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.

AIDS PAST AND FUTURE

Trying to imagine the future shape of the HIV/AIDS pandemic, some two or three waves ahead, is exceedingly difficult. Were the global community now engaged in a highly motivated, multibillion-dollar campaign involving ever more tools (including condoms) in the public health kit, coupled with a Manhattan Project-scale effort to discover and develop an effective HIV vaccine, there might be some cause for optimism. But no such programs exist. If no effective vaccine or cure is found within the next 20 years, areas of the world that are now witnessing explosive epidemics or are in their second or third wave of HIV infection may well find themselves harder hit -- and more deeply transformed -- than Europe was by the Black Death. Many of Africa's characteristics today mirror those of preplague Europe, including an enormous surplus of unskilled labor, a lack of clear property rights for the bulk of the population, domination by tiny elites, widespread warfare waged both by state and mercenary forces, and a transition under way from dispersed agrarian to disastrously urbanized societies. Each of these economic, political, and social characteristics of early fourteenth-century Europe was turned upside down by the Black Death. There is no reason to imagine that Africa's modern plague will have any less of an impact, albeit in slow motion.

The introduction of treatment options for HIV/AIDS could both mitigate and exacerbate the changes. Using antiretroviral therapy to treat key leaders and sectors of society -- including armed forces -- will stretch out the intervals between waves of the pandemic in those select populations. This delay will, in turn, give governments a better chance to cope, both at the national and local levels. But inequitable access to medicine is already creating global tension, as governments in poor countries become angry that they cannot afford to give their people life-sparing drugs that are readily available in wealthy countries. If poor and middle-income countries start using external funds to provide life-extending medicines to their elites, they risk creating the same tensions domestically. On the other hand, the survival of certain states may literally depend on their leaders (including military commanders, top politicians, physicians, teachers, and important bureaucrats) getting access to the medicines.

For donor states the best option is to bite the bullet and spend heavily not only on HIV/AIDS prevention, care, and treatment, but also on development aimed at bringing the poor world into the global economy, so that it may eventually derive sufficient wealth to pay for the great expenses involved with coping with HIV/AIDS.

Given the risks to armed forces, police, and UN peacekeepers, international programs aimed at preventing high-risk sexual activities and drug use, as well as those that provide condoms and sterile needles, should be bolstered and financially supported by wealthy nations.

Viral genetic fingerprinting should be used to trace the spread of HIV and identify key national or transnational forces (such as heroin smuggling) associated with its spread. Global security may require spotting dangerous new evolutionary trends in the virus.

The paucity of reliable data regarding the current effects of pandemics on economic and social issues remains a serious concern. Major scientific institutions in North America, Europe, and Japan should fund and promote such science, conducted in collaboration with researchers from hard-hit regions. Longitudinal cohort studies should be created now to track over the coming decades key population groups, such as children orphaned by AIDS, agricultural workers, soldiers, peacekeepers, migrant workers, and miners.

It bears repeating that were extremely aggressive prevention and vaccine research efforts executed and well funded today, they could render the security concerns of tomorrow moot. Sadly, such funding has not been forthcoming. In 2004, total global spending on HIV vaccine development, public and private, was $680 million, $526 million of which came from the U.S. government and $70 million of which came from private corporations and charities. That amounted to just one percent of total spending on HIV-related programs.

In the aftermath of September 11, 2001, the United States tends to define all national security concerns through the prism of terrorism. That framework is overly limited even for the United States, and an absurdly narrow template to apply to the security of most other countries. The HIV/AIDS pandemic is aggravating a laundry list of underlying tensions in developing, declining, and failed states. As the burden of death due to HIV/AIDS skyrockets around the world over the next five to ten years, the disease may well play a more profound role on the security stage of many nations, and present the wealthy world with a challenge the likes of which it has never experienced. How countries, rich and poor, frame HIV/AIDS within their national security debates today may well determine how well they respond to the massive grief, demographic destruction, and security threats that the pandemic will present tomorrow.