I was honoured to be invited to speak at the International AIDS conference in Munich on “Global Health is a Matter of Global Politics”. The many crises our world is facing impact on our work to end AIDS as a threat to public health and individual wellbeing. We need new champions, new modes of financing, and improved access to the innovative treatments now available. And the range of social determinants, including stigma, discrimination, repression, and marginalisation must be addressed. Please see the full speech below.

Rt Hon Helen Clark, Chair of Global Commission on Drug Policy and former New Zealand Prime Minister

“Global Health is a Matter of Global Politics”: Keynote Address to 25th International AIDS Conference.

8.30 am, Wednesday 24 July 2024, Munich, Germany.

My thanks go to the International Aids Society for inviting me to give this keynote address: “Global Health is a Matter of Global Politics”.

I speak as one who has spent a lifetime in politics – beginning as a student activist campaigning against New Zealand participation in the Vietnam War, against apartheid in South Africa, and against nuclear weapons. My 27-year parliamentary career included close to two years as Minister of Health in the early years of the AIDS pandemic when New Zealand was acting decisively to stop it, and nine years as Prime Minister. Throughout I kept a keen interest in international affairs and global health. That continued through my eight years at the United Nations Development Programme (UNDP) and since in a range of pro bono capacities, including as Chair of the Global Commission on Drug Policy.

What I have come to appreciate is that almost no aspects of our lives, our countries’ lives, and global health are insulated from global politics, and that where our world cannot come together to face shared challenges, we are all the losers.

The case for coming together through multilateralism always was that there are challenges which no country acting alone can resolve. The end of AIDS as a threat to public health and individual wellbeing is one of those. So are other pandemic threats. So is climate change. So is the threat to biodiversity. So are enduring solutions to poverty and inequality, and to intractable conflicts. It is of particular concern that the global peace and security architecture is in shreds and unable to contribute to ending a major land war in Europe, the war in Gaza and the repression across the occupied Palestinian Territories, and numerous other conflicts from Myanmar to the Horn of Africa, the Sahel, and beyond.

We now live in an era of multiple crises where the old challenges we have failed to meet head on have caught up with us, new challenges have emerged, and, taken altogether, these are overwhelming our capacity to respond. This is happening at a time of renewed tensions between East and West, and of deep tensions between North and South. These make collective action around our shared challenges more difficult. 

Those of us who live in the West hear a great deal these days about the importance of shared values, and far too little about the importance of identifying shared interests. A failure to engage effectively across the lines of political systems and across the world’s regions impacts on our joint capacity to respond to global challenges, including in the health sphere.

In this polarised context, even the latest pandemic, COVID-19, could not be tackled effectively, with a huge gap developing between what was accessible to populations in high income countries versus low- and middle-income countries. This is not a new phenomenon as the HIV/AIDS community knows so well. Attempts to build a better and more equitable system of pandemic preparedness and response have struggled in Geneva, and have not yet produced the hoped for result of a new pandemic agreement. The jury is out on whether negotiations on that can succeed at all. At least improved International Health Regulations were agreed. 

Despite real progress, we have not brought an end to HIV/AIDS as a public health threat, nor are we on track to do so by the target date of 2030. HIV/AIDS is the pandemic which has never gone away. It is already estimated to have taken more than 42 million lives, and it takes more every year. The therapeutic and preventive tools to end AIDS exist, but not only are they not accessible to all, but stigma, discrimination, criminalisation, and human rights abuses also play a key role in stopping the end of AIDS. This is intolerable.

The cluster of challenges we are now facing – the so-called “poly-crisis’ - has compounding impacts on global health, including on our efforts to end AIDS.

For example, in any conflict or major disaster, the essentials of life are on the line – like access to food, water, shelter, and essential treatments. People living with HIV may not have access to their medications, and treatments for cancer and other illnesses may also be disrupted. Try accessing health services in Gaza today where health services and facilities and health care workers have been decimated in that horrific war.

The conflicts in Ukraine and the Middle East have been particularly destabilising for economies and societies around the world. Volatile grain and fuel prices have impacted on the cost of living globally and slowed economic growth, with particular implications for the poorest and most vulnerable and the opportunities and supply of services they need.

These impacts came on top of the COVID-19 catastrophe which is now associated with excess mortality of 28.5 million (the Economist Intelligence Unit estimate), a loss of many trillions of dollars to the global economy, and severe impacts on countries’ fiscal positions and debt levels. 

A new study by Debt Relief International found that “developing countries are facing the worst debt crisis in history with almost half their budgets being spent on paying back their creditors”.  They calculate that “more than 100 countries are struggling to service their debts, resulting in them cutting back on investment in health, education, social protection and climate change measures.” (Source: The Guardian, 21 July2024.)

At the height of the pandemic, poverty and hunger rose, along with the numbers of out of school children and the numbers of unvaccinated children. According to WHO, “progress in reducing maternal deaths has stalled since 2016, while survival gains for newborns and young children have lost pace.” Reaching the SDG goals and targets set for 2030 has become an even bigger stretch – only seventeen per cent of the targets are on track to be achieved with just six years to go.

As the old saying goes, money isn’t everything, but it does help. But for a range of reasons to which I’ve already alluded, money for global solidarity and investment around health and sustainable development overall is scarce.

Many of the traditional donors are still trying to bring the large fiscal deficits they built up during the COVID-19 pandemic under control.

Some have already elected or could elect far right governments which care little for global solidarity. A Trump Republican presidency, for example, is a far cry from that of George Bush Junior which set up PEPFAR to support the battle against HIV. PEPFAR is already under threat, and that would only worsen with a change of Administration. The last Global Fund replenishment did not reach its target. Funding for WHO and UNAIDS is very, very tight.

Major humanitarian crises are now consuming significant portions of official development assistance budgets. As well, donor governments are able to offset some of the costs incurred in responding to informal migration from those budgets, and informal migration is at high levels driven by conflict and impoverishment. The previous United Kingdom Government was spending around half of its bilateral aid budget in the UK.

Then there is defence spending – that is being ramped up by many of the traditional donors, while other public spending, including on global solidarity, is constrained. Every dollar spent on defence is a dollar that can’t be spent on health and human and sustainable development. Too little effort goes into conflict resolution. This cannot end well.

Overall, we are operating in a perfect storm which impacts on the effort required to end HIV/AIDS as a public health threat - and on much else. 

And let us not forget the movements with new energy which confront us – not least the anti-rights movement. It is well organised and financed, and it has global reach.

Its campaigns have a very adverse impact on sexual and reproductive health and rights. One of its biggest wins was the overturning of Roe vs Wade in the United States. It also emboldens those countries which criminalise the LGBTQI+ communities and which oppose comprehensive sexuality education. Criminalisation always stands in the way of effective public health responses, as does denial of comprehensive sexuality education which supports us to keep ourselves safe.

The HIV/AIDS pandemic is rooted in inequity and marginalisation. Where it has been addressed effectively, that has occurred through rights-based approaches, with the full engagement of impacted communities, and been supported by universal health coverage, broad packages of social services, and campaigns against stigma and discrimination. But we now observe civic space under pressure in many places and pressures on the public spending required to sustain health and other services.

Around our world, many have been left behind. Among those are people who who drugs – the victims of the more than the half a century long “war on drugs”, sadly mandated by the UN’s drugs conventions. We generally look to UN conventions for good guidance on norms and standards. The drugs conventions are a major exception to that rule, and they bear heavy responsibility for widespread human rights abuses, deaths, disappearances, displacement, and over-incarceration. 

These shocking conventions are invoked by states – both authoritarian and allegedly democratic – to criminalise people who use drugs, and to oppose the effective harm reduction which would save lives. Prisons around the world are bursting at the seams because of this wrong-headed approach. High HIV rates are associated with repressive approaches and lack of effective harm reduction in a wide variety of settings. 

Faced with these many headwinds, what can the global movement to end HIV/AIDS as a public health threat do? 

It is perhaps cold comfort to say that many others are also facing similar pressures – variously from the anti-rights movement, underfunding, crowding out by other priorities, the impact of war and conflict and forced displacement, and an overall indifference in many places to the health and well-being of people and planet.

But therein may also lie part of the answer. 

The movement to fight HIV/AIDS must build links with others who share a vision for a healthy, equitable, sustainable, and peaceful future. We need communities mobilised and a new politics to tackle the real challenges to health and wellbeing and the drivers of exclusion and marginalisation. Women, young people, LGBTQI+, indigenous people, health, environmental and peace activists, anti-poverty and labour rights campaigners and more: these and more must be part of a broad coalition to build a better world. We must build solidarity across movements for a better future. 

New champions are needed to bring the fight against HIV/AIDS back up the political agenda. We have major battles to fight to uphold human rights and gain access to services and treatments. There are scientific breakthroughs in fighting HIV/AIDS which need to be accessible by populations everywhere - like the twice-yearly injectable antiretroviral medication. Let us not see a repeat of the recent inability to access COVID-19 vaccines, therapeutics and diagnostics with the innovations which can help end AIDS. That would be reprehensible.

For me, the ideal would be TRIPS waivers for life-saving innovations which can stop pandemics. But, to date, these have been as unobtainable for the HIV/AIDS pandemic as they were for COVID-19. So, there must be concerted pressure on and negotiations with the pharmaceutical industry to increase supply of innovative treatments and bring down unit costs. Sharing innovation through the WHO’s Medicines Patent Pool to allow generic licensing would be an important step.

The bigger picture would see more investment in R&D around the world’s regions, linked to regional manufacturing and distribution strategies to build regional capacity and resilience. These kinds of solutions have been advocated by a number of us engaged on improving global pandemic preparedness and response capacity. We have taken some inspiration from the WHO’s mRNA “hub and spoke” arrangement, which could be built on to include other technologies.

The pharmaceutical industry has been the beneficiary of much public research investment. With respect to HIV/AIDs, it has benefited from the mobilisation of scientists and engaged communities who have advocated for investment in R&D and treatments. Prima facie, the notion that the companies can then make great profits from and not share the intellectual property created is wrong. The innovations which they are exploiting    commercially need to be seen as global common goods, and ways must be found to make them accessible to all.

New approaches to financing must also be considered. The traditional model of vertical funds has been to seek funding from governments, mainly of high-income countries, and from philanthropy. That funding structure is then reflected in the governance. But as traditional donor finance comes under pressure, those old models won’t stand up long term.

An alternative could be to apply a “beyond aid”, global public investment model to existing and new vertical funds which finance global common goods, like the fight against pandemics. That would see countries of all income levels pay in according to a formula, on the principle of “from each according to their means, to each according to their needs”. The governance of the funds would be inclusive. This kind of funding model could be the future of global solidarity. It is a bold and already well elaborated concept, which needs to be advanced by strong country champions.

It's clear that we do not live in the best of times – to put it mildly. But we cannot give up on the challenges we face, like ending AIDS. Lives and wellbeing literally depend on it.

So, we need solidarity across movements, and we need to advance new ways of achieving access to global common goods. We need more focus on prevention – which will require not only more investment in public health, but also action on the social determinants which have driven the AIDS pandemic. We need universal health coverage, and we need to ensure prioritisation of HIV/AIDS within that.

Above all, we must act with conviction that we can succeed, and that ending AIDSs as a public health threat is not a pipe dream, but a realistic and achievable goal. Everyone gathered at this conference and everyone you represent and work with back home has a key role to play in making this happen. May this conference galvanise new energy and commitment around this great cause.

Thank you.