Text: AIDS May Be Most Serious Health Threat in Recorded History

12 January 2001

Text: AIDS May Be Most Serious Health Threat in Recorded History

U.S. official discusses pandemic

"There is a strong case to be made that AIDS is the most serious health threat in recorded history," says a senior U.S. intelligence official. The disease, he noted, now stands as the number one cause of death in Africa and the fourth globally.

David F. Gordon, the national intelligence officer for economics and global issues with the U.S. National Intelligence Council, spoke at a January 11 meeting of Africa chiefs of mission in Nairobi, Kenya. Gordon, a former congressional staff member, helped work on a "National Intelligence Estimate" of global infectious diseases and their impact on the United States that was recently sent to President Clinton and other top government officials.

The AIDS pandemic, Gordon warned, "has already killed more people than all the soldiers killed in the major wars of the last century, and exceeds the toll taken by the bubonic plague in 1347. ...

"The bad news," he added, "is that we probably are still only in the early phases of the AIDS pandemic."

Since the beginning of the pandemic two decades ago, 17.2 million Africans have died from AIDS, Gordon said, and 2.6 million Africans died of the disease in 2000, which is more than 10 times the number of people who died during that year in all of Africa's conflicts combined.

Gordon termed AIDS a "gateway disease." By attacking the immune system, he said, it spurs on other killer diseases such as tuberculosis and pneumonia.

"By 2010, many African countries will see life expectancies falling to levels not seen since the start of the 20th century," he warned.

While acknowledging that AIDS is now a "prominent feature" on the international community's agenda, he noted that "it was late in coming, and still is not a priority in the very countries that are hardest hit."

Most countries, according to Gordon, have responded positively to increased U.S. efforts against AIDS. He said that developing countries that are actively mobilized on the AIDS issue -- such as Uganda, Thailand, and Botswana -- welcome the disease's higher profile on the world agenda, but he lamented that "denial is still the order of the day" in many countries.

Following is the text of Gordon's speech, as prepared for delivery:

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The Social, Economic, Political and Security Impact of AIDS in Sub-Saharan Africa

Africa Chiefs of Mission Meeting

January 11, 2001

Nairobi, Kenya

David Gordon
National Intelligence Council

It's a pleasure to be back here in Kenya where I had the great honor to serve as a member of the US mission back in the late 1980s and early 1990s; and earlier writing my doctoral dissertation and teaching at the University of Nairobi. My only regret is that the occasion for this conference is a sad one: the devastating impact of AIDS on the most heavily affected countries and the prospect that the pandemic is likely to get much worse before it gets better. In his 1947 novel The Plague, about a fictional epidemic in a sleepy North African town, Albert Camus wrote, "We tell ourselves that pestilence is a bogey of the mind, a bad dream that will pass away. But it doesn't pass away. ... It is the men who pass away." In the case of AIDS, one might add it is the young men and especially the young women that will die -- perhaps as many as one-half, or even more of young adults in the hardest hit countries. But the very fact that this chiefs of mission meeting is focusing on AIDS also is a cause for optimism because it demonstrates that we and others are beginning to come to grips with this deadly scourge that so threatens this continent.

My remarks today will examine the broad social, economic, political and security implications of the AIDS threat in Africa. They are substantially taken from the National Intelligence Estimate we produced last year that played at least some role in alerting US policy-makers to these issues. I will conclude with brief comments about the international politics of AIDS.

A Potentially Catastrophic Health Threat

If national security is defined as protection against threats to a country's population, territory, and way of life, then AIDS presents a clear and present danger to much of Sub-Saharan Africa -- and a growing threat to the vast populations of Asia and Eurasia, which have the world' steepest HIV infection curve. Over 55 million people have been infected with HIV over the last two decades and at least 36 million are currently living with the HIV virus, 5.3 million of which are projected to have been infected this year. The disease has killed over 23 million people, 3 million of them this year.

There is a strong case to be made that AIDS is the most serious health threat in recorded history. It has already killed more people than all the soldiers killed in the major wars of the last century, and exceeds the toll taken by the bubonic plague in 1347. And the bad news is that we probably are still only in the early phases of the AIDS pandemic. AIDS is now the number one cause of death in Africa and fourth globally. Since the beginning of the pandemic two decades ago, 17.2 million Africans have died from AIDS -- 2.6 million of them in 2000 (more than ten times the number of people who died in all of Africa's conflicts combined; and it was a bad year for conflict in Africa). Seventy-two percent of HIV- positive people -- 25.9 million -- live in Sub-Saharan Africa, which has less than 11% of the world's population -- three times more than demographers predicted in 1991. Seven countries have HIV positive rates exceeding 20 percent and 9 exceeding 10 percent. Furthermore, AIDS is a gateway disease. By attacking the immune system it spurs on other killer diseases such as TB and pneumonia. By 2010, many African countries will see life expectancies falling to levels not seen since the start of the 20th century! There is little doubt that these countries are facing more than a health crisis, but also a threat to their very existence as viable societies and states.

Social, Economic, Political, and Security Impact

The conventional view among social scientists and even health experts long has been that social and economic decay, political upheaval, and conflict are a major cause of poor health and infectious disease spread. Only recently have we begun to realize that the obverse also is true: that poor health and infectious diseases like AIDS can contribute to social and economic decay, political malaise, and conflict.

AIDS is rending the social fabric in much of Sub-Saharan Africa, driving poor families deeper into poverty and undermining family structures and the education process. Households in the Ivory Coast with an infected adult spend four times as much on health and half as much on education than non- infected households.

-- AIDS -related illness and death of a major breadwinner reduces family income sharply.

-- AIDS orphans, like all orphans, are less likely to attend school.

AIDS deaths in the context of poverty lead to a vicious cycle of spreading infection and still greater poverty. Increased population mobility after household breakup due to AIDS deaths may increase the likelihood of risky sexual behavior. The growing number of orphans from AIDS contributes to rising crime, as extended families are unable to take in additional orphaned kin. As many as a third of the children under 15 in hardest-hit countries -- some 42 million -- are expected to comprise a "lost orphaned generation" by 2010. The hardest-hit countries, such as Botswana, Zimbabwe, and South Africa, will face a demographic catastrophe as AIDS reduces human life expectancy among currently infected populations by as much as 20 to 30 years and kills up to a quarter or more of their infected populations over the next 10 years -- including up to a half or more of their young adults. Botswana, Zimbabwe, SA and possibly some other countries in Southern Africa face declining populations in less than five years time.

Because AIDS in the hardest hit countries is socially neutral, it is also making major inroads into the professional classes of teachers, civil servants, engineers and other skilled workers, who have formed the social backbone of recent advances in both political and economic life. In 1998, Zambia lost to death two-thirds as many teachers as it trained.

ECONOMIC IMPACT LIKELY TO GROW. AIDS will take an increasingly heavy economic toll. While difficult to measure precisely, the economic costs of AIDS are already substantial for the most seriously affected countries, despite the partially offsetting impact of declines in population growth.

-- Threshold effect after 5 % prevalence rate. At 20%, cost of over 1% of GDP annually.

AIDS LIKELY TO STRAIN BUDGETS. AIDS will make large budgetary claims on national health systems' resources. In Zimbabwe, more than half the meager health budget is spent on treating AIDS, while in Kenya, AIDS treatment costs are projected to account for 50 percent of health spending by 2005. In Rwanda, two-thirds of the health budget is spent on AIDS treatment, and 70 percent of patients at the main hospital have AIDS-related diseases.

Even given the budgetary dominance of AIDS, few countries will be able to afford the high cost of multi-drug treatment for AIDS, which can be $10,000 to 15,000 annually. Only about 1 percent of AIDS patients even in relatively well off South Africa currently undergo multi-drug treatment, for example, while in Malawi a mere 30 of 1 million HIV-infected people are undergoing such treatment.

AIDS WILL TAKE AN EVEN GREATER TOLL ON PRODUCTIVITY, PROFITABILITY, AND FOREIGN INVESTMENT. World Bank President James Wolfensohn has declared AIDS to be the single biggest threat to economic development in Sub-Saharan Africa, and a growing number of studies suggest that AIDS alone will reduce per capita GDP growth in several Sub-Saharan African countries by 20 percent or more by 2010. In combination with high rates of malarial infection, as is the case in some SSA [Sub-Saharan African] countries, the results are even more devastating.

The impact of AIDS at the sector and firm level already appears to be substantial and growing and will be reflected eventually in higher GDP losses, especially in the more advanced countries such as South Africa with specialized work force needs. Several individual firms and their AIDS consultants paint a bleak picture in recent surveys.

-- Using broad measures of AIDS-related costs, such as absenteeism, productivity declines, health and insurance payments, and recruitment and training, they project profits to drop by 6 to 8 percent or more annually and productivity to decline by 5 percent. Managers at one Kenyan sugar company told UNAIDS they suffered a 50 percent loss in productivity over a recent two-year period, while 30 to 50 percent of Zimbabwe's farmland is now being used for subsistence rather than cash crops because of the deaths of so many farm workers.

-- In South Africa, they are especially troubled by the high rate of loss of middle and upper-level managers to AIDS and the dearth of replacements, as well as the loss of large numbers of skilled workers to AIDS in the mining and other key sectors. According to one expert, South African companies will begin to feel the full impact of the AIDS epidemic by 2005. One study of the projected impact of AIDS on employee benefit costs in South Africa concludes they will nearly triple to 19 percent of salaries from 1995 to 2005, substantially eroding corporate profits.

Several months ago, I visited SA. Report to U.S.-SA Business Council. Only questions about AIDS. Little doubt that loss of financial confidence in SA directly tied to both AIDS and the politics of AIDS.

On the foreign investment side, the bottom line is that AIDS will further raise the bar that African countries face in competing for scarce, and mobile, foreign investment resources.

DEBILITATING POLITICAL IMPACT. It is very difficult to judge the potential political impact of AIDS in Africa and other hard-hit countries. But it is unlikely to be positive. The corrosive impact of AIDS on the socio-economic underpinnings of Sub-Saharan African polities threatens to add to political instability, deepen Africa's crisis of governance, and slow democratic development.

The political impact of AIDS threatens to result in many countries in a downward cycle of increasing disease impact weakening state capacity which in turns results in further increases in the impact of the disease. The severe social and economic impact of AIDS and its infiltration into the ruling political and military elites and middle classes of these countries are likely to intensify the struggle for political power to control scarce state and societal resources; reduce the capacity of governments to provide needed services and benefits; and thereby erode their legitimacy.

-- The human losses from AIDS in the most affected countries also will hamper the development of a civil society and other underpinnings of democracy and will increase pressure on democratic transitions in the region by limiting new investment, encouraging emigration of the best and the brightest and in general adding to economic misery and political decay.

While so far, AIDS has not loomed large in national-level political life; this may be changing.

-- South Africa example

-- The AIDS issue also will increase political tensions with developed countries over the cost of and access to anti-retroviral drugs.

INTERNATIONAL SECURITY AND PEACEKEEPING. AIDS threatens to hamper international security and peacekeeping efforts as militaries and military recruitment pools experience increased deaths and disabilities from the disease. The greatest impact will be among hard-to-replace officers, noncommissioned officers, and enlisted soldiers with specialized skills and among militaries with advanced weapons and weapons platforms of all kinds.

-- HIV/AIDS prevalence in the militaries of the heavily affected countries is considerably higher than their civilian populations, owing to risky lifestyles and deployment away from home. Commencement of testing and exclusion of HIV-positive recruits in the militaries of a few countries such as Uganda is reducing HIV prevalence, but it continues to grow in most militaries, where it ranges as high as 80 percent.

-- Mounting infectious disease-caused deaths among the military officer corps in military-dominated and democratizing polities also may contribute to the deprivation, insecurity, and political machinations that incline some to launch coups and counter-coups aimed, more often than not, at plundering state coffers. It is difficult to make a direct connection between high AIDS prevalence in military forces and performance in battle. But, given that a large number of officers and other key personnel are dying or becoming disabled, combat readiness and capability of such military forces is bound to deteriorate.

The negative impact of high infectious disease prevalence on national militaries is likely to be felt in international and regional peacekeeping operations as well, limiting their effectiveness and also making them vectors for the further spread of diseases among coalition peacekeepers and local populations.

-- Although the U.N. officially requires that prospective peacekeeping troops be "disease free," it is difficult to enforce this rule with such methods as HIV testing, given the paucity of available troops and the likely noncompliance of many contributing states.

-- Healthy peacekeeping forces will remain at risk of being infected by disease-carrying forces and local populations, as well as by high-risk behavior and inadequate medical care. Such issues are already coming to the fore in the discussions of PKOs [peacekeeping operations] and threaten to loom even larger in the future.

The International Politics of AIDS

AIDS is now a prominent feature of the international community's agenda, but it was late in coming, and still is not a priority in the very countries that are hardest hit. Most countries have responded positively to increased US efforts against AIDS. Europe and Japan are very concerned about infectious diseases including AIDS and anticipate cooperation with the US, but in resource terms the US remains by far the dominant contributor to international efforts. Developing countries that are actively mobilized on the AIDS issue -- such as Uganda, Thailand and Botswana -- welcome the disease's higher profile on the world agenda. Russia, China, India and some other G-77 countries have opposed efforts to raise AIDS in the UN Security Council, not wishing to set a precedent for interference in their internal affairs. But such opposition is beginning to wane; indeed, the Security Council will hold another session on AIDS next week.

Ironically, many African and other developing countries have avoided confronting AIDS and its political salience until recently has remained low, despite the fact that 95 percent of AIDS deaths occur there. Denial has been the order of the day, reinforced by poor or non-existent surveillance and diagnostic capacity and broader socio-economic constraints. Most governments have refrained from making AIDS a high priority issue. The few that have -- Thailand, Uganda, Senegal, and Brazil -- have significantly reduced HIV and AIDS infections and death rates through educational programs, provision of condoms, and in the case of Brazil, much expanded access to antiretroviral drugs.

Most African and other developing countries are ambivalent about the increased international attention to AIDS, welcoming the prospect of greater assistance, but still reluctant to admit the scope of the problem for reasons of national prestige and a focus on broader policy priorities, such as socio-economic development. In the view of some, AIDS is a function of underlying poverty, malnutrition, and poor health care infrastructures that must first be dealt with. Otherwise, funds and effort devoted to AIDS prevention and treatment will accomplish neither. Indeed, no African government is yet to accept US EXIMBANK loans for AIDS programs. Some also are concerned that their AIDS problem will simply confirm the views of those who like to think of them as failed states, and a few even see AIDS as a form of global apartheid.

But more African leaders are beginning to speak out on the dangers of AIDS, despite the difficulty of addressing sexual issues in their conservative societies. President Moi has urged Kenyans to use condoms to prevent AIDS, and a number of countries have joined Uganda in urging their citizens to alter their sexual behavior to halt the spread of the disease.

But the fact is that, for most of Africa, we are very late into the pandemic and international and national efforts need to pick up pace remarkably fast.

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