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.

There are four essential conclusions that can be drawn from the available information about HIV infection among military and police forces. First, in hard-hit parts of the world, these individuals, who are the protectors of stability and security, are increasingly falling victim to AIDS -- as much or more so than the general adult population. As death claims ever more citizens, it will also claim more troops, posing serious problems for law and order a decade from now.

Second, in some areas with high infection rates, especially in the former Soviet Union, militaries and police are finding it hard to identify healthy recruits to replace the ranks of their aging and HIV-infected forces. Third, while many uniformed services are supplying antiretroviral drugs to their command officers in the hope of prolonging their lives, providing these drugs solely to the upper echelons may eventually undermine morale among the rank and file, even leading to mutinies. Such special treatment may also undermine the moral authority of the police and the military among the general population. And even the life-prolonging wonders of antiretroviral drugs may be short-lived, due to the emergence of drug-resistant strains of HIV.

The HIV/AIDS pandemic is also having a major impact on UN peacekeepers. All military personnel stationed with UN operations are by regulation encouraged to undergo voluntary HIV screening. In addition, the UN's roughly 47,000 peacekeepers all receive training about the risks of AIDS, other sexually transmitted diseases, and appropriate behavior with civilian personnel. They also all get a plastic "HIV/AIDS Awareness Card for Peacekeeping Operations" and five or six condoms a week during foreign deployment. Most of the 65,000 peacekeepers perform their work with noble courage and free of HIV risk.

Nevertheless, the UN has recently been rocked by sex-related scandals among peacekeepers in the Democratic Republic of the Congo and elsewhere, and several studies show that troops stationed away from their home countries are at significant risk for acquiring HIV. A Nigerian military survey, for example, has found that the infection rate among soldiers who are based near their wives and homes mirrors that of society at large -- about five percent. But rates among those deployed for peacekeeping operations in Sierra Leone, Liberia, and Côte d'Ivoire are up to three times higher. Nigeria has witnessed a stark increase in noncombat mortality in its military ranks over the last five years, with 43 percent of that surge directly ascribed to HIV.

One counterintuitive effect of warfare, as the recent histories of Angola, Cambodia, Ethiopia, Namibia, Nigeria, South Africa, and Zimbabwe show, is that it can actually reduce the risk of HIV infection. During wartime, civilians either hunker down in their homes or flee war-torn regions and become refugees. Trade grinds to a halt, borders are locked tight, and social mobility is minimized.

Consider Angola, for example. For 27 years, it was wracked by a civil war that left the now-peaceful nation in shambles. War, however, largely kept HIV outside Angola, since most forms of trade and travel, both within the country and across its borders, were essentially shut down for three decades. Since the end of the conflict in 2002, Angola's borders have reopened. Peace has brought greater trade -- but also an increased HIV infection rate.

One critical and horrifying exception to the general dampening effect of warfare on the rate of HIV infection occurs when rape is used as a weapon. A recent study of women who were raped during the 1994 Rwanda genocide shows that today nearly 80 percent of them are HIV positive. Similarly, a survey of pregnant women in parts of northern Uganda where the rebel paramilitary group the Lord's Resistance Army has committed atrocities, including rapes, for two decades finds that female infection rates are double those in the rest of Uganda. About half of the rape victims who survived the Sierra Leone civil war are also infected.

ON THE TRAIL OF THE DISEASE

DNA fingerprinting is proving to be a vital tool in pinpointing how various HIV strains and clades (subgroups) move around the world. Using DNA testing, researchers have proved that the rapidly growing HIV/AIDS epidemic in the former Soviet Union comes from a new strain and is being spread by an infection method -- narcotics injection -- that minimizes the mutation of the virus as it passes from one victim to another. As this evidence suggests, the HIV/AIDS epidemic in the former Soviet Union may well pose security threats to the region, but it is a domestic phenomenon and cannot be ascribed to outside forces.