THE AIDS PIONEER
Among the many accomplishments in Richard Holbrooke's iconic diplomatic career, arguably the broadest, most enduring -- although perhaps also the least well-known -- was his breakthrough work on HIV/AIDS. Before Holbrooke, the State Department's diplomats rarely mentioned the epidemic. Diplomats of the post Cold War era were trained in the negotiable currency of the geopolitical realm: missiles, trade agreements, and confidence-building measures -- not condoms or intravenous drug use. Holbrooke shattered the taboo against talking about the human behaviors and choices that spread the disease. And through sheer will and energy, he advanced the global health diplomacy movement, one that has gone on to help millions of people in poor regions worldwide.
In January 2000, I came to the State Department's global affairs office with a mission to escalate Foggy Bottom's role in health, especially on HIV/AIDS. By then, the pandemic had raged throughout Africa and threatened to accelerate in all regions of the world. Just a month before, in December 1999, Holbrooke, then U.S. ambassador to the United Nations, had taken a 12-day trip to sub-Saharan Africa, which convinced him that AIDS was a compelling international security issue.
This epiphany motivated Holbrooke to take action, and he brought the issue to the U.N. Security Council for a special session in January 2000. It was the first time a health issue had been brought forward as a threat to international security. A whole movement was inspired, galvanized around the idea that threats to humankind come not just from weapons or bombs but from this terrible virus -- and that both needed to be combated with equal fervor. Holbrooke's diplomacy culminated in a resolution about HIV/AIDS among U.N. peacekeepers and the organization of a special session of the entire U.N. General Assembly to discuss the pandemic. Two years later, Holbrooke's farewell address as U.S. ambassador to the U.N. Security Council was devoted to criticizing the body's approach to AIDS. He called for more HIV testing and advised that peacekeepers needed to be counseled on how to prevent the spread of the disease and how to avoid contracting it themselves.
Back in the private sector, Holbrooke became president and CEO of the Global Business Coalition on HIV/AIDS, then a small organization with few members. He energized the organization with furious networking and force of personality such that the GBC blossomed into a major player in global health. Holbrooke had an uncanny knack for zeroing in on conventional wisdom, and he relentlessly questioned underlying assumptions if he believed them to be off track. He challenged the standing practice of voluntary HIV counseling and testing, calling that strategy a "weak link" and arguing that people tend to avoid testing out of fear of knowing whether they are infected. Instead, Holbrooke called for public health authorities to make testing an opt-out measure, allowing people to choose not to be tested should they feel uncomfortable or unready, but keeping the test as the default option. While heavily debated at the time, by 2007 both the World Health Organization and UNAIDS adopted the opt-out strategy, which they said would reach 200 million more people.
Holbrooke's successes kicked off an era of general success for public health initiatives. Today, new institutions drive the field. The United States is investing $25 billion in a presidential AIDS plan, PEPFAR, that works in 15 heavily hit countries. Several countries have joined the U.S. in appointing ambassadors on HIV/AIDS: Australia, Belgium, France, the Netherlands, Norway, and Sweden, with hopefully more to follow. Likewise, in 2007 a group of foreign ministers expressed their intent to put health higher on the agenda of international affairs, in the so-called Oslo Declaration.
Holbrooke instinctually seized upon the devastating impact of AIDS in Africa to provoke presidents and prime ministers to respond with urgency. His arguments recast the thinking of two prominent global health institutions -- the joint United Nations program on HIV/AIDS and the World Health Organization -- where top experts are typically resistant to changing course, and got them to adopt a new way to test for HIV in developing countries. He practiced health diplomacy as if he were also a doctor: empathic yet forceful with the remedy, whether palatable or not. He deserves exceptional kudos for showing the world how to mobilize against a feared and often misunderstood disease. As a result of his inspired statecraft, millions of people in impoverished regions owe their health and their lives to him.
Jack C. Chow was senior advisor on global health at the State Department's Office of Global Affairs, 2000-2001, and was U.S. Ambassador on Global HIV/AIDS from 2001-2003.