Peter Piot’s Memoir on Infectious Disease

10 July 2012, 0502 EDT

I just finished reading Peter Piot’s lively memoir No Time to Lose of his time as an epidemiologist helping identify the Ebola virus in the 1970s through to his service as the first director of UNAIDS. It is an engaging read not least because Piot conveys a profound empathy for those affected by disease. Piot also projects additional warmth and humanity, from his appreciation for Congolese music to good beer.

More substantively, Piot has a proportionate sense of the outrageousness of bureaucratic politics in the UN system, while recognizing the need to navigate in those shark-filled waters.

Unlike many memoirs, there is some bite here, with some choice words for donors who talk a big game but don’t provide much money (here, France and Italy were named) to mid-level careerists who put turf before those they are meant to serve, as well as some for campaigners whose occasional “extreme” demands or tactics can backfire (his account of an AIDS activist calling France a shit-hole on a live fundraising telethon was on point here).

One aspect of the book made me rethink what I thought I knew about transnational advocacy movements, and his epilogue made me question what scope there is for coordination not only in the UN system but also within the interagency process in the U.S. government.

Who Are the Advocates?

When we think of transnational advocacy movements, our paradigmatic actors are activists, the charismatic leaders of groups leading protests and petitions like Greenpeace, Oxfam, ACT UP, and Doctors Without Borders. However, if you go back to Keck and Sikkink’s foundational book Activists Beyond Borders, you will find that the advocacy networks in their view may also include state actors and representatives of intergovernmental organizations (pg. 9). However, these are the final items six and seven in their list, and in the ten years plus since Keck and Sikkink came out, NGO activists captured the lion’s share of scholarly attention in the literature (This is not a systematic finding but my sense as a reader of that literature).

But when you read Piot’s account of his efforts to help cobble together a broad coalition to fight AIDS, you realize that Piot was an advocate and that those change agents inside governments and international organizations deserve more attention as central figures in transnational campaigns. Piot captured some of the breadth of this movement:

But by the turn of the of the millennium our “brilliant coalition” was taking shape in its diversity and apparent chaos. What could the South African Chamber of Mines, Anglican Church, Community Party, and trades unions have in common with the Treatment Action Campaign, Medecins Sans Frontieres, and UNAIDS? A common goal: defeating the AIDS epidemic and caring for its victims. A powerful joint desire to be a force for change.

The Piots of this world need to take center stage in our analysis, not least because every activist campaign needs countless Piots inside to have their ideas become policy.

Can Organizations Work Together?

In a sense, this book is a coming of age story, of Piot’s transition from medical professional to skilled political operator. So much of what passes for politics in this book is the jostling for position among mid-level careerists in intergovernmental organizations and within countries. UNDP and UNICEF jockey for turf internationally with similar dynamics at play inside countries with the CDC and the NIH having difficulty at times playing nice within the U.S. government.

Among these, Piot comes across as an adult, and for such petty games, Piot has little patience. Nonetheless, he became sufficiently attuned to their inherent part of the game. To survive in this business, he describes his persona as chameleonic (something in common with his UNAIDS successor Michel Sidibe). In an obsessive desire to help those suffering, Piot adopted a healthy, ethical pragmatism and flexibility, of a willingness to work with whoever was needed to get the job the done.

But, his epilogue to the book, leaves me uneasy about the scope and capacity for coordinated action. Even if the financial crisis were not leading to more miserly patterns of foreign aid, the collective response of the international system may be largely unmanageable. Here, Piot wrote of his sense that UNAIDS, the “most advanced” attempt to coordinate various UN agencies to “deliver as one” was fraught:

Over the years I became increasingly skeptical as to whether the current UN coordination governance could ever by effective operationally, despite the goodwill of many, if not most, staff. The two main obstacles for delivering as one UN were the institutional interests of individual agencies — careers, political influence, budgets–and the incoherence and volatility of its member states, which not only had different, sometimes mutually exclusive, interests, but which also lacked internal coherence…

This resonated strongly with me as this week the Obama Administration issued an enigmatic statement suggesting that the much ballyhooed interagency Global Health Initiative would be reconceived/mothballed, leading analysts like Laurie Garrett and Amanda Glassman to parse what went wrong in this grandiose effort to conduct a “whole of government” response.

Here, Piot’s conclusions are ones we should take to heart when we think about global and national governance of development, health, and foreign policy writ large:

My conclusion on UN coordination was that it was a collective failure, and that the international community goes for some bold mergers and acquisitions as the current plethora of organizations is too expensive, or that it accepts that pluralism is a strength, as long as only effective and well-managed institutions are supported and others closed down.

Interestingly, he suggests that setting up institutions outside of the UN system like the Global Fund is “not a solution” as much as he tried to make it a success. Frankly, I’m not sure what to do with that.

Any Regrets?

Aside from the time away from family, Piot’s main regret is whether or not he could have done more to save lives earlier and faster. Here, I’m struck by the other quasi-memoir on HIV/AIDS that also came out this year Tinderbox by journalist Craig Timberg and public health professional David Halperin. In that book, they charge Piot with late attention to male circumcision, a powerful AIDS prevention technology that took too long to gain currency.

Piot at one point, in what might be a veiled reference to the duo, dimisses efforts to identify what prevention strategy worked in Uganda to stem the tide of new infections – was it A (abstinence), was it B (be faithful), or was it C (condoms), writing: “However, some scientists and journalists continue to fuel the debate in a fairly obsessive search for the magic bullet in HIV in prevention…” And to be fair, Halperin has long been obsessive about male circumcision, but as I wrote in a piece for CSIS in 2008, perhaps rightfully so.

Was Piot slow to the uptake on the promise of male circumcision? He praises it as one strategy among many that have taken center stage of late on prevention, but I don’t know the internal history well enough to judge. In general though, I agree with those like Mead Over who see the prevention agenda to have largely been a failure amidst this incredible and important turn to treatment access over the last decade.

But, I would be wary of blaming Piot for that. While one can quibble on the margins with aspects of his service (I think some campaigners would say he was too accommodating of the branded pharmaceuticals companies), Peter Piot clearly has been on the right side of history on HIV/AIDS with remarkable skill, poise, grace, and pragmatism.

Josh Busby

Joshua Busby is a Professor in the LBJ School of Public Affairs at the University of Texas-Austin. From 2021-2023, he served as a Senior Advisor for Climate at the U.S. Department of Defense. His most recent book is States and Nature: The Effects of Climate Change on Security (Cambridge, 2023). He is also the author of Moral Movements and Foreign Policy (Cambridge, 2010) and the co-author, with Ethan Kapstein, of AIDS Drugs for All: Social Movements and Market Transformations (Cambridge, 2013). His main research interests include transnational advocacy and social movements, international security and climate change, global public health and HIV/ AIDS, energy and environmental policy, and U.S. foreign policy.

1 Comment

Clifford Bob on 12 July 2012 at 01.55 EDT

Great review, Josh! Your and Piot’s point that govt officials are advocates is exactly right; often they are the most powerful, especially if they are in domestic institutions. NGOs and others spend lots of time cultivating them and trying to coopt key institutional positions, both national and international. The only thing I’d add, again tooting my own Global Right Wing ‘s horn, is that in many cases there is jockeying for these positions between rival networks, which are fundamentally divided by ideologies, policy goals, “scientific” data, etc, etc. This often makes for nasty tactics, like those in the circumcision debate Piot documents, and for strange bed-fellows, like the Baptist-burqa network of Christians and Muslims opposing gay rights, which I analyze. Scholars have spent far too much time on cooperative strategies, abstract logics, and left-wing networks, neglecting comparable right-wing ones and the divisive strategies all sides use in fighting one another.

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