Earth Summit 2002 online debate at www.lifeonline.org/debate:
'What should Earth Summit 2002 be trying to achieve?' 

Summary of the debate of week 3 (17 - 21 September 2001):
HIV/AIDS is a great threat to sustainable development; how can multi-sectoral responses be developed to influence government policies and pharmaceutical companies on this issue? How can Earth Summit 2002 tackle the wider question of equitable health care?

Purpose and structure of the debate
Ten years after the 1992 Earth Summit in Rio, the world's nations will gather again in Johannesburg next September to review progress and plan for the future. Preparations for the World Summit on Sustainable Development 2002 are well under way, emphasising a transparent and participatory approach. 
The debate was part of www.lifeonline.org - a multi-media initiative exploring the impact of globalisation on the poverty and social development agenda of the Habitat+5 meeting in June 2001, as well as the upcoming 10-year review of the 1992 Earth Summit. This electronic forum was aimed at initiating a focused and constructive public discussion on some of the priority issues. People were invited to share their ideas, knowledge and diverse perspectives.
The report, incl. the summaries of all four weeks, will be widely disseminated to policy-makers and all other interested stakeholders engaged in the 2nd PrepCom of the World Summit on Sustainable Development (New York, January 2002).
To download the pdf or txt version, please go to www.earthsummit2002.org/es/life/default.htm 

Moderation process
The debate was moderated by Jasmin Enayati, UNED Forum (www.unedforum.org) with support from Lifeonline partners One World, TVE, and PANOS. 
The purpose of moderation was to keep the volume of material posted to a manageable size (max. 10 messages per day), as well as to ensure observance of the ground rules. In addition to the ground rules, the criteria we considered were: relevance; substance of contributions; concreteness of argument; and constructive tone.
Numbers
By the end of this week we had more than 770 registered participants from 88 countries, representing many different stakeholder groups (academics, architects, artists, businesspeople, faith communities, governments, NGOs, Indigenous Peoples, local authorities, media, scientists, students, UN officials, women's groups and individuals).
Summary
The following is an attempt to summarise and give an impression of the arguments as they developed through the debate, using mainly selections from the submissions.
Where possible, the name, organisation and nationality of the contributor will be given.
Initial contributions
We had invited four key actors to contribute initial articles for the debate:
Dennis Altman, Professor of Politics in the School of Politics, Sociology and Anthropology at LaTrobe University, Australia. Co-chair of this year's Congress on AIDS in Asia and the Pacific.
Martin Foreman, director of the Panos AIDS Programme in London. He has worked in international aspects of AIDS since 1986.
Dr Yusuf K Hamied, Chairman and Managing Director of Cipla Ltd, India.
Mencer Donahue "Don" Edwards, managing partner of Justice and Sustainability Associates, LLC, a U.S. based management consulting firm. He is a member of UNED Forum's Earth Summit 2002 International Advisory Board.
Thanks
Thanks to these four authors and all the other participants for making this debate happen and putting their time and effort into this debate.
Introduction
Contributions to the debate focused on a number of key issues and ways to tackle them; such as prevention, access to treatment and global guidelines on Intellectual Property Rights, specifically looking at the TRIPS agreement. Following on from that some of the key barriers to achieving a multi-sectoral approach to the AIDS epidemic were identified; including specific barriers, like the provision of particular goods to general requirements, such as the empowerment of women and a value system that is based on just and equitable principles. Several examples of good models and ideas on how to overcome barriers were suggested, ranging from examining the role of culture and religion to further establishing multi-stakeholder partnerships in the fight against HIV/AIDS.

Background
Two points characterised the debate of this week. First of all, we have to think about the HIV/AIDS epidemic not merely in terms of a disease but in terms of a behavioural issue. And, we need to consider the interdependence between the HIV pandemic and any number of development dynamics: migration and population movement, the impact on skilled labor, health costs, economic impacts, food security, etc.:
”In the last twenty years, over twenty million people have died from HIV/AIDS. Another thirty-six million are living with the virus and every year at least another five million become infected. While many aspects of HIV are shared with other diseases - such as the fact it is sexually transmitted and if untreated is inevitably fatal - AIDS presents a unique challenge to sustainable development in the twenty-first century. Two areas in particular are of concern: how to reduce the rate of transmission and how to make treatment widely accessible.”
(Martin Foreman, Panos Institute, UK)

Key issues and ways to tackle them
Prevention
All contributors agree that successful prevention of HIV infection is a very complex issue, involving social, cultural, economic and psychological factors:
”Provision of health care is both a human right and a prevention tool; for example, reducing the prevalence of other sexually transmitted diseases reduces HIV transmission rates, as does provision of care for HIV/AIDS itself.”
”Reducing transmission rates mostly depends on changing sexual behaviour. However, how often people have sex, who they have sex with and whether they use a condom is determined by a wide range of social, cultural, economic and psychological factors, with poverty and gender in the forefront. As a general rule, women who lack economic independence - most women in the developing world - frequently find themselves in sexual situations that they would not otherwise choose. These can range from a one-time encounter in exchange for money, services, "gifts" or shelter through longterm relationships as mistress or "babymother" to lifelong marriage. Unsurprisingly, many men - some knowingly, others unwittingly - take advantage of women's availability…”
(Martin Foreman, Panos Institute, UK)

A multi-sectoral, comprehensive approach is fundamental, involving an integrated public and private sector response and including religious institutions and NGOs.
Most importantly, this means to instigate a widespread and inclusive debate:
”providing an analysis of the social, economic and other factors underlying sexual behaviour, and engendering widespread debate as to the best way of respond to the epidemic. Such debate should involve policymakers, the media, those working in HIV/AIDS care and prevention and, above all, those individuals and communities most affected. This last group is the greatest challenge, because they are often the women and men whose lack of education, poverty, behaviour etc has forced them to the margins of society.”
And also to disseminate information about the transmission of the virus:
”wide range of information campaigns directed at different audiences (eg targeting men and women separately, according to age, socio-economic background etc), opportunities for those at risk to discuss prevention messages, provision of voluntary counselling and testing with basic treatment options, poverty reduction strategies for vulnerable groups and legal and political initiatives that tackle basic gender inequalities.”
(Martin Foreman, Panos Institute, UK)
”Effective prevention requires an end to government and religious hypocrisy about sex and drugs. "Information campaigns" (a weak phrase) only work when they speak honestly, realistically and non-judgmentally about behavior. As long as most of the world's governments refuse to recognise the existence of homosexuality, drug use and sex work in their countries, and seek to brand anyone who engages in these practices as deviant and criminal, prevention efforts cannot work…”
(Dennis Altman, LaTrobe University, Australia)

Access to HIV treatment
How to ensure a better quality of life for people living with HIV/AIDS
”Lowering the viral load and delay the progress of the disease are two basic objectives of this treatment, but prices are so high for almost all people with HIV infection. Who pays? Government is sick of bureaucracy. NGOs are too weak to respond to PWA [people with AIDS] needs…what happens with the rest of these people [that have no social security due to unemployment, eg in Mexico this group accounts for 40% of PWA]? One part has access to treatment through local NGOs. Self-help groups are doing so much to reduce the stigma of infection increasing a sense of community and providing sensible treatment and support. Such self help groups may be an ideal vehicle for drug distribution which is likely to be more effective and equitable than that which can be provided by many present health care systems crumbling under the burden of many infectious diseases... UNAIDS said …”People with HIV/AIDS require comprehensive support, and not just medicines” 
(Francisco Rosas, Consultant, Independent Consultant, Mexico)

Global Guidelines on Intellectual Property Rights (outlined in WTO’s TRIPS agreement which regulates the export of drugs)
Setting prices globally in line with those prevailing in the developed countries can prevent access to essential medicines for the poor. Please see Dr Hamied’s contribution, quoted nearly in full length, which explains the implications of the TRIPS agreement:
”Under TRIPS, patent protection must be given by all WTO countries to pharmaceutical products. Patents lead to long-term monopoly and are essentially "restrictive" whereas WTO stands for FREE TRADE. Patents prevent anyone except the patent holder to market the patented invention. Consequently, patents accord a market monopoly to the patent holder, who, free from market competition, can set prices according to what the market will bear, different in different countries but invariably as high as the market will accept.”

Pricing policies
”The prices of essential medicines including those required for HIV/AIDS can be kept reasonable and affordable through a package of measures that include:
1. voluntary co-operation with the patent holder can lead to voluntary licensing and technological transfer which will allow local production of essential medicines. Where this is not forthcoming, the present TRIPS agreement includes legal safeguards which allow countries to produce or import drugs of their choice through compulsory licensing or parallel import at lower prices offered elsewhere on the world market.
2. It is essential and imperative that the developing and least developed countries be able to use these safeguards to the fullest extent possible. They will then be able to provide positively towards the health and welfare of their population including major diseases such as HIV/AIDS etc.
3. It is also important that the international community (ie) the developed countries, in particular those attending the WTO Ministerial Conference in November 2001 in Qatar should in turn strongly support the public health measures in the present TRIPS agreement to allow developing and least developed countries to use these safeguards freely without fear of trade retaliation.
4. Based on the above, perhaps the developing and least developed countries should be given an additional 10 years to abide by and fully comprehend the TRIPS provisions. These are by themselves not clear and need careful interpretation.
5. Perhaps there will be a more positive development post November 2001 of having separate and distinctive provisions and guidelines within TRIPS - TRIPS North for the developed countries and TRIPS South for developing and least developed countries.”
(Dr Yusuf K Hamied, Director of Cipla Ltd, India)

Another key issue that was suggested is further debt cancellation (coupled with improvement in health services).

Key barriers to achieving a multi-sectoral approach to the AIDS epidemic
”The barriers to sustainable and effective responses to HIV/AIDS are both specific and general, meaning that they range from the provision of particular goods (eg. condoms; clean needles; therapeutic drugs) to more general requirements such as the empowerment of women, adequate food, water and shelter, and the protection of both those who are HIV positive and those vulnerable to infection from discrimination and stigma.” 
(Dennis Altman, LaTrobe University, Australia)
”…the main reason … is the unmitigated greed that continues to be contest in the battle of sustainable vs. unsustainable development. With so much money having been made during the last decade, if the rich people would have simply given more of their money to the people who actually know how to improve the lives and livelihoods of the poor people, maybe we could have mitigated some of the frustration, hopelessness and anger that is at the root of the branch whose thorn deeply pierced the United States last Tuesday.”
(Don Edwards, Justice and Sustainability Associates, US)

Certain lessons can be learnt from Brazil, which has been able to provide a full range of anti-retroviral drugs to the majority of its citizens with HIV and countries such as Thailand, Uganda, Senegal and Cambodia. However, a simple duplication of ”success stories” in the fight against HIV/AIDS would be very difficult to achieve for the very poor countries in Sub-Saharan Africa, where the rate of infection is far higher.
”organised religions, whose opposition to the promotion of condoms and to the rights of those whose behavior they disapprove of is the major barrier to effective HIV prevention. This applies equally to rich and poor countries; religious hypocrisy has harmed HIV prevention in the United States as much as in Egypt and the Philippines;
"Equitable access to health care" depends upon a large scale reallocation of global resources … attention needs to be focused on the spending priorities of all governments not only the rich. As long as a number of the worst affected countries continue to spend large parts of their income on military adventures (eg. in the current civil war in the Congo) it is futile to expect that more international aid will directly assist those living with HIV;”
(Dennis Altman, LaTrobe University, Australia)
Don Edwards (Justice and Sustainability Associates, US) emphasizes the importance of building up a public health system
”construct the foundation of a pan-African Saharan health system which is surely what has never existed - not even under colonialism.”

Various contributors agree that the attitude of policy-makers, the private sector and the media need to change:
”what is needed is… a willingness to address aspects of human behaviour that are still not seen as fit for public debate and a willingness to bring into the discussion the most marginalised, and most vulnerable, members of society.”
(Martin Foreman, Panos Institute, UK)

One contributor points to the importance of collecting data for demonstrating to policy-makers and official governments the impact of epidemics such HIV/AIDS on the development of communities. Conflicting perceptions and priorities still seem to bar the way forward:
”For many policy-makers costs of prevention and treatments of seropositive people is a waste of money; so they do not realize the relation of health and development.”
(Roberto Lopez, Coordinator, Accion Internacional para la Salud, Peru)

Don Edwards, Justice and Sustainability Associates, US opens up the issue of white supremacy as the key barrier to achieving equitable health care and equity in general:
”I believe it is absolutely true that African lives are currently valued less than all of the world's other lives. And, the roots of this lesser valuation are grounded in the pseudo-science and racist social mythologies that the entire world has been oppressed for over 500 years. 
It's my opinion that from the standpoint of sustainable development, it is a matter of realizing that how goes Africa is how goes the world! If we use the five capitals model (human, social, natural, manufactured and financial), we cannot avoid a commitment to creating a just and sustainable Africa. The planet's future requires it. In order to achieve global security, we will have to establish the socio-economic, human and environmental security of Africa. And to do that simply comes down to placing the same value on black mother's children as is placed on white mother's children. 
One of the foremost HIV/AIDS behavioral researchers in the US, Dr. John L. Peterson, Georgia State University, states that "the social and physical environment can promote or impede HIV risk behaviors in communities (e.g., social norms, places for meeting, etc). Therefore, efforts are critically needed to change the social ecology of communities that affect the social and physical dynamics of community empowerment over HIV transmission in vulnerable populations." 
(Don Edwards, Justice and Sustainability Associates, US)

Good models / ideas how to overcome barriers
One crucial issue that has been discussed continuously is the creation of partnerships as a way forward (see more in the section on suggestions for Earth Summit 2002)

Set up ”A Season of AIDS Awareness”
”As suggested at a session at the UNGASS on the topic of AIDS and Human Rights, the Board of Directors [of the African Services Committee] will look at the proposal to hold a regionally-based worldwide annual period of reflection and review on what governments are doing regarding HIV/AIDS and what NGOs are doing.
This period of time would be modelled on the Season of Non-Violence sponsored by the Interfaith Center of NY. The Season of AIDS Awareness would stretch from December 1, World AIDS Day, through December 10, Human Rights Day, and each region would have two days in which to hold consultations to review what progress has/has not been made.
The compressed timeframe might serve quite well - the idea found interest with ILO Director-General Juan Somavia, with whom I spoke in June in New York City.”
(Richard Jordan, Board of Directors of African Services Committee, US)

Be aware of the role of culture 
”From our point of view as indigenous peoples of Kenya, it is a good idea if the issue of culture in relation to HIV/AIDS is critically addressed. We should openly discuss HIV/AIDS among all members of the households, clan and community at large for better understanding of the issue. We also suggest the incorporation of effective family life education into school curricula in order to inform young children about how they can prevent themselves from AIDS.
With the invention of the anti-retroviral drugs we hope will liase with pharmaceutical companies, to ensure that they are affordable and readily available to the whole population, more so to the indigenous peoples (Nomadic pastoralists) who occupy the marginalized, discriminated Arid and Semi Arid lands."
(Peris Kebenei and Judy Imbanga, Indigenous Information Network, Kenya)

Role of religion
One contributor emphasizes the positive role religions can and should play in influencing people’s lives:
”I think that the problem of HIV can't be solved only by the governmental policies and pharmaceutical companies, it needs awareness of people themselves… - limiting this disease needs a good motive inside themselves, not only to have better health, but to have a better life. And I think that's the role of religions in all societies. To give people motive for change…”
(Yara, Medical student, Ain-shams University, Egypt)

How can Earth Summit 2002 tackle the wider question of equitable health care?
First of all, it is important to strengthen the link with the existing international process on HIV/AIDS:
”The Earth Summit might look at both the recent United Nations Declaration on HIV/AIDS and what it omits to say. In particular governments need to accept that the health of their citizens is fundamental to national survival, and that arguments about tradition, culture and religion cannot be used as alibis to prevent effective information and programs such as the provision of clean needles and condoms which have been proven effective in slowing the rate of HIV transmission.”
(Dennis Altman, LaTrobe University, Australia)
Additionally, multi-stakeholder partnerships for implementation must be strengthened
”Partnerships! This should be the key word at the Summit. The Governments need the support and money of pharmaceutical companies to develop effective health care and the governments need to ensure that health care is distributed equitably. Without acknowledgement by stakeholders that government and private enterprise need to work in partnership with each other, I do not believe that equitable and SUSTAINABLE health care will prevail through the nations of the world.”
(Stephanie Dunstan, Australia)
”HIV/AIDS is an auto-immune disease, with multi-dimensional disastrous results. It causes many changes to private relations, family bones, and has changed the whole of society. We need to stick together all the social sectors. Our role in the Summit for Sustainable Development will be to awaken the social conscience of our citizens to obtain more cohesion and up-to-date scientific, reliable information…. we have to become partners, and decide to undertake common projects and organize meetings to exchange ideas. Our initiatives have to aim toward further developing reliable knowledge.”
(Kalliroi Nicolis, Social Aid of Hellas, Greece)
”setting up a multi-sectoral approach to the pandemic should not concentrate on developing policies only, but concentrate on the implementation part.”
(Ellis, AIDS Expert, Namibia Red Cross, Namibia)
Young people: A population in real danger
Francisco Rosas describes the threat HIV infection poses on young people in Mexico City, due to abuse of drugs and alcohol, unemployment, sex work, domestic violence and troubled gender relations. Problems that are a threat to the country’s future and that can be found in most countries heavily affected by HIV/AIDS:
”I would like to hear from people from the government what they will do with this population of young adults with the shadow of AIDS on their lives. In Mexico, sex experiences are starting at early ages in this group of teenagers and young people. I would like to invite people from government to take real decisions that favour young people affected. Efforts from professional sex educators are useful, but not enough. Until now there is no sex education national programme and efforts from NGOs are in small scale. I would like to hear from people from governments their opinion about the treatment of HIV on young people. Are the young people a new lost generation?” 
(Francisco Rosas, Independent Consultant, Mexico)

Summary provided by Jasmin Enayati, moderator of the Earth Summit 2002 online debate.
For further information please contact Jasmin Enayati at jenayati@earthsummit2002.org
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