The Future of AIDS

Nicholas Eberstadt

From Foreign Affairs, November/December 2002

Summary:  In the decades ahead, the center of the global HIV/AIDS pandemic is set to shift from Africa to Eurasia. The death toll in that region's three pivotal countries--Russia, India, and China--could be staggering. This will assuredly be a humanitarian tragedy, but it will be much more than that. The disease will alter the economic potential of the region's major states and the global balance of power. Moscow, New Delhi, and Beijing could take steps to mitigate the disaster--but so far they have not.

Nicholas Eberstadt holds the Henry Wendt Chair in Political Economy at the American Enterprise Institute and is Senior Adviser to the National Bureau of Asian Research. This essay draws on a longer study prepared with the assistance of Lisa Howie; for more detailed results see www.AEI.org/scholars/eberstadt.htm.

GRIM TOLL IN RUSSIA, INDIA, AND CHINA

HIV/AIDS is a disease at once amazingly virulent and shockingly new. Only a generation ago, it lay undetected. Yet in the past two decades, by the reckoning of the Joint UN Programme on HIV/AIDS (UNAIDS), about 65 million people have contracted the illness, and perhaps 25 million of them have already died. The affliction is almost invariably lethal: scientists do not consider a cure to be even on the horizon. For now, it looks as if AIDS could end up as the coming century's top infectious killer.

At present, the HIV/AIDS pandemic, though global, is overwhelmingly concentrated in sub-Saharan Africa. Although this situation has exacted a terrible human cost, the rest of the world has been largely unaffected by Africa's tragedy. Things will be very different, however, in the next major area of HIV infection. Eurasia (which for the purposes of this essay is considered to be the territory encompassing the continent of Asia, plus Russia) will likely be home to the largest number of HIV victims in the decades ahead. Driven by the spread of the disease in the region's three largest countries -- China, India, and Russia -- the coming Eurasian pandemic threatens to derail the economic prospects of billions and alter the global military balance. And although the devastating costs of HIV/AIDS are clear, it is unclear that much will be done to head off the looming catastrophe.

WORLDS APART

Today HIV/AIDS is decimating sub-Saharan Africa. According to UNAIDS, as of late 2001 more than 28 million of the world's roughly 40 million HIV carriers lived in that region, and about 9 percent of all sub-Saharan inhabitants between the ages of 15 and 49 were HIV carriers. (In parts of the continent, the rate is far higher: adult infection exceeded 30 percent in four countries last year, and in Botswana it was near an almost unimaginable 40 percent.) UNAIDS' best guesses put AIDS-related mortality in sub-Saharan states at over two million in 2001 -- suggesting that the disease accounted for every fifth death. So far perhaps 20 million sub-Saharan people have perished in the pandemic.

Africa's AIDS catastrophe is a humanitarian disaster of world historic proportions, yet the economic and political reverberations from this crisis have been remarkably muted outside the continent itself. The explanation for this awful dissonance lies in the region's marginal status in global economics and politics. By many measures, for example, sub-Saharan Africa's contribution to the world economy is less than Switzerland's. In military affairs, no regional state, save perhaps South Africa, has the capacity to conduct overseas combat operations, and indeed sub-Saharan governments are primarily preoccupied with local troubles. The states of the region are thus not well positioned to influence events much beyond their own borders under any circumstances, good or ill -- and the cruel consequence is that the world pays them little attention.

Circumstances are rather different in the world's other area of rapidly spreading HIV infection. Eurasia is home to the great majority of the world's population; five out of every eight people on the planet live there. It has substantial economic weight -- its combined GNP in 2000 of $15 trillion exceeded that of either the United States or Europe. Militarily, it is home to four out of five of the world's million-strong armies, and four of the seven declared nuclear states. Thus, unlike in sub-Saharan Africa, unexpected shocks there -- such as the unfolding HIV/AIDS epidemic -- will have major worldwide repercussions.

In absolute terms, HIV/AIDS is already firmly established in Eurasia. According to conventional estimates, more than 7 million of the region's inhabitants were HIV carriers in 2001. And according to those same official estimates, it took less than a decade for sub-Saharan Africa's HIV population to leap from 7 million to 25 million.

It must be emphasized that there is currently no reliable method for accurately forecasting the long-term trajectory of the HIV/AIDS pandemic. Nevertheless, the prospect of tens of millions of Eurasian HIV cases -- and AIDS deaths -- in the decades ahead is by no means fanciful. To the contrary, absent a cure or a vaccine, it is quite possible that the center of the global HIV/AIDS crisis, in terms of absolute numbers, will shift from Africa to Eurasia over the coming generation.

Despite uncertainty about the future direction of the disease, a number of basic facts are already clear. First, even without approaching the infection rate of sub-Saharan Africa, HIV/AIDS is poised to exact a staggering human toll over the next quarter-century in the region's three pivotal countries -- Russia, India, and China. Second, the economic costs of the disease in these three countries will be vastly larger than they have been in sub-Saharan Africa. Finally, given how the disease spreads, some key Eurasian populations will be harder hit than others -- and some regional governments will prove less competent than their neighbors (and competitors) in handling the crisis that ensues.