The Lessons of HIV/AIDS

Laurie Garrett

From Foreign Affairs, July/August 2005

Summary:  To get a sense of the broader damage a new pandemic might do, it helps to consider the one the world is currently enduring: HIV/AIDS. Because this deadly scourge moves slowly, many of its social, political, and economic effects have yet to be understood. But the impact is hard to overstate. And it is growing.

Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations. This essay partly results from meetings convened by the council in collaboration with the Joint UN Programme on HIV/AIDS.

Even within Africa, the timing of HIV/AIDS and its impact have varied. The Great Lakes region has been suffering for 35 years now, long enough that every facet of society there has been reshaped. On the other hand, Botswana, Malawi, Swaziland, and most of western Africa are now in a third generation of low-amplitude waves. South Africa, Namibia, and Angola have yet to experience the full death tolls of their first, rapidly rising wave of infection.

Around the world, affected societies have begun to adapt to the changes wrought by AIDS to varying degrees: extended families have started absorbing orphans, communities have begun altering farming practices, and governments have started increasing their health spending. Thailand, for example, has successfully adopted effective containment measures (such as massive condom distribution and public education) that have brought the epidemic under a remarkable degree of control, both in the country's military and its civilian population. Uganda, conversely, may be backsliding after what seemed like early progress against the disease. Ugandan scientists warn that the apparent downward trend in HIV/AIDS there may merely be a hiatus in the epidemic, caused not by an effective AIDS-control campaign but by the wholesale death of the infected adult population; April 2005 data show that adult infection rates are indeed climbing. If these analysts are correct, Uganda could experience yet another round of infection, disease, and death when today's youth become sexually active adults.

The long shock waves caused by AIDS, moreover, are washing over many countries that are simultaneously being swamped by other diseases -- malaria, tuberculosis, childhood dysentery, gonorrhea, antibiotic-resistant bacterial infections, and newly emerging infections such as severe acute respiratory syndrome (SARS) and the Marburg virus. Many of these countries also suffer from other problems that impede economic development and cause social disruption, such as military conflict and social unrest. It is therefore extremely difficult to predict how HIV/AIDS will affect these states and their societies, economies, cultures, and politics. The full impact may not be known for a generation, and the results will vary around the planet. The Joint UN Programme on HIV/AIDS and the Shell Corporation have attempted to model the pandemic's future, and their forecasts are gloomy. And even these predictions depend on government actions that may not be taken.

Politicians are usually shortsighted, and those making HIV/AIDS policy have proved to be no exception. To date, no HIV/AIDS policy enacted by any government or by the UN addresses more than one HIV/AIDS wave's worth of activity, and most epidemic policies have only been implemented in reaction to specific instances of public outcry. Few political leaders and officials recognize that current anti-HIV/AIDS drugs are not curative and, to fend off death, must be taken daily for the rest of a patient's life. The World Health Organization, in a program funded by rich nations, intends by year's end to equip a modest three million people in poor countries with antiretroviral drugs. But to be effective, the program must last for many years rather than be a one-time expense. If wealthy donors cut off their assistance, few poor countries will be able to pick up the treatment costs on their own. A massive wave of death would ensue, as the rich world turned off the life support system of all three million people.

MILITARY MATTERS

When assessing the effects of HIV/AIDS on most military and police forces, two factors stand out. First, infection among uniformed personnel has risen sharply. Second, the rate of infection in most countries' forces is at least as high as it is among their civilians. In Russia, the HIV/AIDS rate among potential 18-year-old draftees has shot up 25-fold since 1999. The annual new infection rate for HIV in Russia's military forces has also risen sharply, climbing from about 0.1 cases per 100,000 soldiers in 1995 to nearly 40 per 100,000 in 2003. In both 2002 and 2003, about 5,000 conscripts -- or about a third of all young men drafted -- were rejected for military service for health reasons that included, chiefly, HIV/AIDS, tuberculosis, drug addiction, and "psychological problems."

Murray Feshbach, a noted demographer at the Woodrow Wilson International Center for Scholars, has written that Russia will find it increasingly difficult to staff its army as illness claims more of its youth and its overall population shrinks. Feshbach sees similar trends in the armed forces of Ukraine, the Baltic states, and possibly Belarus and Moldova as well. The HIV/AIDS and tuberculosis epidemics in these countries are spiraling out of control, probably growing faster than anywhere else in the world.

This is not to say that HIV infection among police and armed forces elsewhere is not also a grave problem. Troop strength in Malawi, for example, has already reportedly fallen to 50 percent of the minimum capacity needed to guarantee state security. In 2004, the Zimbabwe Ministry of Defense admitted that the military's HIV infection rate was about 3 percent higher than that of Zimbabwe's civilian society, which was then just above 26 percent. In Mozambique, police recruits cannot be trained fast enough to replace those dying of AIDS. High HIV infection rates have impeded South Africa's attempts to transform its previously all-white military command into one that more closely mirrors South African society. In Ethiopia, a 2004 test of police officers' wives found that nearly a third of them were HIV positive. Nothing is publicly known about the HIV rates within the world's two largest military forces: China's 2.5 million-strong People's Liberation Army, and India's 1.33 million-member defense forces. Nor is much known about the levels of infection in the rest of Asia's military and police forces. In May, however, India's minister of defense stated that AIDS was the fifth-leading cause of death for his nation's armed forces.

Dead recruits and infantry troops tend to be easy to replace. A general or top technical officer, however, often represents decades of training and acquired experience. Around the world, many militaries are quietly putting their infected commanders on antiretroviral medicines, in hopes of buying time to train their replacements. U.S. military experience reveals the wisdom of this move, as HIV/AIDS-related death rates among infected U.S. armed forces plummeted from 40 percent during the period from 1985 to 2001 to just 1.4 percent since 2001, thanks largely to such treatment. Brazil's experience, however, offers a stark counterpoint. Brazil, like the United States, has also used antiretroviral drugs to treat the estimated one percent of its uniformed personnel who are HIV positive. But the Brazilian officers and enlisted men treated have grown steadily more resistant to the drugs, with some 86 percent of affected personnel now reporting resistance to at least one of the powerful protease-inhibitor drugs used to hold the virus at bay.