Stephen Merson

The Resignation of Jonathan Mann

This chapter describes how tension between Jonathan Mann, Director of the Global Programme on AIDS (GPA), and Hiroshi Nakajima, the new World Health Organization (WHO) Director-General, resulted in Mann’s decision to resign from his position. Nakajima’s biomedical approach to AIDS contrasted with Mann’s broader social, economic, and human rights approach. This misalignment was compounded by personal dislike, mistrust, and disrespect. In addition to his frustrations with Nakajima, Mann had to contend with increasing donor dissatisfaction and competition for funding with new bilateral aid programs. To thwart efforts made by Nakajima to gain greater control of the relatively independent GPA and bring it more in alignment with the larger WHO structure, Mann encouraged GPA’s Management Committee to launch an external review of the program.

The Response Before the Global Response

While the Centers for Disease Control and Prevention (CDC) organized its first Task Force on what came to be known as acquired immune deficiency syndrome (AIDS) shortly after the first cases were reported in the United States in 1981, it took the World Health Organization (WHO) 2 years to initiate surveillance activities, and until 1985 to seriously engage in efforts against the disease. This chapter explores the reasons behind this delay, and the efforts made by researchers and institutions to explore the emerging pandemic in Africa and other low- and middle-income countries. One of these projects was the joint United States/Belgian Projet SIDA undertaken in what was then Zaire under the leadership of Jonathan Mann, which uncovered some of the most important early knowledge about the epidemiology and transmission of HIV in sub-Saharan Africa.

Challenges and Criticisms

This chapter explores the increasing number of obstacles, challenges, and criticisms encountered by the Global Programme on AIDS (GPA) as the pandemic worsened with increasing rates of new HIV infections and AIDS cases. Among these challenges was an ever growing sense of political and social complacency due in part to the development of new AIDS drugs and low infection rates among heterosexual populations in high-income nations. GPA sought to combat this complacency, increase political will, and promote AIDS awareness by enlisting the support of celebrities and increasing publicity around World AIDS Day. Meanwhile, the world press directed much of its attention to the dysfunctional relationships between the World Health Organization and other United Nations agencies, instead of on the pandemic itself. Growing attacks on the program by its previous Director Jonathan Mann and his newly formed “Global AIDS Policy Coalition added to public criticism.” It was in this climate that donors became less and less certain that GPA could continue to lead the global response.

Health, Human Rights, and the Global Programme on AIDS

This chapter explores how Jonathan Mann, Director of the World Health Organization’s (WHO) Global Programme on AIDS (GPA), came over time to champion a health and human rights framework for confronting the AIDS pandemic and made it a key component of the Global AIDS Strategy. Mann strived to draw attention to issues of discrimination, including national policies restricting the immigration and travel of people with HIV and AIDS. He argued passionately that fundamental human rights violations put populations at greater risk for HIV infection and hindered their appropriate access to prevention, care, and treatment services. Significantly, in May 1988, the World Health Assembly passed a resolution calling on governments to advocate the need to protect the human rights and dignity of people with HIV and AIDS. This led GPA to establish collaborations with human rights organizations and to apply the health and human rights framework to the rights of women.

UNAIDS: Trying to Gain Traction

This chapter describes the evolution of the Joint United Nations Programme on HIV/AIDS (UNAIDS). At a time when the discovery of Highly Active Antiretroviral Therapy (HAART) had energized the AIDS community, UNAIDS faced significant difficulty trying to establish its leadership amongst shrinking budgets, quarrelling cosponsors, inconsistent and inadequate support from donors, and a strained relationship with the World Health Organization. UNAIDS established UN theme groups on HIV/AIDS to provide a single UN voice on AIDS policies in countries, strove to improve access to HAART, especially in low- and middle-income countries, and built relationships with nontraditional partners, particularly non-governmental organizations, faith-based organizations, and the business community. Against this back drop, the AIDS world lost one of its greatest champions when Jonathan Mann tragically died in a commercial plane crash.

Assuming Global Leadership

This chapter covers the evolution of the World Health Organization’s (WHO) AIDS program and its leadership in the global response. The program was renamed the Special Programme on AIDS (SPA), and would focus on prevention, reducing the personal and social impact of AIDS, and coordinating the national and global response. In order to have the necessary prominence and flexibility, the program was moved into the Director-General’s office and operated outside WHO’s traditional regional structure. The chapter explains why this move was necessary and how the SPA Director Jonathan Mann sought funds for a program whose budget was the largest in in WHO’s history. It further describes the development of Mann’s Global AIDS Strategy, and the establishment of country national AIDS programs. In January, 1987, WHO’s Executive Board renamed SPA to the Global Programme on AIDS.

Creating a Global Response

This chapter covers the challenges faced by Fakhry Assaad and Jonathan Mann as they took the reins of the Control Programme on AIDS. It describes how they fought to increase awareness of the global threat of AIDS, engaged governments to respond to the pandemic, and raised extrabudgetary resources for the program. It also details the levels of denial across many countries, and the bold stand taken by the government of Uganda during the World Health Assembly in May 1986 to acknowledge the presence of the disease in the country and call for assistance from the World Health Organization (WHO). By that fall Mann had assumed Directorship of the program, viewing WHO as the leader and coordinator of the global response as proclaimed at the United Nations General Assembly that November. The chapter discusses Mann’s new role and the impact that Assaad had on the foundation of WHO’s global AIDS efforts.

Growing Tensions Among United Nations Agencies

The structure of the United Nations and its specialized agencies, such as the World Health Organization (WHO), and internal disagreements over how best to address the AIDS pandemic made coordination difficult and challenged WHOs leadership of the global response. This chapter discusses the particular conflict between the United Nations Development Programme (UNDP) and WHO, and UNDP’s decision to launch its own global AIDS program, which resulted in competing strategies and requests for funding. In addition, GPA was faced with the behavior of its donors, such as the United States Agency for International Development (USAID), developing their own bilateral AIDS programs and desiring more control over AIDS funding. All this occurred as GPA was coming under more and more scrutiny and external criticism.

Containing the Global Spread of HIV

The pandemic continued to wreak havoc across the world as the number of AIDS cases increased, especially in Africa. Each country had its own unique epidemic, and thus national governments needed to tailor their programs accordingly. This chapter details the efforts made in particular countries, their successes and challenges, and the assistance provided to them by the Global Programme on AIDS. In particular, we focus on programs in Uganda, Thailand, Brazil, and Senegal as successful case studies in HIV prevention. All were characterized by strong national commitment, a multisectoral response, participation of non-governmental organizations, and sufficient resources. However, despite these successful examples, most countries were still struggling to slow down the spread of the disease within their borders and provide care and support to those infected.

The Launch of the Control Programme on AIDS

The World Health Organization (WHO) finally began moving forward on AIDS under the leadership of Fakhry Assaad, the Director of WHO’s Division of Communicable Diseases. WHO Director-General Halfdan Mahler had initially thought that AIDS was outside of WHO’s mandate, but external pressure and emerging evidence on the extent of the disease convinced him to the contrary. This chapter explains how the rapid increase in AIDS cases across the world put extraordinary pressure on Assaad’s time and energy. It describes the early actions he took to assist countries, including the establishment of WHO Collaborating Centers and the formation of the WHO Control Programme on AIDS. Assaad eventually recruited Jonathan Mann to join the program, positioning WHO to lead the global response to the pandemic.