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.

For India, the model suggests that GNP absent HIV would be almost 170 percent higher in 2025 than in 2000 -- with growth driven both by a larger work force and by increasing worker productivity. Under the mild epidemic scenario, GNP would still rise substantially -- but by about a third less over that quarter-century than the "no AIDS" baseline would have predicted. If there was an intermediate epidemic, predicted GNP in 2025 would be 40 percent lower than in the baseline scenario; national output would still grow, but growth would be cut by three-fourths over the next 25 years.

As for China, health-based predictions of economic output suggest relatively modest output growth of 80 percent between 2000 and 2025. The mild epidemic scenario would be predicted to cut that growth by more than a third; an intermediate epidemic, by much more. The more pessimistic scenarios would suggest even more dramatic economic repercussions for the Chinese economy.

Health-based predictions of future economic output are admittedly an overly simplistic measure for assessing the prospective performance of extraordinarily complex societies. Even so, health and wealth are closely connected in the modern world. To the extent that HIV/AIDS compromises national health prospects, it also compromises economic potential.

A GATHERING STORM

In the decades ahead, the likelihood of HIV breakout into the general population in Eurasia will depend on the extent to which local Eurasian populations can avoid replicating the risk factors that led to such a breakout in sub-Saharan Africa. Fortunately, Eurasia enjoys some ecological protections that sub-Saharan Africa lacks. Nutrition in India, China, and Russia is generally superior to that in sub-Saharan states, and the burden of endemic disease is also distinctly lower. With respect to behavioral risks, we know very much less about the situation in China, India, and Russia than we would like. Sexual transmission patterns, the prevalence of risky sexual practices, and the extent of other dangerous practices (such as iv drug use) will do much to determine the future trajectory of the HIV/AIDS epidemic in these three countries. Amazingly, neither local nor international health studies have examined in any sustained manner these potentially deadly risk factors.

Despite the limits of our knowledge, available information suggests that major HIV epidemics are already underway in China, India, and Russia, and that local social mores and behavioral practices are set to further spread the disease. The precise trajectory that HIV/AIDS will follow in these three countries cannot be foretold at this time. But as the hypothetical scenarios show, even fairly mild epidemics (by sub-Saharan standards) could have a tremendous impact on long-term health and mortality trends in all of these countries. Indeed, China, India, and Russia together could experience more HIV infections and AIDS deaths over the coming quarter-century than the entire planet has thus far.

From a purely ecological standpoint (that is, focusing on nutrition and endemic disease), India probably stands a greater risk today than either Russia or China for an HIV/AIDS breakout. Yet in the simulations, the country whose economic prospects seemed most threatened by the disease was Russia. Two factors largely account for this result: the country's poor health performance, entirely irrespective of HIV, and, relatedly, the country's prospect for long-term population decline. In HIV/AIDS scenarios well within the realm of current informed expectations, Russia's economy 25 years hence might be no larger than it is today. In a world characterized by general economic growth, such a result would only increase Russia's marginalization both within the world economy and on the world stage.

But Russia's limited future economic prospects seem to be established already by a host of other factors that have nothing to do with HIV. From a geopolitical standpoint, then, the most pertinent question is whether the unfolding HIV/AIDS epidemics in China and India will be sufficiently powerful to alter the future economic or political balance between these two rising and ambitious states. To judge by these simulations, it is possible that HIV/AIDS could play such a role in the years ahead -- and again, relying on these simulations, the balance of risks presently appears to weigh more heavily against India than against China.

On the other hand, and somewhat paradoxically, China may have more difficulty mounting an effective response to an emerging HIV crisis than would either Russia or India. The reasons have to do with constraints on anti-HIV/AIDS policies in China. In contemporary Eurasia, perhaps the most successful HIV-control campaign thus far has been Thailand's. The Thai campaign relied on cooperation between the government and civil society to educate the public about HIV and to intervene with high-risk groups. Analyses of the program by the World Bank and other groups have stressed the value of civil-society participation, as well as the importance of popular trust in the government in lending credibility to the state's massive public education effort. Whether China could replicate Thailand's approach is by no means clear. A public health campaign premised on the independence of nonstate actors and the population's confidence in its government could be rather more difficult for Beijing.

Even without these constraints, the prospects of a Thai-style campaign doing much for Russia or India still look grim. When Thailand inaugurated its muscular anti-HIV campaign, adult HIV prevalence was lower there than it is today in Russia and India. And even after Thailand's policies went into effect, the estimated number of HIV carriers more than doubled over the subsequent decade -- the grim arithmetic of the disease being that newly diagnosed infections will add to the patient pool for some time, even if an effective program is diminishing the stream of newcomers.