New Leadership in India's Fight Against HIV/AIDS

World AIDS Day Peace Tiles created by participants in a Gram Bharati Samiti workshop in Jaipur, India (Global Peace Tiles/Flickr)
World AIDS Day Peace Tiles created by participants in a Gram Bharati Samiti workshop in Jaipur, India (Global Peace Tiles/Flickr)

October 14, 2003

Discussion Panel in New York (at Asia Society):
Seth Berkley, President and CEO, International AIDS Vaccine Initiative (IAVI)
Trevor Neilson, Executive Director, Global Business Coalition on HIV/AIDS
Nicholas Platt, President, Asia Society
Anil Purohit, Executive Director, Francois Xavier Bagnoud Association, USA
Allan Rosenfield, Dean, Mailman School of Public Health, Columbia University
Teresita Schaffer, Director, South Asia Program, Center for Strategic and International Studies

New Delhi Participants (at the Confederation of Indian Industry):
Ashok Alexander, Director, Bill & Melinda Gates Foundation, India
Nafisa Ali, Social Activist
Cyrus Broacha, VJ, MTV India
Heather Burns, Senior Vice President, Booz Allen Hamilton
Tarun Das, Director General, Confederation of Indian Industry
Oscar Fernandez, Member of Parliament
Richard Holbrooke, Chairman, Asia Society; President and CEO, Global Business Coalition on HIV/AIDS
Pawan Singh Ghatowar, Member of Parliament
Geeta Sodhi, Director, Swaasthya
Mark Tully, Author and Journalist
Jaspal Rana, Olympic Marksman

Via telephone from Thailand:
Helene Gayle, Director, HIV, TB and Reproductive Health Program, Bill & Melinda Gates Foundation
Peter Piot, Executive Director, Joint United Nations Programme on HIV/AIDS (UNAIDS)

Nicholas Platt: Hello, New Delhi, I am Nick Platt, President of the Asia Society, and I am delighted to welcome all of you here, both in New York and in Delhi. I know this is going to be an engaging and important discussion on an issue of great importance to India, to the region and to the global community. We have a distinguished group of panelists, both in Delhi and in New York, who represent the leaders in India's fight against AIDS. Their bios are provided and please refer to them. Secretary General Kofi Annan, who had hoped to join this discussion from India, unfortunately will not be with us. Let me now turn to Ambassador Richard Holbrooke, chairman of the Board of the Asia Society, who is in New Delhi and Ambassador Teresita Schaffer, from the Center for Strategic and International Studies, who joins us here in New York. Good morning and good evening!

Teresita Schaffer: Good morning on my behalf as well. I would like to talk a little bit about what CSIS is doing in its AIDS project and to introduce the panelists in New York. You will find we have an extraordinary group of people as panelists and you should think of this as a menu of appetizers and I hope you will all come back for the second course on many future occasions.

For the past two years the Center for Strategic and International Studies in Washington has been working to familiarize US political and policy circles with the dimensions of the AIDS epidemic and the most effective ways to respond. We are a policy research organization, focused on a Washington audience but this is of course a worldwide problem. The first two years we focused on countries with full-blown epidemics, most of them in Africa, and on aspects of the problem that affect the whole world: vulnerability of women and girls, resource mobilization and problems of scale, understanding the national and the security impact of the epidemic and forging links among key constituencies. The second phase of the project will focus on the second wave countries: India, China and Russia, whose earlier-stage epidemics threaten to cause catastrophe on a scale we have not seen before if something is not done about it, and Nigeria and Ethiopia.

The point of focusing on second-wave countries is that catastrophe can still be averted. In looking at these countries, particularly India, we want to turn the spotlight on best practices and promising developments. We are preparing a trip to India, which we hope will include members of US Congress and the scientific and business communities. We hope some of the colleagues around the table in India will meet with this group as well and this will serve as a way to galvanize response in Washington and in India.

Let me introduce my fellow panelists: Seth Berkley, chief executive officer and co-founder of the International AIDS Vaccine Initiative. Next to him is Anil Purohit, who is with the HIV/AIDS program of Francois Xavier Bagnoud, which works all over India, in all of the states and union territories. Trevor Neilson is Executive Director of the Global Business Coalition to fight AIDS, which I am sure Ambassador Holbrooke will tell us more about. He comes from a career in foundations that have made a real contribution to health and family issues. Finally, Dr. Allan Rosenfield, Dean of the Mailman School of Public Health at Columbia University in New York and professor of obstetrics and gynecology, who has also worked in Nigeria and Thailand on health problems there. I will now pass the mike to Delhi.

Tarun Das: Good evening from New Delhi. It is good to be with you. We have just completed 3 days of discussions, simulations, strategies, deliberations, concluding with the Bill & Melinda Gates Foundation Board meeting yesterday evening. Today is the fourth consecutive day where we have focused on the issue of HIV/AIDS - talking about the way forward, the agenda for partnership and the special partnership between the Asia Society in New York, the Global Business Coalition for HIV/AIDS, the CII (Confederation of Indian Industry), the India Business Trust, the Bill & Melinda Gates Foundation, NGOs, Members of Parliament. We are actually the group sitting around this table, representing all these segments: Geeta Sodhi is Director of Swaathsya, an NGO; Juspal Rana, a very famous sports hero of India; two members of Parliament, Mr. Paban Singh Ghatowar, and Mr. Oscar Fernandez, who plays a very lead role in addressing the HIV/AIDS issue in the Indian Parliament; Cyrus Broacha, who is MTV India and MTV does a great deal of work in the area of HIV/AIDS; your own Richard Holbrooke; Ashok Alexander, head of the Bill & Melinda Gates Foundation in India; Nafisa Ali, who heads Action India and is into the care area; Heather Burns from Booz Allen Hamilton, with her group in Delhi, speaking and presenting the simulation strategy which you will hear about; finally Mark Tully, a household word because he has given his life to this country, working here.

Richard Holbrooke: This is the inauguration of a new program that the Asia Society will carry out on AIDS in Asia with some of the people in the room in NY, including some like Betsy Williams, who are not on camera, and in conjunction with the Global Business Coalition on HIV/AIDS and in close cooperation with the Center for Strategic and International Studies, here led by Ambassador Schaffer. And we are doing this in close collaboration with CII in India. The grant that made this possible is from the Bill & Melinda Gates Foundation. We are very honored that they gave it to us and we hope to move on from India to other places in Asia, including most importantly, China. I have often said that AIDS is not just an African disease and what we are going to explore in the next two hours is the nature of the disease in India and how we can work together in partnership to deal with it.

By phone:
Peter Piot: We are joining you from Chiang Mai and the Board of the Global Fund against AIDS, TB and Malaria. This is an important initiative, which is timely and needed. Asia is truly at the crossroads when it comes to AIDS. If business as usual continues, we will see tens of millions of people infected and major economic and societal damage.

What is most needed is leadership at all levels. Just last month at an extraordinary meeting of the UN General Assembly, there were about 20 heads of government, heads of state from all over the world who were talking about the need to respond to AIDS. But not a single one, not a single prime minister or president, came from Asia. And that is really disturbing and worrisome.

And yet we have seen real leadership from the region, here in Thailand, and earlier this year in Delhi. Oscar Fernandez and colleagues and UNAIDS, cohosted the Indian Parliamentary forum on AIDS. This was an historic meeting with over 1500 elected representatives and Prime Minister Vijpayee the keynote speaker. We need many more such initiatives across the region. I have also just come from Bangkok where we launched the Asia Pacific Leadership Forum, chaired by former Prime Minister Arum Panayarchum from Thailand, who was the architect of the Thai response to AIDS. So I can assure you of UNAIDS full support for this initiative and I am delighted to be deepening our collaboration with you through the Global Business Coalition, the Asia Society and the Bill & Melinda Gates Foundation.

Helene Gayle: We felt it important to add our support to this initiative. I am very pleased that the Bill & Melinda Gates Foundation has been working already with the Global Business Coalition on HIV/AIDS on really broadening the partnerships and particularly getting the business sector involved in the fight against HIV/AIDS, as well as our continued collaboration with CSIS. It is in this spirit we are extremely happy to be able to support the Asia Society in increasing the engagement of Asia for all the reasons that Peter Piot mentioned and to broaden the coalition of groups that we are able to work with, to energize the support for the fight against HIV/AIDS. In addition, we had our first program Board Meeting for the new initiative in India that the Bill & Melinda Gates Foundation is supporting and with that I would like to reintroduce Mr. Ashok Alexander, who is the director of that program in India and is really energizing the activity there.

Ashok Alexander: Regarding our strategy in India, the Foundation approaches India from the perspective that the epidemic in India is at a very crucial inflection point; that there is a window of opportunity of less than 10 years before the numbers get out of hand. So we have to mount a very comprehensive prevention program in this period of time. Our program in India is (in English) Call for Action. The goal of our program is in conjunction with others in the field, to stem the growth of the epidemic in India by 2008. We will do that in two ways: one, by being very focused in reducing HIV and STI transmissions among populations most at risk; and secondly, and very importantly, creating an enabling environment.

The strategy consists of six initiatives that link together well. Two are core, large-scale prevention programs and there are four supporting initiatives. The first of the prevention programs we call District Focus and State Impact, looking at the six states where the epidemic is the highest, in particular to the 100 districts within those and trying to bring an effective package of interventions to carefully identified populations there. The second large-scale prevention program is The National Highways programs, which covers the entire 7,000 kilometers of highway and we are trying to work in partnership with companies like the Transport Corporation of India, the Indian Oil Corporation, Population Services International, to bring interventions to identified hold points, where there is a lot of aggregation of trucking activity and virus transmission. So these prevention programs are ambitious. If you think of the scale of India, each of these states is one-quarter to one-third the size of the United States. Each district is about as big as Botswana. So we are thinking of a very large program here.

These intervention programs would not be complete without four supporting programs: one in communication so we can think through the entire architecture of communication that is required - from interpersonal to education and mass media; the second is advocacy, so we can try to create a better enabling environment from the national to the district level; the third is knowledge-building and measurement, which are both very important aspects; capacity-building is the last one.

I will close by saying that we had our first board meeting yesterday. We were very excited to announce that our foundation has enhanced its commitment to India from $100 million to $200 million, given the scale of the epidemic here. And we were pleased to announce our first set of grants, which came to $70 million and were directed to the states of Andhra Pradesh and Karnataka and the National Highway Program.

Holbrooke: Heather Burns will set the frame of the rest of the discussion by outlining for us what came out of the simulation of the last three days.

Heather Burns: Thank you very much. Let me tell you about the game that took place over the last few days in Delhi. it was a great success. We at Booz Allen, working with CII and the Global Business Coalition for HIV/AIDS expected 60 people and we were told the night before that 200 were showing up. I think that is a huge success. The stakeholders were state and local government, NGOs, international experts on AIDS, a large number of industries and many others.

To set the stage, it is important to understand that it was a simulation, based on medical and economic facts bases: There is less than 1% prevalence but still an absolute high number with between 3.8 and 5.2 million cases, 85% of those being sexually transmitted. Our simulation also included a model that is able to project the implications of the current base line as well as the implications of actions the participants decide to take. We showed the participants a graph that indicated a very steep future curve of prevalence, with the numbers of new infections growing dramatically each month. We showed how the curve would move according to actions and the incidence curve went dramatically down to a very much flattened curve. We showed a further impact on the potential loss of GDP.

The first key learning was that active business as well as government leadership is absolutely vital to the solution. Communication barriers and assumptions made by one side against the other absolutely have to be dissolved and transformed into a partnership and what we saw over the weekend is that they can be dissolved. The main point here is that business must take leadership roles. The AIDS crisis cannot be solved without that.

The number two learning is that strategic priorities must be carefully considered and weighed. Resources are not unlimited. Difficult choices will have to be made and India will not be able to fund all the desired solutions. They may, for example, carefully weigh and balance spending of resources on prevention versus treatment. No one would say that India should ignore treatment but India is in a very different situation than South Africa and prevention, including destigmitization, may need to be the priority now to avoid a much worse crisis in five to ten years. The third conclusion that the participants drew was that broad collaboration is essential and can, in fact, be achieved. Collaboration is required both within and across sectors and the results can be spectacular. At the outset of the games, stakeholders did not know how to work together. By the end of the game, they were generating brilliantly innovative ideas for attacking the problem, in groups.

Let me end my comments by giving one final observation and my own personal takeaway. I think the games showed that even with constrained resources, incidence of AIDS can be reduced dramatically. You can move from the very steep curve that I talked about at the outset to a much flatter curve. The horrific situation that has happened in South Africa does not need to happen in India. It can be prevented through immediate and sustained action. I saw incredible excitement come out of the simulation. We were able to show that lives were saved, the epidemic checked and on a final personal note, I (left) far more hopeful than when I arrived a week ago, that with the hard work of business and the government, the solution is in fact very achievable. Thank you.

Holbrooke: I want to thank Booz Allen Hamilton again for their extraordinary pro-bono work on this project. We all participating in it learned an enormous amount.

Schaffer: I wonder if I could start with a question for Heather. I was impressed with the statement that the policy measures that you gamed out flattened the curve of increase in HIV incidence. Which policy measures seemed to be particularly important in producing that result?

Burns: We completed the game about 24 hours ago and we have not sorted out in that level of detail. But it was an aggregate of the nine groups working together and it was the total impact of all of the actions taken at one time. It included literally hundreds of suggestions so I cannot narrow it down to just a couple. When we get our report out, though, we would be better able to answer that kind of precise question.

Schaffer: We will be looking forward to the report. I think we have some comments on what we have heard so far from Dr. Rosenfield.

Rosenfield: Good morning. Just a couple of quick comments. One, I think the focus on prevention is critically important in countries such as India where the prevalence is one percent or less, even though the numbers are already high. I would urge that some attention be given to the experience in Thailand, where the prevention messages have been most effective in taking a relatively high level of prevalence to a much lower level. And most important in Thailand was the commitment at the highest level of government, from the prime minister's office and all the major ministries and in India it would seem to me that would be important both at the level of the central government and at the level of state government. With multi-ministerial responsibilities, not just the Ministry of Health, but all ministries taking a role in communication, education, stressing safe sexual practices, safe drug use and such, India does have the chance. It would be one of the worst things we can think of if India ten years from now were to have a prevalence of ten or 15 or 20%. The numbers would be just astronomical. So what you are undertaking is hugely important and I welcome the steps you are suggesting.

Schaffer: I would like to invite Nafisa Ali from Delhi to give some thoughts on what we have heard so far.

Ali: Regarding the simulation, I believe that it was the business elite that got together to create this program and to the educated mind, it seems very plausible that it can work. But for me, who works in ground reality, I find it very hard to believe that the graph can take a curve down so quickly. Yes, I am very excited that the politicians are trying to get together, the corporate houses are trying to get together, the international community is trying to get together but there is a ground reality which is, in India, people are not educated, women do not have the bargaining power. This is a sexual issue in our country and I really feel for the people in my country. I feel because when you give care, I find it a human right violation that we only talk about prevention. And I always appeal, irrespective of where I go, that I know that over 98% of all funding goes into awareness programs, but can we not change it to 10% for care and 90% for awareness programs. And I will happily work for all awareness programs and become part of that movement as well. But you know for me, as a caregiver, I can't cast people aside and leave them to a pitiful death. I find it very hard.

Schaffer: Dr. Rosenfield had a thought on that last point you raised.

Rosenfield: I agree completely, one should not be focused only on prevention or only on care and treatment. In all of the programs, whether in Africa or in Asia, both are hugely important. The priorities in India might be higher on prevention simply because of the magnitude of that challenge. But one should not ignore in any way the care and treatment of those already infected.

Schaffer: One of the things that simulations usually do for you is to change the way the participants think, because it forces them to look in a systematic way of the consequences of possible decisions. I wonder if one of the parliamentarians in India can give us some thoughts on how one could raise the sense of urgency and of possibility among politicians?

Oscar Fernandez: It is too late in the day that we have realized that the elected representatives should play a role in the prevention of the spread of HIV/AIDS. But there is a saying, it is better than never. In May and recently we had a national conference of elected representatives which included the parliamentarians, representatives of the state legislature, and a third pier of governance-local self governance-we had representatives of the panchayats. All of us deliberated on the need of getting every elected representative in this country into this moment. At the panchayat level, we have 3 million elected representatives in our country, out of which one million are women. And if we can get them into this moment, I am sure we will carry this message to the masses in this country.

We should understand the size of this country and the population involved. Ours is a large country and the population is one billion and to say that we will handle this problem within a period of five years or even in a period of ten years is wishful thinking. But every effort is required. We the members of parliament have decided that from the resources at our disposal, the Area Development Fund, we will use to create infrastructure in the country. There are several states where the institutional deliveries are as low as 10% so the rate of detection is also very low. We are talking about high prevalence states and low prevalence states based on the detection rate. Now we should understand in this country from where this disease flows. The city called Bombay is called the gateway of India. It was known to be the place for people from all over the world to come. In our country, people from all over are going to Bombay in search of employment. Ashok has talked about a project to deal with the trucker's problem. The biggest problem in this country is employment. People move in search of employment and when they go back, they carry the disease. The youth is another area we have to deal with. We have recent reports that college students have unprotected premarital sex. If we don't deal with this area, we will have a big problem facing this country.

Das: Can we bring in Cyrus Broacha of MTV?

Cyrus Broucha: There is a guy called Bill Clinton, you guys have probably heard of him. But we did this show with him in Barcelona and he complained that the biggest problem he had with Indian politicians or even with people in government positions, is that here people do not want to talk about sex. And I have this huge problem we are having in the media. Before getting to AIDS, if you mention sex, people look the other way. So that's a bit of a problem and I don't know if Mr. Fernadez…

Mr. Fernandez: I mentioned it! I spoke of pre-marital sex. I said that's the major problem we are facing.

Broacha: Maybe when you spoke of it Mr. Holbrooke took off his coat so now I am really worried about it. I am just saying, it is like a war which on different footings has to be fought in different languages and cultures because it is so complex in India and I think the government as well as the NGOs as well as people like us, we all have to talk to different people and explain to them that sex happens. Otherwise how come we are one billion? This huge secret - nobody has sex, nobody talks about? One billion people, tomorrow, boom!

Holbrooke: You are waking them up in New York.

Schaffer: We are all wide awake now. But one of the interesting questions is should one look on HIV primarily as a public health problem or should one look on it as a problem that goes beyond public health into many other areas of national life? We already know that when prevalence levels reach 5%, economic growth is noticeably affected. When they reach 10%, economic growth effectively stops. Perhaps Mr. Ghatowar could give us some help on this. What do you think is the most compelling argument in India for taking this problem seriously? For trying to do what Mr. Broucha suggested and actually talk about sex in order to attack the problem.

Mr. Ghatowar:One of the main problems that I see as an elected representative of the remotest part of India is awareness. And keeping that in view, we, some of the parliamentarians, have organized what Mr. Fernandez has already said, that we want to involve the opinion leaders from the grassroot level to the national level. If the opinion leaders don't speak about sex and HIV/AIDS, who else will speak to these people? In India, more than 30% of the people are illiterate. They have no accessibility to the TV. They cannot read the newspaper. So who will speak to them about this great menace, which is harming the society? I think one of the main problems is the awareness, creating awareness. Yes, the business people and other leaders, they know. But what about the 70% of people who live in the villages, who live in the hills, many of them have never heard of HIV/AIDS. And many do not believe when they go to the major cities for work and they come back and they have gotten HIV/AIDS. And they don't know where to seek help. I have some personal experience. They never believe that their husband will go to another woman. They say he has infected himself and he carries that disease to his innocent wife, who is living in the remotest of the country. I think creating awareness has to be one of the major problems.

Geeta Sodhi: While awareness generation is extremely important, but … boys and girls don't even have the skills to be able to negotiate access to services, to be able to negotiate access to support, to condoms. Mere availability and mere awareness generation is not going to do the job effectively. I think skills building and inclusion of that across HIV/AIDS programs or education programs per se is extremely important. Another big gap and in my personal experience, having worked for several years with adolescents, is that the social fabric is so weak and disabling. the context actually disallows the adolescents to even step out of harm. The girls even today have restrictions on their mobility. The girls get pushed into marriages and they cannot (deny their husbands) sex when they get married, let alone negotiating condom use. So I think we need to pay some attention to the social/cultural context within which these individuals are placed.

We need to also look at the boys, the men, who forever are under a lot of pressure from their peer groups to prove that they are macho, to prove their virility. And the journey actually begins on the first night of marriage. That is when sexual coercion very often comes about and it just continues and the woman keeps on going through sexual assault, without ever raising a voice. Because that is what is expected of a good woman, a good wife, a good daughter-in-law. So she is caught in the trap of a social/cultural context, which promotes and propagates sexual coercion, which actually contributes to her vulnerability to HIV/AIDS and other negative outcomes of sexual intimacy like unwanted pregnancy. So we have a social fabric that we must deal with, through integrated programs and they need to be strategic in terms of who are the partners being pulled into those programs. For example, women in India are not accessing services very often. But they do access services when they get pregnant. I think we need to take advantage of that window of opportunity and we can do that effectively if we partner with the public health system. Another example is adolescents not going to school. So that is where the partnership with civil society comes handy, just as it is very important that the corporate sector be pulled in as a partner, especially to address men at the workplace.

Holbrooke: I want to ask Cyrus to address the question that is most on the table, which is how we communicate with the large number of people, particularly women, who are not literate?

Broacha: Cyrus is the name, it rhymes with virus. What I am trying to say is that we are trying to communicate in India through lots of different groups. We are not a homogenous society. We have the elite, we have the English speaking elite, we have the Hindi speaking north, the south-a different country altogether in certain ways-the northeast, a different country altogether. So it's not easy to communicate with just one guy, one person. Everybody has to do their bit. It is like a holistic movement and only then will we be able to reach all the people in different ways. I personally feel if you are talking to youngsters, your MTV generation, you talk in a certain manner for more than one minute and they will shut the television off and start beating their parents. So we don't want that. I think we have to keep it light. We have to find a way to reach people, hold them for a second and get them interested in, as the good doctor said, the skills, the whole act of putting on a condom, why, what, where. And then we can deal with the whole stigma issue as we go on. It will be a step-by-step process, which together if some kind of holistic status comes about, will happen.

Schaffer: We have been talking about awareness, prevention and treatment. And I'd like to come back to the other two for a second and to follow up on the point that Nafisa Ali raised about the balance between prevention and treatment and the interconnections between them. Seth Berkley's organization has been making great strides towards developing a vaccine. I wonder if you could talk about that and how prevention and treatment need to reinforce each other.

Seth Berkley: We have to think about the epidemic in short term and in long term. Over the short term, as we have heard from the other participants, we have to do everything we can to slow down the epidemic by using prevention. We have to do what we can to treat people and we obviously have to mitigate the consequences of the epidemic. But over the long term the goal really has to be to end the epidemic and we are only going to be able to end the epidemic with a vaccine. And I think if you did any type of simulation, you would see that. So the challenge is to move ahead as expeditiously as possible on the development of a vaccine while we keep the others going with full force and full speed. So these two can't be in competition, but they have to be going on in parallel.India has a really special opportunity and is also taking extraordinary leadership on this issue. The Prime Minister of India and the President of India both have made AIDS vaccine a national goal of India. They have declared them a national goal with a mission-like focus, which for the Indian government means trying to cut through all the bureaucracy and drive it forward with the speed that it needs. There has been extreme leadership within the Parliamentary group as well. There has been discussion in Parliament on some of the very important issues like reducing stigma, trying to make sure the empowerment of women, legislation supporting that, goes through and looking at any way they possibly can to try to make it a more friendly environment for AIDS prevention programs. But at the same time there has been extraordinary leadership on vaccines as well in the Parliament. And the challenge really is to turn this leadership into an accelerated program for India. We have been working closely on trying to move a range of products forward and we hope to start clinical trials on the first quarter of next year and we have had assurances that this will be driven through with unprecedented speed.

The other important point about this is that as we think about manufacturing vaccines for the world, we have to think about the vast quantities that will be needed, particularly in the early stages when you play catch up for an entire, very active sexual population. So we need to think about countries that can produce large quantities and of course India has a fabulous manufacturing system for pharmaceuticals and vaccines. We are trying to look at technology transfer of vaccine products to Indian manufacturers as soon as possible so they can not only work on getting right the process of vaccine manufacturing but also work on the tools needed to scale up manufacturing from a small lab base to the large industrial processes that are necessary. And I must say that CII and FICCI (Federation of Indian Chambers of Commerce and Industry), the two Indian agencies working with the private sector, have been very supportive of this effort as well. So I see India as taking a real leadership role on this and I think the challenge for us is to take that science community, that political community, that industrial community, wrap them all together into this driving program that can not only make a vaccine for India but also be potentially manufacturers for the region or perhaps for the world.

Schaffer: That certainly is a very exciting prospect. I am assuming there will be another five years or maybe ten before you have a vaccine that can be generally in use.

Berkley: Absolutely. We obviously can't promise when that vaccine is going to be there. What is exciting now is that there are many technologies that are moving forward. But what is important is that if we follow business as normal, which is to go ahead and wait to do the distribution, to do the scale-up, to think about how we are going to get this to vulnerable women, and how we are going to pay for it for the very poor, what will happen is the day we succeed, we will have a minimum of a five or perhaps a ten year delay from the time we have that vaccine to the time we get it to the people who need it. And that unfortunately has been the tradition of vaccines. They normally start in the north and then trickle down to the south ten or fifteen years later. And the largest grant from the Bill & Melinda Gates Foundation is not for India, although I think this is probably the second largest. The largest is actually for IAVI, which is a program that is trying to break through that problem and really begin to get those vaccines to people who need them as soon as possible. I think the challenge is to continue that research, to push forward on vaccines but not let it interfere with the critical work on prevention, on empowerment, on treatment that is going on now.

Holbrooke: I would like to interject and Mark (Tully) would like to say something. Seth, when Kati and Tarun Das and I called on President (APJ Abdul) Kalam on Saturday, you will be interested to know that he talked at length about you and IAVI. And he had your spreadsheets all over his desk. And everything he said was in parallel with what you said, which is a great tribute to what you have done. But there was one issue that you just raised that he didn't raise and it is the central one. And that is this enormous gap between where you are now and the day in which any vaccine, even if it works, will be implemented. I am speaking very honestly now, because the issues are life and death, the last part of your message, the number of years, was simply not there. So I hope that the totality of what you are saying, not just the first part, will get through.

Berkley: …It is critical that we get the leaders to put this into perspective but I am delighted that there is such leadership in this issue because one of the problems has been in the past is that we haven't had leadership on this issue and that's one of the reasons we are so far behind where we need to be in the vaccine effort.

Mark Tully: I just want to make two points. One is on this business of awareness. I don't know how many people are aware that my former organization, the BBC, and the government of India have been very successfully collaborating on an awareness program. This arose out of an earlier awareness program for leprosy, which was considered to be very successful. Without in any way wanting to undercut Cyrus' organization and media, it is very important that we all remember that radio is actually a far more powerful medium in this country than television. And especially when we are talking about reaching remote areas. And the BBC program does have a radio content to it.

The other thing is that some people in the women's health area did raise questions, if not objections, during the process of the BBC program, about condoms and I think this is a real problem in this country. We have to face up to the fact that there is no way that we are going to combat this thing unless people are prepared to accept the use of condoms.

Third thing I want to say, about two or three years ago I made for a pharmaceutical manufacturing company, which have been so rightfully praised, a film about AIDS awareness of treatment which is available. And I was appalled by the medical ignorance that I came across in making this film. I came across some doctors who were brilliant and totally aware. But there was an alarming degree of medical lack of awareness and an alarming degree of doctors who were simply prepared to literally turn AIDS patients away because they were so ignorant they could not explain or convince their other patients that there was no danger to them from the doctors treating these patients. I think in India there is probably a subordinate but very important problem in medical education.

Alexander: I would like to make two points. One is on the issue of creating awareness. The awareness levels among sex workers is about 95%; their behavior doesn't change. Too often in intervention programs we played in the awareness lever but we have to think of other levers that are important such as controlling STI infection.

I wanted to pick up on the remarks of Dr. Seth Berkley. If I understand the experts, they say the development of a vaccine is some years away and then the time it will take for that vaccine to reach marginalized populations, probably some more years away. So the question to ask us in India, what do you need to do about treatment in the period that runs up to the cure. There are one or two key considerations here.

First, India cannot afford ARV treatment. If today you gave ARVs to every single person who needed it, you would be spending $350 to $400 million, about six or seven times what we spend on all of HIV/AIDS. The per capita income is $400 a year. So you can't provide ARV. Second, these drugs will become more expensive after 2005. The whole ARV argument in turn is oversimplified by many well-meaning people. This country cannot afford care, and without care you shouldn't do treatment-if you cannot do nutrition, if you cannot do the monitoring and all of that. So the whole treatment argument is also very complicated. It has got to be linked to the care argument. And finally, no prevention program can work in the absence of some proto-testing and care. It is a whole big continuum. To boil it down, the vaccine is some time away, we need ARVs because you cannot do prevention without treatment, India cannot afford that. So the country could make a far more cogent case with groups like the Global Fund and the World Bank and so on on how we can get some help in this regard. To take up these things in isolation does not help too much.

Schaffer: I think that is a very important point, Ashok. I would like to at this end call on two people who have some very specific experience in dealing with the nexus between prevention and treatment. Dr. Rosenfield and Anil Purohit.

Allan Rosenfield: I agree with your comments about the cost, although the dramatic decline, which is now somewhere between $200 to $300 per year per patient, is a huge difference from the costs in this country. But I do agree that in poorer countries, without the Global Fund, the World Bank, USAID and other donor communities, it is not feasible. But it is feasible, quite easily, with foreign assistance in this particular area of care and treatment. And the Global Fund, while having growing pains in trying to raise the kind of funds it needs, I believe will be successful. And with the Global Fund and the commitment of the World Bank and others, I believe we no longer need to consider that all those people who are HIV positive in Africa and Asia need to consider it is a death sentence. We can begin to put these programs in place. There is good evidence to suggest that with treatment available, prevention programs, too, and care, voluntary testing will increase as people have hope. I would urge that in India we see an approach to both prevention, care and treatment. The organization amFAR is initiating a program to try to help train, through their Treat Asia program, efforts in this area. I think there is a great deal that can be done and I hope that we will do it together.

Anil Purohit: I would like to quote examples of our programs in India. We have an MTCT program (mother to child transmission) in Vishakapatnam in Andhra Pradesh and that is totally funded by the government of Andhra Pradesh and FXB is providing several of the physicians and a couple of health care workers. Also in Jodphur we have 500 patients enrolled in our clinic and we cannot provide anti-retrovirals at FXB but we are working with the government for the patients who are below the poverty line and having the government help more than nine of our patients right now. Plus we are mobilizing the business community which is undefined, like rural businessmen who are like billionaires in Chenai and Calcutta are helping us. I agree with Dean Rosenfield, that prevention, treatment, care has to go together and we are mobilizing the business community, the government and ourselves to make this work. We at FXB do agree without prevention, treatment won't work and without treatment, prevention won't work. A lot of drug companies have really brought the rates down and we are getting a very good offer from them. So we are having our business community help us fund these small programs.

Rosenfield: The PMTCT (the prevention of transmission to the child) coupled with the MCTC plus the treatment of the HIV-positive mother, her children and the family is a beautiful example of the marriage of prevention and treatment.

Nafisa Ali: I wonder how many of you are aware that the Health Minister of the country, Sushma Swaraj, just made a statement that in six months time, all children in India who are HIV positive under the age of 14 will be given free anti-retrovirus drugs. It makes me very hopeful. The issue then becomes, what do we do for the mother? If she did make that statement, we would hold her to it. But let's then try to protect and give dignity of life to the mother because the love of a mother bringing up her child is so important. Technically, an HIV positive mother who gives birth to an HIV positive child may have elder children who are negative. So to keep her alive becomes part of the process of a human right. These are big issues for us.

Cipla (Mumbai-based pharmaceutical) says they will give one dollar a day treatment, it supplies internationally. My appeal would then be to Cipla to make it half a dollar a day, because in the work I do, I have corporate support, I have the Gates' support, for example. We can help a lot more people. The message is to the mother: why would anybody want to test themselves if you cast them aside.

Das: I want to bring in Jaspal Rana, a young outstanding sportsperson in India.

Jaspal Ranal: I see the children watching TV all the time but you don't hear anything about AIDS or about condoms. There is nothing that people can hear and get educated. India is a big country. A lot of people don't cast their vote. The Member of Parliament agree that they go to remote areas and they convince people that they have to cast the vote. Even blind people come and cast their vote. Why cannot we convince them of these (prevention) things? At the same time, Cyrus and I are here. People call us for these kind of group discussions and seminars. Why can't we be taken to the remote areas and let people listen to us? If you take movie stars, people will listen more to them.

Schaffer: Have other sports figures besides you or actors from Bollywood become interested enough in the AIDS problem to lend their faces, to go out to remote areas and talk to people?

Broucha: One of our biggest icons has come on television, and has spoken about polio and also about HIV. I don't completely agree with Mark about radio being bigger. Radio is bigger perhaps in the sense that it reaches areas where TV doesn't, but if you look at numbers…but it is all about a holistic campaign. It is a war on different footings: spokespersons, film stars, VJs, waiters at restaurants, everyone has to contribute. That's the only way it is going to happen. We can sit and talk and eat biscuits all day but that's the way I think.

Schaffer: An issue that I would like to focus more on is the role of the business community. I am going to ask Trevor Neilson to talk about this as part of the Global Business Coalition to fight AIDS. And will India focus on what the local business community can do.

Trevor Neilson: Thank you Ambassador Schaffer. The first thing that comes to mind is the fact that we need to recognize that the international business community has been slow to respond to this issue as a worldwide emergency. But there are signs of hope and some of that hope is coming from India.

There are three ways of thinking about the business role in this issue. One is leadership. Business leaders in India and elsewhere need to stand up and talk about this issue. We know that stigma is really the engine of this epidemic and we know that business leaders carry a unique profile and credibility in a community where they live. If we get them talking as some of the people in the room have been talking that can be a very important contribution. Another important contribution is partnership. We know from other parts of the world that when the business community works in tandem with civil society and with government, unique things can happen. The simulation that took place in India the last few days, led by Booz Allen and CII, is a perfect example of that. And we hope that very concrete actions come out of that simulation. The third area of business involvement is innovation. We know that right now parts of India - Bangalore, Hyderabad-are the envy of the world when it comes to their innovations in information technology and in biotechnology. If we could harness the intellectual energy that is coming out of Bangalore and Hyderabad and out of the Indian business community and direct that energy toward this disease, there will be an incredible impact. I think this comes down to getting people involved who are not currently involved. We can't just talk to the people who already care. We need to look at the work of people, like Tarun Das, like (Ratan)Tata and others in India and work to use them as examples for other members of the Indian business community and ask them to get involved.

Schaffer: My own experience in trying to step into this arena came last June, when I came to New York to speak to a group at the annual meeting of the US-India Business Council. I had been specially asked by the US-India Business Council to talk about HIV/AIDS. I spoke to a very eager room, which had one business person and a whole lot of NGO representatives in it. I am hoping that the next time the balance will be a little different.

Das: To add to what Trevor just said, Peter Piot said this evening and said it to me on the 22nd of September in New York that none of the Asian heads of government had participated in the special session on HIV/AIDS. I was there speaking on behalf of business and I think that happened because of the partnership that we have between the Global Business Coalition and CII. Let me tell you what I said there, in terms of very practical things that Indian business is doing now. It is a drop in the ocean but at least it is a drop and it is not completely barren. Like what Trevor said, Indian business was also slow in coming on board. There was an early stage of denial and also saying, is it our responsibility? It is somebody else's job - the government, or the NGOS. But this has changed in India. That was the recognition that came through in the UN General Assembly, asking the CII to make this presentation to heads of government and heads of state.

What have we done? One, we have put together in consultation with business, a code for industry on HIV/AIDS. The do's and don'ts by business. Second, there is an AIDS in the workplace program, conducted in different languages and communications materials prepared in different languages, which is distributed to companies and factories across the country. As of now, nearly 2,000 companies have participated in this program. Third, with the help of the Australian government, we are training doctors around the country so that this issue which came up earlier, about reticence and reluctance on the part of doctors, can be overcome.

Fourth, we are working with select NGOs in providing employment and self-employment to HIV-positive people. Fifth, we are helping HIV positive people to set up micro-enterprises. We are providing a small amount of funds and helping them to access larger amounts, supplementary funds, using our credibility with banks and institutions to get them that money. We have set up a first of a series of counseling help lines and people are actually phoning in asking for information. Amazingly, after five to six weeks of this help line working, people are dropping by, which is a major development, because people don't want to ask for information face to face. It is much more comfortable to make a call. Next, we are organizing sports and recreation activities of HIV positive people with others so that this whole issue of stigma and superstition that you can get it contagiously, can go away. We have established an Indian Business Trust for HIV/AIDS, headed by Ratan Tata (industrialist). He was personally here yesterday at the conference, giving his and his group's commitment to this work. And finally what is very rewarding is this whole international partnership that we have gotten into, sharing best practices, sharing information. Brian Brink (senior vice president, medical affairs, Anglo-American mining group) from South Africa and others who have been here have been extremely helpful in knitting all this together.

Schaffer: I wonder if any large businesses in India, particularly the Tatas, who have branches all over the country, have had experience doing large-scale awareness or treatment among their workers?

Das: Yes they have. In fact the 2,000 companies that I mentioned, each of them has done awareness programs with workers, their families and the community around. I think you should hear Ashok Alexander and what he is doing with the Indian Oil Corporation.

Alexander: Yesterday we announced our first set of grants, and it is interesting that of the first set of grants, two are going to major corporates in India because they bring the scale, the mindset, some of the business acumen to run a program like this. So the Indian Oil Corporation is a Fortune 200 company, it is India's largest company. It has got 9,000 gas stations along the highways, a natural linkage with truckers. And they have opened up their entire infrastructure to us for intervention purposes, not just awareness creation. There will be billboards, there will be things like retro to STI services. The other corporate is the Transport Corporation of India, the largest giant trucking company. They reach 600,000 truckers. And they are going to run the interventions. These are now companies that are really stepping forward. Our board itself, of 21 people, eight or nine of them are leaders of industry. Tarun is on our board. We are hopeful that the business solution is what will make a difference to the epidemic in India.

Holbrooke: I think that based on my very limited observation of this issue, over the last two years, working with Ratan Tata And Tarun, and Ashok and others, I think the Indian business, primarily because of the leadership of CII has actually been somewhat ahead of the government until recently. And this is quite different from the GBC's experience elsewhere. Tarun may be too modest to say it, but this is beginning to have a ripple effect. But I would defer to our Indian colleagues on the panel.

Das: In the 200 people that were there in the three-day conference with Heather (Burns) there were a large number of corporates. There is no question of being one business person there and 99 NGOs. And there were Indian executives of corporations sitting through the weekend, and these are companies that are managing AIDS in the workplace programs for their workers, the families and the communities. That is a new level of commitment which we are seeing. We still have a long way to go.

Broucha: To turn the conversation away for a second, in the media our problem is that we want to talk about certain things and there is not enough support coming. For example, if you want to talk about homosexuality openly, that won't be allowed because it is still a crime in India, as far as I know. Maybe 50, 100 years later it won't be. But that's the way it is right now. Above all our whole perspective is on people who have HIV or full-blown AIDS. If you leave them aside for a second, the problem is the people who don't. So we've got to target them and get them to watch the programs and say, ok, everybody is normal, let's do what we can, under the circumstances. That is the problem: the families and the support systems and even the government has to come together and do that. And then I think the media will be effective.

Holbrooke: May I just add a point on the media, based on the media coverage of the HIV issue all over the world: I am struck constantly by the fact that the American media gives it more attention, and more prominent display than Europe or India. Africa is grappling with it on a case-by-case basis. Tarun says that the situation in India is changing for the better in terms of attention. But on a comparative basis, the story has not gotten as much attention in the Indian press as it deserves. And since media attention is the most critical element to getting people to change behavior, I think the media has got to reconsider things on this issue.

Neilson: I want to touch on Anglo-Americans' new efforts in South Africa because it relates to our discussion of business' role. Anglo-American has announced that they are going to begin treating communities in which they work. This is an important evolution for two reasons. One, Anglo has realized that treatment of employees alone won't work. If you don't treat the broader community essentially HIV will come back into the work force and all the good work within the work force will be for naught. It's important for another reason. If Anglo's model in South Africa is effective, the notion of co-investment, the notion of governments or private foundations as Gates is doing in India, working together with the private sector, to use their infrastructure and delivery systems, can become something that we think of in our response. Right now if Seth found his AIDS vaccine tomorrow, the infrastructure wouldn't exist to deliver it and we've had Hepatitis B vaccine for 20 years and it still isn't making it to parts of the world. But if we get the business community to work together with the public sector, to create that infrastructure, we can make some exciting progress.

Schaffer: Geeta, do you have some further thoughts on how maternal and child health clinics and schools can be made active partners and not just passive ones in the effort?

Sodhi: We constantly grapple with the whole issue of cross-sectoral programming, the whole issue of convergence. I think the corporate sector has the potential to respond to that need. They are able to go beyond a bio-medical or public health approach. And the corporate sector has the unique opportunity to make integrated programming happen. That's already happening: its about addressing families, its about addressing mother and child together, its about looking at the woman as a woman rather than a patient, potential HIV positive or HIV positive. That's the kind of broad programming we would like to see more and more within the corporate sector.

As far as school-based programs are concerned, I have a very serious opinion on that issue because very often school-based programs are not linked to strong outreach. Therefore we are actually addressing adolescences and young people without addressing the context within which they are expected to, suddenly and rather magically, change their behavior patterns. School-based programs need to be linked with outreach services where the gatekeepers could be pulled in and that is where linkages with civil society organizations are extremely important.

Dr. Rosenfield: I think the issue of women and children as a focus is particularly important with this pandemic. In this country, and in Africa and I suspect in India as well, it is increasingly becoming a woman-centered issue. So those programs that focus attention on entering the family through the woman are a very important initiative. This has particularly been the case in sub-Saharan Africa where now women outnumber men who are HIV positive. I think we have an opportunity at an earlier point in India to focus our attention very carefully on young women, adolescent women, in schools as well as those married who are HIV positive and those who are not yet and hopefully will not be.

Question from New Delhi audience: Thank you. Perhaps I am the only guy from the medical community here. Mark Tully just pointed out that he finds very few doctors know about HIV treatment, antiviral therapy, and how to go about it. Has anybody questioned why the medical sector in India is not so involved? I have been in HIV care for almost ten years. I have done training programs, mostly sponsored by the pharmaceutical companies. In spite of that, I don't find much of an interest from the medical community in India. I may be wrong. Medical education is not very easy in India. The cream of the students gets into medical studies. But most of the doctors prefer to go into specialties like neurosurgery, cardiology. Very few stay in internal medicine. And working in infectious diseases and HIV/AIDS, I find a very small proportion of doctors are really interested in this. I really wonder whether we can increase incentives, encourage training programs, get partnerships. Can you add anything to this?

Holbrooke: Combined with what Mark Tully said, this is a very powerful indictment.

Al, what do you think? You are the professional in the field. Is this a generic problem around the world or India-specific?

Rosenfield: I don't think it is India-specific. In this country (USA) in the early days of the AIDS pandemic, there were relatively few physicians who were willing to be engaged. The infectious disease community, however, grew in this country and now we have a fairly large cadre of dedicated infectious disease people involved with AIDS care and treatment. I agree that in India it will take time to galvanize and motivate physicians and it will take place through some of the efforts you talked about there. But it is not a problem limited to India. In Africa, there are relatively few doctors who have been trained in infectious disease. The goal is that general physicians and other health care workers can be trained to provide this kind of care and treatment. In India and in many other countries we have a tendency to believe that only specialists can provide a variety of levels of care and that is not the way to proceed. We need to galvanize a whole cadre of health care workers to provide care and treatment as well as preventive activities in India and elsewhere.

Schaffer: We have some questioners in New York.

Question: We had a conference on AIDS in Africa this year and one of the principal problems was NGOs and the claim that is made that not much of the funds made available by large organizations, by foundations, by governments, trickles down to the grassroots level. I was wondering if it was the same situation in India.

Alexander: The issue is not whether it goes down to the grassroots level, but whether that is necessarily a good thing. India is blessed with having one of the world's most vibrant networks of NGOs, literally thousands of NGOs. But having said that, there is not always proper accountability of NGOs, there are a lot of pure crooks disguised as NGOs, and so on. For another reason, sometimes you need scale. Sometimes you need to work at another level completely. But I think the money gets to the grassroots.

Sodhi: I think you are right, Ashok, that we have a robust and dynamic NGO sector. And we have ample examples of innovative responses to the pandemic. At the same time we need to recognize that increasingly the NGO sector is getting more professional, more willing to be accountable. Accountability mechanisms are in place and can be put in place; there is a willingness. We view today's NGOs from yesterday's understanding of the sector. It is the NGO sector that will be able to effectively get into the populations that are required to be addressed. To say that the NGO doesn't have the capacity, I would beg to differ. In our own experience, we have designed a very effective model which we have measured as successful, using statistical tools. What we need are resources. There is a willingness on the part of the government to plug its own infrastructure, or resources, into an effort to carry it to scale. We need to see the NGO sector with a new set of lenses and with an open mind.

Schaffer: This is an issue that will is going to be a challenge but one that the world has to meet.

Holbrooke: Before you go on, one more comment from the chair of the International Women's Health Coalition, Kati Marton, who along with Adrienne Germain has been an integral part of this process for the IWHC.

Kati Marton: I would like to call attention to a situation here that goes beyond both the NGOs' capacity and the marvelous response of the business community and that is that there is a new path in India. It consists of HIV positive women. I base this on field visits and interviews the last two days, including to Nafisa's wonderful care giving center. It seems that however a woman is infected with HIV, whether through a blood transfusion or from her husband, she is shunned. What then happens is she gets neither care nor skill training and she is then forced to sell herself. Obviously the result is that the disease is spread. The most vulnerable segment of the population here are young adolescent women, who are married off early and ill equipped and don't know how to protect themselves. Yet they respond so readily to education and information.

Question from NYC audience: I am interested in the debate about the role of civil society versus the other sectors. It is our experience that the public sector is really treating the largest population, in both India and other countries, and badly. They suffer from a decay in the infrastructure that won't allow for or encourage people to use that infrastructure because it is in such bad shape. If we are going to make an attempt to do prevention on a large scale, or treatment, as in MTCT programs, we need to do something about the health services at their lowest level, in those places where the largest number of the population will come for services. My question is whether Dr. Berkley could comment more on vaccine preparedness. I don't really understand what that means on the ground.

Berkley: The whole concept of vaccine preparedness is to prepare every level of society for the development and ultimate distribution of a vaccine. We have talked about media, about politicians, about the delivery of services on the ground, about researchers, health care providers. The challenge has been in the past that research has been done at some level that doesn't connect all the other levels. The research may be right, but it gets stopped by some other factor, whether it be bad rumors spreading around the community, or physicians who don't understand or politicians who don't understand. The concept of vaccine preparedness is to get all of that in sync. But it cannot be done in isolation.

Going back to your original point and the challenges we see in India, India has this unbelievable infrastructure but the ability to reach down to that infrastructure not only takes time but getting the training out, being able to deliver good quality services is going to be a huge challenge. So I think some of the work that Ashok and others are doing now, to figure out what alternate mechanisms are there to reach out and enhance the capacity is going to be important for today's prevention, tomorrow's treatment and ultimately for the distribution of the vaccine.

One last point, we have to remember that we are working with different groups. Adolescent girls are one of the priorities here. In immunization, we don't reach adolescent girls in general. In other programs, adolescent girls are not the focus. So we have to think of novel ways to get out and reach these people, both for prevention and ultimately for vaccines.

Tully: A very interesting question is that of the infrastructure being in bad shape. A major problem in India is that the infrastructure is not delivering what it could deliver. I was interested in an NGO in West Bengal which was concentrating on making the infrastructure work in the district in which it was operating. In Rajasthan, for instance, I know another NGO which is doing that. This seems to me in the field of HIV/AIDS, that NGOs could concentrate on this. They could be almost the catalyst, which force the infrastructure to work.

Question from Delhi audience: While we have a lot of policies in this country, we need laws. For without laws, nobody is going to listen. We have HIV people who go to hospitals and are refused treatment and they can do nothing about it because there is no law, there is no accountability. Even if (enabling) legislation is just tabled, there would be a national debate and this whole issue will come up and people will start talking openly about it.

Berkley: I agree completely with the critical need to get the laws right. We recently had a visit of the Indo-US parliamentary group, and Ambassador Schaffer was at that meeting. What was interesting is that the Indo-US parliamentary group on the US side is the largest interest group in the United States Congress. It just goes to show the interest. One of the challenges is going to be to take advantage of that interest, focus it on the issues of HIV and to work with parliamentarians in India to get these laws right, particularly those around women, so that we have some of the stigma reduced.

Fernandez: As Seth Berkley said, we had a conference of the Parliamentarians and elected representatives in Delhi in July and one of the decisions taken there, which the prime minister had committed to, was that we would have a special session of Parliament. And the speaker in this conference agreed he would devote one full day to discussion on this particular issue. There is already legislation that has been prepared. And this will be discussed as well as all the issues relating to laws will be discussed.

Question from NYC audience: We started talking about prevention, then care and treatment and then cure. What I think is left out is the youth aspect. What steps are being taken to engage youth in the leadership initiatives in Asia and in dealing with this issue? And how do you plan on engaging key opinion leaders, such as religious leaders.

Sodhi: We have some very strong and interesting examples of inclusion of adolescents and their leadership within the NGO sector. A Delhi-based network of groups that are working on adolescents, are actually considering setting up a parallel subcommittee of adolescents that will advise them and be the voice from the younger generation on what kind of programs are required for adolescents. Over a period of time it's a hope that the leadership of the network will be shifted from the parent leaders into the hands of the adolescent peer groups.

Rosenfield: On the issue of adolescents, Seth Berkley said there was not a lot of experience. The family planning programs in India and in many countries have focused very heavily on adolescents and we should build on the experience there. On the legal issues, particularly in relationship to property rights, in India and elsewhere, this is extraordinarily important for women. But in Africa, this becomes a huge issue for orphans, who in many settings have no property rights whatsoever. These issues should be taken up.

Purohit: Our focus is worldwide parenting AIDS orphans and the Countess, the founder of the organization, always talks about forgotten places, issues and the population. We do have a lot of programs on youth in India and we are hoping that by December 2003 we will have programs for youth in all 25 states and territories where we work. Also, we run a summer school for youths in Delhi and Jaipur and Jodhpur and other parts of India, on a yearly basis. It is a 3-week summer program and is very effective and if anybody is interested, I would be more than happy to provide information and it is on our website.

Question from the NYC audience: The thing that is fueling the AIDS epidemic in India and elsewhere is the severe gender discrimination. The only forum that truly reaches all the villages are the panchayats. There are one million elected women representatives in the panchayats. They are the constitutionally mandated representatives of the people and the natural catalysts for the kind of profound social transformation that will allow HIV/AIDS to be stopped. Currently the panchayats do not have access to the resources they need to make the infrastructure work at the grassroots level. My question: is the leadership for stopping the spread of HIV/AIDS going to push for devolution and push programs that empower, support, educate the women elected representatives of the panchayats?

Fernandez: We from the Parliamentary Forum on HIV/AIDS have drawn up a program to reach out to every panchayat in this country. Our program is to have a one-day session of the panchayat to discuss the problem of HIV/AIDS. If we can successfully reach every panchayat, the second stage is when the people in the village, twice a year, discuss the developments of the panchayat. In two to three years, we will be able to cover the entire population of the country.

Holbrooke: Our time is over. There are tons of people to thank in New York and in Delhi, in the Asia Society and here in Delhi with the GBC. But none of it would have happened without Tarun Das. My hat is off to him. And the CII team. This is the perfect way to end an extraordinary four days. I hope we can do this in Beijing within a year, to extend the Gates' funded Asia Society project to China.

Das: We always talk about economic reform but here we are talking about a much deeper social reform, a mindset reform, a behavioral reform, a private lives reform. It makes it so much more difficult to address. There are so many players. Around this table in Delhi is a cross section of all the segments, from the political leadership to the NGOs to sports persons, to business. We are as a country, conservative and cautious. What I want to leave you with is the process is on; there is a movement underway. It is not yet a national movement but the effort is to change this country and make it much better, especially in regard to health issues and HIV/AIDS. I thank you, Asia Society, and the Global Business Coalition for partnering and being with us.

Schaffer: Let me add my thanks in New York. Almost two years ago I released a report from CSIS, called rising India and US policy options in Asia, which looked at three scenarios of what India might be like ten years from now, focusing on broad economic and security issues. One of the statements I made in that report has been amply confirmed today and that was that the biggest single uncertainly hovering over India's future is what it does with HIV/AIDS. If it turns that into a small problem, this is a country poised on the brink of extraordinary development. If it doesn't then it will justify the cynics. And I would hate to see that happen.