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.

On an annual basis, the numbers are equally astonishing. According to UNAIDS, the current annual aggregate death total from AIDS is about 3 million people per year. By comparison, the mild epidemic scenario suggests that Russia, India, and China would suffer a collective total of nearly 1.7 million deaths a year in 2010, and 2.3 million by 2015. In an intermediate-epidemic family of scenarios, deaths would top 3 million in 2010 and would approach 6 million in 2025.

New AIDS cases. In every scenario considered here, Russia, India, and China would each have to contend with massive numbers of new AIDS cases in the decade 2010-20. That result follows simply from the long incubation period between HIV infection and the onset of AIDS, and the large number of HIV carriers that each country is projected to accumulate between 2000 and 2015. The discussion also presumes that a cure for AIDS will not be found during this time frame.

The model's illustrative calculations, for example, suggest that China experienced "only" 30,000 new AIDS cases in 2000. By 2015, assuming just a mild epidemic, new AIDS cases in China erupt at a pace of nearly 100,000 per month. In India, the projected numbers are equally shocking. In 2000, according to these estimates, India was facing a significant burden of 100,000 new cases of AIDS a year. But even under a mild epidemic, the total would exceed one million a year in 2015, and would rise still higher for every year between 2015 and 2025 (see Table 3).

Population changes. The HIV/AIDS epidemics modeled here could significantly alter population dynamics in these Eurasian countries and might substantially reduce the future size of certain economically important population cohorts. Under the milder epidemic, for instance, the aggregate populations of India, China, and Russia would be almost 90 million lower in 2025 than Census Bureau projections (the baseline) currently anticipate (see Table 4). Worse, the cohort often labeled the "economically active" population -- persons 15 to 64 years of age -- would be about 44 million fewer than currently projected (see Table 5). Under less optimistic scenarios, the demographic impact is correspondingly greater.

In these projections, Russia is hit especially hard demographically. This trend occurs not simply because the model posits somewhat higher HIV rates for Russia than for India or China but also because Russia's population is projected to decline over the coming quarter-century -- even in the absence of any worsening of its HIV crisis. Under the conditions of even a mild epidemic, however, that decline is projected to accelerate dramatically.

Reduced life expectancy. Finally, and in some ways most portentous, all of the scenarios point to either a stagnation or a reduction in national health levels as reflected by life expectancy at birth. This decline is an inescapable arithmetic consequence of the expected surge in mortality. In many ways, the future looks bleakest for Russia. For instance, under the severe epidemic scenario, Russian life expectancy would be a full decade lower a generation hence than it is today. The projections for China and India, although not as dramatic, are still deeply troubling (see Table 6).

This modeling exercise can be faulted in a number of respects -- modeling exercises always can. What these separate scenarios commonly highlight, however, is this: reasonable, historically grounded assumptions about the future course of HIV/AIDS suggest the real possibility, and perhaps even the likelihood, of an unprecedented cost in human lives for Russia, India, and China in the years just ahead.

THE ECONOMIC CONSEQUENCES OF THE DISEASE

Eurasia's HIV/AIDS epidemic will clearly have far-reaching economic ramifications in the coming decades. The number of dead, to begin with, threatens to be absolutely enormous. Furthermore, AIDS typically does not kill its victims immediately but subjects them to a prolonged period of gradually mounting debility and incapacity. This is a period, often extending for years, during which the victim's needs grow while his or her own ability to attend to them steadily diminishes. And AIDS does not kill randomly but instead tends to strike people in their prime reproductive ages -- years that coincide in most populations with the highest rates of labor productivity. Given this combination of factors, what sort of impact can we expect an HIV/AIDS epidemic to inflict on the economies of Russia, India, and China?

This question has received surprisingly little rigorous consideration. Two decades into the epidemic, the state of economic thinking about this complex set of interactions can still be described fairly as introductory and exploratory. The emerging economic literature on the subject has identified some of the potential macroeconomic repercussions of AIDS-related illness and death. Population growth, labor supply, and savings rates all will be hurt -- indeed the more comprehensive the framework employed, the more negative the conclusions seem to be.