P-I Focus: AIDS a century from now

Former New York Mayor Rudolph Giuliani's response when asked to estimate how many casualties would result from the collapse of the World Trade Center was one of the most profound statements in the wake of the Sept. 11 terrorist attacks.

It also answers another, more global question: "What will be the impact of the AIDS pandemic 100 years from now?"

The next 10 decades will be painful. We could easily see a billion deaths from AIDS. Each will represent a family torn apart. Together, AIDS will devastate villages, cities, national economies and the very fabric of society, especially in the developing world.

And the United States will feel the effects -- economically, politically and socially.

The AIDS epidemic already has devastated my continent, Africa. Of the 42 million people worldwide with AIDS, more than 29 million live there. But the pandemic's center of gravity is shifting to Europe and Asia, where sheer population size -- let alone military and economic power -- threaten global security.

This will not be the first time the world has been torn apart by disease. In the mid-14th century, the Black Death is believed to have killed 25 to 50 percent of Europe's population, and an equally high toll from Asia and North Africa. It created labor scarcities that, some historians argue, accelerated economic and social change, leading eventually to capitalism.

A century from now, will my great-grandchildren live in a world that has seen greater social progress, albeit at an awful price? Or will we have paid that price for nothing but what historians will call the "Black Death" of the 21st century?

It is difficult to predict the exact course AIDS will take over the next century -- and, more significantly, how the world will respond. My medical training is of some help.

But AIDS is far more than a medical problem. It has profound economic, political and social ramifications and requires a multi-faceted response.

Africa's AIDS epidemic has been easy to overlook. Africa lacks military power and economic influence; by many measures, the entire continent contributes less to the world economy than Switzerland alone.

The West, however, will not be able to ignore the emerging AIDS crisis in Eastern Europe and Asia (Eurasia). Their combined economy is greater than that of the United States or Western Europe. Four of the world's five largest armed forces are in the region, as are four of seven declared nuclear states.

Conservative estimates put the number of people with AIDS in China, India and Russia at 7 million. Even with a "mild" epidemic, the number of AIDS cases in China, Russia and India alone would reach 66 million by 2025. Under a worst-case scenario, these three countries together would have more than 250 million cases by 2025.

"Eurasia's HIV/AIDS epidemic will clearly have far-reaching economic ramifications in the coming decades," contends Nicholas Eberstadt, writing on "The Future of AIDS" in the November/December edition of "Foreign Affairs."

Economic output could stagnate or decline in all three countries, depending on the severity of the epidemic. Russia, in particular, could be marginalized. Once one of the two most powerful nations on earth, Russia already has experienced more than a decade of turbulent political and economic transition. Coupled with demographic and military decline and questionable control over its nuclear arsenal, Russia represents a dangerous incubator for a disease for which there is still neither cure nor vaccine.

India, with a population greater than the entire continent of Africa, "can either be the home of the world's largest and most devastating AIDS epidemic -- or, with the support of the rest of the world, it can become the best example of how this virus can be defeated," said philanthropist and Microsoft co-founder Bill Gates. Gates, who better than most corporate executives recognizes the potential economic impact of the pandemic, last month traveled to India to make a $100 million contribution to local AIDS efforts. He cited the country's "vast human resources and burgeoning pharmaceutical industry" as strategic advantages in fighting AIDS.

However, life-extending drug therapies will be out of reach for most AIDS patients in India, and virtually all in Africa. At $600 per patient per year, they cost more than most people with AIDS earn -- annually.

Prevention is much less expensive than cure, a lesson most African countries have learned too late. But Eurasia still has time to learn from Africa's experience.

AIDS has wiped out, even reversed, hard-won development gains in Africa. Most countries in sub-Saharan Africa have seen decline, often drastic, in both income and life expectancy. By 2010, for example, a child born in Botswana can expect to live 27 years.

AIDS seems fickle, devastating one country while leaving others relatively unscathed. The reasons are telling.

For example, what is euphemistically called "female circumcision" (genital mutilation) makes women's bodies more vulnerable to AIDS. Equally significant, this and other harmful cultural traditions are practiced in societies where women suffer from decidedly unequal social -- and sexual -- status. Moreover, women in many African cultures are powerless to negotiate the terms of sex, including use of condoms. Wives are taught to look away if their husbands take on lovers. Rape often goes unpunished.

As a result, Africa has the dubious distinction of being the only continent where women with AIDS outnumber men.

Significantly, the one African country that has turned the corner on its AIDS epidemic has done so by stressing responsible sexual behavior. And, as a result, the status of women has been elevated. While Uganda has suffered greatly due to AIDS, HIV infection rates have dropped from 31 percent in 1990 to a reported 5 percent in 2001. In response to an unprecedented public education campaign, a majority of Ugandans now practice abstinence before marriage and faithfulness after. Strong national leadership and sustained international support were key.

By contrast, the nation of Botswana, one of the wealthiest and most stable in sub-Saharan Africa, has an infection rate approaching 40 percent. Its population of 1.6 million could be reduced by more than 50 percent over the next generation, absent a Uganda-style turnaround. No such turnaround is on the horizon.

"The impact of AIDS in sub-Saharan Africa is society-wide, with few sectors untouched, whether social, economic or political," says Peter Piot, executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS). "The long-term impact of the crisis is clear: in the worst affected countries, a reversal in decades of development and tremendous loss of investment in human capital and economic development."

Children are especially hard-hit. Within seven years, the United Nations estimates Africa will have more than 42 million orphans, half of them because of AIDS. Orphans are more likely to be malnourished, experience psychological and social problems, drop out of school, face abuse and exploitation -- and repeat the cycle that leads to AIDS.

For each child who has lost a parent to AIDS, two or three more are extremely vulnerable because their parents are chronically sick or because they must share meager family resources with fostered children who have already lost their parents. Estimates of the number of children severely affected by HIV/AIDS are as high as 100 million by 2010.

Children without appropriate guidance stand in danger of becoming "angry young men and women," who make their homes in anarchy and lawlessness, which often lead to civil and political unrest. And as armies suffer the loss of up to half their troops to AIDS, we could see many more failed states, which, like Afghanistan under the Taliban, become breeding grounds for terrorists.

In contrast to the current war on terrorism, America's response to the war on AIDS has fallen far short of the needed $10 billion a year. This year the United States contributed slightly more than $1 billion to all international AIDS efforts.

The price tag for AIDS will only rise.

Yet hope remains alive, often through micro-lending programs. An African mother sells sachets of herbs, offering hope to others who are dying of AIDS and an income for her daughter, whom she is teaching to carry on when she dies. A widow, herself HIV-positive, in the Dominican Republic has learned to use a sewing machine to make clothes to raise money for her children's care.

Such is the human nature to survive and a basis for hope that AIDS will be defeated.

Man has always modified his environment for his own survival. We die fighting. Likewise, man has resisted and fought diseases by developing vaccines, medicines and other therapies.

Solutions to the AIDS pandemic and its economic and social ramifications will require greater equality for women, a sustained war on poverty and a more equitable engagement between wealthy countries of the West and poor countries in the developing world.

With such a response, my great-grandchildren could live in a better world in the next century. Without it, they undoubtedly will face a bleak and brutal reality, much like people in the 14th century.

Either way, the cost of AIDS will be much "more than we can bear."

Joseph Riverson, M.D., a native of Ghana, lives in Auburn and is a medical advisor on AIDS for World Vision, the international Christian humanitarian organization. For more information, visit www.worldvision.org .

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