate around the world, have less good access to health care, healthservices, die needlessly from childbirth, and so if you look at any statistic, social or economicor health statistics, women are always disproportionately impacted.On the other hand, we know that if we affect a woman's life, you don't only help that women, but thatwoman's child is affected. If you educate a woman the health outcomes for her children are improved.The chances that her children will go and get an education are improved. And that just starts a virtuouscycle. So if you help improve the lives of women, women re-investin their families and in their communities.And you can have the greatest return on investment if you will by investing in women. So I think westrongly believe, our 60 years of experience show us that by investing in women, you can have thegreatest impact on making a difference in communities and societiesand ultimately I think that's the real solution for changing our world.I'm wondering in your position certainly you--There's one friend of mine who said, you know we've let men mess it upfor long enough, why don't you give women a chance and see what happens.More applause. Um, in your position, you run into, you have, you're at conferences with Bill Clintonone day, the next week you may be out in Bangladesh or whatever looking at the effects of poverty.Are there particular moments that have been as you've seen it transformational in your career, whereyou've seen something that's changed how you felt aboutparticularly poignant moments, come to mind?Well you know I have had the opportunity for lots of poignant moments. And you know, for me,seeing the reality that the kinds of programs that we run and support up here really do make adifference at a really fundamental level. And so as an example, when I was in Guatemala not too longago, and visiting with a group of women who are part of an empowerment circle that get together andjust talk about really basic concepts that they just have not been exposed to as women who were noteducated, didn't have access to education or economic opportunities.And in one of these groups I talked to a woman who said, you know, "Before joining this group andbefore having a chance to talk to women and share our experiences and really learn what rights wehave and why we can make a difference in our society, you know, I didn't have much of a sense of afuture. Now, when I look into the mirror, I see a woman with a future. And nobody can ever take thataway from me." And I think those kinds of moments where you realize that you really do changepeople's lives in really fundamental ways, you change the way thatthey think about themselves, you change their opportunities.You know, another project that I visited when I was also in Guatemala was a project that combinesmicro-lending with girl's education. So if you're a woman, and this is in the Mayan community wherewomen were not formally sent to school, they, women could take out loans to start out businesses ifthey sent their girls to school. And so they were able to send their girls to school, the young girls thatwe talked to had this great sense of pride because now they were sitting in schools just like theirbrothers, they started feeling a different sense of value, a different sense of possibility, the motherswere able to take out loans and start businesses, they were able to put that money back into thefamilies, you know, the girls got education, families were able toincrease their productivity, start new enterprises.And it really just starts a whole different cycle, as I said, not only for that woman but for the wholefamily. You know, the women say their husbands look at them differently now. Their husbands seethem as contributors to the family. So it really does set a whole newdynamic and you see that you're changing people's lives.I'm going to want to go to audience questions in just a moment, but before we do, there was onequestion, as I'm hearing you talk about some of the incremental, very difficult good work that you'redoing, it makes me really realize the magnitude of what you're trying to do. I'm wondering, Dr. Gayle,if I could, if we could wave a magic wand and put you in charge of the world for a day, which readingyour biography, might not be a bad idea, what would you say would be the essentialsteps that the world in a global commitment could take to eradicate poverty.Well I think the thing is that there is no one step, and it really is a comprehensive collection ofactivities that have to happen. And we look at it as kind of three different levels. One, you have towork on basic human services, and basic human conditions. So if people don't have food, and if theydon't have education, if they don't have shelter, access to economic opportunities, they're not going tobe able to change their lives. But at the same time, if they are living in an environment in a failed state,with bad governance and corruption, no matter what they do, they're not going to be able to make adifference, and if they're socially isolated or don't have equal status in their community like womenthroughout the world, marginalized populations, minority populations in communities, if you don't lookat people's standing in their societies, all those other things don't matter either.So it's really looking at the interaction between helping individuals, looking at people's places insocieties and then looking at the enabling-- the environment in which they live, and the interactionbetween all of those, and I think if you don't look at all those different levels, you're not going to beable to make a difference and ultimately have the impact on poverty that you want to have.Great, well, let's go to some audience questions.