In Africa, The Virus Is AIDS. The Disease Is Poverty

National Journal, January 22, 2000

To this day, a whiff of death lingers about a song that generations of children have sung:

Ring around the rosie,
A pocketful of posie,
Ashes, ashes, all fall down!

The ring was a circle of people around the rosie, who was a victim of the Black Death (bubonic and pneumonic plague), with reddened face and eyes. The posie was the bag of prophylactic herbs and flowers that people carried; "ashes, ashes" was the sound of sneezing. The last phrase speaks for itself.

The first great onset of the Black Death in Europe, in the middle of the 14th century, killed perhaps a third of that continent's population, and possibly half of England's. "The living did not suffice to bury the dead," reported one contemporary account. "And the sheep and cattle wandered about through the fields and among the crops, and there was no one to go after them or collect them." The Black Death may have been the greatest natural catastrophe of the second millennium. Now, as if to mock human aspirations for the third millennium, something like it is happening again.

In the world today, almost 34 million people have human immunodeficiency virus, the virus that causes AIDS. Seventy percent of those people are in sub-Saharan Africa, which has less than 10 percent of the world's population. Almost 14 million Africans have died so far (as against 450,000 in North America's savage but much more limited epidemic). Most of the more than 23.3 million Africans now infected will die in the next 10 years.

The virus moves quickly in Africa, where it is transmitted mainly by ordinary heterosexual intercourse. In 1999 alone, according to the United Nations, 3.8 million Africans were newly infected. In some countries, such as Botswana, Namibia, Swaziland, and Zimbabwe, more than a fifth of the adult population is infected.

To speak with development officials of what is unfolding in Africa is to hear echoes of the Black Death itself. One official tells me that, most weeks in Africa, at least one of his meetings is canceled for a funeral. AIDS takes elites (who are mobile, urban, and sexually active) as well as the poor, and it takes adults in their most productive years, when they are raising their children and caring for their parents.

The impoverishing effect of losing these breadwinners, says Jean-Louis Sarbib, a vice president for Africa at the World Bank, is ghastly. "The progress that's been made in the second half of the 20th century," he says, "could simply be wiped out by the AIDS epidemic."

In Africa's southern region, life expectancy rose a full 15 years -- to 59 years -- between the early 1950s and the early 1990s. "Because of AIDS," reports the United Nations, "life expectancy is set to recede to just 45 years between 2005 and 2010" -- the level of the early 1950s. Half a century, erased.

The Clinton Administration and Vice President Al Gore's presidential campaign, of which the Clinton Administration is a subsidiary, did something good last week. Gore went to New York City on Jan. 10 to preside over a special session of the U.N. Security Council that was devoted to the African AIDS crisis: possibly the first crisis Gore has proclaimed that actually is a crisis. At the United Nations, he announced the Administration's forthcoming request for an additional $100 million to fight AIDS abroad, mostly in Africa. The new money would increase to almost $350 million the total amount that America spends on overseas AIDS.

Though I am as cynical about politicians' motives as the next smug Beltway journalist, I have to acknowledge that going to the widely unpopular United Nations to propose an increase in foreign aid -- when Americans are dying at home -- is not the sort of thing a presidential candidate does in order to pander to voters in Iowa and Michigan. Good for Al Gore. Good for Bill Clinton.

Still, it bears remembering that $350 million is not all that much. For about the same amount, America could buy the Africans a couple of new jumbo jets. "It's a drop in the bucket," acknowledges Sandra L. Thurman, the Clinton Administration's AIDS policy director. The World Bank says that financing a full-scale prevention program for Africa would cost as much as $2.3 billion.

Here is a suggestion: Find the $2.3 billion and spend it. In Africa, that kind of money can buy a lot of prevention. According to the United Nations, more than 30 percent of young southern African women believe that a healthy-looking person can't carry HIV, and up to 90 percent of carriers are unaware they are infected.

"If we don't learn our lessons in Africa today," says Thurman, "we're going to be facing the same kind of epidemic in India or the former Soviet Union in 12 or 15 years." One of those lessons is that aggressive prevention efforts cannot be started too early. A broader sort of lesson, however, is also relevant: In the third millennium, the great killer of humanity is not disease but poverty.

America spends more than $2,000 a year on each new HIV infection; Africa spends less than $4, and strains to do even that. The new triple-drug antiviral therapies that have brought about the sharp decline in AIDS deaths in the United States and Europe are expensive even by American standards; Africans might as well fly to the moon.

Moreover, the therapies require taking a dozen or more pills every day at precise intervals without fail, plus high-tech monitoring for viral resistance, plus still more drugs to control side effects. Try that in an African town with dirty water and mud roads.

"The important thing to remember about triple-combination therapies," says Thurman, "is that given the infrastructure, or lack thereof, of health care and education systems in Africa, it wouldn't matter if we had all the free drugs we could get our hands on. We couldn't deliver them to people under existing circumstances."

It is interesting to note, in this connection, that bubonic plague is alive and well in America today. Several dozen species of rodents and fleas carry it, creating a reservoir of infection as large as in any of the plague centers of the Old World. Undiagnosed, the plague can still kill as many as 60 percent of its victims. Nature has not changed. What has changed is civilization: doctors and drugs and refrigeration and sewage treatment systems and satellite phones and ambulance jets.

In 2000, we know a thing or two about where wealth and innovation come from: profits. The same Clinton Administration that is busy promising to meet the challenge of African AIDS is also busy hammering drug companies for price-gouging. "Brandishing new data showing that the drug industry earns higher profits and pays lower taxes than most other industries," reported The New York Times on Christmas Day, "White House officials say drug companies may bring price controls on themselves if they continue to resist President Clinton's plan to have Medicare provide pharmaceutical benefits." In his campaign, meanwhile, Gore (reports The Times) "portrays himself as the consumer's advocate in Washington against predatory drug manufacturers."

A member of my family is alive today only because the drug companies have managed, just barely, to produce new HIV drugs about as quickly as the virus defeats the old ones. One wonders where, exactly, the President and Vice President believe these new drugs come from.

We also know, in 2000, how poor nations grow wealthier: They trade with rich nations. The Koreans and Japanese and Singaporeans accomplished miracles that way, and Africans can do the same, provided that their exports receive a warm and unstinting welcome in First World markets. Memo to Al Gore and liberals: Opening American markets to Third World exports, rather than closing them while muttering about sweatshops in developing countries, is not just economically sound but morally imperative.

For a while it looked as though capitalist development, beyond a certain fairly rudimentary point, was a luxury. Once people had food to eat and a roof over their heads, what good was it to create millionaires and supply them with yachts? Anyway, there was lots of time to experiment with interesting or convenient or self-serving alternatives: socialism (in the former Communist bloc), protectionist nationalism (in India), cronyism and kleptocracy (in much of Africa).

Surprise. The lesson of the AIDS crisis is that there is not a dollar or a moment to lose. Every forgone increment of economic product makes the AIDS virus -- and Mycobacterium tuberculosis and the cholera bacillus and the malarial parasite -- more deadly. Every deferred decade of development means not just that some people will miss out on Chicken McNuggets and cosmetic dentistry but that millions and millions of people will die.

"Globalization" -- otherwise known as international trade, investment, and development -- is unpredictable, unsettling, unforgiving. It is also the only hope of ensuring that nowhere in the world will the 21st century ever again look like the 14th.