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The Elliott School of International Affairs
The George Washington University
November 20, 2002

HIV/AIDS, National Security, and Policy Responses

Presented by George C. Fidas, Intelligence Officer-in-Residence

It's a pleasure to be here to talk to you about the increasingly important topic of AIDS. For the record, my comments will reflect my own views rather than those of the Intelligence Community.

In his 1947 novel The Plague, about an epidemic in a sleepy North African town, the French writer, 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 more of young adults in the hardest hit countries.

I would like to start with a discussion about the scope of the AIDS pandemic and why it is likely to get much worse before it gets better. I will then explain why AIDS is a national and global security threat. I will then discuss the domestic and international politics that will shape and be shaped by the AIDS crisis and the challenges that lie ahead on issues such as funding, and the mix between prevention and treatment. And I will conclude with specific policy recommendations that would ameliorate AIDS both as a health threat and a social, economic, political, and national security threat.

This is a daunting task because there will rarely if ever be a smoking gun that can tie HIV/AIDS directly to national and global security and mobilize the world's countries to deal with it. Instead, to paraphrase Thomas Hobbes, the disease will make life even more nasty, brutish, and short. It is the cumulative effects of this Hobbesian process that will erode national and global security as AIDS undermines social and economic development, stymies political development, and intensifies the struggle for scarce resources and thereby destabilizes already troubled polities. Recent events in Zimbabwe and the emerging famine in southern Africa that threatens nearly 15 million people may be manifestations of these cumulative effects.

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 the Caribbean countries-and a growing threat to the vast populations of Asia and Eurasia, which have the world's steepest HIV infection curves. Some 60 million people have been infected with HIV over the last 2 decades and at least 40 million are living with the virus, 5 million of whom were infected last year. Half are women and one-third are between the ages of 15 and 24, of which two-thirds are women. The disease has killed nearly 30 million people, 3 million of them last year. And by 2020, at least another 68 million will die of AIDS, 55 million of them in Sub-Saharan Africa..

Nearly 75 percent of HIV-positive people or over 30 million live in Sub-Saharan Africa. AIDS is now the number one cause of death in Africa and fourth globally. Since the beginning of the pandemic, over 25 million Africans have died from AIDS or more than ten times the number of people who have died in all of Africa's conflicts. Seven countries have HIV positive rates exceeding 20 percent, 1 of which is approaching 40 percent, and 9 exceed 10 percent.

In developing countries, AIDS hits the rich as well as the poor. Botswana, the richest Sub-Saharan country, also has the highest HIV infection rate at 39 percent, and two thirds of its 15 year-olds eventually will die of the disease. Some 40 percent of equally well off South Africa's adult population will be infected with HIV by 2010, and some 1.5 million of those aged 15 to 34 will die annually over the next two decades. By 2010, many African countries will see life expectancy fall by 30 years to levels not seen since the start of the 20th century! And AIDS-related child mortality already has wiped out the gains of the past 20 years as childhood deaths have increased as much as 44 percent in South Africa, 58 percent in Namibia, and 121 percent in Botswana .Can anyone doubt then, that these countries are facing not only a health crisis, but also a threat to their very existence as viable states?

But AIDS is not just an African problem. It is spreading quickly among the populations of Asia and Eurasia, where it is likely to exceed the number of infections in Africa within a decade. India already has some 4 million HIV carriers and could have as many as 25 million by 2010, China as many as 15 million, and Russia 8 million.

Even in developed countries, AIDS remains a major health threat despite the fact that antiretroviral drugs have reduced the number of annual deaths in the US to under 20,000 from a high of nearly 50,000 in the first half of the 1990s. Nearly 1 million Americans are HIV positive, 45,000 are infected annually, and some 4 to 5 million are at risk, owing to behavioral factors. Complacency and growing microbial resistance, moreover, suggest that the number of infections and deaths are again on the rise. The same dynamic is at work in Europe, which has some 550,000 HIV positive persons and 30,000 infections annually.

Social, Economic, Political, and Security Impact

The conventional view among social scientists and health experts long had 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 diseases such as AIDS can contribute to such destabilizing factors.

AIDS is having a devastating social impact as it rends the social fabric in hard hit countries. The degradation of nuclear and extended families will produce severe social and economic dislocations with political consequences, as well. In Malawi, 65 percent of children are being raised by a grandmother because their parents and grandfathers are ill or have died from AIDS. 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. Families losing a breadwinner to AIDS experience up to an 80 percent drop in disposable income.

AIDS will further impoverish the poor and often the middle class and produce a huge orphan cohort of some 25 million that will be unable to cope and vulnerable to exploitation and radicalization. The pervasive child soldier phenomenon may be one example. As much as a third of the children in the hardest hit countries will comprise this lost orphaned generation by 2010, most of whom are likely to drop out of school. Zambia will witness a 20 percent reduction in its primary school age population by 2010 and Zimbabwe a 25 percent cut.

Because AIDS is socially neutral in developing countries, it is also making major inroads into the professional classes of teachers, civil servants, engineers, doctors, nurses and skilled workers who have formed the social backbone of recent advances in both political and economic life.

• In Zambia, 40 percent of teachers are HIV positive, nearly double the rate of the larger population. In Botswana, 35 to 40 percent of all teachers are HIV positive. In South Africa, nearly one-third are infected. And in Swaziland an astonishing 70 percent are infected.

• Health care workers also are being ravaged by AIDS and are often dying faster than they can be replaced. In Malawi, 25 to 50 percent of health care workers may be dead by 2005 due to AIDS. Doctors and nurses in Zambia are experiencing 5 to 6 fold increases in illnesses and deaths.

• By 2005, 23 percent of South Africa's skilled workforce will be HIV-positive and by 2020, Botswana, Zimbabwe, Mozambique, and South Africa will lose 25 to 30 percent of their workforces to AIDS, and as many as 25 million agricultural workers. Thirty to 50 percent of Zimbabwe's farmland is now being used for subsistence rather cash crops because of the deaths of so many agricultural workers.

AIDS will take an increasingly heavy economic toll. 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 GDP growth by 20 percent or more in the hardest hit countries by 2010 and nearly 10 percent in the Caribbean countries.

• The economic costs of AIDS are already substantial as it reduces productivity, profitability, and foreign investment. Several are experiencing profit declines of 6 to 8 percent and productivity declines of 5 percent annually due to absenteeism, insurance costs, and training expenses.

• Managers at one Kenyan sugar company told UNAIDS they suffered a 50 percent loss in productivity over a two-year period, while nearly a third of southern Africa's mineworkers are HIV positive, threatening the viability of that important sector.

AIDS will make large budgetary claims on health and overall budgets. This will be the case even taking into account the dramatic cuts in the price of AIDS drugs by major pharmaceutical companies, since administering them will require costly new improvements in health care delivery.

• In Zimbabwe, Zambia, Rwanda, Malawi , Kenya, and elsewhere, more than half the meager health budget averaging $10 per capita is being spent on AIDS and 50 to 80 percent of hospital beds are taken up by AIDS patients.

The corrosive impact of AIDS on the socio-economic underpinnings of Sub-Saharan African polities threatens to slow democratic development and add to instability.

• The infiltration of AIDS into the ruling political and military elites and middle classes is likely to intensify the struggle for political power to control scarce state and societal resources; reduce the capacity of governments to provide needed social services; and thereby erode their legitimacy.

• The human losses from AIDS also will hamper the development of civil society and other underpinnings of democracy and will increase pressure on democratic transitions by limiting new investment, encouraging emigration of the best and the brightest, and generally adding to economic misery and political decay.

• The AIDS issue also will increase political tensions with developed countries over the costs and availability of AIDS drugs.

AIDS also will hamper national and international security and peacekeeping efforts as militaries and police forces are ravaged by the disease. The greatest impact will be among hard-to-replace officers, non-commissioned officers, and soldiers with specialized skills and among militaries with advanced weaponry.

• HIV-prevalence among militaries is often 3 to 5 times higher than that of civilian populations, owing to risky lifestyles and deployment away from home.

• Commencement of testing and exclusion of HIV-positive recruits in the militaries of some countries, such as Uganda and Thailand, are reducing HIV prevalence, but it remains pervasive in most militaries. Angola and the DROC have military infection rates as high as 60 percent, Zimbabwe and Malawi are at 75 percent, and South Africa is at 17 to 40 percent. One study estimates that AIDS may kill between 25 and 50 percent of the Malawi military by 2005.

• Mounting HIV infections and AIDS deaths among the officer corps 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.

The negative impact of high HIV prevalence on militaries is likely to be felt in international and regional peacekeeping operations as well, since some 37 percent of peacekeepers come from high prevalence countries. They also become vectors for the spread of AIDS.

• Although the UN officially requires that prospective peacekeeping troops be "disease free," it is difficult to enforce this rule given UN reluctance to test for AIDS, the likely non-compliance of many contributing states, and the paucity of available troops.

The Politics of HIV/AIDS

Following two decades of indifference in developed countries and denial in developing ones, AIDS is now a prominent feature of the international community's political agenda. But it was late in coming, and still is not a priority even in many of the countries that are hardest hit or newly threatened.

Because AIDS in developed countries long was thought to be limited to already stigmatized gay populations, it was a taboo subject with low political salience. It was only when infections surged among the broader population and annual deaths approached 50,000 in the US in the early 1990s that the issue gathered force politically and large sums were allocated to finding drug treatments. The success of those efforts soon reduced the number of deaths dramatically and improved the quality of life for AIDS carriers throughout the developed world. But it also nipped the sense of crisis in the bud, and AIDS has been viewed mainly as a developing world-mainly African-problem- even though nearly 1 million Americans are HIV positive and another 4 to 5 million are at risk

It is fair to say that since the millennial year, developed country leaders led by the United States finally have become sensitized to the potentially catastrophic impact of AIDS in developing countries and are beginning to take measures to combat it. It was in that year that a National Intelligence Estimate linked the well-known health risks of AIDS and other infectious diseases with the prospect of social disintegration, economic decay, and political instability and conflict abroad. This prompted the Clinton Administration to declare AIDS to be a national security threat and to launch a major effort in Congress, the UN, and with US economic partners and international lending institutions to secure more funding for it.

After some initial stock-taking, the Bush Administration has followed suit, with Vice President Cheney and Secretary of State Powell reaffirming that AIDS is a national security threat, a doubling of the amount of spending on international AIDS programs that already had been doubled by Clinton to its current $1 billion, and support for the establishment of a Global Fund to Combat AIDS, TB and Malaria, which is poised to play an instrumental role in combating these diseases. "I know of no enemy in war,"declared Secretary Powell at the UN Special Session on AIDS in June 2001, more insidious than AIDS, an enemy that poses a clear and present danger to the world." Just last week, Secretary Powell noted that AIDS-not terrorism-posed the greatest threat to the world.

This enhanced effort appears to enjoy broad public and elite support. A CSIS Task Force-sponsored poll last December found great concern over the impact of AIDS and substantial support for US efforts to deal with the pandemic abroad. Public and elite support is converging with that of longstanding AIDS activist groups in the US and Europe, philanthropists, NGOs and IGOs such as UNAIDS, the World Bank and the IMF.

Developing country hesitancy is abating. With the notable exception of Uganda, Senegal, and Thailand, which launched successful AIDS prevention programs in the 1990s, and Brazil and Botswana, which also are providing treatment, most developing countries initially were ambivalent about this increased attention to AIDS. They welcomed the prospect of greater assistance, but were still reluctant to admit to the scope of the problem for cultural reasons, national prestige, fear of its impact on tourism and foreign investment, and a focus on broader priorities such as socio-economic development and defense.

• In the view of many, led by South African President Mbeki, AIDS is a function of underlying poverty, malnutrition, and poor health care infrastructures that must be dealt with first.

• Cultural and religious taboos concerning gender inequality, sexual behaviors such as cross-generational and multi-partner sex, and stigmatization of HIV/AIDS cast a wall of silence about the disease at both the elite and mass levels.

• And Africa's many conflicts, dismal economic conditions, and poor institutional capacity further dissuaded governments from confronting the pandemic even though it promised to make their citizen's lives even more nasty, brutish and short.

These attitudes have begun to change over the last two years. The meetings on AIDS at the UN Security Council and General Assembly and the AIDS conferences in Durban and Barcelona all have exerted political pressure on government leaders to respond to the pandemic. The growing funds being offered by the international community are beginning to provide them with the means.

This abandonment of the policy of denial in favor of confronting AIDS was highlighted by the African leaders summit in Nigeria in April 2001, which produced a Framework Plan of Action in which they resolved to give AIDS the highest priority in their national development plans and to eventually increase their paltry health budgets to 15 percent of total government spending.

Several African leaders subsequently reaffirmed these commitments at the UNGA session on AIDS and now head national AIDS commissions and councils in their own countries. In addition, grass roots political pressures are on the rise as AIDS activists and NGOs across are serving notice that AIDS must be a priority in national agendas or governments will be punished at the polls or experience street unrest. And they are winning the support of national judiciaries, beginning in South Africa, where the courts have ruled that the government must provide HIV-infected pregnant women with drugs to reduce mother-to-child transmission.

It may be that, just as democratization in Eastern Europe was spearheaded by the environmentally focused green movements, the AIDS pandemic will foster greater democracy in Sub-Saharan Africa and elsewhere as a by-product of the AIDS campaign.

Key Challenges and Choices

As the donor community and hard-hit countries in Sub-Saharan Africa, the Caribbean, and the second wave countries such as India, China, and Russia contemplate their responses to AIDS, they will face a variety of complex challenges and choices.

First, policymakers must assess the salience of the issue, including its political salience, since this will influence the attention and resources it is likely to receive.

• Is AIDS just a serious health issue, alongside other major killers such as heart disease and cancer? Or is it truly a national and global security issue whose impact calls for a more robust effort?

• The trend is toward highlighting both the health and security risks, but opinion will likely remain divided on this. Ironically, many developing and former communist countries who have the most to gain by labeling AIDS a security threat also oppose that nomenclature because they associate it with interventionism by the US and other developed countries on behalf of more traditional security concerns. Clearly, AIDS will be far better funded if it is seen both as a serious health and security issue.

Second, policy choices need to be made along three dimensions: spending for health versus spending for other objectives such as education; treating AIDS versus treating other serious illnesses; and preventing HIV infection versus treating those with AIDS.

• AIDS will pose cruel budgetary dilemmas in Sub-Saharan Africa and the Caribbean basin where annual treatment for one AIDS patient can cost as much as educating several primary school students. Few developing countries will be willing to allocate much of their already scarce resources toward more health spending--so any increase will depend on external assistance and further debt rescheduling.

• The priority given to AIDS compared to other illnesses also will remain controversial in developing countries, who fear that AIDS will further overwhelm their already meager health budgets. To the extent that funding for AIDS is at the expense of funding for non-communicable diseases such as heart disease and cancer in developed countries, it will become controversial there as well.

• The issue of who gets treated and who does not-meaning the choice between who lives and who dies-could dramatically widen the health divide between rich and poor nations and become one of the most contentious issues of the 21st century. Although virtually all known HIV infected individuals in North America and Europe have access to both prevention and treatment programs, most developing countries can do neither. Even with drug treatment costs dropping to $500 annually, only about one percent or 250,000 of the world's 40 million plus HIV-infected people are on anti-viral therapy, 100,000 of them in Brazil, and most of the others in the more advanced developing countries in Latin America and Asia-and now in Botswana, thanks to an innovative partnership between the Gates Foundation, Merck, and the Government. By contrast, only 30,000 people in the whole of Sub-Saharan Africa were taking such drugs last year. Bilateral assistance programs are currently geared to prevention over the far more costly treatment of AIDS, but pressure for treatment is likely to grow.

Third, the emerging international coalition in the form of the Global Fund will remain fragile even though it is off to a decent start with some $2.1 billion in pledges, including $500 million from the US, and its awarding of grants worth $600 million for projects in 40 countries.

• It will remain particularly dependent on the commitment of the major developed countries, agreement on the allocation of aid, and the success of approved projects. It will also be dependent on proper handling of the intellectual property rights issue to ensure that the need of drug firms to protect the fruits of their research and earn at least some profits is balanced by the need to provide affordable access to the millions of AIDS sufferers.

Fourth, even with plummeting drug prices and growing international commitment and assistance, no international aid effort will succeed unless the recipient countries show similar resolve and receptivity to its goals and make their best efforts to use their own resources to combat the AIDS threat.

The Way Forward

Although the challenges ahead are formidable and potentially divisive, a number of sensible policy responses are already underway or in the proposal stage, spearheaded by UNAIDS, the World Bank, the Global Fund, and think tanks and task forces such as the CSIS Task Force on HIV/AIDS chaired by Senators Bill Frist and John Kerry. These proposals and responses vary in the attention they focus on prevention, treatment, and broader socio-economic development. But all note the need for a multi-sectoral approach and a dramatic increase in funding.

As for funding, winning the war on AIDS will be expensive, but pales in comparison to what the International Community spends on defense and more superfluous purchases. The UN Special Session called for an increase in annual spending from some $2 billion in 2001 to $7-to$10 billion, the minimum requirement to make major inroads on prevention and treatment, which is no more than the cost of 4 to 5 BI stealth bombers. With $2.1 billion in pledges, the Global Fund can begin to make a difference, but that is still a long way from the requisite $7 to$10 billion and farther still from the $10 to $14 billion needed annually by 2007, according to a recent WHO commission report, which also assumes that developing countries will have to come up with $22 billion. According to the CSIS task Force, the US should continue to fund roughly half of the international AIDS bill, including a quarter of the Global Fund.

As for how to conduct the war on AIDS, virtually all policy proposals underscore the need for partnerships and multisectoral approaches to better marshal the requisite material and human resources.

• In Africa, for example, emerging national AIDS commissions typically include several ministries as well as representatives of civil society.

• NGOs and community action groups were instrumental in securing and implementing Brazil's prevention and treatment program and in pressing the South African Government to commence mother-to-child prevention.

• Some major firms in Africa have begun providing anti-retroviral drugs to their employees.

• Several pharmaceutical firms have formed partnerships with governments to provide drugs at dramatically reduced prices.

• And the Global Fund itself is a unique public and private partnership that includes NGOs on its board and grants money to both governmental and non-governmental proposals.

Interventions aimed at AIDS prevention must themselves be multifaceted.

First, there must be a stronger effort to deal with the most immediate and destabilizing impact of AIDS-its relentless inroads into the very elites upon whom these countries must depend to confront the disease. The needs of refugees and orphans who are potential recruits as child soldiers, criminals, and even terrorists also must be met. UNAIDS , in this regard, has developed a Strategic Action Plan that includes education and training in prevention and provision of condoms. The US Department of Defense also has initiated efforts to raise AIDS awareness in military-to military contacts with developing countries.

Second, the stigmatization and discrimination against people living with HIV/AIDS must diminish if they are to become receptive to testing and then receive at least a modicum of treatment and care. The number of those in Africa who do not even know they are HIV positive is some 90 percent and 50 percent in Brazil. Even in the US, one-quarter to one-third of HIV positive Americans are unaware of their infection and continue to spread the disease.

Third, programs to educate and empower women must be encouraged because they are tantamount to major programs of prevention. Various surveys show that women are far less informed about AIDS; are reluctant to be tested or to tell their husbands or other sex partners that they are HIV-positive; and unable to avoid sexual contact or make safe sex choices, for fear of being beaten and/or abandoned. As one UN official noted, "Women's subordination and presumed inferiority are the reason that AIDS is not a disease but an epidemic."

Ethics, equity, and the growing availability of funds and affordable drugs also call for a greater focus on treatment and care. Indeed, treatment is tantamount to prevention because it reduces the infectiousness of those fortunate to have access to anti-AIDS drugs.

The WHO has set a goal of extending anti-retroviral drugs to 3 million people in developing countries by 2005, a 12-fold increase over 4 years. Thus far, Brazil and now Botswana, are the only developing countries to make such drugs available for free to all those needing them. Brazil's focus on prevention and treatment has cut AIDS deaths by about two-thirds at a cost to the government last year of some $500 million.

According to the CSIS task force, several challenges will emerge as HIV-treatment programs expand:

First, health care delivery capacity must be expanded. Most essential will be training the large number of health care workers that will be needed through such means as the pairing of developed and developing country health institutions, the expansion of aid programs to include such a mission, and even the formation of developed country volunteer health corps to serve in these counties. Already virtually all Peace Corps volunteers will be trained to impart HIV/AIDS education and other forms of HIV/AIDS assistance over the next five years.

Second, treatment must be made even more affordable and sustainable. Although the cost of treatment has dropped as much as 100 percent to $500 annually, it is still far to high in countries where annual per capita health expenditures average $10 and people earn less than a dollar a day. One option is for governments and the Global Fund to contract with pharmaceutical firms to provide drugs at low but still profitable or prices in return for assurances on differential pricing and protection against diversion of low cost drugs into developed country markets(which is already beginning to happen). Alternatively, governments or the Global Fund could buy the drugs and provide them at little or no cost to infected populations.

Third, treatment programs must be better integrated with prevention programs because of the tendency for complacency to set in among treated individuals, who then revert to risky sexual practices and offset the gains of treatment.

Fourth, a concerted effort must be made to limit the inevitable development of anti-retroviral drug resistance, as has happened in developed countries where 10 to 25 percent of those being treated have acquired some degree resistance. That percentage is likely to be higher in developing countries where there is greater likelihood of non-adherence to drug regimens, with a strong blow-back potential to developed countries, where drug resistance is the single biggest threat to HIV positive people.

And fifth, hospitals and clinics must be expanded to care for both the surging number of untreated HIV carriers and for those undergoing treatment, who will be living longer but will still need regular care.

A War on Two Fronts

Finally, the war against AIDS cannot be won without winning the war on poverty and underdevelopment. In that sense, Prime Minister Mbeki is correct. Tackling the social, economic, political, and cultural factors that make states vulnerable to HIV/AIDS is essential in forging an effective response and sustainable response.

• This means policies aimed at reducing hunger, increasing education levels, particularly among women, and reducing child mortality.

• It means better governance, more democracy, respect for the environment, and more conflict prevention and amelioration efforts.

• It means that there must be greater collaboration and coordination between health and development-focused NGOs, IGOs and government agencies to ensure that development and anti-AIDS programs are complementary rather than competitive.

• And it means that governments, IGOs and NGOs should resist the temptation to make tradeoffs between confronting AIDS and confronting poverty. Both wars need to be won and that means devoting more to both.

Taking the long view

In closing, it is important to remember that dire as the AIDS crisis is, we are only at the beginning of the pandemic or at most, at the end of the beginning to paraphrase Churchill in referring to another war at another time and place. If current trends continue, and especially with the projected inroads among the vast populations of India and Eurasia, the pandemic will not peak until mid- century. This demands that the US and others must take the long view in forging their policies and programs and be prepared to maintain a robust and sustainable effort lasting several decades.