The Lessons of HIV/AIDS

Laurie Garrett. Foreign Affairs. Volume 84, Issue 4. July/August 2005.

Security at Stake

If the deadly bird flu discussed in the previous three essays were ever to sweep across the world, the impact on national security would be obvious everywhere. Nations rich and poor would quickly recognize the vulnerabilities of their citizens, economies, public health systems, and armed forces.

But what about the security implications of an existing pandemic, HIV/AIDS, the full impact of which is taking years to be felt? When the disease first struck, few leaders of the hardest-hit countries in sub-Saharan Africa acknowledged the links between HIV/AIDS, social stability, and national security. It took many of them two decades to face facts, and by then HIV/AIDS had spread through their populations and killed large numbers. Nor was such myopia limited to Africa; it was prevalent in developed countries as well. The resulting delays have caused millions of deaths around the world.

Were the Asian bird flu to start infecting humans, the death toll would rise even more quickly. Preparation is therefore critical. Unfortunately, the example of the HIV/AIDS pandemic is not reassuring. Adequate resources for combating the disease have yet to be marshaled, even though the potential for it to cause destabilization has now been recognized at the international level. In 2000, the UN Security Council issued Resolution 1308, warning that the HIV/AIDS pandemic, if unchecked, could threaten world stability and security. Five years after its passage, the resolution will be formally reviewed this July.

AIDS has killed at least 26 million people, orphaning more than 12 million children, and today the virus afflicts 40 million people directly. Although the illness was first officially recognized in the United States in 1981, it has raged in the Great Lakes region of Africa since the 1970s. And yet policymakers still lack sufficient data, computer modeling, and empirical analyses of the disease for effective guidance on prevention and treatment. As a result, the pandemic’s impact on economic activity, agricultural practices, childhood development, and the credibility of political leaders is still poorly understood. Too little is known about its effects on businesses in hard-hit countries, which lose upward of three percent of their labor forces to the virus every year. Even less is known about infection rates in most police and armed forces.

Nevertheless, three crucial points have become clear. First, HIV/AIDS is the most complex disease humanity has ever faced and presents it with unprecedented challenges of research and analysis. Second, new threats to stability and security may emerge as the pandemic escalates. Third, a well-conceived campaign to curtail the virus, particularly through development of an effective HIV vaccine, could short-circuit the attendant security concerns. Such a campaign would be achievable. But it has yet to be undertaken.

Death in Slow Motion

Unlike the massive pandemics of the past, such as the Black Death or the influenza outbreak of 1918-19, HIV/AIDS inflicts death very slowly. For three decades, the current pandemic has created waves of infection, followed years later by waves of acute disease, and years after that by waves of death and family disruption. In the prior two megaplagues, the periods between infection, illness, and death and family disruption were days to weeks. Entire societies experienced the shock simultaneously, grieved in unison, and witnessed the impact on the society and state as one.

In the case of HIV/AIDS, however, the intervals between these waves have lasted up to 14 years, and the waves themselves have been staggered, with the progression of infection and illness varying from person to person and region to region. Successive high-amplitude waves have swept over sub-Saharan Africa for up to four human generations. On the other hand, low-amplitude waves have gone almost unnoticed for ten years or more in India, Indonesia, Russia, Southeast Asia, and Ukraine. Only now are these areas experiencing large-scale infection. Illness, death, and the mass creation of orphans are still ahead.

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.

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 Cte 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.

In contrast, molecular evidence paints a very different picture for Asia, where several different clades (and unique recombinations of those clades) are now circulating in the area that spans from eastern India to southern Vietnam. Several research teams have proved that these various HIV clades can be tracked along four major routes, all originating in Myanmar. One type can be traced to a route that runs from the forest regions of eastern Myanmar into Yunnan, China. A second strain has followed the same route, and then continued up to Xinjiang, China. A third runs through Laos, into northern Vietnam, and then into Guangxi, China. And a fourth travels from western Myanmar to Manipur, India.

Surveys conducted at significant risk inside Myanmar—a weak state governed by a corrupt junta; riven by civil war; beset by rival gangs of drug, gem, and sex-slave smugglers; and one of the world’s top opium producers—show that the various types of HIV are concentrated in key population groups in the country. The highest infection rates are found among prostitutes, who account for about half of all those infected, and among heroin users, who suffer from infection rates as high as 77 percent in the country’s north. HIV cases and specific HIV subtypes cluster in poppy-growing regions and then travel along heroin-smuggling routes across Asia. This evidence suggests that Myanmar may be the greatest contributor of new types of HIV in the world. In fact, there has been only one outbreak of HIV in Central Asia that seems to have originated anywhere else.

Africa’s epidemic is much more difficult to track genetically than Asia’s because it is much older and involves enormously diverse strains of the pathogen. Most perplexing is the situation in Congo, where war has raged for years, engaging military forces from all over the continent and peacekeepers from all over the world. Scientists find the area too dangerous to work in, making it almost impossible to gather samples of the HIV strains there. What evidence is available, however, suggests that Congo has become a mixing pot for HIV, with dozens of unique forms of the virus circulating in the vast nation.

As the case of Congo illustrates, the use of genetics as a form of verification or to track the spread of HIV is currently limited by the way blood samples are collected. Most sampling around the world is performed by scientists seeking to answer questions unrelated to HIV, and genetic studies on those samples are usually conducted by still another group of experts. Funding should be made available to support the targeted collection and analysis of samples. Scientists engaged in such efforts would need protection, such as that currently provided for UN weapons inspectors, as the regions most likely responsible for promulgating and spreading new forms of HIV tend to be among the world’s most dangerous.

Funding such efforts would have an enormous benefit: it would help scientists understand the overall evolution of HIV. The virus mutates at a very high rate, and since its appearance in human beings several decades ago, HIV has burst out into many genetic branches. At the moment, no scientist can say where this evolution is headed or what new attributes the virus might one day acquire. Studying the virus’ evolution could help answer those questions.

AIDS and Politics

The most obvious political dimension of the security threat caused by HIV/AIDS is the risk that it will claim the lives of national leaders, as parliamentarians, cabinet members, ministers, and the military become infected and die. Until now, such deaths have generally gone unacknowledged: the deceased are listed as victims of tuberculosis, “prolonged illness,” or other less stigmatizing problems. To date, the death of not one head of state has officially been designated an AIDS death. Nevertheless, the illness has taken its toll, depriving many nations of seasoned leaders and institutional experience. For example, between 1964 and 1984, Zambia held 14 by-elections to replace incumbents who had died in office. In 1984, the country officially acknowledged its first AIDS case, and between that time and 2003, the number of by-elections soared to 102. Of this total, 29 were due to the death of the incumbent. Each of these special elections represented a loss of political experience and came at enormous monetary expense to the government. The Institute for Democracy in South Africa has published long lists of similar figures for countries all over sub-Saharan Africa.

The ranks of Africa’s civil servants are also being thinned by the pandemic, rendering some previously weak bureaucracies only marginally functional. In areas with the highest HIV infection rates, even those government workers who survive often miss work due to the exigencies of caring for relatives or rearing the children of deceased family members. The UN AIDS program has documented the steady erosion of key civil-service sectors in sub-Saharan Africa. Teachers, hospital workers, and financial-sector employees have been the hardest hit.

As serious as these problems are, the most profound challenge to state stability caused by HIV/AIDS will be the death toll among men and women aged 20-50 years, who are workers, parents, leaders, and trained professionals. Already, AIDS is distorting the populations of some countries, where the older, dependent population remains comparatively intact and children and adolescents are coming to radically outnumber adults. Throughout much of sub-Saharan Africa, life expectancy has dropped precipitously.

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.

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.