AIDS at the Crossroads

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.. .. .. .. .. .. .. .. .. .. .. .. .. .. . . .. .. .. .. .. .. .. .. .. .. . .. . .. . . .. . . . . .. .. .. .. .. .. ... .. thousand people who've come to San Francisco this week for the sixth international conference on AIDS, and these are the challenges we will discuss tonight with a distinguished group from around the world.

You know, AIDS is a metaphor for many of the health problems the world faces. What is new about AIDS is the specific virus and the group at targets, but another respects AIDS is similar to every other epidemic. It exposes the underbelly of many social issues, poverty, prostitution, drug abuse, racism, and inequality between nations. For example, runaway kids ignore AIDS because of their preoccupation with immediate needs like food and shelter. Many in the world are like these runaway kids. They are by necessity preoccupied with daily survival. I'd like to start this evening if I could with you, Dr. Fauci, has directed the National Institute for Allergy and Infectious Diseases. There's a growing feeling amongst some people, especially those with AIDS, of desperation, that medical science isn't moving fast enough, that we're not getting to where we should be. Could you recount how quickly we've gotten to this point? What have been our successes and maybe some of our failures?

Well, if you look at from a pure scientific standpoint about the rapidity of scientific advances from the time in the summer of 1981, when we just recognized that we were dealing with a new disease, that over such a relatively short period of time, the virus has been identified, diagnostic tests, very sensitive and specific have been developed. There have been some therapies that are not perfect, but nonetheless effective in suppressing the virus as well as early trials in vaccine. That's unprecedented scientific advances, unfortunately, because of the enormity and the magnitude of the epidemic and the magnitude of the suffering and the death, one cannot stop and say, gee, look how great we have done scientifically, even though in a vacuum scientifically, that is the case. So science has to continue to move very quickly, but there are so many other societal and other issues that are involved with the suffering and the pain and the death of AIDS that they seem to get dwarfed the scientific issues. And what you said reminds me of something that someone else once said, and that is that

we have learned more about AIDS in a shorter period of time than any other history, any other disease, I should say, in the history of man and humankind. That is correct. That is correct. Dr. Rosenbaum. Dr. Rosenbaum is Professor of Infectious Diseases at the University Hospital in Parish. You were the first to see a case of AIDS in Paris. What was that like? What happened around then and what has been the response of France and Europe in general, if you could? Well, it's true in France, I saw the first patients, but it's in U.S. that the epidemi was recognized. Well, since then in France, as you know, we have participated in the discovery of the virus and also are the increasing knowledge in the therapeutic aspect. And the means, especially in the fight, in the technical fight in France and in Europe, is much less important than in the U.S.

But I would say the social response is perhaps a little different because we have a tradition of insurance, which are perhaps a little more accurate or with a larger taking in charge of patients. Do you think, Dr. Rosenbaum, that you as physicians and the government in France, with its provision of health care is dealing with this better than, say, maybe we are here in the United States? Well, for example, there are a campaign in France to accept the disease, to accept the patients, to be more friend with patients, but it's true that it costs nothing. And so everyone has access to care. There's also people who have a better access to care because of the national insurance

is perhaps more accurate for this kind of opinion. I'd like to go to Dr. Engogi, Dr. Elizabeth Engogi. What has been the impact of AIDS on Kenya and Africa? AIDS did not come in a vacuum. AIDS came at a time when Africa was suffering from many other diseases that have been controlled in other countries. For instance, tuberculosis, measles, rotrapic accidents, polyumelitis, meraria, malnutrition, deriodiseases. It came on top of all that. And AIDS is asking that in spite of other diseases, poverty, unemployment, it'd be given its right place within the social structure, within the health structure. Thank you.

Dr. Jonathan Mann. Dr. Mann is the former chief of the global program on AIDS at the World Health Organization and responsible for establishing that program. Dr. Mann, picking up on what Dr. Engogi said, what has been maybe the global impact of AIDS and how has the global program on AIDS at WHO dealt with the issues that Dr. Engogi is talking about and the issues that I think will be here for the rest of this program? Well, I think one way of looking at this to generalize across a decade and around the world is that the realization that we are now facing a truly global epidemic is a part of the realization that we are part of a global community. I think that in our time we are seeing much more the kind of pragmatic and concrete evidence that literally the products we consume, the air we breathe, the sunlight that comes to us and the viruses that are in our environment are all part of a global network to a much greater extent than ever before.

And at the same time, I think that AIDS generally, this is a broad generalization across many cultures and many different health systems, that in general AIDS has helped to show just to what extent the previous ways of thinking about health and the previous existing structures of health have been inadequate to the task that they set for themselves, let alone the additional task of facing AIDS. So it's in that context that I think we're actually living through the midst of a revolution. We're living through the midst of a complete and dramatic change that will involve a break from the past and looking at to the future at a revolution whose name could be called the right to health. What is the outlook for the spread of AIDS within the presence of these other tragic epidemics? Presently there are probably about 8 million people infected in the world of those about 3-quarters are in the developing countries and 1-quarter in the industrialized world. The pace of the epidemic is not slowing worldwide.

This is a young epidemic and very quickly that has three consequences. It is a very young epidemic in historic terms. First it has the consequence that the ultimate shape of the epidemic is not clear. The epidemic is still volatile, it's still dynamic, it's still moving, it's reaching new geographical areas like India that was little touched just a few years ago. So it's still moving, it's a young epidemic. Secondly, the major impact of this epidemic is still to come. The decade of the 90s will be much more difficult in almost every scale, on almost every measurement and the decade of the 80s has been. And third, because it's a new epidemic, we still have a tremendous potential for prevention. The problem is that the gap between our capacity to prevent this epidemic, prevent infection, and care for people who are infected and ill. That capacity is not really keeping pace with the pace of the epidemic itself. But I think as we've already heard, the AIDS epidemic often targets quite different groups of people in different nations, a film that was made for last year's international conference

on AIDS, graphically illustrates that point. The rocks New York, every 16th person is infected by the virus here, according to new studies. Many some parts of Central Africa can match the high infection rate in the Bronx. The virus strikes mainly among the intravenous drug users. There are more than 250,000 IV drug users in New York alone. More than half of them are already infected by the virus and are now spreading it to their sexual partners. I'm an example about the woman out there today that anybody couldn't get AIDS. I didn't go out there, going out with different men.

I had a husband to start with. I didn't use drugs. I didn't lead any kind of life to get AIDS and here I have the virus. Europe had an earlier warning than the United States and Central Africa. The generation gap between the young and the adults feeds the fears on certainties and prejudices that surround AIDS. Our parents were when they were young. They were using condoms but it was to prevent birth. Now the program is it's where you're using them to prevent death. It's really stupid to have it. You don't really feel it. You don't feel sick or whatever but you can't have children.

You can't have sexual relations with people you might like to have with and it's a shame. Once the Vietnam War there has been a surge in the international sex market and drug trade. The American military and Western culture have violently penetrated the ancient Southeast Asian arena. I was one of New York City, this is the best place in the world, why is there nothing you want here. Are you not the state of AIDS? What would you need, man, if you're a homo? The virus has just begun to spread deeply into cities like Rio de Janeiro, Mexico City, and

San Paulo. The poverty and the Rio slums, the favelas, forces many young girls and boys into prostitution. Their customers are mostly married men who pay up to three times the going rate for sex without condoms. We have many bisexuals. This bisexual men, they are usually married and they have their own family. Because the society in Brazil don't accept them as homosexuals or bisexuals, they pretend they are heterosexuals and they have a sexual life outside their homes. Even they usually don't know their partners, that that's what makes more danger for them to get infected.

Central Africa, the disease here is heterosexual. As many women as men are infected with the virus. Along the trans-African highway, 86% of the bar girls and 47% of the truck drivers are infected with the virus according to a recent study. Well, at our friends we used to go out together, that's who's quite looking beautiful. When we go, we go to the hospital, we find that she's losing weight, she's coughing, coughing too much, diving in one week, he lives with it. One of the bones knows skin, you know. So this means we head about and we all might say that too friend of mine, it passed away

with AIDS. A growing international gay community, prostitution and IV drug addiction have made Sydney a dangerous crossover point for AIDS. As far as the AIDS thing, we wouldn't know anybody knew anything about it, so we just kind of, if you didn't have a fit, you would use somebody else's, subsequently I borrowed the wrong syringe off the wrong person and gave myself a dose of AIDS. I think what we've just seen demonstrates very clearly how AIDS has created the opportunity for scapegoating of homosexuals, prostitutes, drug users and other affected populations. I'd like to ask Pastor Leonard Koskin and with the Swedish Ministry of Social Affairs

in Stockholm, why this is so, why does this have to happen? From the history we can learn that different deadly diseases are connected to different emotional themes like fear, guilt and shame, for example, cancer is strongly connected to fear. Only the name of cancer has grown a great fear. Take a leprosy or the best Valencia from the Middle Ages, they were strongly connected to guilt, people thought this was a punishment from somebody, hopefully not my god. And say the venerel diseases like gonorrhea are specifically syphilis was connected to shame, they were shameful diseases, and you were not allowed even to speak about them. But never in history we have seen any disease which is so strongly connected to all those three themes, fear because it's deadly, shame because it is because so many think it is

some kind of punishment and guilt and shame because of the connection with sexuality. So people are not on a rational level asking where do these disease come from? What can we do? But people are looking for scapegoats. Dr. Walsey, this year, World AIDS Day is dedicated to women. Why do you think that's necessary? What special problems do women have with regard to AIDS and if you'd stand up? They're infected without knowing they're infected, they bear children in deal with the grief, they're caring for children who are infected while they themselves are sick, they're not identified as a risk group by the medical establishment. And so the suspicion that this might be AIDS isn't brought to bear in the examination room and the list goes on and on.

Thank you. Going over to the panel, Dr. Munson in the Philippines, do women in the Philippines, are they facing the same kinds of problems that we just heard about? Well 70% of the HIV infected people are females in the Philippines and these are primarily women who work in such places as bars and massage parlors. And the problem there is mostly economic. The females become infected because they come to Manila, which is where most of the infected patients are that have been found and they work in such establishments where they have contact with customers who will then give them additional money. And this money then in turn is saved by these females, sent to their families in the provinces where they have mothers, parents, sisters and brothers who they are supporting through school.

So it's mostly an economic problem in the Philippines. I'd like to ask Dr. Engugi, what is the issue with women in Africa and AIDS? If her fertility is threatened by HIV infection like it is threatening now, she loses her womanhood in society. We find a growing drug problem and someone has said that if we don't deal with the problem of drug abuse, we probably won't be able to deal with the problem of AIDS. Dr. Don Desjurele, who is the Director of Research of Chemical Dependency Institute at Beth Israel Hospital in New York, what are you seeing about the drug issue and its relationship in a relationship with AIDS? Okay, first I'd like to correct the same as slightly. The AIDS and drug problem is not just the developed world. It is a problem in developing countries in Southeast Asia and in Latin America with potential spread to the rest of Asia.

So it's truly a worldwide problem. That creates the ability for countries to learn from each other. We should be able to look at prevention programs and treatment programs in different countries and then translate successes from one country to another. Right now, the biggest problem with respect to AIDS and drug abuse is the tendency for each country to only try to do one thing, to take what it was doing before AIDS and then just do more of it, either whether it's providing treatment or legal access to sterile needles or whatever, rather than trying any sort of comprehensive approach. Is one of the problems, the issue of the stereotype, of stereotyping all drug users as individuals who really don't care, who don't care whether they die, and therefore AIDS is of no import to them? Yeah, but drug users don't want to die from AIDS. It's a very painful way of dying. It means being sick for years. It's a way of dying that not only kills you, it may kill your spouse and may kill your children.

It's one of the worst ways of dying. It's not the type of death anybody would like and drug users really want to avoid that type of death. Thank you very much, Dr. Dejali. When we talk about discrimination and certainly that's what we have been talking about right now, the most burning example of this that we find is in the nation is being raised right now at the International Conference and it's about U.S. immigration. It's a law that we have in this country that provides for the exclusion of HIV positive people. While President Bush has made an exception for delegates coming to this conference, the discriminatory policy has sparked a worldwide boycott of the meeting and has provoked numerous demonstrations here in San Francisco. And I think as you look around the audience and on the panel, you'll find people wearing a red band as a demonstration of our solidarity with those who could not come because they were discriminated against and also to show our anger at this policy. We now have some tape of the protests that have been related to this and then we'll

hear from Shell Rinder, the Swedish gay rights activist who helped organize the boycott of European delegates. This interview is taped just a few days ago in Stockholm. European organizations for people with AIDS and HIV and also organizations for gay and lesbian rights have decided to boycott this conference. I do consider this decision quite correct because a ban on entry into the United States for people with HIV increases the stigma of an already stigmatized group. It's absurd because how can you ever control who's got HIV?

Of course daily people with HIV enter the United States, some of them without even knowing that they've got HIV. The same goes for homosexuals. How can you control who's homosexual? Now how many here, and if we could get a wide shot, how many here agree with the US immigration policy that this country has? As I look around, I don't see any hands raised. Could I ask a few people from the audience, why then did you attend this conference if there was a boycott? All right, we'll move up here to the third riser, if I can come upstairs here, and if you'd introduce yourself and who you're with. My name is Renee DeRiza, I'm Director of Public Policy for the San Francisco AIDS Foundation. I would just like to point out that the problem with US immigration and visa policies isn't just with travelers coming to this country, it's how people who are in this country who are applying for permanent residency are treated as well.

They are subjected probably to the largest mandatory testing program in the world. And the abuse is under this system, and the abuses of human rights under this system is uncalled for and is just as offensive as the restrictions that we have on travelers. We're talking about a law that impacts probably upwards of 2 million people who potentially could apply for residency here, so I just wanted to make that point. The reason the AIDS Foundation chose not to boycott this conference because we felt that boycott essentially was pitting very essential critical information and education goals worldwide against human rights. And we have been put in a position to choose one or the other. We don't think that necessarily we should be asked to do that. So we chose to come to this conference because we do feel that it's important for the information to get out, and we have to continue to fight the infringements on civil rights through the U.S. immigration and visa policy through other means, but not by trading off our need to get information.

Thank you very much, Renee. I'd like to ask Dr. Baier if you'd give us your title, Professor of Public Health at Columbia University. I think it's although it's been very important to focus on the sheer stupidity of American policy with regard to immigration and travel that we not forget that this is not unique to the United States. The list of countries around the world that exclude people with HIV infection from immigration or long-term visiting spans the political spectrum, it spans east and west and north and south. And I think if we only focus on the United States, we will have lost an enormous opportunity, a very important opportunity to focus on the question of really what amounts to a worldwide quarantine against people with HIV infection. You visited Cuba, what did you find and what is your perception of that? Well, as some of you may know, Cuba is the only country in the world that has made a decision to control the AIDS epidemic within Cuba by a universal screening of the entire population and by the isolation of all HIV infected individuals. The Cubans have told us and they've said it over and over again throughout the world

that they have an epidemiological opportunity that they're not going to miss. It's an island nation with no democratic tradition. They feel perfectly justified in quarantining everyone with HIV infection. They understand, it means lifelong quarantine, but that they believe will protect Cuba from the kind of ravages of HIV infection that will occur elsewhere in the world. And what it really represents is a kind of medical preventive detention. When I asked the Cuban authorities why they believe they had to isolate everyone with HIV infection, why they didn't believe education could work, they said, rather amazingly, did you know Cuban men, they all want one more woman? And when I said, how can a society that has devoted so much to education and the beliefs and the creation of a socialist man, why do you believe that education can't work? And they said, basically, we'd rather be safe than sorry. Very interesting. Dr. Fauci, is there any possible positive effect? I mean, there's any good reason to, and you think, for such a policy? Absolutely not.

I mean, any reason, whatever, that type of quarantine, which is much more of a punitive than a public health measure, could have any positive impact on public health. Bishop Swing is right Reverend Swing here in San Francisco. What is the church's role? What should the church's role really be in this? And how has the American church, and I say church, and is a euphemism for all the religions? How have they behaved, if you will, in the United States, with this epidemic? I think across the board, pretty poorly, when we've come to other moments in history where the church has seen the plight of a human being being unjustly addressed across the board, the church traditionally has gotten behind people and supported people. In this epidemic, I think, an awful lot of the right-wing aspects of the church have seen this as God's wrath, and I think the mainline churches by and large have been embarrassed about it, because it has to do with homosexuals and other people that the church wants

to have nothing but a negative image to. A lot of times, the church will say, we love the sinner, but hate the sin, and so I end up in San Francisco talking to a lot of these people, and I say, does it feel like you're being loved? And they say, absolutely not. It holds for the church in Europe, too. And not only the big organized churches, but all these small religious groups who now see an opportunity to condemn people and feel that now we are right. I just get a booklet like this, which is spread in 12 million copies about AIDS from the Jehovah's Witnesses in all over the world, where they are telling that, look, we were right.

homosexuality must be seen, now they get their punishment, blood is something very dangerous, they may not take blood, and all sexual activity outside, matrimony is also seen. If you stick to us, you will avoid AIDS, which is a way of condemning most of the population outside these groups. So I think this double morality is so dangerous. Dr. Here, with the government program and the AIDS program STD program in Zambia, what are you seeing there? The HIV transmission hasn't slowed down, and we've been seeing that lots and lots more people are getting infected eventually. And this is primarily because we are talking of health education and one-to-one counseling in terms of control efforts. But what has been neglected all along, and for almost decades, is a control of sexually transmitted diseases, the conventional sexually transmitted diseases. And we do believe that with such high prevalence of STDs in Africa and most of the southern

hemisphere, unless these STDs are controlled, I think it will be very, very difficult to get a handle on HIV transmission. Dr. Rosenbaum. Yes. In France, for example, the parliament has voted low one months ago against discrimination of HIV people. No, today, in France, if somebody makes some discrimination against HIV infected patients, they can be punished. Going jail. Dr. Munson, what about hearing about that? Are there any laws or are there any need for laws in the Philippines to deal with the problem of discrimination? There are no laws as such, although the Department of Health has come out with a set of policies with regards to the different issues, including no discrimination of HIV-infected

people. Without a doubt, the key to preventing AIDS, or at least limiting its spread, is through education. Education means explaining an understandable language, what the virus is, how one gets it, and most importantly, what specific steps one can take to avoid being exposed. In many nations, television is the most effective way to deliver these messages. For the next few minutes, we're going to show some short TV spots that are in use around the world. If a condom is employed, if a condom is employed, if a condom is employed. If there are any

Let's see, if I take him down, please stay down and land along. Hi! The two are soft and more. See?

See that? See? No. No, no. See? See? No, no, no. See? No, no. No, no, no. See? No, no, no. See? No, no. No, no. Terry. Yeah? What? Save the safe. Token dairy on the farm? Oh, Terry. Discover how to enjoy safe the safe. Hey, sorry. Someone go to AIDS for the camp. Who said? Am I joking? AIDS. The facts everyone should know. Are you Vicky? I've got a condom. You know how to use it? Sure. Well, now when you need somebody use it with. Well, you certainly saw a number of different approaches using television.

Dr. Bayer, some of those were fairly explicit. What has been your feeling about the kinds of ads that we've been seeing on television in the United States to really try and reach people? Let me give you an example of something that happened in New York City last year. The New York City Health Department developed an extremely interesting and might have been an effective program directed towards both gay and bisexual men in black and Hispanic communities. The networks wouldn't run them. There was more news about these educational campaigns than actually running of the campaigns. And when they did run them, they ran them extremely late at night. What that shows is a kind of timidity, a kind of stupidity. But more than simply anti-homosexual bias, it reflects an inability to deal explicitly and openly with sexuality in the American mess media. Which is very interesting. If you stop and think about it, because most of our products here are sold with sex,

and many of our soap operas and many of our programs have a lot of sex either implicitly or explicitly. Dr. Mann, any comments? One of the silliest things that I heard in four years of working at WHO would be people who would come to me and say, now, how are you going to prevent AIDS in illiterate societies? And I would try to point out to them how beautifully tuned so-called illiterate societies are to spreading information. I mean, we're talking about culture here. We're not talking about simple television or simple newspapers. We're talking about culture and culture's capacity to transmit useful information. One last point I would like to make if I could is that the problem here is not just knowledge. We all know that. Now, I'd like to come back to the pastor's comment to something deeper here for people who, despite all the information, still believe that HIV is transmitted casually. Survey is all over the world. We'll show the between about 15 and 25 percent of people in every society still believe, despite repeating and repeating and repeating the information, still believe that HIV can be spread through a handshake or through sharing a drinking glass and so forth.

And those people are dangerous to us because they perpetuate misinformation and they scare other people. Now, why don't they believe us? And the us is not just medical professionals or government leaders. It's also their neighbors. It's their community. I think we better understand some of the deeper roots of this fear, some of the themes that the pastor mentioned are at the basis of it. Otherwise, we can repeat until we are literally blue in the face and people are not going to believe us. And if they don't believe it, ultimately they will react with fear rather than reacting with knowledge. An excellent point. Dr. Cortez, what about Brazil? We are planning first actually to educate the people who have the power to make decisions in the country. I think one of the problems in Brazil with the discrimination, for instance, at the beginning of the epidemic, not only they discriminate the people, but they discriminate the disease, thinking that the disease was not important. So, we have to educate people in Brazil that the disease is important.

And the education in Brazil right now accounts with 12,000 aid cases, 150 million people, 32% of illiterate people that are not having access to the information that's being written, that doesn't have access to the information that uses vocabulary that's a little bit more sophisticated like diseases and sexual transmission and IV drug use. We have engines, we have so many things to educate. We have street kids, homeless people, et cetera, et cetera, et cetera. So, what we'll be doing after having the people who make decisions, I think it's a very important point being aware of AIDS. We'll try to educate the Brazilian population, not only how the virus is transmitted, but where the epidemic can do in a country like Brazil. Let's begin. Oh, thank you, sorry. Yes, 250,000 American males go to Thailand every year, and only 8% of them use condoms.

And we talk a lot about discrimination, everyone's talking about homosexuals, but these, I sat in the bars, these are normal men. They look like you guys, they look like me because I sat there with them, and they're going to come home to their wives, and they're going to give them AIDS. And that's going to wipe out a lot of discrimination because these men are just normal businessmen. Directors of big companies, the lady there from Philippines, the same situation exists in the Philippines. I'm now an expert on the Philippines, but I am on the bars in Bangkok, and the same thing as this. Everyone's talking about the prostitutes. What about the customers that are prostitutes? Moving to the first row here, yes sir, if you get up and give us your name and your thoughts. I want to express the concern at the anxiety of Africans, as far as the draft is concerned. Right now, it said that AZT is efficient to trade, or at least to decrease the evolution of the disease. Still, in Africa, nobody can afford to use AZT. So our concern is that maybe even tomorrow, when we discover a vaccine, this situation would be the same.

So really, I think this is a major problem, and we cannot close our eye about it. I think you make a very good point, and that is that as we talk about ourselves here in the United States, we see that we have, I think we spend somewhere about $2,000 per person per year for healthcare. In some of the countries that you're talking about, sir, we're talking about maybe 50 cents or a dollar. And I think that raises a good question, and I'd like to ask Dr. Mann, who's responsibility is it to help deal with this economic issue? I mean, it's certainly a disease issue, but the economic issue of developing countries to try and fight the spread of this disease. Well, first, I agree completely with Professor Kubtwein. I'd like to just add a few more numbers to what he has said. Most of the treatments, most of the tremendous advances in the care of infected and ill people that are being discussed at this conference, unfortunately, remain irrelevant to the majority of the people in the world who could benefit from those advances.

One way of looking at that is that most of the national AIDS programs in the world actually cost less, or are given less resources, I should say, than it would cost to take care of 15 people in the United States with AIDS. In other words, the cost of caring for 15 people with AIDS in the US is more than the money that is available internationally to an individual country on average to fight AIDS in its country. Another way of putting that is that I would estimate that the total amount that the industrialized world is contributing to the global fight against AIDS, that is the fight against AIDS in every country and in the developing world, is at most about $200 million a year. And that's one fifth of the amount of money spent in the state of New York for AIDS prevention and care in 1989. Now, the inequity has to be first recognized for what it is. It's a tremendous inequity. The question of who is responsible, the biggest danger there, Murf, would be to say, oh, that agency, because that would miss the whole point. The point is that the changes that will be required to rectify that kind of fundamental inequity in the availability of health care and health services is going to require much more than the action of one agency.

It's going to require a willingness on the part of countries to say the problem isn't resolved yet here, but even before it isn't, even before it's resolved, we're going to help the others. And we're going to help the others because if we don't, the whole system will fail. The whole world will fail. This is the basis of solidarity. Either we will develop solidarity and address those issues, or we will fail as a world to meet this test. The consequences of failure will be enormous and not just for AIDS. I think that's an interesting point and leads me to ask the question about testing of new vaccines or drugs in developing countries. What are the responsibilities there for the developed nations? Well, I think that it's critical that drugs and vaccines be tested anywhere using the highest ethical standards because, in fact, those ethical standards are going to be related as well very practically to the quality of the research that is being done. Now, there are questions being raised should have vaccine when it's available to be tested in developing country and so forth.

The real, obviously, ethical standards have to be observed, but the big issue is the one professor, Cuptoim, mentioned. When a vaccine does become available, will it be available only to the rich and to the rich in countries, or will it be available to the entire world's population in need? Unfortunately, Murr, the status quo would be that the technological progress would give us a vaccine and then we would fail miserably to use it effectively and rapidly for the world's population. I think AIDS gives us the opportunity for the first time in the history of the world to do it right. It's not going to be easy, but it's not going to happen by itself and it's not going to happen because an agency takes an action. It's going to require people around the world saying we do not accept the idea that that vaccine would only be available to the rich and, therefore, we insist that changes be made. It's not going to be easy, but it's part of the revolution I referred to earlier. I have to agree with you. Pastor Cascannon. This is the war we have to fight. Why not cut some 10% of the army and war costs and use during some time for this purpose,

if the industrialised countries could take the money they save on this army and use exclusively for this, for some period of time. This problem would be solved at least the economic problem, so that is our challenge. Dr. Engugi. Thank you very much, Mr. Chairman. One thing Africa doesn't want and doesn't need is to be used as a guinea pig. We don't want all the tests, vaccine tests to be done in Africa. We don't want all the drugs to be tested in Africa and we don't gain. We would like to feel that the vaccines, drugs are tested in various centres of the world, both developing and developed. And when that has been perfected, we want the distribution to be equal so that every HIV infected person,

aids people can benefit equally. Thank you. Going to this first row over here, if you could identify yourself, sir, in your comments. I want to make two points. When I think that this virus is a very democratic virus. Because for the first time, I think we are together, developed and developed words talking together about one disease. We had Malaria never had anything like that, and she sort of lies in the lab, we can name it, and there are many of them. And I think that would be the point. If we have citizenship, we may change things. If we don't have, we're going to be paternalistic waiting for them, developed countries to give us something back. The second point that I think the prejudice is so big that if I wasn't Thailand, and if I heard our friend he is saying that 250 Americans went there, I would do the same as American did. I would prevent them to having a visa.

Because the chances are that they were would be the ones that would give the HIV to Thailand and not the vice versa. So these things are very dangerous to speak about. We are living in a way that now we are the scapegoats, and talking to myself as a physician. And the scapegoats are someone else, the politicians, the educators, the social workers, the governments and the military, and the religious people. We are the six and the seven and the line of people that are preventing that HIV can be treated as a disease to get with many others that have to be presented. Thank you. The gentleman next would stand up and identify himself. Thank you. Dr. Mann will translate simultaneous translation. Thank you. That's very good. He comes from a small country in West Africa called Burkina Faso. He is the most important person in the world.

He would like to say very straightforwardly and simply that AIDS in his country has created tremendous upheaval. In Burkina Faso, the life is collective. People are accustomed to helping each other. And now they are living through a tremendous drama, a tragedy in which there is a grave threat to the collective quality of life, to the helping of people of each other. In general, in Burkina Faso, a dying or ill person would be cared for by the family, by members of the family. And now in the capital city of Burkina Faso, there are dying people in the hospital of that city who have been abandoned by their family.

This is what the gentleman wished to say. Thank you very much. I actually would have done that translating, but I wanted to give Jonathan a chance to practice his branch. Dr. Woffsey, you had something you wanted to say. Yes, I changed from the eloquent discussion that just happened back to the issue of Thailand and the sex industry in which American men or visitors from companies all around the world may be giving or taking disease. And I'm concerned that a population with the greatest amount of education, who can read all of the words in the newspapers, who can understand everything on television and has extraordinary networks, don't either alter behavior and if unable to alter behavior and insist upon going to prostitutes, why not do it safely? It just proves that the issue of education is not one of exposing knowledge. It's taking in information and that's sort of an invisible group.

The male power group that travels a lot has every means to employ self-protection and protection for the woman or the man prostitute and it isn't employed and it's one of those invisible issues. I hate to draw us away from that, but I think before we end the program we ought to take a look at the future. We've looked at the past, we're right now in the present and what we need to do is look towards the future and what the statistics look like the projections for the world. The estimated case is 650,000 in 1996 million in the world by the year 2000, estimated infected six and a half million in 1990, possibly 20 million in the next decade. Dr. Mann, what does that say to you? Well, the message is very clear, the impact of this epidemic is going to be felt much more during the decade of the 90s than in the 80s and that's going to be an impact in terms of numbers of people with AIDS, numbers of people becoming infected and infected, the social political economic stresses that result from that. And so I think for all those reasons, we deserve a week or some time here in San Francisco and around the world to take a deep breath and to think about our next steps and to advance together into the decade of the 90s, the difficult and dangerous decade of the 90s with all the solidarity and all the knowledge and all the intelligence and all of the humanity that we can muster.

What do you think of it? You're not now with the global program anymore, but what are your hopes for the World Health Organization and the global program in this to help bring about that? I know no single agency can do that, but how would you like to see that role played out? Well, the World Health Organization has a constitutional responsibility to direct and coordinate international health, and I fully hope and expect that responsibility to be continued. We all need them to do that. But the message that's come through I think very nicely during this whole discussion is that it's a big mistake to say to somebody else, please take care of this for me. And it's a big mistake to say, it's your problem, not my problem. Last night at the quilt at the names project, quilt, I saw what I thought was a beautiful quote on one of the panels. And it said, remember that the military and the government do not empower us. We empower the military and the government. And I think that what we have to do is reach way back and realize that for a problem to be universal, it first of all has to be very personal.

And we're with AIDS at a point where the personal depth of this problem and the global scope of this problem can somehow become better joined so that we can reach towards the kind of solidarity that will address the issues we've mentioned in which we take responsibility for ourselves and responsibility for others. What is your sense having attended and brought together conferences of the leaders, the health leaders of the world and being involved with the world health organizations, leaders that that's something like that can take place. Well, I think that we have collectively, and I mean the we collectively in all the countries of the world have set in motion, as I mentioned earlier, something that I don't believe can be stopped because it is something that is important to happen in the world today. It is to say that we look at the objective conditions of the world, we consider the situation we are in together, and leaders who are incapable of providing the leadership towards solidarity that we need will no longer be seen as leaders.

What we need to do, therefore, is to do this work together, I think I'm optimistic, I'm always optimistic about these things because look what we've done, look how far we've come in one decade, it's as if it were a century ago, we've come that much distance in terms of our understanding of the needs of people and what the revolution for the right to health can mean to the world and for peace. That seems like one of the cornerstones on that, and we keep getting back to it is education, and most of us have talked about educating those people who are practicing adverse behavior, education from the church to their congregants by the school teachers, to the children, the students from parents, to their children, and we've forgotten, and I think it's a point you've made, possibly that what we really have to do, all of us, all of us, the 12,000 that are at this meeting, many, many thousands more that are around the world that we have to educate our leaders.

We have to educate our politicians to do the right thing, and then with our ballot in most countries we can sort of make our feelings known through the vote, we can go and say you're not responsive, you're thinking only in terms of yourself or your country and not in terms of the world. And I think we see it's a global problem requiring global solutions. You know, as we end this program, I'd like to tell you about a letter I read several years ago. It came from a mother and a company to cloth panels she had made to be part of the names quilt project, the project that Dr. Mann has just talked about. And this project encouraged people to deal with their grief by sewing a panel in the name of a loved one who died of AIDS. She wrote that instead of one name, she was placing two names on the panel since both her sons had died of AIDS. Whenever I think about this, I'm reminded that whether a person is older young, homosexual or heterosexual, male or female, black, white, brown, yellow, everyone with HIV infection. Everyone with AIDS-related conditions or AIDS or everyone who has died of AIDS, each one of these people is someone's child. And hopefully we can show the kind of compassion and sensitivity towards them that we would like to have shown towards ourselves.

As I mentioned, AIDS is a global problem and we need to work together to find the global solutions. I'd like to thank all of the people who took time away from the conference to join us here tonight. And I would like to thank especially you for watching. On behalf of KQED and interactive events, I'm Dr. Mervin Silverman. Good night. Thank you.

Thank you. Thank you.