David Gartner, Policy Director, Global AIDS Alliance; Peter McDermott, Chief, Global HIV/AIDS Programme, UNICEF; Sara Sievers, Director, Orphans Initiative, Association François-Xavier Bagnoud; Chung To, Founder and Chairperson, Chi Heng Foundation; Steven Wang, Founder and President, China AIDS Orphan Fund

Welcome remarks and moderated by Nafis Sadik, UN Special Envoy for HIV/AIDS in Asia and the Pacific

Nafis Sadik: Thank you very much. It’s a pleasure to join you here tonight for this very important program on the next aids generation: orphans in Asia and the world. I am very pleased to be part of this program of the Asia Society, especially as the Asian social issues are very important and especially now HIV/AIDS.

Asia with its huge population—two-thirds of the world’s population—has the second largest number of total number of cases in the world of HIV and India which has an estimated 4 million HIV, the second largest number of any country after South Africa. So you can see that Asia is the region where in fact the epidemic can take on very huge proportions in terms of numbers, not necessarily in terms of prevalence levels. But you know very low prevalence level in Asia can be much higher numbers than what you see today in sub-Saharan Africa. And as we know the epidemic takes a very heavy toll on children in Africa. We know that half of all new infections are occurring amongst young people. There were estimates not too long ago of 13 million orphans but that has been surpassed, as you will hear from Peter Mcdermott today. And children who are orphaned by parents who have contracted the infection and the full-blown syndrome are much more likely to suffer all kinds of risk and are so vulnerable: they are exploited both sexually and otherwise and they are very likely to get infection, especially in high prevalence countries.

Peter McDermott: Good evening everyone…Let me pay my thanks to the Asia Society for not just inviting us but really putting on this evening. I think it’s both very timely and increasingly a very important subject. I’d also, if I may, just take a second to really pay tribute to Nafis—her leadership both as when she was the executive director of UNFPA and recently, the last few years, as the Envoy for Asia, has been really wonderful and they are not easy days for the UN, and they’re not easy days for issues to due with sexuality, in particular in many countries where, in particular in south east Asia, where cultural norms are not always comfortable in dealing with a subject like this. So Nafis, if I may, on behalf of UNICEF and all of us working in this field, thank you.

The situation globally for HIV/AIDS is disastrous and people get tired of me saying that the worst is yet to come. I think predominantly we’ve always been focused on sub-Saharan Africa and truly sub-Saharan Africa is currently bearing the brunt; whether it’s in HIV/AIDS infections, the number of deaths, whether it’s the number of children that are dying. Sub-Saharan Africa represents about seventy percent of those grim and increasingly dire statistics.

But I think that we really have to start by saying one thing: that HIV/AIDS is increasingly an urgent global problem. I’ve just come from London this afternoon and we were talking this morning with British government—HIV/AIDS is increasing. Last week we were in Dublin, with the Irish EU presidency and we were talking about the 5000 percent increase in HIV/AIDS in some of the session countries to enlarge Europe—Estonia, Russia, Ukraine, and countries where we have a severe problem. We were talking very hypothetically about a second wave of HIV/AIDS. I think we need to talk about, now, the third wave. I think the second wave is with us.

And I think that we need to focus this evening on what then is the potential impact really, now, and potential impact, in the future, on children. In some ways we have not focused empirically on the evidence in Asia, the numbers are still for the most part quite small, and some of the data especially for some of the bigger countries has been challenging to get, especially in China and India. But whether its China, India, Thailand, Cambodia, Vietnam, Papua New Guinea, I think it’s quite clear that the impacts are larger and getting larger and as I keep saying, and the worst is yet to come.

But I think we need to be quite realistic. We need to understand that, as in sub-Saharan Africa, there is not one HIV/AIDS pandemic. There are really some quite key differential, biological, social, economic determinants which we can use as predictors for where we will have a major pandemic and, if so, how. But on the other hand, I would like to urge some caution: in 1992, in southern Africa, in fact, in South Africa, just before the transition from Apartheid, to the new rainbow coalition, South Africa had a rate of about two or three percent. It wasn’t really clear because the analysis was unavailable in particular in some of the black population areas. But who would of thought that between 1992 and 2002, a decade, South Africa would become the area of the world with four million people infected and some of the highest increased death rates due to HIV/AIDS and a reduction in life expectancy and an increase in child and infant mortality so dramatically? And yet other countries are now, at least in terms of percentage terms, surpassing that: Swaziland, Botswana, and etcetera. [These countries now] have higher national prevalence rates.

But I am not suggesting that we will necessarily see such vast growing and aggressive HIV/AIDS pandemic in South East Asia. But already globally, an HIV/AIDS pandemic in Asia will impact in a much more significant way because of the difference, between the percentage increase of one percent in India or china, will dwarf anything that we have seen to date in sub-Saharan Africa. We already have between 2.8 and 3.2 million children who are being born positive every year. The current projections and the new projections, that will be out shortly from Children on the Brink, will indicate that we have 14 million orphans due to HIV/AIDS currently and that, conservatively, 25 million by 2010. 11 million of those are currently in sub-Saharan Africa.

But there are a couple of other dimensions I think we need to bring out: one is that the pandemic, in Asia as well as most other parts of the world, is young people. Of the 6,000 people currently getting infected every day, half are young people. Increasingly there is a female face, and this is particularly evident in sub-Saharan Africa but also in India.

Just to illustrate the point about how things can change, in 1986, almost no black on the map whatsoever, but by 2003 already we’re beginning to see that breakthrough point of one percent in some parts of the region.

I think that we need to emphasize the potential catastrophe but we need to be realistic that we don’t have it yet. And as I said there are some underlying key determinants that will act as predictors, as we move from that threshold of the one percent and above, as to what will happen in certain societies. The big question I think that we need to pose to ourselves tonight and in the discussion around the children and HIV/AIDS in Asia, is: are we beginning to see that change in terms of numbers and in terms of the types of subpopulations that are affected? Historically in China, India, Thailand, Vietnam, Cambodia; it’s been high-risk populations, young sex workers. In Myamnar, for instance, something like 60 percent of the sex workers are young girls, forty percent of whom are HIV positive. In other areas, through blood contamination or injection drug use, we are beginning to see, and this is the crucial period, increases in HIV/AIDS in antenatal presenting pregnant women. So it is no longer in some cases just high-risk groups.

In terms of projections for children, I think the numbers are increasing in absolute terms, but the percentage for the most part remain quite small with one or two notable exceptions. Thailand because of the maturity of the pandemic and also Cambodia, although both have shown quite significant decreases over the last few years.

So the point I want to make here is that if you look at what is happening in terms of percentage you can see that sub-Saharan Africa, like Asia, was on a downward trend of the percentage of children that were orphaned until HIV/AIDS hit sub-Saharan Africa. And you can see what that additionality—it doesn’t come out quite so clearly but—the contrast between the top box and the bottom. In Asia, we have had—as in elsewhere in the world—a general decline in the number of orphans. Economic development, better healthcare, education, women’s empowerment, etcetera, but if you just start to see again, I’m sorry for the color, but we are beginning to see as in parts of sub-Saharan Africa, an increase.

But then we look at not percentages but absolute numbers. You can see that, India, China, together as their populations are so large, mean that historically even without HIV/AIDS, the orphan problem, quote unquote, has been huge in Asia, but the trend has been overwhelmingly positive in terms of absolute number reduction. But again we are beginning to see those top boxes increase so the numbers are also possibly increasing in terms of the additionality that HIV/AIDS brings. And again, I am going to go through many of these slides very quickly because of the time. And just to try to illustrates the point in that we are now getting quite significant differences between and within countries.

And the presentations will be made available so don’t necessarily try and keep up. But I want to try and do is to come on to this issue. Because we were talking about: there’s a change, there’s a wave, between what’s happening in sub-Saharan Africa what’s increasingly happening in Central and Eastern Europe—Russia, Ukraine—and also now what’s happening in Asia.

But let’s bring this back to children. We also have a series of waves in how children and when children get affected. The first wave is when populations get infected. The second issue, then, is the cumulative factor of when people get infected and start to die. And then, there is a lag between infection and death. And then there is the cumulative factor, the impact after that, of when we get the number of orphans. So, for instance, in sub-Saharan Africa currently, Uganda after many years has gone from just about 25-30 percent national prevalence, down to 5 or 6 percent, and it’s quite a success story. But it is only now that we are getting the peak of orphan-hood in Uganda. So as much as everybody says that we have a success story on our hand in reducing the pandemic in Uganda, the burden on the state, the family, is now, because of the number, the cumulative number, of orphans. And we can plot this out, as we have done in Children on the Brink 2002 and we will do in the forthcoming [Children on the Brink] 2004.

We currently have 11 million orphans due to HIV/AIDS. We project in the region of 25 million by 2010. What we’re seeing, because of the additonality, is that in some countries, primarily sub-Saharan Africa, but increasingly elsewhere, we are beginning to see precipitous drops in life expectancy, and reversals in hard wins gained around under-five mortality and infant mortality. We are basically wiping off ten, twenty, and in some cases of thirty years, in development investment in countries. And of course when the adults die, it’s at the peak period and is often some of the most productive people around.

But for children, what we’re seeing is that for the most part, there is a greater disparity now between a child who’s orphaned and a child who’s orphaned because of HIV/AIDS and even other poor children, in some of these crucial areas. And the evidence on the orphan generation published by UNICEF and by others shows this disparity on nutrition, education, healthcare, massively on psychosocial impact.

But we are also beginning to see the state responses. This is probably where we have quite the differential with sub-Saharan Africa. The countries in sub-Saharan Africa, currently, which are the most heavily impacted, are also the least able to cope. They have the most rudimentary health system, they have the weakest and limited human capacity, they have a development and investment gap. Overall they are least able to respond. In Asia, one would hope, that at least in some countries, the status of the health service, the status of the education service, the government’s ability to provide welfare, social welfare, etc., especially in countries like India, is quite developed. The issue is, can they withstand the shock of a significant additionality on their social welfare, social education systems? Already, as I said, we are beginning to see disparity even within the Asia context, and this is Indonesia and Philippines, between orphans and non-orphans and double orphans—children who have lost both—and how likely they are to drop out of school. I’ll skip the next bit…

We really have over the last couple years, developed a consensus around what needs to be done, we have the Millennium Development Goals, we have UNGASS goals, we got the Goals for Children, and within UNICEF, HIV/AIDS has become a massive priority. Since last year, and the year before really—and UNICEF has brokered this strategic framework for assisting children affected by AIDS—we really do know now what needs to be done—strengthen families, strengthen communities.

But I also want to emphasize, although we use the term orphans, the children affected by AIDS is much wider than that. Children are crucially affected during the illness of their parents. Their formative growing up experience is sickness and death. They then become orphans. And then they drop out of schools. Then they go and live with other families and in addition to the orphans we’ve got this increasing number of positive children. We really have got a methodology, at least in process terms, of what needs to be done. It’s quite clear that unless we know the extent of the problem, where the problem is in the country, and how children are specifically affected within their country and cultural context, we can’t act. And we’ve been taking countries through this five-point plan for a number of years. And from UNICEF’s side, I think we are really trying to do five things: one is, we have meetings like this where we convene around thematic issues, country issues; we build partnerships; we try to provide the evidence; and we try to raise and mobilize resources; and advocate for change.

In Asia over the last few years we’ve had a number of successes, thanks to Nafis and many other colleagues, in getting global leaders in Asia--the prime ministers, presidents, high personalities—to come together. There has been a significant response by the Buddhist community and I think that has really been some of the testament of hard work by Robert Bennoun and others. And I think that in India we are starting to see quite a successful rollout of mother-to-child programs where we can, because we have the technology, dramatically reduce infection between parent and child. And in China, for all of the problems and sometimes the disservice people say about China, we are beginning to see a change. I think we are seeing a change in the openness, we’re seeing a change in the rhetoric and I think we’re seeing a change in the policy. And of course, I think one of the great things about china is that once there is a commitment to make a change, it has the capacity to actually implement it. But clearly, much more needs to be done. Thank you very much.

Nafis Sadik: Thank you very much Peter. I’m sorry, this was a most interesting presentation, and I’m sorry that we have to cut you off short. But the time is limited. Our next speaker is going to be Sara Sievers. She is the director of the Orphans Initiative at the Association François-Xavier Bagnoud… She’s between both the academic and the active community of people who actually work in the field and has hands on experience in dealing with orphans and HIV/AIDS. Sara, you have the floor.

Sara Sievers: Thank you very much. I’d like to thank, as Pete did, the organizers of this event, the Gates Foundation, the Asia Society. It’s a tremendously important challenge, the challenge of children orphaned or made vulnerable by the pandemic and it’s something that the organization that I represent, the Association François-Xavier Bagnoud, has been working on for more than fifteen years now. We’ve been involved, first in the United States, setting up homes for children who were left vulnerable by the pandemic in Newark and also in Washington, DC, but quickly moved to about twenty countries, several of which are in Asia.

I titled this talk, as you’ll see, Orphan Care: a Rights-Based Approach. And the image I’d like you all to have in your mind as we go forward actually comes from a wonderful political philosopher of the 20th century named John Rawls, who wrote a book called the Theory of Justice. And if we can sort of step back and have in our minds something that Rawls called the ‘initial’ or ‘original position’ and what his argument was and I think it is wonderfully applied to how we approach caring for children who left in the aids pandemic is in order to build a just society, the builders of that society are the future inhabitants of that society but they don’t know where they’re going to land when they get there. There’s what is called a ‘veil of ignorance’. So imagine if you will, that we are living in a world that we’re constructing, which is probably accurate in many respects, but you don’t know where you’re going to land. You know you’re going to land as a baby and build forward from there.

The Association really feels very strongly that a rights-based approach—there are many other ways of doing it—our approach is a rights-based approach, for a number of reasons. We believe that the fundamental characteristics of the programs that we implement on the ground are distinct in ways that are characteristic of keeping in mind things like Rawls’ ‘initial position’ or other forms of rights that have been more formalized in legal, such as the Convention on the Rights of the Child.

I’ve excerpted just a couple of articles to get us in the spirit of what more than 190 countries in the world have signed onto already—not yet the United States, but I have a little pitch at the end of those of you who want to do something about that—that basically says what children are entitled to, how we take this sort of vague political concept of children’s rights and turn it into technical legal language. Look at the kinds of things, if you will, that are included. I just pulled a couple articles. As you can see there are many of them. Article 27, I thought, was very notable because it starts outlining, as Pete explained in some of the earlier slides, what children in this world are entitled to, what are their rights when they come here, what are we, as adults, obliged and we as state parties and as individuals and families obliged to provide for them. I think it’s a relatively compelling, non-controversial, list of things. And even more basically, if we look at Article Six that states, “parties recognize every child has inherent right to life,” not unreasonable, and states parties “ensure the maximum extent possible the survival and development of the child.” Now as we think about the statistics that Pete gave us earlier and the level of intervention we are aware of or non-intervention, given the scope of the pandemic, we may not even be prepared to meet the basic requirements of Article Six, which is a pretty modest bar. And the numbers of children for whom we may not be meeting those rights is millions and millions and millions and growing.

So in that context, the Countess, who sends her apologies that she wasn’t able to be here, actually after having lost her only child, channeled her energy into, and her financial resources, into trying to right for the as many of the children as she could, their lack of rights. As I said, we’re located in a number of different countries. I, for obvious reasons, I decided to focus initially on our program in (India) but I’m going to broaden that a little bit into some of the Africa programs as well.

In India, what this sort of spirit of rights and child’s rights has translated into on the ground is something we actually call, orphan prevention. You get a sense by the size of the outreach and the extent of the involvement and there’s another slide that gives some more description of the project, I’ll give some more slides as we go along. But essentially, as Pete showed us, the number of children orphaned, or the percentage of children orphaned due to the HIV virus, if you remember his charts, is somewhat smaller in India compared to some of the places where the pandemic has reached the curve proportions that he’s described. In light of that, with an eye towards children’s rights and towards children affected by the disease, we felt that prevention and preventing orphans was a more important intervention, initially, in India than anything else we could focus our resources on.

Some of the specific projects, and here, this emphasis on rights is interesting: migrant workers, as we think about populations that are particularly vulnerable to contracting the disease. Migrant workers, people who are moving around. And so FXB started a project in India that was basically, with Gates Foundation support actually, traveling back and forth, looking at populations that were traveling back and forth, within Rajasthan and in Mumbai, to get a sense of what was going on there and to make interventions to try to prevent transmission.

In addition, and this is one of my favorites: the Barber Intervention. And the story behind this is quite hilarious, in my opinion. So Albina was on the ground, trying to figure out what she could do to try to help. Don Casey can correct me if I get this story a little bit wrong, I’m new to the organization, but this story is memorable. A barber came up to her and said, ‘Countess if you really want to spread the word, you need to be active in barber shops.’ Now who would have thought? It turns out, that in the places where she was, the kind of discussions men have when they’re getting their hair cut are the kind of discussions that probably need to have a little bit of aids prevention thrown in for good measure. We would never have known that from the outside, but, or unlikely, but this barber felt very empowered to come right up and explain what was going on, what was needed and how to focus efforts. And it launched a whole initiative within AFXB, which I think illustrates one of the points that we feel particularly proud of: a real ability and interest in focus on listening to the communities that we are working in and responding to the initiatives that they bring, so that we can maximize our effectiveness in spreading messages and giving services.

Again, particularly vulnerable groups, bars, pubs and wine shops, so that’s another program we have going on in India, trying to spread prevention possibilities and techniques there.

We also have been working in fishing communities. Now, we hear a lot about the truck drivers. It turns out, in Albina’s words, ‘In some places in India, the fishermen are the truck drivers.’ Migrant behavior, various kinds of going back and forth, hither and yon, and the kinds of at risk behavior that can be dangerous for transmitting the virus. So we have programs that help to try to try to prevent in fishing communities.

Here we have a more of a traditional program. We’re targeting directly services to children of sex workers so that we can try to target particular vulnerable populations. And this is one of our oldest and most established projects in India.

Finally, tele-counseling, I thought it would be fun to see the technological perspective tossed in. For a variety of reasons, sometimes people don’t want to show up in person. The idea that you can do some of these things via tele-counseling, is an interesting adaptation.

Turning now to some of our programs in Africa, briefly, since the program focused on Asia and the world. The nature of our programs in Africa is a little bit different. It’s actually focusing on care. So if you decide you feel particularly moved by the existence of actual orphans, most of them are actually in Africa now, most of the kids who don’t have adults taking care of them. We started in Rwanda, about five years ago, and basically provide comprehensive care for families or cobbled-together families in communities—it’s a community based support initiative—to try to help not only with making sure that all kids are able to go to school, so paying school fees, or paying uniform fees, or any other costs associated with going to school, but also making sure these kids are able to access the local healthcare networks, to the extent that they exist.

And one of the things that I was most impressed with, when I was first introduced to the organization, a really quite clever, simple, but well conceived and locally driven and locally adapted micro-grant program. Granny-loans, if you will, except granny-gifts actually, without the loans. The idea is that families, that have very very little, or women who have very very little, aunties, grannies, whoever it is who are taking in three, four five, however many orphaned children, need financial resources. And one of the ways of providing those resources is through the micro-grant industry. In light of the pandemic and financial burden and the disease burden, we don’t require repayment. We give grants, in kind grants—beehives, cows, whatever—which has worked out quite well. There is a two-tiered system which is relatively unique in the micro-grant world. Individual grants to individual—usually, but not always—women and then also the women form groups together but not for purposes of repayment, for purposes of collective support—they tend to be positive, the women. So as they get sick, the other women can step in and help with the individual projects. And then there is also a group project that’s financed. So women who have particular ingenuity and entrepreneurship are able to take their individual projects and see it grow and blossom. And the women who are ill or for whatever reason, have a bit more difficulty, tend to be supported by the communal projects. And there are, at this point, thousands and thousands of children and women in the AFXB programs in Rwanda—beneficiaries who are taking advantage of this system.

Turning now to the final program I’d like to highlight, very briefly, and it’s one that we’ve started much more recently. Community-based care is surely one of the most important intervention but that is not always possible to pull off as a comprehensively as we like, and it probably shouldn’t exist in isolation anyway. We also are testing out in South Africa, various forms of school-based care, after school programs, school meals programs, school fee elimination programs where we finance those sorts of things. They’re only a couple of years old and we’re still working on them but we’re reaching at this point, hundreds and soon to be, we hope, thousands of vulnerable children, particularly teenaged girls, which in terms of sexual vulnerability, as a population in south Africa, that faces many challenges.

So why does this focus on rights matter? The two parts of my talk may seem somewhat disconnected. It matters for a bunch of different reasons. For starters, we provide guiding principles based primarily, actually, on an assumption of universal human dignity and then basically toss programming and the specific use of financial resources fairly wide open, for a real emphasis on local leadership, local definition of what’s needed—the barber example—and adaptation as needed—the fishermen example. There are very very few people working on AFXB programs who are not from the country that’s being served. And we’ve made that decision, in large part, based on sort of the overarching ‘rights’ philosophy and then finally from the outside we do do some, of course, some conventional foundation oversight work. There’s financial and management oversight and Albina, in particular, is very active with that. We also have had, the great good fortune, of having a very flexible funding source so we can afford to experiment, adapt, and make mistakes without facing some of the pressures that conventional foundations and NGOs would. We also feel that, based on this work and based on what we understand of the needs, that we have a particular responsibility to be active in the advocacy community.

And with that I’d like to thank you all very very much and very quickly, if you want to do something on the Conventions on the Rights of the Child before our next speaker comes, here’s the UNICEF pitch actually. Pete, I got it from the UNICEF website. Thank you very much.

Nafis Sadik: Thank you very much. I’m sorry that all the speakers have to be rushed. Each one of them could have spent the whole evening with you… Our next speaker’s going to be Steven Wang. He is the founder and President of the China AIDS Orphans Fund. And this is an individual who has decided to do something, as an American, to help china. He is at the university but he’s already very active in this field.

Steven Wang: Good evening. I would like to thank the organizing committee for inviting us to share our experience and for allowing me to share the podium with such a group of distinguished speakers.

Tonight I’m going to talk to you about our experience, the China AIDS Orphan Fund in our effort to tackle this AIDS epidemic. For me, I got involved in this project back in August 2002, when I’d just left from New York City to Minneapolis, St. Paul area, to start my residency program. It was a Sunday morning, august 25th, and when I read this New York Times article, by Elizabeth Rosenthal, on my kitchen table, entitled: AIDS Scourge in Rural China Leaves Villages of Orphans.

This is a section, I’m just going to read it for everyone: ‘200 of village’s of 600 families have one parent dead and other ill, often too frail to work or even rise from bed; they receive little government help; experts say blow dealt by AIDS to villages like Donghu has been sharper and crueler than anywhere else in world because of unusual and efficient way disease is spread there; in 1990's, nearly entire adult population of some villages was infected almost simultaneously as poor farmers flocked en masse to sell their blood at blood collection stations whose unsterile practices introduced hefty doses of HIV directly into their veins; now victims are falling ill and dying, almost in unison.’

So ten years out, you can imagine, many of those parents are dying and what’s left in those villages are orphans. As I delved more into the subject, I encountered more horrifying facts. And this is some pictures illustrating kids watching their parents dying. And this is a child watching, sitting in front of the cemetery of both parents. And those stones right here are the cemetery’s housing the remains of the dead, often affected by the HIV virus. In view of this health crisis, we decided to start the China AIDS Orphan Fund. And the organization is initially founded in March 2003.

Our mission is relatively simple: to improve the lives of children orphaned by HIV in central china, especially the Henan province. We have four specific agenda: first deliver education for the AIDS orphans. And as you’ve heard from the other prior speakers, education is the key. Without education, they will be continually disenfranchised and they will not have any chance to improve their lives. Second: we want to provide humanitarian relief service to the families. Third: deliver medical care and training. Lastly, initiate some sort of foster care and orphanage programs. To do this, our strategy is relatively simply, again. We want to raise public awareness in the States, as well as internationally, via communication through friends, colleagues, families and media. We want to raise the appropriate fundings to support our project. Lastly, to ensure the funding is spent effectively to help the victims.

The team behind this group… [Please refer to the China AIDS Orphan Fund website for information on the CAOF team, at http://www.chinaaidsorphanfund.org/committee.asp.].

In addition, we have partners with local foundations. The Minneapolis Foundation, which is the oldest foundation in Minnesota, established in 1915, with some 135 charitable funds. In addition, we have partnered with Give2Asia, which is a national organization founded by the Asia Foundation. They have 17 offices throughout the entire Asia region. The function of the three partners: First, for us, we want to focus on building awareness, raising the funds to achieve objective. The Minneapolis foundation gave us the credibility initially to raise the money in the local area as well as the resources of advice and expertise. The Give2Asia provides the due diligence service because they have people, offices on the ground, to ensure the money the organization that we are giving the money to, are appropriate, and that they do the job they say they do.

So, what are our progresses? Since our inception in March 2003, we have received a large number of coverage, especially in the Twin City area. We had most of Minneapolis’s papers describe our effort and we were on the Minnesota public radio station. So far we have raised 60,000 dollars mainly from individual donors. Most of them are from the Twin Cities area. We have also received money from England, Canada, and other cities, including Chicago and New York. And there are some touching letters. For instance a kid received his birthday gift and decided to donate he money to us. In addition, we have a dozen foundations, schools, and universities across the country that have donated money to our effort.

This is the Minneapolis Timberwolves, and they’ve decided to donate a thousand dollars. This is, I’m sorry, I apologize for the poor quality of the picture, but this is a local school. They decided to raise money for our effort. This is a local individual who is a founder of the Circle 88 Group and they decided to raise more than 10,000 dollars for us. And this is a group of Yale students who tracked us down from the Internet and decided to raise money for us.

In addition, we have a website; we release quarterly newsletters and we decided to save as much money as possible to relieve, deliver, all our news/media electronically.

Lastly, we created this Living Dreams in a Dying Village, which is an art/documentary exhibit in conjunction with Chung To. This is the title. This is a picture. In addition to the pictures, the drawings by those kids, they also have Chinese essays by those kids describing their hopes and dreams. This one says, ‘Doctor is treating patient.’ The next one says, ‘Tomorrow will be a much better day.’

In addition, we have delivered more than 10,000 dollars to Chi Heng, to support 200 kids for one school year. We are in the process of delivering another 10,000 to ensure those kids have another for the upcoming school years.

Lastly, we initiated of the due diligence process to deliver 5000 grand to Amenity. Our effort right now is seeking and researching other reliable and trustworthy NGOs that can receive the fundings.

What is our future plans? First we want to launch a national tour of this exhibit. Tentatively the states, large cities, like Chicago, San Francisco, L.A., New York, Boston, and Washington, DC. The reason for this is to both raise awareness as well as raising fundings. Second, we are planning an AIDS conference in Chicago and we have lecturers, question sessions, to attract the public in this area. But, the ultimate objective is to start a second chapter. If this works, we plan roll out other chapters in other major cities. Minneapolis is great but it’s too small, it’s not as wealthy as other cities.

Now, what are our challenges ahead? For us, the most difficult challenge, in addition to all other challenges faced by other non-profit organizations, is identifying the trustworthy organizations that are working in China. Because, in short, we have absolute responsibility to our donors that the money they give to us will have been spent appropriately. Next, in this effort, I’ve learned there are other people, other organizations, that are trying to do the similar type of work. I feel that we need to link up with them and to save up the resources. Third, there are larger organizations, like the UNICEF, like the Asia Society, that have tremendous money resource. We need to tap into that. And most importantly, we need to speed up our process. I think it’s too slow for us to raise the money, go through the diligence process, [and] give [the funds] to someone else to do the work. That process takes three to four months. But it’s needed because we need to ensure the quality of the work. Now, what’s the challenges faced by our community. I may not be a good speaker. But from my point of view, I see there are other communities out there, other organizations doing a similar type of work. We need to conserve resources. And each dollar we save by each organization, that money can be transferred overseas to do the real work. In addition, I think a network, a database, for ideas, information, for collaborative projects, needs to be created. For example, we have this tour, this art exhibit tour. But we don’t know who to give it to. We need to contact those outside individuals, outside cities—that takes up energy, time, and money. And also, there are people out there who probably want to do the same effort, but they can’t find us. Wouldn’t it be great if there were some sort of Internet-based ideas? Lastly, there are tons and tons of people out t here who really want to participate in this effort, but we have to let them in. We have to let people to join in this effort. And I think with that, I’m going to wrap-up.

Nafis Sadik: Thank you very much, Steven Wang. I wonder what we did before all this technology came into existence… So our next speaker is going to be Chung To, who is the Founder and the Chairperson of the Chi Heng Foundation. You already heard some mention of it and his association with Steven Wang. He is going to tell us about his work in HIV/AIDS in China. And what he’s doing as far as children are concerned.

Chung To: I’m very delighted to be here. Before I start I really want to thank Elizabeth Rosenthal of the New York Times because without her article I think I wouldn’t be able to hook up with Steven and Steven wouldn’t be able to do all the great work. I think she is here as well.

I will spend most of my time talking about our work, but just a very brief background. In the AIDS epidemic landscape of China, one place called Henan stands out. During the early to mid 90’s, many peasants in that area sold blood and because of the unsanitary practice, many of them got HIV. And now, ten years after that, a lot of them have died and are getting sick.

If you look at the blue or green box over there from a UN report, it kind of illustrates the extent of the problem. In 1998, they cracked down on illegal blood collection stations and confiscated over 6,000 bags of blood. And through a random testing of 101 bags of them, 99 out of the 101 bags, were HIV positive. So this is the extent that we are dealing with. And today in some of the areas, we are talking about as high as 60 percent of the adult population, in some villages who are HIV positive. And those are also the productive force of the village. People who donated blood at that time were also people in the 20s and 30s and 40s. So you can imagine the kind of effect, or impact, to the local people. And one of the consequences of this is the children being orphaned by AIDS. If you are talking about as high 60 percent of the adults having HIV, you are also talking about 60 percent of the children being orphaned by AIDS as well.

I was able to visit Henan more than two years ago. I was very concerned about the situation and I was shocked by what I saw. We have been working on AIDS for a long time, and I have been working on AIDS myself for many years as well. But I have never seen so much human suffering, in such a small area. It became one of the reasons why I’m working on this so hard. I began to understand also the difficulty faced by the local government. We are talking about potentially 15-20,000 HIV positive people in one small little county, which is already a poor county in china—below the poverty line even by Chinese standards. That is about seven to ten times the total number of HIV positive patients Hong Kong has to deal with today, or more than the entire country of Japan has to deal with. So at the time, while we are criticizing the government for not doing enough, I also became very sympathetic towards local government because of the limited resources. So instead of talking about it, I decided to go in and help. Not only AIDS is giving them a hard time, but also the export labor got rejected, foreign investment were stopped and a lot of stigma and discrimination caused by the media.

I visited the area at the peak of the people dying. In a village with 2000 people, there were eleven funerals in one single day. Only one person did not die of AIDS, the other ten died of AIDS. And in another village during that summer, five people committed suicide successfully, in one month. So if you annualize it, 3 percent of the total population successfully killed themselves. Not to mention that a lot more are dying of AIDS.

During one of my first visits, I visited a family, you could see it’s a Christian family because there is a cross there. Actually because of earlier missionary works there was a lot of Christian families there to my surprise. At the time when I visited this family, the father had already died of AIDS, leaving behind the mother and two children. There was a little girl behind the mother who was the older daughter and there’s a younger brother. When the mother saw me she came up to me and asked me to help her son. I said there might not be a lot I could do for your son, but I would make sure that your daughter could go to school. And I will never forget the images that I saw of people dying of AIDS, so horribly. It is not about just dying, it is dying without dignity. I think they deserve to die with more dignity. I thought I would only be seeing images like this in Africa but this is happening just a few hours away from Beijing by car. So a few months later I visited the school making sure that the daughter could go to school and there she was. It was wintertime and she was in winter clothes. I think that is the spirit of our project, which is to help the surviving children to live through the disaster by giving them an education. You could imagine also the psychological trauma that this girl had to go through, seeing her father dying of AIDS, and also her younger brother dying so horribly of AIDS. Her mother also might be HIV infected, if that were the case, [the daughter] will become a true orphan.

And after four semesters of low profile work, we started with one village with 127 orphans, we are now helping over 1200 orphans in 13 different villages, from pre-school to college. This makes us the oldest and also by far the largest non-governmental effort for AIDS orphans working in China, at least for the blood selling effort.

I noticed a few trends; I’ve been to Henan 16, 17 times over the past two years. One is that the grandparents are assuming the role of the parents after the middle generation was wiped out. These are grandchildren living with the grandparents. They are not siblings of each other, but they are cousins of each other. That means that when the parents died, they would be sent to live with the grandparents. The grandparents had four children, all four got HIV. Two have already died and two more are dying. The black and white picture was taken two years ago, this was taken last month or a few months ago. And you can see the children have grown up a bit. This is the youngest son, who is also dying, and actually, two weeks ago, when I saw him, he said, ‘Well, next time when you come, I might not be around anymore.’

The children sometimes become the head of the household. You will see that if the oldest child is old enough, maybe 14, 15 years old, they will become the head of the household, taking care of the younger siblings.

We also see a reconstruction of families. The man is the father of three children (one is not seen here) and the mother is the mother of two other children. They got together not because they are romantically in love, but because of survival. I think we see this in Africa as well, a lot of provisional families. I admire the children a lot because they not only have to bear the physical burden of doing the housework and making dinner but also the emotional burden of helplessly seeing the deaths of their parents in front of them. Most of us do not have to deal with the passing away of our parents until we are 40, 50 years old. But when we have to deal with it, we still have a hard time dealing with it. But these children have to prematurely deal with this when they are so young.

I see a lot of humanity and filial piety in this effort as well. This child, when I first visited this child, he was using the wooden cart to push his father around to get some fresh air. And it was completely spontaneous and completely out of his love for his father. His father past away shortly after and there he was also at school. HIV is also killing the children. I will skip the other stories because of time.

Many people ask me why I’ve chosen to work on the orphans in that area. I think there are many reasons. Orphans will affect the future social stability tremendously. China admits it has a million people living with HIV or people who have died of AIDS. If we are talking about a million people with HIV or died of AIDS we also are talking about close to a million or more children impacted by AIDS. If they cannot get an education now, if they are not being cared for, when they grow up, they will be gangsters and street kids, move to big cities. Most of them are HIV negative and they would be in the society for 60-70 more years to come, therefore creating a huge force of social instability. There is also a sense of urgency because the numbers are growing quickly and there is only a narrow window of opportunity for helping them because if they have missed school for a few semesters, it is hard for them to get back. Also, it provides a lot of care and comfort to the AIDS patients, directly. That means their parents. I have talked to a lot of parents who said, ‘I know I’m hopeless, I know I’m dying, but I’m very concerned about my children. If I know my children can go to school, I can die in peace.’ And also it’s less politically sensitive. Two years ago, when we first started, there was a practical reason. And also to send a message to these orphans, who might have a lot of hatred in them, thinking that the world is not fair to them and that their parents died unnecessarily, that there is love and hope in the world. That someone that they do not know is giving them an education and hopefully they will reciprocate when they grow up. Also, education for the next generation is also a social resources investment.

I mentioned the work so far which we have done and there are a few unique aspects of the project. One is that we would fund the students village by village. We take care of all the qualified children in one village before we move to the next so that we avoid unnecessary competition and antagonism. They don’t have to compete and look poor and pitiful in front of us in order to get a sponsorship. As long as they meet the criteria they will get it. And the criteria is very scientific and objective: either their parents HIV or not. Unlike some poverty relief programs which can be very difficult in due diligence and subjective, this is a lot more objective. It makes our job much easier. And also once their parents HIV status is confirmed [the status] cannot go back and forth. They cannot become negative and positive. We will continue to sponsor, we want to help students all the way, at least up to ninth grade. And we also do not give money to the children or their parents or their family. We give money directly to the school so that they only have a choice whether to go to school or not. And so far the dropout rate is about two percent, which is quite low. I think most kids do take up the opportunity to go to school.

I think the challenge is sustainable funding, because we want to expand. Based on our research in the three counties that we are working in, we have the potential to expand to seven to eight thousand children but the challenge is how can I have enough funding to sustain it. Because I don’t want to run out of money one year and have to tell the children, ‘Sorry, we can’t help you this year.’ And another challenge is to expand geographically to more villages. The third is that I’m moving from quantity to quality. That means that in addition to providing a basic education, we also want to help them in many different areas such as psychological support, such as art therapy—you see the drawings and essays that are outside [the auditorium]—and summer camps, field trip for their self-esteem, vocational training, and also we hope to start ARV for the children. Out of the 1200 children, we some of the children in our program are HIV positive and I hope to provide them with ARV. But that is another big project.

In closing: I met this guy two years ago before he died. That’s his son over there and I talked to him a lot that summer. He has died since then. He actually had five siblings. All five, including himself, were HIV positive. So it is another example of the middle generation being wiped out. You could see the grandmother in the middle. The grandparents had six children and all six got HIV. When I first visited this family two years ago, two had already died of AIDS, and four more were dying. And last month, when I went to the same family, five of the six children had already died of AIDS. Only one is surviving. And I asked the grandparents, ‘What keeps you going? I mean, it is such disaster for your family.’ And the grandparents still had to work very hard to make a living and to take care of all the grandchildren. And they said, ‘The grandchildren, the future, our hope. I know all my children have died of AIDS or are dying of AIDS. I know all my children will be wiped out by AIDS, but I still have hope because I have the grandchildren.’

And that’s why I think, in order for them to survive this we have to help the generation of children. And I’m very grateful that over the past two years I was able to help a group of desperate people when their suffering was unknown to the world and when outside help was not available. So I will end here, thanks.

Nafis Sadik: Thank you very much. I think another very touching example of what an individual initiative can do. I‘m sorry that we don’t have enough time to listen to everybody. Our last speaker, and I don’t envy him, and not the least, is David Gartner. He is the Policy Director for the Global AIDS Alliance, which I think everyone is familiar with. David, you have the unenviable task of being the last.

David Gartner: Before I start I want to apologize, because I didn’t bring any technology today, so… But quite seriously, I want to thank both the Asia Society for having this and the Gates Foundation for helping to put it on. And I want everyone to recognize the collection of people here today is actually leading the way in terms of sounding the alarm about the orphans crisis. Because we’re hearing more these days about the AIDS crisis, but the orphans crisis remains the stepchild of the AIDS crisis and it’s exciting to be with people who are leading this charge both nationally, internationally, and in a region and a country, in china, which has gotten much too little attention.

So with that introduction, the purpose of my talking to you today, is I want to talk a little bit about why there some reason for hope. To begin where Chung To ended. There are lots of reasons not to see hope. To put just the statistics back on the table again: the CIA is estimating that 100 million people will be infected with HIV by the end of the decade. If you look specifically at Asia, India’s in the single digits now, in terms of the percentage of people with HIV, far lower than Botswana, which is near 40 percent. But India can stay in the single digits and still become the country with the most people suffering from HIV and AIDS. So the implications of the crisis for India, for China, are frankly staggering.

This is, quite simply, the moral crisis of our time. But it’s not only that, it’s also a national security crisis, one that frankly gets for too little attention in a world where attention is focused elsewhere, on other issues. Colin Powell gets this though. He said, ‘AIDS is more devastating than any act of terrorism than any weapon of mass destruction.’ Quite frankly, I would argue it’s the biggest threat we face in the next generation. And the orphans crisis is the sort of terrible and natural extension of the AIDS crisis. Every fourteen seconds another child becomes an orphan because of AIDS. And if you look down the road to that hundred million people infected by the end of the decade you can only imagine how many millions and hundreds of millions of orphans we potentially could have in the world.

So with that, I want to argue to you that there is reason for hope and there are things that people are doing now and frankly the things that people in this audience can do that can make an enormous difference.

So first, why is there reason for hope? Well to take the AIDS pandemic. Only a decade ago, people weren’t paying any attention, frankly. And it wasn’t clear what could be done, to many. A couple of things have changed. One is the emergence of political will around this question, particularly around AIDS—hopefully soon around orphans, and I want to talk about that. Second, the dramatic decrease in the price of medicines, which can keep people alive, dropped to a dollar a day. This didn’t happen by accident, this happened through lots of hard work by activists and others. It’s now as low as 37 cents under what the Clinton Foundation has negotiated with generic producers in India and elsewhere. So, for far less than a dollar a day, people can be kept alive. The third reason for hope, and I want to talk a little more about this, is that there are new mechanisms out there, new models of how to respond to this crisis. One I want to talk a bit about is the Global Fund to Fight AIDS, Tuberculosis and Malaria. The reason that’s so important is because it’s particularly giving some attention to the crisis in China, in India, and elsewhere.

So what can we do about this crisis? Quite frankly, as I was saying before, the orphan crisis remains the stepchild to the AIDS crisis. Last year, the President made a path-breaking announcement at the State of the Union. Congress decided to pass legislation, and, frankly, Congress went beyond the President in its level of funding both overall and for the Global Fund. Included in that global AIDS legislation, not much noticed, was an amendment that was offered by two congress people. One, Dana Rohrabacher, a conservative from California; one, Betty McCollum, more on the liberal side from the Twin Cities in Minnesota. They got together and they said, ‘If we’re going to take on this AIDS crisis, well we better do something about orphans, too.’ And they introduced an amendment that said ten percent of this global AIDS funding, ten percent, not a lot, should go to deal with the crisis of orphans. And it passed. And we’re still not there yet in terms of even spending ten percent of the overall AIDS funding on orphans, but it was the beginning of building the political will around this orphans crisis.

I work with a group called the Global AIDS Alliance and it’s part of a broader coalition called, the Global Action for Children Coalition--which includes lots of the leading churches and service providers like the Hope for African Children Initiative. One thing that’s happened this year is that the organizations in this Coalition are working together and working with some of those very same people in Congress. We put together a Bill called the Assistance for Orphans and Vulnerable Children Act. Now, what that Bill is about, is trying to paint the framework for a comprehensive response to this orphans crisis. And to help build political will around responding to the orphans crisis, so that it’s no longer the stepchild that I described. One of the exciting things over this past year, when, quite frankly, the momentum around AIDS, the way it got attention on the front pages last year, has not been the same this year. But one of the exciting things, in a more quiet way, this legislation has gotten the support of nearly 100 members of the House of Representatives. Broad across the spectrum. It actually passed unanimously through the relevant committees. Pretty soon, my hope, and I’ll get back to this, with your help, I think it can become law. So we can move from the place where people stuck in a little amendment to say, ‘Hey, orphans, too,’ to a real piece of legislation, saying, ‘we need a comprehensive response to the orphans crisis. So that’s one thing that I think we can work on.

But another thing, to get back to a point that was made earlier by Sara, is orphans prevention. Quite frankly, we’re never going to get ahead of the orphans crisis unless we take seriously the new hope there is around treatment and keeping parents alive, and keeping the kids alive too, because many of these orphans are, in fact, HIV positive. So in terms of orphan prevention: people here should know that the President’s initiative is going to have enormous focus in fifteen countries. Those fifteen countries are in Africa and the Caribbean. So, Asia is not part of that plan at present. Maybe it will be in the future and a number of people have suggested that India should be added as a fifteenth country. I don’t think that’s what’s going to happen—I think Cambodia may be added. But that still leaves India, China, and much of the region, without support from that particular initiative. There are efforts going on from the private sector, from the foundation world—the Gates Foundation is doing a lot of work in India. But then that brings me back to the Global Fund. So the Global Fund is an international mechanism to deliver financing to scale up treatment, to scale up prevention, and hopefully, in the future, will take on more of the work around orphans as well, specifically. It’s using this extraordinary reduction in the price of these drugs and it’s starting to bring them to people now. What’s worrying to me frankly, is that a year after this great breakthrough, the proposal in the Administration’s budget is to cut the Global Fund by 64 percent. That’s a real problem. If that happens, the Global Fund will not be able to renew its current grants, let alone have another round of grants. Just so you know, there’s something on the order, nearly three billion dollars of new proposals. And these proposals are bubbling up from the bottom up. It’s a really exciting thing. It’s a mechanism that’s bringing together private sector, religious community, NGOs, in the field, to try to come up with proposals, coordinate them, and have the world’s leading experts pass judgment on them. So what I’m saying to you, is without stronger political support around AIDS funding, particularly around funding for the Global Fund, the steps that we’ve made forward in orphan prevention are going to be left by the wayside. So I don’t want to forget that, even as we’re focusing on the orphans crisis.

One of the things that Chung To was talking about was education, and how important that is for the next generation. Certainly, the parents here get that. And if you were dying of AIDS, you would probably get that even more. One of the biggest barriers to the adoption of AIDS orphans, is that nobody wants to pay the fees because public schools don’t exist in much of the world. Nobody wants to pay the fees that it takes for them to go to school. So AIDS orphans are left with a double bind. They can’t afford to go to school in much of the world, and in addition, nobody wants to adopt them because they don’t want to take on that financial burden. They are part of a broader group, mostly girls, but it’s over 100 million kids who never step into school for the first day.

Here, again, I just want to point to some new models and new opportunities for hope. To take an African example, in Kenya, within the last year, there’s new political leadership that stepped up to the plate and said, ‘We want to get rid of these school fees.’ They did this actually before the international community stepped up and offered anything. They just said, ‘We’re going to do it.’ As a result, more than a million more kids are in school today in Kenya. It’s hard for me to think of much in the world that leads to such dramatic change. In the end, the international community did step up when Kenya went hat-in-hand to the IMF and the World Bank, ‘Will you help us?’ But that’s not good enough. And what I want to propose to you today, and one of the things that’s included in that legislation that I mentioned, is that we need to be moving towards making this a universal, international right, to get back to Sara’s point. We need a mechanism, we need a basic education incentive fund, that’s going to encourage countries to follow Kenya’s lead and to do it not with just hope and hat-in-hand, but to do it because we, as part of this global community, think that these kids, these orphans, deserve a chance in this world. So, I’ll come back to that as well.

Finally, a lot of these kids are HIV positive. As their parents die of AIDS, either through birth or breastfeeding catch the disease. Very little is being done right now, in terms of treatment of kids with HIV. It’s sort of startling frankly, because you think people would start there and then build up. But that’s not how it worked at all. So, one of the things that also included in this piece of legislation is a focus on pediatric AIDS, the treatment of children. But this is an arena in which we don’t have to rely only on legislation and what the government can do. There’s lot of good work that the folks at UNICEF are trying to do. There’s also a new group out there, that’s actually directly providing treatment to children. It’s called Keep a Child Alive. Leigh Blake is founder, I don’t know if she’s here or not. It’s really working in exciting ways to capture the public imagination and say, ‘Look, for about a dollar a day, you can actually keep a child alive.’ It’s a pretty remarkable translation of the new hope and opportunity there is given this reduction in prices in medicine.

So just to turn it back to what the people assembled here can do. This has been a pretty powerful, but also, frankly, devastating survey of what’s going on in the world today. And I want to just offer a couple of things that the people here, assembled, can do. One is around that piece of legislation, so that orphans is no long a stepchild. You can call your member of Congress and your Senator and say, ‘I want you to support, to sponsor, to lead the effort on orphans. I want you to support the Bill numbered HR4061.’ Pretty soon it will be before the full House of Representative. You can call your member of Congress and say, ‘Please support that.’ You can call your Senator and say, ‘Please support that.’ In addition, you can call them and say, ‘I want you to support funding to eliminate school fees.’ And you can call them and say, ‘I want you to, at least, restore funding for the Global Fund to Fight AIDS, Tuberculosis, and Malaria’—and frankly we need to do much more.

But it’s not only through calling Congress. To get back to what you can directly do, you can help treat children today. The website of the group is called keepachildalive.org. Take a look. That may not be the way you want to contribute. You may already be contributing through other means. But these are two very specific things you can do as you walk away today. And then more broadly, frankly, we need to build the kind of political momentum in this country as was done with AIDS. And it was done by bringing together wide sectors, from the evangelical community to the African-American community, and folks in the gay and lesbian community have been fighting around these issues for decades. We need to build that same kind of broad constituency, here in the United States and around the world, on orphans. Because otherwise, it will remain the stepchild and for all the good of the conversations we’re having here today, those hundreds of millions of orphans will still be left in a world without parents, without teachers, and without hope. So, I hope you’ll join me, and the others on this panel, in changing that future. Thank you.

Nafis Sadik: Thank you very much. UNICEF, obviously, you have a very strong ally here. We have a few minutes for questions.

Question: I have been concerned with the Convention on the Rights of the Child and it’s passage in the United States, and have been following the work of UNICEF for many years and know they’ve made great strides in reducing infant mortality, particularly through breastfeeding. I know breastfeeding is a concern today, because on the one hand, it can provide life for a child in areas where there is not formula readily available or clean water. On the other hand, it could be death dealing. Could someone respond to measures that are being taken?

Peter McDermott: I think it’s actually a very very good question, and thank you for putting it on the table. As you know, one of the biggest difficulties we have, even in non-AIDS situations, is keeping children alive and the lack of clean water, mother’s knowledge, caring practices, is a major problem. But on the other hand, it’s quite clear from 20, 30, 40 years of research on what the benefits of breastfeeding are.

The compounding factor that we have clearly in an HIV/AIDS environment is that although we can use the new technology of nevirapine and AZT and the combination, to reduce infection between mother and child, there is then a degree of infection through breastfeeding. And then we have this real dilemma, as do mothers. Do you then not breastfeed, and use formula? And in those cases where it can be used appropriately, and safely, and effectively, with the mother’s knowledge and clean water, etcetera, then that’s fine. But in fact those conditions do not avail themselves in most parts of the world. Or do you then continue to breastfeed, and then have the percentage chance you will infect your child? And it is a real dilemma. And the big issue, of course, is to make sure that the mother, and the mother’s care practitioner, can actually have clear guidelines so that they have informed knowledge and choice, and that they can be counseled appropriately. In fact, there is some very exciting work that’s probably, I need to be a bit careful about what I say, that will be presented in Bangkok in literally eight to ten weeks. A study of 14,000 mothers, many of whom were positive, in Zimbabwe, which shows actually that through good counseling and exclusive breastfeeding, we can reduce quite dramatically infection rates through breastfeeding. So I think that there is work in progress. It’s a very difficult decision for the mother to make and I think that the bottom line comes down to this ability for UNICEF, and others, and partners to make sure that mothers are counseled correctly and that they make an informed choice. Thank you for the question.

Chung To: In one of the counties that we work with, beginning 2002, there was a UNICEF program for antenatal prevention. But it was a single dosage nevirapine treatment. But we learned afterwards that there was no funding for formula. So we actually gave some money to the county government, so that they could have the formula. Since then, the county government has realized how important it is and they have taken up the measure to provide the formula themselves.

Question: I think it’s notable that the areas where there’s such high prevalence with 60 percent or more prevalence in China are the result of unsafe, dangerous medical practice. In this case, unsafe blood practice. And there are statistics also from World Health Organization that suggests that unsafe medical practices are one of the leading causes of HIV/AIDS spread. One of the other notable pieces of data is that in India, 24 percent of disease spread is due to reuse of injection devices. My question is do you think there’s enough focus being placed on unsafe healthcare practices which are prevalent in the developing world, and not only from the standpoint of funding but also a policy setting, policy influence and knowledge transfer—does there need to be more emphasis on this?

Peter McDermott: In particular, given the fact that Steven and Chung did such wonderful presentations earlier about putting the human face on this. I mean it’s easy to give the global statistics.

First of all, as China illustrates—if you don’t get the fundamentals right, i.e. protect your blood sources, you can have a disaster as we have in China, massively. And I think that’s a concern in China but in many parts of the world and perhaps we’ve underestimated that. And I’m glad to say at least in sub-Saharan Africa there’s been a massive attempt to try to get blood supplies secure. I think that what has happened in the last at least three or four years, again…[transcription unavailable].

…private practice or in the informal sector or in particular among drug using groups, there is a tendency to reuse needles and I think we have underestimated. We’ve been seeing a blip in the number of young children—South Africa is a good case and point—who are HIV/AIDS positive and that cannot not be correlated with transition from the mother. So I think that the work WHO has done in the last couple years in terms of trying to renew safe practice around needles, needle exchanges, needle destruction, and getting new policies for governments is coming down the stream. But if we don’t get a handle on it, clearly it’s going to be a major area.

Sara Sievers: I am more familiar with the statistics on Africa and there was some articles I believe in the Lancet and elsewhere throughout the course of the year that have basically highlighted, frankly, medical practices and a correlation between high prevalence areas and areas in Africa that had medical clinics. A correlation, not a causality was demonstrated.

And I agree with Pete completely, we want to find out what’s going on. One of the curiosities for me is always been that we don’t really have, that I’ve ever been able to see, a comprehensive explanation of how the pandemic in Africa has spread the way that it’s spread to the countries that it’s spread. We don’t actually have a great explanation for that yet. There are a series of hypotheses that have been tested empirically a variety of ways, but we can’t definitely really explain. And one of the things that people thought for a while particularly this here might be interesting to look at, was this question of correlation that you raise. And I think we should look at it.

But we shouldn’t be distracted from the fundamental drivers of the pandemic which are basically a lot of practices that a lot of times we don’t like to talk about very much. About people doing things that we think are not very pleasant for public discussion. So while in no way shape or form would I ever say, don’t focus on safe medical practices, absolutely. Let’s not let it distract from what we understand and know to be the main drivers of the pandemic in most places, with notable pockets of exception, which are these sexually transmitted methods and needle exchanges because of drug use and a variety of other things.

David Gartner: In contrast to orphans where that 10 percent never turn into a real earmark. Actually, safe medical practice is one of the few things of which there is an earmark within AIDS funding. So, I think it bodes well for that issue.

Question: How come in some Asian countries, religion, ethics, or morality, has helped these countries to keep their child incidence low like Bangladesh, Pakistan, Saudi Arabia, like it did in the Middle East. And if that is the case, do you think that asking others to obey some ethical rules—we can ask people not to smoke, not a drink alcohol before 18—can we ask people to behave and come to sexuality and make laws to make it a better world. We have made this world a very loose place. Can you bring laws and spiritually to make incidence of HIV go down by looking into the Muslim countries where the incidence is very low?

Peter McDermott: I tried to infer earlier, that we have to be really clear about what the key determinants are within different regions. First of all, biologically, the virus is not the same. The HIV/AIDS virus we have in North America, Europe, Africa, Asia—they are different. And within those different viruses, HIV/AIDS 1 and 2, you got the different types. But the second point is that we know that there are certain protective practices. And there is a lot of work that’s going to be published in the Lancet later in this year, which clearly shows that, USAID has been funding the trials for the last couple of years now, that male circumcision is actually quite a protective factor. I don’t want to give a percentage here because the results are not there. The correlation between male circumcision and Islam is actually quite very real. So there is a protective factor there. The second issue is that I think most people would agree with is within not just the Islamic community but also in a lot of traditional societies that there is still a strong moral family code and religious ethics and behavior and sometimes this can be very powerful and overpowering maybe, but it does exist and that’s one other. The other issue is that there is, again, not causality but correlative factors about polygamy because if you’re sort of having a small family unit and you may have multiple partners but you don’t go beyond that group for sexual activity, you do actually manage to contain infections—not just HIV/AIDS but sexually transmitted disease and etcetera. So, there is a combination of factors that are not peculiar to Islam, there are other religions around the world that have similar, if you like, key determinant protective factors. But taken together, and if you do look at the map in terms of overlay there are quite key overlays between certain religious beliefs, male circumcision, the existence of polygamy and strong moral codes and the outbreak of the epidemic, in conjunction to how strong the infection rate of that particular virus is in that region. And I want to emphasize the biology as well as the sociology.

David Gartner: I guess I was going to make a sociology point because I think what your question touches on, in addition to spirituality, is prevention, and how do you prevent the disease. And there is a very live debate between the A, the B, and the C—the Abstinence, Be faithful and Condoms. And everybody points to Uganda and everybody, quite frankly, draws different lessons. For the most part the administration is pointing to the A –the Abstinence. Some people who I quite respect are pointing the B, and saying it’s Be faithful, that zero grazing had an impact. And some other groups that I really respect are pointing to the central role of Condoms, especially in a world in many cultural contexts, in which women really don’t have choices and are faced with situation where sex is coerced. So, what the group that I work with would argue is that you really do need a comprehensive approach and quite frankly I’m worried by the current state of the debate, where it looks like the A really is trumping the B and the C. Because unless you have all of them together, I think we have a lot of reason to worry about the future.

Nafis Sadik: I think also we have to remember that in many of our societies, male risky behavior is condoned or even accepted and is considered macho, but it is the female behavior that is not. And many women especially in South Asia but also in Southern Africa are getting HIV infection from their spouses. And all the data, for example, in Asia, South Asia, shows that 95 percent of them have just the one partner, but the infections come from that one partner. And they have got it from somewhere else.

So I think it is not correct to say that any particular, I mean, all religions, I mean all people can be infected, anyone, everyone in this room is at risk unless they behave appropriately. I’m not sure it’s to do with any particular region, religion, or whatever. It is what you have been educated and brought up and your own inclination. And I agree with David that a comprehensive approach is the best approach because it is a deadly disease and the only true way to stop it is to prevent any new case. However we deal with those are already infected and the consequences of the disease. But if you want to eliminate it, you really have to find a way to not get the next infection. And what are the ways to do that? And I think Abstinence, Be faithful, using a Condom, whatever, education, all of these, I think we have to use.

I think that the debate is as you said, this or that, I think that this choice is not really something we can afford to make. I think we have to have a holistic approach in which all strategies and all approaches have to be available in the country. I don’t want to be a terror, and start talking so much, but for example, even in Pakistan, there are 80,000 cases, at least the estimates and the estimates are increasing. And all the groups, which in fact if you have these pure societies you shouldn’t have sex workers, you shouldn’t have intravenous drug users, you shouldn’t have sex outside of marriage, but all of this exists in all of our societies.

So I think everyone is at risk and you may have the religion but not everyone necessarily follows. And that’s, I think, the challenge. You can’t legislate that. I think you can try to teach it.

Question: My question is specifically for Mr. To. I think your last point that education and treatment should go together is a brilliant point and I know that a project that’s being funded by the Global Fund for TB, Malaria, AIDS are be implemented in China in southern provinces, including Henan. I wonder since you work directly there, how are people really complying with the treatment given the really wicked and debilitating side effects?

Chung To: I think that there are a few issues. Don’t be confused. Number one: the Global Fund has not been implemented. It has been approved. You are right that it includes Henan, but what you are reading in the news today is an ARV program funded by the Chinese government, not because of Global Fund money. And the ARV program has a few issues: one is that the regiment is quite outdated. That is not China’s fault. Because of the WTO and the patent restrictions, China cannot manufacture the most updated drugs with fewer side effects. Although there have been talks and lobbying groups advocating that China should exercise its compulsory licensing rights to make the more effective drugs. But I don’t want to get into that.

But the side effects are true. Also, the adherence rate is low and even the Chinese government has admitted that. But it is because of a lot of reasons. Because of the timing, the Administration lacks experience. I think some people in the government initially thought that, ‘Ok, we want to solve the problem,’ so giving them the drugs is the problem. But they don’t realize that this is not Tylenol, this is not aspirin that you can give, ‘Here, take it.’ There is a lot of follow up and monitoring to be done. And I think the Global Fund would address it and also the government is addressing it. It is training a lot of local doctors, so it will take time.

But of course there’s the other issue with AZT, what happens 18 months later, in terms drug resistance. Adherence now is becoming less of a problem. Distribution also is another issue: that means people are not getting it, or may not be getting it evenly.

So, the ARV and the treatment program, there is still a lot of difficulties, but at least it shows the determination of the government. I was quite surprised by how quickly the government moved. Largely, thanks to SARS, that in the past few months how the government progressed from a state of denial—that means, ‘we don’t have an AIDS problem’—to now admitting they have a serious AIDS problem and seriously addressing it. Not to mention addressing the drug issue, paying for free testing issue, infrastructure building, and etcetera. So I am seeing extremely rapid progress but there is still there is a lot to be solved.

Question: My question is also for Chung To. You said that you dealt with orphans in education programs because it was politically less sensitive. And I’m wondering, in your experience, what has been the reaction of the local governments when you go into the villages?