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.

Nicholas Eberstadt, of the American Enterprise Institute, argues that declining life expectancy constitutes the single most important threat to the security of hard-hit countries, as it will lead to diminishing state capacity. According to the U.S. Census Bureau, 40 nations will have declining life expectancies by 2010, and in 35 of them, HIV/AIDS will be the primary cause (25 of these countries are in sub-Saharan Africa). Eight Caribbean nations and seven former Soviet states will also see their life expectancies drop compared to 1990 levels, and some of the declines will be due to HIV/AIDS. It may not always be possible to tease out the impact of AIDS from the toll inflicted by its frequent companions, such as tuberculosis, malaria, and poverty. But it is noteworthy that the key reversals in life expectancy seen in Africa started between 1985 and 1990, when the first great wave of AIDS deaths swept through the region. In Malawi, by 2000 life expectancy had fallen to the country's 1969 level, essentially reversing 30 years of development investment. Life expectancy in Botswana dropped by 30 years between 1990 and 2002 -- a decline that is unprecedented in known human history.

Most of the countries now hit hardest by HIV/AIDS already had "youth bulges" before the virus arrived, meaning that a disproportionate percentage of their populations were under 29 years of age. HIV/AIDS is now exaggerating these bulges, with the greatest percentage increases appearing in the adolescent population. In 1975, only 17 countries in the world had youth bulges so severe that more than half of their population fell in the 15-29 age bracket. Today, 37 countries belong to that category, nearly all of them in sub-Saharan Africa. Several studies show that countries that had such radically large youth bulges in the period between 1990 and 2000 were three times more likely to suffer civil wars, coups, or armed insurrections.

In general, the presence of three key population problems in a given country indicate a likelihood of instability: a youth bulge, rapidly rising population concentrations in underdeveloped cities, and poor crop or fresh-water production. Fortunately, in many countries, all three of these factors are subsiding, thanks to economic improvements and the strengthening of civil society. But in the poorest parts of the world, they are becoming increasingly pronounced, with dangerous consequences.

That HIV/AIDS is hitting hardest precisely those areas most afflicted by dire poverty may make it impossible to observe direct disease impacts on most local and regional economies. Nevertheless, the pandemic is pouring salt on economic wounds and exacerbating already widening chasms in wealth and food security, and this process will only get worse in the future. The presence of HIV/AIDS also dissuades outside investment, as few companies are interested in building operations in a region where labor productivity and costs are so dramatically affected by disease and death.

RICH VERSUS POOR

Widening gaps in access to anti-HIV drugs are creating glaring differences between the life expectancies of infected Americans and victims in the rest of the world. Resentment is building in both middle-income and poor nations, as the wealthiest nine countries become gerontocracies, while the poorest nations witness the evaporation of previous development gains, rising foreign debts, and increased mortality rates.

In his 2002 State of the Union address, President George W. Bush called for a $15 billion program to combat HIV/AIDS, largely on a bilateral basis, in 14 countries. Known as PEPFAR (the President's Emergency Plan for AIDS Relief), the program eventually added a 15th country (Vietnam) to its list of targets. As of March 2005, PEPFAR had spent only three percent of its funds, providing treatment to 155,000 people worldwide. The program plans to treat 200,000 people by June 2005. PEPFAR has also provided supportive (that is, nonmedical) care to 1.7 million people affected by the epidemic, including 630,000 orphans. As currently conceived, PEPFAR will treat 2 million people by the end of 2008 and provide other types of care to another 10 million. No other nation has mounted an HIV/AIDS campaign of this scale, though many have contributed to the UN's Global Fund to Fight AIDS, Tuberculosis, and Malaria, which sponsors treatment and prevention campaigns worldwide that rival the scale of the U.S. effort.

In 2004, the appropriations bill allocating money for PEPFAR stipulated that a third of the prevention and education funds had to be spent on abstinence-promoting programs, that none of the money could be spent buying sterile syringes or needles for intravenous drug users, and that faith-based organizations should receive special priority in the receipt of care and treatment funds. A more recent White House stipulation has required recipient countries and organizations to denounce prostitution. All of these restrictions have proved enormously controversial, both inside the United States and overseas. Brazil, for example, recently rejected U.S. support on the grounds that it would not be possible to promote safer sexual practices among prostitutes and their clients while morally castigating them. As a result of such strictures, PEPFAR is hardly winning many hearts and minds. Perceptions will likely improve, however, if Congress continues funding the program and U.S.-backed treatment becomes far more available and visible.