Plenary Address:  Fifth International Conference on AIDS in Asia
Kuala Lumpur, Malaysia, October 24, 1999   
Speech Delivered by Mieko Nishimizu
Vice President, South Asia, The World Bank                            Download PDF Version of this speech.

Imagine a world free of poverty. A world, where quality of life guarantees human dignity. A world, where everyone exercises basic human rights. A world, where all children will live to their fullest potential. That is the dream the World Bank shares with all member nations. That is why we remain impressed by Asia's achievements in social, economic and human development. But, that is also why I am here to talk about AIDS. AIDS threatens Asia. AIDS threatens to reduce, halt and even reverse economic growth of Asia. It threatens to kill the people of Asia at the prime of their productive years. It threatens to tear apart the very social fabric of Asia. Ultimately, but without exaggeration, AIDS threatens the security and stability of nation states. It is unlike any other disease. It is decidedly not just a public health matter. It is a singularly most critical socio-economic development issue. 

AIDS threatens Asia, today. Not in generations, not in decades, not in years, but now -- today. At least 33 million people are infected worldwide. One quarter, or about 8 million, of them are here in Asia, and most likely more. Yes, already spreading silently here in Asia, where a lion's share of the world's population live. Preventing AIDS epidemic is, therefore, not the agenda of Asia alone. The highest absolute number of the poor live in Asia still. The majority of our world's children belong to Asia. AIDS' threat to Asia is a threat to the world. To void Asia's hard-earned economic and social achievements is a global threat. To deny the people of Asia the dream of the world without poverty is to deny that dream for the entire world. Preventing the epidemic in Asia is, indeed, a global development agenda. 

We can be part of the problem or part of the solution. The World Bank is prepared to be part of the solution. But, it must be Asia's own solution, to protect your society, economy, proud nationhood -- all that you have, all that you want, all that you dream of. It has to be Asia's own commitment, starting at the top political leadership and throughout the civil society everywhere. It must be Asia's own will to act, with governments and non-government organizations united as true partners under one common cause. For leaders both in government and in civil society to choose not to act -- knowing fully the consequences -- is unethical and a betrayal of their people. To focus the might of leadership everywhere on the problem, orchestrating all the change agents throughout the society, is at the heart of the solution. Asia's future is in our hands. The choice, is ours. 

What do I -- just another macroeconomist -- know about AIDS? Am I just reading off a speech my public health colleagues wrote? Am I here just to do what I was told to do? No. Hear me out, please. I spent one day in July deep inside the old city of Dhaka, Bangladesh, where I saw the dream of poverty reduction and the threat of AIDS that could shutter it at the same time. I spent that day with commercial sex workers. Not at high-class brothels or middle-class ones, but at a rest house for street workers run by two non-government organizations. A house, where these workers come in off the streets each morning, to wash, rest and to receive medical care.

The most remarkable group of women I have ever met. Their shining faces spoke the power of self-empowerment they discovered. Their beaming eyes showed that leadership stuff they are made of. They have mobilized themselves into a self-help group, with membership fees and saving schemes-- to look after the old and the sick among them, to learn new occupational skills to "get out of this darkness", to take marshal arts lessons to defend themselves from abuse, to send their fatherless children to school, and to secure an old-age pension for themselves.

Nadia, their leader, said to me: "Sister, you must learn about AIDS to protect yourself from ruins." She and her fellow workers taught me, patiently, what the disease is, how it is transmitted, and what methods they use to avoid infection. They showed me a range of condoms they sell, for a small profit margin going to the savings group. They laughed at me when I confessed I have never seen a female condom in my life. As I bid farewell, Nadia took my hands into hers, and said in her firm, confident, voice: "Remember, younger sister, knowledge is your power to a better life." That day, I could almost smell, taste, and touch the dream of a world free of poverty.

A day like that ought to make me feel elated and renew my resolve to go on, "to fight poverty with passion and professionalism for lasting results" (Mission Statement, the World Bank Group). At the end of the day, instead, I was thrown into the deepest despair I ever knew. I possessed one knowledge that they did not: that many of these sisters were already infected. It was too late, and they did not know it yet. Their empowerment, mobilization, and hard work for the dream -- to get out of the destitute poverty -- was already denied to many of them.

On the way back, with a heavy heart, I stared at a crazy Dhaka traffic. I remembered that Bangladesh has the world's highest death tolls from road accidents. Suddenly, a chill ran though my spine. What if I get into an accident? What if I am taken to a hospital? What if I receive injection with an unclean needle? What if I need a blood transfusion? What if? What if? For the first time on that day, the threat of AIDS I thought I knew became a threat I truly knew -- one that I share with the commercial sex workers of Dhaka, all the poor of Bangladesh and beyond, and the rest of mankind, personally and professionally.

AIDS -- a single fatal infectious disease -- is indeed touching every one of us, in ways totally unlike any other disease. The HIV virus is already present in all countries of Asia. Whether or not we want to admit it, there are people engaged in high risk behaviors everywhere. There are people who inject drugs. There is commercial sex. People engage in unsafe sexual practices. In most countries, the blood supply is not free of HIV and infection control procedures are poor, posing risks for health workers, patients, the general public -- you, and me, alike.

AIDS can shrink economies, as it threatens people in their most productive years. In the hardest-hit Africa, life expectancy is 10-20 years lower today than it would have been, because of AIDS. The harder-hit, moreover, are those who are contributing to their economy -- at the prime of their productive lives. Just search for any Nairobi newspapers on the internet, and open the obituary section. Page after page of young beautiful faces -- full of hope and vitality. Cause of death: "unknown." Page, after page, after page ... every day.

The worst-hit countries in East Asia are feeling a similar impact. Cambodia, Myanmar, and Thailand have lost 2-3 years of life expectancy to AIDS, and the majority of those infected are not yet showing signs of illness. Since 1970, life expectancy in nine East Asian nations rose by 10 years or more. In South Asia, countries such as Bangladesh, Bhutan, India, and Nepal raised it by 14 years or more. Impressive gains. But, AIDS can cancel and reverse this progress, with significant impact on the growth and size of economies. It will cancel and reverse the progress, if we do not act now.

The AIDS epidemic will overwhelm health finances. But, it will not stop there -- the entire public finances will come under an enormous pressure. To project this is not rocket science. AIDS patients require a variety of medical care, as they cope with repeated bouts of infection and tuberculosis. This raises health-care costs, even in places that cannot afford expensive drug therapy.

India has been fighting the spread of HIV/AIDS for almost a decade now, but she already has the largest number of infected people of any country in the world. Suppose the infection rate rises to 5 percent of adult Indian population. The nation's public health budget could swell by at least 30 percent. Average treatment expenditure per year on each and every AIDS case costs more than educating 10 primary school students in India -- without counting expensive therapies.

Larger health expenditure from an AIDS epidemic will force very hard trade-offs in public finances. Here, I am on a safer ground. Every time I look at such financial projections, I shudder. We economists are not good at making impossible, unethical, financial trade-offs. I do not wish such nightmares on anyone, including and especially Finance Ministers. But, they will be the reality one day, if we do not act now.

But, AIDS threatens things we value more than finances. It destroys families. It intrudes in the most intimate relations between people. It erodes our trust in each other. It devalues our basic right to procreate. It spreads silently. It kills. It tears at the very fabric of society. It is like no other disease. In a fundamental sense, it is a threat to the security of societies and of nation states. That threat is here today. It will strike if we do not act now.

Asian governments must act now. In all nations of Asia, preventing the AIDS epidemic and mitigating its impact must be at the center of development policies and programs.

Denial is pointless. In every country with a serious AIDS epidemic today, people once said: "It can't happen here. We don't have the behaviors that spread AIDS." They were wrong. It is too easy to be complacent, when no one appears visibly sick with AIDS. It is too easy to look the other way, when thousands are dying of other afflictions.

But, HIV/AIDS respects no international borders. It does not discriminate by nationality, race, gender, or religion. And, I repeat, human behaviors and social conditions that spread the virus are present in all countries. Internal and international migration, or political and social upheavals, also facilitate the spread of the virus. By the time hospitals are seized by AIDS patients, it is too late. The virus will already have spread to epidemic proportions.

Asia can learn from the Asian experience. Thailand offers an outstanding example of how to slow down the spread of HIV by enabling people to adopt safer behavior. The nation's vigorous response worked -- program promoting 100% condom use in commercial sex, public information campaign about HIV/AIDS, and various other prevention measures. The number of STD patients is one-tenth its former level. Infection rates among army conscripts have halved. Such achievements are tribute to Thailand's government and civil-society leaderships, working together.

Thailand teaches us to act forcefully. But she also teaches us to act immediately -- in spite of her tremendous success, the virus has now infected nearly 1 million people of Thailand.

Today, Asia has a golden opportunity to act early. Asia does have pockets of concentrated epidemics. Nearly 600 million Asians live in countries with such pockets. The success of Thailand, and others such as India, teach us that concentrated epidemics can be contained, that one can slow down the spread of HIV, by enabling those with the greatest risk to protect themselves and others.

Asia is fortunate. To date, there are no Asian nations with "generalized" epidemic -- where HIV has spread to more than 5 percent of the population. Three-quarters of the people of Asia live in countries or states or provinces where HIV/AIDS is not widespread -- such as many states of India, much of China, Indonesia, the Philippines, Korea, Bangladesh, Bhutan, Sri Lanka. Africa and some Caribbean nations were not so fortunate. By the time scientists understood how HIV was transmitted, it was too late.

Asia has a small gift of time. Time to act. Time to act early. Time to prevent a generalized epidemic. Use it, before it turns against you.

Before closing, I want to tell you about Sonagachi. In the Sonagachi red-light district of Calcutta, sex workers are leading the war against HIV/AIDS. They have organized themselves into a crusading force to promote the use of condoms. With support of the government, non-government organizations, and international agencies, the Sonagachi women raised condom use from 3% in 1992 to over 90% in 1998. HIV infection is held to about 5% there, compared to more than 50% among sex workers of Bombay.

But, the impact of this program have gone well beyond HIV prevention to development -- economic, social and human development. Like those sisters in Dhaka, they too have their own financial cooperatives. They are becoming literate, have organized to demand protection from police abuse, and are preventing child prostitution.

Confronting AIDS is not easy. Acting to fight it is even tougher. But, engagements like the Sonagachi and Dhaka ones can prevent AIDS epidemic. They jump-start sustained social transformation that is development -- grass-roots social mobilization with empowerment, human dignity, and visible shifts in the quality of life. Early and enlightened government actions like these -- in true partnerships with non-government organizations and the civil society -- can shift the paradigm, the path and outcomes of nation building in Asia, and the rest of the world beyond.

I end my remarks with a favorite passage of mine, from the Koran: "Verily never will God change the condition of a people until they change it themselves, with their own souls." I call on all leaders of Asia, in governments and in civil societies, and all change agents amongst the people of Asia, to act, act forcefully, and act now.