<http://www.foreignaffairs.org/> Foreign Affairs
The Lessons of HIV/AIDS
By Laurie Garrett

From Foreign Affairs, July/August 2005

Summary: To get a sense of the broader damage a new pandemic might do,
it helps to consider the one the world is currently enduring:
HIV/AIDS. Because this deadly scourge moves slowly, many of its
social, political, and economic effects have yet to be understood. But
the impact is hard to overstate. And it is growing.

Laurie Garrett is Senior Fellow for Global Health at the Council on
Foreign Relations. This essay partly results from meetings convened by
the council in collaboration with the Joint UN Programme on HIV/AIDS.

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
Côte 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.