Ever since the International AIDS Conference in Durban, South Africa, in July 2000, world attention has been riveted on the rapid expansion of the HIV/AIDS epidemic across the globe. Of course, troubling news had been coming out of Africa and other regions of the world for some time. But the hosting of the conference in Africa highlighted the growing disparities between the developed world, where antiretroviral therapies are increasingly available, and the Third World where they remain largely unknown.

This series of short articles, some of which were previously published in the magazine A&U_, tackle several of "the big issues" involving the fight against global AIDS. Among the topics explored below are the overwhelming magnitude of the global epidemic, the parallel epidemics in different world regions, how HIV has spread from region to region, the impact of HIV on international relations, and prospects for the future._

76 Miles of Wall: Coming to Grips with the Global AIDS Epidemic

Throughout the epidemic, views of AIDS have often taken two diametrically opposite perspectives -- the highly personalized form of individual stories and memoirs and works of art versus the highly impersonal form of charts and graphs and statistical tables. But are there other ways to attempt to come to grips with the incredible magnitude of the worldwide scope of AIDS, other means of trying to understand the vast numbers involved? Consider the possibility below, one that many Americans can relate to.

In a literal sense, numbers in the millions are beyond human experience or comprehension. But so, too, are numbers even in the tens of thousands. Still, when the number of AIDS deaths in the U.S. hit the 60,000 mark, over a decade ago, a new statistic began to be widely circulated. The epidemic had at that point claimed more Americans than the Vietnam War.

This statistic might seem, on its surface, a bit of a strange -- or perhaps strained -- comparison. What, after all, did U.S. military casualties in a Southeast Asian civil war really have to do with civilian deaths from an immune deficiency. Conservative pundits were, unsurprisingly, quick to dismiss the figure as meaningless.

HIV/AIDS pandemic
The geography of AIDS: While the epidemic is global -- "pandemic" in technical terms -- there are major regional variations.

But many others understood why this was a powerful comparison. First, the death toll of the sixteen-year-long Vietnam War had been deeply etched into the public consciousness as the collective trauma of a nation. Even more importantly, though, evoking the number of deaths in Vietnam was also one way to help people comprehend the scope of mortality figures -- 60,000 individual lives -- that had scaled too high for anyone to meaningfully grasp, except perhaps in the purely abstract.

American deaths in Vietnam became etched in stone, literally, with the 1982 dedication of the Vietnam Veterans' Memorial on the National Mall in Washington DC, which is today the most visited in the country. Nearly two decades after its dedication, the memorial retains its power.

The monument itself is simple: two sheer 247-foot-long walls of black granite meeting at a right angle. The viewer starts walking alongside a low wall only a few feet off the ground inscribed with a handful of names, then walks step after step after step as the wall grows in height and encompasses more and more names -- first hundreds, then thousands, then tens of thousands of deaths.

At the vertex of the two walls, the memorial stretches to more than ten feet high, towering over the viewer. And at that point, the list of names seems to go on forever in either direction. If the viewer still has not grasped the exact dimensions of 58,209 deaths, their sheer magnitude, at least, becomes inescapable.

Now, consider that in the U.S. the cumulative number of AIDS deaths reported to the Centers for Disease Control and Prevention by the end of 1998 was 410,900 -- or the equivalent of over seven Vietnam memorials, a wall which would stretch on for two-thirds of a mile.

And now, consider that AIDS deaths in the U.S. account for only about five percent of the world's totals. A comparable memorial for global AIDS deaths would consist of over 13,900,000 names and would require 238 Vietnam memorials, about 22 miles of wall.

Yet even the number of AIDS deaths to date pales before United Nations estimates of the number of those now living with HIV/AIDS: 33.4 million people. This figure would require nearly 574 additional Vietnam memorials and about another 54 miles of wall.

Thus, in all, a memorial commemorating all those who have had HIV, living or deceased, would require a total of 842 Vietnam memorials or 76 miles of wall. Reading all the names aloud, at one a second, day and night, would take over six weeks.

Such are the basic contours of the global HIV/AIDS epidemic at the start of the twenty-first century. Still, 76 miles of wall is far beyond what the eye can take in, and it would take days to visit 842 Vietnam Memorials. And with 5.6 million people worldwide newly infected with HIV in 1999, some ninety new memorials and nine more miles of wall would have to be built annually. When our rational ability to comprehend numbers fail us, we have no choice but to turn to metaphors and imagery. Yet what does it tell us if, even in the metaphorical realm, the global AIDS epidemic has become too huge to grasp?

The Parallel Pandemic: The Many Global "AIDS Epidemics"

While it is common to speak of the "global HIV/AIDS epidemic," that term obscures as much as it enlightens about HIV in the world today. Consider that all forms of weather are, ultimately, part of one big "global" system -- but that doesn't mean that the weather in Buenos Aires, Kuala Lumpur, and the Aleutian Islands have very much in common. And so, it is more accurate to speak of multiple, separate, if overlapping, AIDS epidemics as being part of one worldwide "parallel pandemic."

In the U.S., many people have long recognized the existence of parallel epidemics among, say, hemophiliacs, gay men, and injecting drug users. These epidemics interact but they are driven by very distinct forces. The same is true, on a far vaster scale, on the international scene. In order to help make sense of this trend, the book AIDS in the World (Oxford University Press, 1996) edited by Daniel Tarantola and the late Jonathan Mann, organizes the globe into 10 "geographic areas of affinity," (GAAs) clustering countries with "similar HIV/AIDS epidemiology, societal factors, and programs for responding to the pandemic." These 10 GAAs offer a cogent guide to the parallel pandemic.

The first three GAAs are the best known to Americans, as they comprise the Western industrialized democracies: GAA1 (the U.S. and Canada), GAA2 (Western Europe), and GAA 3 (Australia and New Zealand). Treatment and prevention services for HIV/AIDS are widely available in these areas and the AIDS epidemic has been somewhat stabilized for the moment. The next best known epidemic to Americans is probably now that of GAA5, sub-Saharan Africa, which is almost the mirror-image of GAAs 1-3: new HIV infections are exploding and treatment -- even basic pain relief -- remains beyond the reach of almost all of the millions of people with HIV/AIDS. But even beyond these two extremes, there are several other parallel courses in the pandemic. Consider AIDS in these other areas of the world:

  • Latin America and the Caribbean: Both in sheer numbers, GAA4 (continental Latin America) and GAA6 (the islands of the Caribbean), are among the most heavily impacted in the world, linked to GAAs1-3 by widespread tourism. Haiti and the Dominican Republic have particularly horrific AIDS epidemics, together accounting for 85 percent of HIV cases in the Caribbean region. The situation in continental Latin America varies, but Brazil has emerged as a regional leader by employing its extensive pharmaceutical industry to provide inexpensive versions of antiretroviral medications.

  • North Africa and the Middle East: The predominantly Islamic nations of GAA5 are by most measures the least impacted in the world. However, serious questions have been raised about whether AIDS is actually much more serious than official numbers indicate in these socially conservative countries, where extramarital sexual activity and all forms of drug use are highly stigmatized and thus hidden. Time will undoubtedly tell.

  • Northeast and Southeast Asia: Although adjacent regions, GAA9 (Northeast Asia) and GAA10 (Southeast Asia) have very different epidemic profiles. Southeast Asia follows only sub-Saharan Africa in HIV/AIDS caseload, most notably in India and Thailand. Throughout the region, HIV is concentrated heavily along drug smuggling routes. Northeast Asia includes Japan and Korea, which in many respects resemble the industrialized democracies, as well as China, in which some regions are relatively insulated from AIDS and others heavily affected. Whether China will follow the model of Japan and Korea or that of its neighbors to the south remains to be seen, but will be hugely important to the future of the pandemic.

  • Eastern Europe and the former Soviet Union: GAA 7 encompasses formerly Communist countries stretching from the Baltic states in the far northwest, to Central Asia in the south, to Siberian Russia in the northeast. This region constitutes a unique one in the world, being the last to become involved in the AIDS epidemic (see more below).

Of course, even this division of the global AIDS epidemic into ten regions only begins to point out the multiple challenges posed by HIV around the world. But these subdivisions can at least suggest that beyond the AIDS epidemic we see around us in the U.S., and the horrible African plague we are increasingly seeing on television, exist many other complex -- and equally urgent -- AIDS crises. (For more on regional differences, see the article from the United Nations in this issue.)

Airplane Hub
Ticket to ride: Historically, many epidemics were contained by slow transportation and long distances -- but not anymore.

Getting from Point A to Point B: What Links the World's Separate HIV Epidemics?

AIDS may be a global phenomenon, but the connections between the various "global areas of affinity" are often far from clear. Yet these are powerful forces, linked to economic and political globalization that are essential to understanding the "global pandemic."

For most of us, it's not hard to imagine how HIV spreads within our own particular neighborhood or specific social group. The microlinkages that bind people together in everyday life are well known to us from our own experience. Much less intuitive, however, are the macrolinkages that can bridge different continents and distinct populations of people. Immigration is an obvious source of population transfer, but in a globalized world, other forces interconnecting such seemingly separate communities -- and separate epidemics -- can be surprisingly powerful. Consider three of the most important: mass tourism, work migration, and refugee displacement.

  • Mass tourism: In the early 1980s, the role of tourism -- particularly so-called "sex tourism" or travel expressly for the purpose of having sex -- was often discussed as a major cause of the spread of HIV. The most notorious case was that of the much-traveled gay French Canadian flight attendant Gaetan Dugas, regarded as the so-called "Patient Zero" of the North American epidemic.

    Yet the Dugas story, like that of sex tourism in general, has been invested with far too much significance. It's highly unlikely that Dugas was the "first" North American with AIDS, and certainly was not the only person to bring HIV to the continent. Sex tourism may have been a crucial link in the very first spread of the virus, and no doubt still accounts for individual new infections. But many major destinations frequented by sex tourists (such as Bangkok, Thailand) have undertaken major safer-sex campaigns. At this point in the epidemic, there's little reason to believe that tourism continues to play a major role in the spread of HIV, at least not relative to the larger-scale population flows discussed below. This explanation for the spread of HIV may appeal to those who see "hedonism" as the root of the AIDS epidemic, but the realities are based in much harsher economic and political realities.

  • Work migration: Dire economic circumstances force many people to spend long periods of time away from their homes and families, whether it be African miners, Indian long-distance truck drivers, Chinese drug smugglers, or Mexican migrant farm workers. In places such as highway stops and farm camps where these migrants gather, far from loved ones and with few sources of entertainment, there can invariably be found rampant prostitution and drug use -- and thus unprotected sex and needle sharing. This is especially true along drug smuggling routes on which the supply of injectable heroin is plentiful but clean syringes scarce.

    Eventually, of course, most migrant workers return home at least for visits, where they can become crucial links to previously sheltered regions. Countless male migrant workers have knowingly or unknowingly infected their wives with HIV, endangering the health both of those women and of any children they may bear. Apartheid-era policies in South African mines provide the worst example of enforced work migration, but such labor patterns are an integral part of an inequitable global economic system. HIV prevention outreach in such settings can help, but real change depends upon systemic reforms on a scale almost no one is even discussing.

  • Refugee displacements: From Angola and Cambodia in the 1970s to Kosovo and East Timor in the 1990s, political turmoil, civil unrest, and outright warfare have a unique ability to displace populations amidst conditions of chaos. Refugees face many of the same problems as migrant workers, yet under even less controlled situations. With armed soldiers on one side and economic desperation on the other, prostitution rings sometimes expand into gigantic networks of sexual slavery. Likewise, rape is increasingly being recognized as a common war crime. Under such circumstances, short-term survival becomes the paramount concern, trumping longer-term concerns about safer sex or drug use. And when outside forces intervene, it's to stop killings or famines with little thought to "secondary" concerns like HIV transmission.

Taken together, mass tourism, work migration, and refugee displacements account for a good deal of the world's exchange of people -- and of HIV. And while it's true that HIV has already spread worldwide, attempting to understand these mass patterns is more than just an academic endeavor. HIV has many clades (subtypes) with different transmission properties that can shift the dynamics of the epidemic as they are introduced into new regions. Similarly, the use of antiretroviral therapies is, inevitably, promoting new strains of drug-resistant HIV (and other infectious agents) that will circulate throughout the world. But perhaps most importantly for the future, the lessons we learn about the spread of HIV may help to stop whatever next great epidemics may be looming over the horizon.

Berlin Wall
The fall of the Berlin Wall in November 1989: When the wall came down, freedom came through, but so too did new opportunities for the spread of HIV.

The Third Wave of AIDS

During the explosive spread of HIV in the 1980s, one area of the world was largely insulated; the region identified above as "Geographic Area of Affinity 7" or the formerly Communist areas of the former Soviet Union and Eastern Europe. But now even they are no longer immune.

The 1999 report by the United Nations Joint Programme on AIDS (UNAIDS) on HIV/AIDS in the formerly Communist countries of Eastern Europe and the former Soviet Union was grim.

"Although current rates of HIV infection in the region are low compared with the shocking rates in some African countries," the report states, "the region is ripe for an explosive AIDS epidemic unless effective preventive measures are urgently put into place. The number of HIV infections in Eastern Europe has increased nine-fold in just three years, growing from less than 30,000 HIV infections in 1995 to an estimated 270,000 infections by December 1998."

The UNAIDS report cites as major factors contributing to the epidemic widespread and worsening poverty, exponentially increased prostitution and injecting drug use, crumbling educational systems, a collapse of the health care system, and skyrocketing rates of sexually transmitted disease -- all amidst an environment in which information about HIV prevention is often nearly nonexistent and effective treatment options are prohibitively expensive.

Of course, on the international scene, most of these problems are depressingly familiar; the world has been hearing about such concerns for years in the context of developing countries around the world. What is different here is the timing: these events are happening in the late 1990s, not the mid- or late 1980s, a fact which may offer some hope for blunting the impact of AIDS in the region.

To understand this timing, it's necessary to realize that HIV/AIDS has broken upon the world in three distinct waves. The first wave focused mainly on the general population of sub-Saharan Africa (the region in which HIV originated) and among certain high-risk, socially marginalized populations in the largest urban centers of the industrialized world. The second wave of AIDS encompassed those regions and populations which were at some distance, either geographically and culturally, from the first wave but whose steady interaction with the first wave allowed for an expansion of the epidemic. The second wave includes parts of Southeast Asia, India, the Caribbean, and Latin America, as well as rural and suburban areas and lower-risk populations in first-wave regions.

The third wave of AIDS, which is breaking upon the world now, focuses mainly on those areas of the globe which were isolated from the first and second waves, sometimes for geographic reasons but mainly for political and historical reasons. Thus, the third wave is primarily striking those countries in Eastern Europe and the former Soviet Union that, until the period 1989-1991, were ruled by Communist systems characterized by closed borders, state-organized economies, and severe restrictions on the flow of information. This tight control allowed for little contact with the outside world in the form of immigration, tourism, trade, or other types of interaction, thus artificially sealing off these countries from the first and second waves of AIDS.

The former Communist systems were economically inefficient and politically oppressive, but nonetheless capable of a certain level of functioning and able to insulate their populations from outside influences, both positive and negative. However, the sheer suddenness and rapidity of the disintegration of Communism after the breach of the Berlin Wall in November 1989 -- six Communist systems fell within a matter of months -- allowed no time for thoughtful or measured transitions to a more decentralized political and economic system.

As a result, the region's pre-existing systems of health care delivery, education, and disease control have in many cases simply collapsed. Thus, while the HIV/AIDS epidemic would inevitably have arrived in the formerly Communist countries, the unique set of prevailing circumstances threatens to lead to an epidemic of catastrophic scope.

Still, even within this context, there is a silver lining: AIDS is not emerging in this region as a mysterious, seemingly inexplicable illness as it did in the first wave in 1981. Today, there is an abundance of solid evidence about how HIV is transmitted and what types of prevention can stop transmission before the epidemic reaches African proportions.

The Western world is often, and quite rightly, criticized for neglecting impoverished regions of Africa, Latin American, and Asia. But the West has proven its willingness and ability to project its influence into Eastern Europe, be it in the form of the expansion of the NATO military alliance and the European Union or through outright military interventions in Kosovo and Bosnia. Will the West do the same for AIDS -- or will it sit by as a preventable epidemic explodes?

Beyond bombs and missiles: National security concerns have traditionally involved military and diplomatic issues, but now include global AIDS.

Viral Defenses: AIDS as a National Security Issue

The disappearance of the Soviet Bloc, and the economic and political disintegration that has followed in many of those countries, has definitively called an end to the Cold War. Yet for many in the U.S., the mentality of the Cold War lives on.

A decade after the collapse of the Berlin Wall -- and much of Communism along with it -- there is almost a nostalgia among some in America for the "simplicity" of the Cold War. Back then, it seemed that "we" were on one side, "they" were on the other, both sides were playing a zero-sum game, and national security was all about atomic weapons and army battalions, nuclear-powered submarines and stealth aircraft.

So it was jarring for some old Cold Warriors to hear that the United States now officially regards the global AIDS epidemic as a threat to national security. Predictably, some of the isolationists who somehow continue to dominate the U.S. Congress dismissed the very idea out of hand. This, said Senate Majority Leader Trent Lott, Republican of Mississippi, was just Clinton's way of pandering to "certain groups."

Many such reactionaries cling to such Cold-War relics as space-based missile-defense systems and denunciations of Castro's Cuba as the cornerstones of contemporary national security. Yet while such traditional anti-Communist concepts of security may be reassuring, geopolitics has never been a clear-cut affair, not even during the Cold War itself.

In tidy retrospect, it's easy to say that the Korean and Vietnam Wars were simply about containing Communism, as were the U.S. decisions to face off the Soviet Union during the Cuban Missile Crisis, to deploy Pershing missiles in Europe, to invade Grenada, or to arm the Nicaraguan Contras and the Afghan Mujahedeen. But in its own time, each of these historic events was bitterly contested, with many sides identifying different implications for U.S. security. Likewise, even at the height of the Cold War, there were many issues that never really fit into the framework of the superpower rivalry: environmental degradation, the population explosion, international trade, decolonization, drug smuggling, and others.

So, it's more than a little disingenuous for contemporary politicians to claim that it is bizarre to think of AIDS as a security issue. HIV may not have the short-term destructive power of a volley of Tomahawk missiles, but it now kills more people than wars each year on the war-torn continent of Africa. HIV may not conduct espionage, but it can and does infiltrate every corner of societies, threatening to wipe out the gains in international development and economic integration that have promoted peace and stability in Europe, Latin American, and Asia. AIDS may have no implications for the spent ideological debate between the U.S. and the USSR, but it can still provide a devastating critique of the indifference of the capitalist system to basic human needs.

For all these and many other reasons, AIDS has suddenly of late become a focus of concern in the security establishment. New funds for combating the international epidemic include provisions for the Department of Defense to assess the impact of AIDS on potential troop deployments and operations. The U.S. Department of State recently updated a report on the "U.S. International Response to HIV/AIDS" outlining the role of the foreign policy apparatus. Last January, the United Nations Security Council held sessions on AIDS, focusing for the first time on a health issue rather than on a conventional military or diplomatic concern.

Most recently, the National Intelligence Council released an unclassified version of a report on the "Global Infectious Disease Threat and its Implications for the United States." Encompassing diseases such as tuberculosis, influenza, hepatitis, malaria, and cholera along with HIV, the report states that "these diseases will endanger U.S. citizens at home and abroad, threaten U.S. armed forces deployed overseas, and exacerbate social and political instability . . ." In particular, the report outlines that infectious diseases may:

  • account for the deaths of at least 170,000 Americans annually;

  • cause more military hospital admissions than battlefield injuries;

  • weaken the capabilities of international peacekeepers, and thus their ability to mount military interventions;

  • reduce the gross domestic product of some countries by as much as 20 percent;

  • cause demographic upheavals, particularly in the form of 42 million "AIDS orphans";

  • cause diplomatic conflict between nations if HIV and other infectious diseases become barriers to immigration and travel;

  • conceivably be developed into weapons of bioterrorism.

Compared to this tangle of political, economic, social, and military issues, the nuclear stand-off of the Cold War may seem appealingly, if misleadingly, simple. But that's no cause for nostalgia about the past or denial about the future.

A world at risk: What will AIDS mean for the future of the global population?

Between Hope and Horror: Future Scenarios of the Global AIDS Epidemic

The need for new thinking, in touch with changing realities and transcending old left-right divisions, becomes clearest when we think about the fact that the horrors wrought by AIDS might just well be the beginning. But at the same time we need to remember that the future is not preordained.

"Steady Progress." "Progress Stymied." "Deterioration then Limited Improvement." With these simple labels, the unclassified version of a national security report sketches out three scenarios for the future of the global HIV/AIDS epidemic that would have profoundly different consequences for the U.S. and the world.

The report by the National Intelligence Council, "The Global Infectious Disease Threat and Its Implications for the United States" is the first widely circulated government report to assess the likely future course of the HIV/AIDS epidemic, along with such other infectious diseases as tuberculosis, malaria, hepatitis, influenza, and cholera.

The first broad finding, known to all those familiar with the global HIV/AIDS epidemic, is that "developing and former Communist countries will continue to experience the greatest impact from infectious disease -- because of malnutrition, poor sanitation, poor water quality, and inadequate health care." Among the regions, trends it identifies are the continuing weaknesses of the health care system in sub-Saharan Africa, the proliferation of multi-drug resistant microbes in Asia and the Pacific, and the explosive spread of infectious disease in the former Soviet Union amidst that region's ongoing economic collapse. It also notes a few bright spots, including progress in Latin America to control disease outbreaks and the insulation of parts of the Arab world due to climate, conservative social mores, and oil wealth.

The report then weaves together these various regional profiles into its three overarching scenarios for the future. The first, "Steady Progress," revolves around a decline of infectious diseases due to aging populations, declines in fertility, advances in general health and living conditions and improvements in medical technology. But the report calls this the "least likely scenario" because of the severity of the demographic and socioeconomic challenges facing developing countries and the increased emergence of drug-resistant microbes.

The second scenario, "Progress Stymied" is described as "more pessimistic -- and more plausible" with "little or no progress in countering infectious disease." In this scenario, "HIV/AIDS reaches catastrophic proportions as the virus spreads throughout the vast populations . . . whole multi-drug treatments encounter microbial resistance and remain prohibitively expensive for developing countries."

Still, the report holds out hope that this scenario will be supplanted by "Deterioration, Then Limited Improvement." Under these circumstances, the world faces a grim decade in the 2000s, but with hope for the 2010s. The next decade would continue to be characterized by grinding urban poverty and overstretched health care systems, with uneven global development causing the poorest countries to become "reservoirs" of infectious disease. But after about a decade, the report is hopeful that the advances described in the "steady progress" scenario can be realized.

This last scenario, hardly rose-colored but also not without hope, is contingent on there being no surprising developments such as the "appearance of a deadly and highly infectious new disease, a catastrophic upward lurch by HIV/AIDS, or the release of a highly contagious biological agent capable of rapid and wide-scale secondary spread."

In short, this period would have to be more like the period 1960-1980, the era of antibiotics and concerted public health campaigns against smallpox and other diseases, than like the period 1980-2000. Such circumstances, however, will not "just happen," but will need to be made to happen. But this is a task of such magnitude that it may seem to be impossible to influence, not much different than fighting the law of gravity or the earth's revolution around the sun.

The "Steady Progress" scenario is dependent upon what the World Bank and World Health Organization characterized as a "health transition" made up of several distinct components, each of which can plausibly if not easily be advanced. Lowered fertility demands family planning education and technology, along with greater freedom for women. "Socioeconomic progress" is simply a blanket term of such issues as food and water safety, improved nutrition, and enhanced literacy. Economic gains must be at or close to the levels found in East Asia, in which real per capita income levels rose 200 percent from 1970 to 1995. Improved health care capacity, most notably immunization programs, prenatal care, drug availability, and contraception, may be most essential of all.

Each of these are tangible, achievable goals. The future is not an abstract inevitability, but a product of the past and the present -- and none of these scenarios are set in stone. There is also no mystery about how to accomplish any of the tasks associated with the so-called "heath transition." What the world needs now is the social conscience, the political will, and the financial commitment to make hopes into reality.

Raymond A. Smith, Ph.D. is the editor of Body Positive_._

Back to the August 2001 Issue of Body Positive Magazine.