Wherefor UNAIDS?

‘Tis the season to be jolly? Not so much for the global heath community. Our foundations this year have been rocked by the management crisis at UNAIDS.

In mid-December 2018, the UNAIDS’ Program Coordination Board (PCB - the nearest thing UNAIDS has to a Board) met to review the report of an independent expert panel that it had established earlier in the year. The panel’s remit was “to inquire into the following primary areas at UNAIDS, harassment, including sexual harassment, including sexual harassment, bullying, and abuse of power”.  

The report of the Panel concluded that “the Executive Director of the UNAIDS Secretariat has created a patriarchal culture tolerating harassment and abuse of authority, and in his interviews with the Panel, he accepted no responsibility for actions and effects of decisions and practices creating the conditions that led to this review”.

At the end of the two-day meeting, Michel Sidibe, the Executive Director, agreed to resign.

Sort of. And not until June 2019.

 The best summary of these events was written by Laurie Garrett and I strongly recommend it. Her anger and heartbreak capture the mood.

The big question now is what happens next?

Waiting until June is not an option. What does an already battered UNAIDS look like after six months of lame-duck leadership? The future would be grim: Global AIDS leadership in mothballs until the beginning of July. The (largely) exceptional development professionals working at UNAIDS will be further demoralized and seek other opportunities. Outside, there is some talk of exploiting this “interregnum” to end UNAIDS, as part of a reorganization of the global public health “architecture”. I disagree. The world is not experiencing the end of the AIDS epidemic. This moment is a welcome pause in the number of deaths (but not in new infections) resulting from enhanced access to biomedical advances.  Mission is not accomplished yet.

The genius of UNAIDS has always been to meld quality biomedical and behavioral science into incontrovertible rights-based policy. Its regional and country offices have helped governments implement and evaluate, and support successful applications to the Global Fund. Michel Sidibe was one of the sharpest and most successful leaders of this approach. Appointed Executive Director in 2008, he was an exemplar of modern globalist African leadership. His first years were exciting, marked by a vivid devotion to the marginalized and persecuted, those at most risk of HIV. He spoke truth to power in defending LGBT rights in Africa. His advocacy, literally, saved lives. But things started get strange. UNAIDS trumpeted the “End of AIDS by 2030” predicting most impact would be achieved by 2020. Meanwhile HIV funding was stagnating. Then came a botched sexual harassment internal investigation which led us inexorably to December 2018. Regardless of how effective he has been - and way past a question of honor - Michel Sidibe’s only option is to leave now -a modern Samurai committing Sepukku.

The UN Secretary General appoints the UNAIDS Executive Director, and is the only person who can fire him. If Michel Sidibe will not go now, Secretary General Guterres has to terminate his contract and appoint a successor as soon as possible. Curiously, Guterres has remained silent. Our best hope is that he is quietly working on an announcement for early in the New Year. In the meantime, unsavory explanations are being offered: Are there too many #metoo scandals facing the UN, in public  - and possibly still awaiting exposure  - causing the SG’s discretion? Is AIDS just not that important enough any more? Syria, Yemen, the global refugee crisis and pressure on global governance are the UN’s urgent priorities. Why speak out on a very “20th century global health problem” when public and private donors relish rolling out “universal health care” in 2019?

Of course Gutteres is working on finding a successor. How would we advise him? Make this a priority. The successful candidate needs to be a principled, internationally respected leader. Firstly, they must have the gravitas to persuade heads of governments to reinvest in a silent, relentless epidemic (the results of that investment not being seen for many decades). Secondly, they need the character and emotional intelligence to enthuse and mobilize staff. These two skillsets are not often found in the same person. But there is a cadre of exceptional leaders from a range of disciplines emerging in South America, Africa and Asia  - nearly all of them women – that Guterres must be considering.

Gutteres will be talking with governments, both those of countries currently affected by AIDS, and those who fund (or should fund) the UN’s own response. Knowing the UN, this is unlikely to be a prompt process. 

So what happens in between? Some have suggested installing an interim manager to “clean house” – someone willing to root out the bad seeds. When the successor is thoroughly searched, vetted and appointed, they will then be able to focus on the future, not atone for the sins of an inglorious present and past. We may not be talking about an individual so much, as a group of managers who are familiar with the bureaucracy of the UN, but not connected in any real or perceived way with UNAIDS’ current leadership. And to be clear, Im not proposing myself or one of the usual international management consultancies. This is very peculiar, disappointing set of circumstance. It requires a specific, tailored response, which needs to be recommended to the SG by leaders in the development and AIDS movements.

Whatever he decides, Guterres needs to ensure that the process of eliminating cronyism and bullying though a formal, transparent, independent and legally impeccable process starts as soon as possible into the New Year.

And that means a fully independent review of the harassment case that brought the crisis at UNAIDS to a head. The first internal investigation was fatally flawed, with arbitration and decision resting with the Executive Director. This undermined the final outcome. So there is no misunderstanding, I am not commenting on the case itself and have worked with both parties professionally. An independent review needs to sieve out gossip from fact, and provide a finding, that while devastating for some, is rigorous enough to withstand challenges. Very bluntly, UNAIDS cannot move on until this controversy is resolved.

This crisis is also a failure of UN governance. The current PCB is not fit for purpose. The Executive Director does not currently report to it. When UNAIDS was established, the relationships between the UNAIDS Secretariat, partner UN agencies (called “cosponsors”) and national governments were deliberately designed to be opaque. This gave the UNAIDS Secretariat the greatest flexibility in moving a stagnant, colossal bureaucracy into action against the frightening new virus. But now it needs reform itself. The first critical step is for the PCB to assume the transparent governance responsibilities normally assigned to the Boards of international agencies.  This will probably require a new UN-level resolution, so don’t expect rapid change.  However, intent will send strong enough signals.

The current chair of the PCB, the UK, was ineffective and distracted (perhaps like so many things, by Brexit. But that is for another time). It steps down at the end of this year anyway.

So, the responsibility falls on the incoming chair, China, and its vice-chair the USA. A first reaction might be howls of desperation. But consider: China prides itself on close relations with emerging economies – particularly in sub-Saharan Africa. In international relations, it has been a stickler for adhering for process, and abhors vacuums when there is none. China can employ its leadership to ensure a steady and firm process of governance, in line with international law. This is something its diplomats can get their teeth into, rather than avoiding rights-based programatic discussions.

The USA has different problems. It was firmly aligned with the 909090 strategy, which does not really engage prevention and passingly nods to HIV testing, and then as only as an entrance to treatment.  Expect to see US leadership on global AIDS explored in future podcasts and blogs. We need note here only that the incoming Democratic leadership of the House of Representatives needs to add the close monitoring of UNAIDS to its already long list of priorities.  Advocates will rightly reinforce the argument that the PCB “Until June” fantasy is untenable: It is tantamount to the endorsement of cronyism, the primary domestic challenge.

This time of the year - whether enjoying sun or snow, trudging around shopping malls or not getting prompt e-mail responses from colleagues - is usually reserved for reflection. As in so many areas of our lives, these are different times.  Let’s trust that Secretary General Guterres and his colleagues are diligently working away on a solution in quiet. But, in between mince pies, they need to harken to the need for prompt action to save UNAIDS, and preserve its role in coordinating the response to one of the greatest threats to human health.