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.

HIV is currently transmitted in China by three main routes: extramarital heterosexual intercourse (abetted by the ongoing expansion of China's commercial sex business), illicit iv drug use, and the sale of unsafe blood. This latter factor is in many respects particular to China and reflects the realities of China's ongoing economic transition. With the demise of the rural commune system and the attendant disintegration of public health care in the Chinese countryside, both patients and doctors needed new means of financing rural health care. One such method was the sale of blood or plasma by impoverished farmers to pharmaceutical concerns, clinics, or unregulated agents called "blood heads." These transactions typically took place without the benefit of fresh, disposable needles. Officially encouraged through the early 1990s, this trade in blood was outlawed in 1998 -- yet it still continues.

The Chinese HIV epidemic appears to be predominantly heterosexual in nature, and the risk of HIV infection is disproportionately high among the rural poor. High-risk subpopulations include IV drug users, buyers and sellers of blood, and commercial sex workers. Larger at-risk groups may include the so-called floating population (the more than 100 million migrants from rural areas seeking opportunity on the fringes of Chinese urban life) and the "unmarriageable males" (the rising number of young men in China who, due to the country's growing gender imbalance, have no realistic prospect of finding a bride). Although epidemiological data on HIV risk factors for China are spotty, there is also no doubt that behavioral mores are rapidly changing. One telling indication is that between 1985 and 2001 the registered incidence of sexually transmitted infections in China soared by more than a hundredfold.

Until very recently, Beijing's response to the mounting HIV crisis was, at best, peripheral. Despite many warnings from public health experts, China's political leaders seem to be in denial. In September 2002, news reports revealed that the Chinese Communist Party's Central Committee had ordered a study of the nation's HIV situation (apparently the first ever such study initiated by the government). This past summer the Chinese government also began cooperation with the U.S. National Institutes of Health to monitor the epidemic. But open discussion of HIV in China is still not officially permitted. In particular, the issue of HIV-tainted blood remains taboo -- perhaps because of the regime's arguable complicity in the gathering tragedy. Research on the blood problem continues to be discouraged; activists who bring the problem up continue to be jailed. Unfortunately for the government, an epidemic cannot be censored -- and unfortunately for China, suppressing information about HIV/AIDS only makes matters worse.

THE BOTTOM LINE

For all the shortcomings of available information about HIV in Eurasia, several facts are clear.

First, regardless of the sources one prefers, enormous numbers of people are already infected with HIV in Russia, India, and China. If one trusts UNAIDS estimates, the total for the three countries already exceeds 5.5 million; if one prefers the U.S. intelligence community's statistics, the collective figure may be as high as 12 million.

Second, in each of these countries the continued rapid transmission of HIV is assured and is poised to "break out" into the general population. Russia and China in particular seem to have special potential "epidemiological pumps" for exposing broad segments of their populations to HIV risk -- in the former, the national prison system, and in the latter, the prevalence of HIV-tainted blood transfusions combined with the newfound mobility of the rural poor.

Finally, none of the governments in question has pursued effective public health measures to prevent the spread of HIV. To the contrary, each of these governments has taken at best a halfhearted approach to stemming the HIV epidemic. Taken together, these facts strongly suggest that the HIV/AIDS crises in Russia, India, and China are only just beginning. But how far will these crises go -- and what will be their economic and political consequences?

In seeking to predict the future course of HIV/AIDS, there is much we still do not know or understand. Although scientists have exhaustively analyzed the genetic makeup of the virus, the public health community knows far less about its spread -- the very human demographic, sociological, and behavioral factors that account for its grim progress through the world. Indeed, as The New York Times medical correspondent Lawrence Altman M.D. noted in early 2001, "HIV's toll has vastly exceeded the most pessimistic report issued earlier in the epidemic, and the misjudgment largely reflects gaps in knowledge about HIV and AIDS." For now, modeling the future of the HIV pandemic is at least as much art as science; intuition counts no less than technique.

To consider what may yet happen in Eurasia, we need to be able to explain what has already befallen sub-Saharan Africa. Twenty million deaths into Africa's AIDS catastrophe, the medical and public health literature remains curiously vague -- even euphemistic -- about exactly how HIV spread so fearsomely fast through the region. In broadest outline, however, Africa's HIV disaster is evidently due to a collision between ecological risks (prevalent malnutrition and a heavy preexisting burden of infectious diseases, both of which impair the body's ability to fight disease) and behavioral risk (more specifically, sexual transmission patterns and specific sexual practices that raise the odds of contagion).