Humanity's Challenge What Each of Us Must Do About the African AIDS Crisis.

Twenty-two million to 25 million people in sub-Saharan Africa are infected with HIV. About 14 million have already died. Millions more will die in this decade. In some African countries, newborns have a 30 percent chance of being infected at birth, and a child a 50 percent chance of dying from AIDS. Millions of children are already orphans, with many millions more to come, and few will have socialization, education, or regular care. Families, communities, the infrastructure of entire nations are being destroyed. There has been a dramatic lowering of life expectancy. The loss of young adults in their prime deprives many African nations of their teachers, medical workers, government employees, police and military, destabilizing the area. Where AIDS has hit the hardest, the social progress and development gains of thirty years are being lost.

Nearly two-thirds of the 36 million people worldwide who entered the twenty-first century infected with HIV live in Africa. Sub-Saharan Africa remains the center of this global epidemic, with AIDS now causing one out of five deaths. Eastern and southern Africa have been hit particularly hard: home to just 4 percent of the human population, these two regions contain over half of all people who are HIV-infected and was home to more than 60 percent of those who have died of AIDS. About 12.2 million African women and 10.1 million men are infected. In Zambia, colleges graduated 300 new teachers in 1999 but AIDS took the lives of 600 teachers. In Kilgali, Rwanda, 34 percent of the people with post-secondary education are infected with HIV--nearly three times the rate for the population at large.

And as appalling as these figures are, AIDS is only part of sub-Saharan Africa's problems. Half of the adult deaths from infectious disease are caused by tuberculosis, while malaria still takes about as many victims as AIDS. And even basic AIDS care is so costly it leeches resources from addressing these other diseases, as well as from social and economic programs. The result is that the current African crisis is a series of interlocking, cascading disasters.

How did the situation become so desperate? It was ignored.

In the first place, the challenge of HIV is far greater in Africa because this is where new variants are emerging. There are many kinds of HIV. North America and Europe have mostly experienced HIV1-B, which is relatively difficult to catch. The United States, for example, has had 1.5 million AIDS cases and 660,000 deaths from HIV1-B. Africa, on the other hand, has to deal with HIV1-A, HIV1-D, and especially HIV1-C, the latter of which is far more virulent and spreading like wildfire. Africa also has numerous new subtypes of HIV1; new chimeric versions, as virus subtypes combine in new, stronger forms; and HIV2. When 25 million HIV-positive people go untreated they become 25 million laboratories in which HIV can continue to evolve into uncountable versions. Thus people who get HIV may have or become infected with other diseases as well. If the United States were facing HIV1-C and other variants on the scale Africa is, could it cope?

Another factor contributing is the fact that the African nations hardest hit have the least resources to tackle the crisis. They don't have enough drugs, funds, health care workers, educators, or commitment--and what few resources they do have aren't always deployed wisely. Economically, the nations of sub-Saharan Africa carry enormous debt, and much of their revenue is committed to military spending. In 1998, African governments spent about $6 billion, largely on waging war with each other. In Zimbabwe alone, the government spends about $1 million a month on HIV and AIDS prevention but $70 million on the war in the Congo.

The challenge to address this massive African health crisis with too few resources has been made all but impossible by the difficulty of altering social behaviors. Traditional sex roles, for example, come into conflict with the changes needed. Males in particular must become part of the solution. They have been socialized to take risks, largely refuse condom use, and feel entitled to exploit women. Sexual practices need to be altered and educational activities and outreach to youth greatly intensified.

Still another factor that exacerbates the situation in Africa is the remorseless pressure of population growth. During the worst pandemic in history, the population of sub-Saharan Africa continues to increase. Population expert Malcom Potts writes: "Despite this devastating impact [of AIDS on sub-Saharan Africa], the population of Africa is set to grow from 750 million today to more than 1.7 billion in 2050 because of the momentum built into the population's youth-heavy age structure."

The situation in sub-Saharan Africa would have been difficult enough had it been decisively confronted twenty--or even ten--years ago. It wasn't. Very few African governments immediately acknowledged the reality of the threat and took effective action. Religious teachings, taboos, shame, and denial created a conspiracy of silence about HIV and AIDS until the epidemic had reached nightmarish proportions.

While Africa has been hit the hardest by this disease--at least 25 percent of its young adults and children are infected--adult prevalence of HIV has topped 1 percent in only a handful of countries. Other nations hard hit are in Central America, the Caribbean, and Southeast Asia, including Guyana and Cambodia, where 3 percent of the adults are infected, and Haiti, where 6 percent are HIV-positive. In most of the world, only high-risk, urban populations have high infection rates.

Perhaps that is what has led most countries--particularly the United States--to respond to the crisis irresponsibly. Many of us in the United States looked upon assistance to Africa as charity that we had a right to offer or withhold; we refused to acknowledge such aid as enlightened self-interest and a human imperative. We acted as if by ignoring the problem it would go away. And this apathy was strongly reinforced by inappropriate and counterproductive attitudes--mostly by religious groups whose talk of sin, blame, and shame promoted silence, homophobia, and racism. These neurotic attitudes contributed to catastrophic delays in recognizing HIV as a species-wide problem and allowed it to incubate to pandemic proportions.

Our irresponsibility, however, extends further. U.S. pharmaceutical companies hold patents on the drugs that prevent the replication of HIV and often can sustain those infected for years. Such medication has often led to the false impression that we've achieved a truce with HIV. Even this halfway technology could have prevented much of the vast suffering of Africa had it been made available. Unfortunately, the drug companies for the most part have refused to produce cheaper, generic versions of the drugs, making them too costly for Africans or their governments to afford.

Recently President Clinton and the United Nations have put pressure on the pharmaceutical companies, and some manufacturers are cutting their prices 70 percent. It may be too little too late. The drugs still have to be purchased with funds yet to be found and delivered in a reliable way to patients in countries where health care delivery mechanisms, some never strong, are unraveled by the deaths of trained personnel.

A deep sense of entitlement has often led those of us in the United States to believe that our "scientific superiority" and "inherent virtue" will lead to a "silver-bullet" vaccine. However, it will be very difficult, if not impossible, to develop a vaccine for a virus that can take uncounted forms. For some time efforts were directed toward a vaccine for HIV1-B, the virus prevalent in the United States, and not for the forms affecting Africans. Work on HIV1-C is now underway, but theoretical as well as technological advances are yet to he made, and vaccine clinical trials take years.

It is folly to suppose that those protean forms of HIV now prevalent in Africa won't affect us in the future. In the year 2000 alone, 552 million people will travel internationally by air. That is how AIDS was transported to the United States twenty years ago. We aren't ready.

Africans and North Americans share four general barriers to dealing rationally with AIDS.

First of all, they both lack strong political commitment. Development experts, writing in the recent World Bank Report on this problem, say that "government commitment to creating an enabling environment for all partners is key." Senator Trent Lott (Republican--Mississippi) says he doesn't think AIDS affects national security. He can't possibly be in possession of all the facts. Senator Dianne Feinstein (Democrat--California) tried to make cheaper drugs for Africa part of the proposed African trade bill, but Congress removed the provision. President Clinton's executive order upholding the provision can be overturned when he leaves office.

Obviously, people in the United States are still very deeply in denial--perhaps catastrophically so. AIDS in this country is already the number one killer of black men and the number two killer of black women between the ages of twenty-five and forty-four, and one of the four major causes of death for whites in the same age range. We can work now to stop new forms of AIDS in Africa or confront them, with vast suffering and difficulty, when they reach our own shores, possibly soon. Government will not protect us.

The second barrier we share is competing priorities. Other health, political, and social problems clamor for our attention, and we haven't yet learned that infectious diseases need to be on the top of the priority list.

Third, Africa doesn't have or can't deploy, and the United States won't commit, enough resources to meet the scale of the crisis. We need to do more and cooperate more effectively.

Fourth, cultural norms and religious beliefs lead to denial of a problem, rejection of those infected, and a refusal to alter behaviors that put people at risk. Religious groups need to work with governments, nongovernmental organizations, health care agencies, and the afflicted instead of being part of the problem.

Far from having a truce with HIV, our encounter with it may have only just begun. There are other emerging diseases to be faced, as well as those for which current drugs are no longer effective. We must learn how to deal with this, and we can by taking five important actions:

* Support scientific research, including scholarships for biomedical students, and stress the importance of addressing Africa's needs.

* Make a firm commitment to providing anti-AIDS drugs and health care delivery to Africans.

* Urge Africans to help themselves, support all effective initiatives, educate and encourage when necessary; credit superior efforts.

* Make ourselves thoroughly informed on the issue (see "Recommended Resources," left). Adequate action wasn't taken two decades ago, therefore the solutions today will require not only heroic efforts on a never before achieved scale of international cooperation but also funding of equal proportions--at least $1 billion a year. "A stitch in time saves nine" but one has to know that the stitch needs to be taken and where. Humanity can't afford to be blindsided again by emerging diseases.

* Press the issue. U.S. citizens should write to their senators and representatives in Congress. Research how they have voted in the past on these critical issues. Tell them AIDS and other infectious diseases must be moved to the top of the priority list. From the list of impediments to anti-AIDS action, select one as your personal concern. Support organizations doing effective work. Increase educational and preventative efforts on a community, regional, and national scale.

Society is not yet ready to deal with the reality of HIV. For all our sakes we can and must prepare.

Recommended Resources for Understanding the Whole AIDS Picture

* Myron Essex's "The New AIDS Epidemic" in the Harvard Magazine, September/October 1999

* Carol Ezzel's "Care for a Dying Continent" in Scientific American, May 2000

* The Harvard AIDS Review, Fall 1999/Winter 2000. Also check the archives at www.hsph.harvard.edu/hai/publications

* International AIDS Vaccine Initiative (summary report of the Eleventh International Conference on AIDS and STDs in Africa, September 12-16, 1999); at 216.150.6.228/5/ index.asp?issue=5.2.5&article=3

* The International Partnership Against HIV/ AIDS in Africa at www.unaids.org/africa partnership/whatis.html; and the speech can be found at www.unaids.org/whatsnew/speeches/ eng/newyork/71299.html

* January 2000 issue of Scientific American: Philip and Phylis Morrison's "Wonders" column: "Roll Back Malaria" and Malcolm Ports' "The Unmet Need for Family Planning"

* Paul Raeburn's "Wanted: Early Warning for Global Epidemics" in Business Week, November 1, 1999

* World Bank Report: "Intensifying Action Against HIV/AIDS in Africa: Responding to a Development Crisis" at www.worldbank.org/aids

Anne Trowbridge is a freelance writer with a special interest in studying and writing on the human social condition. She has traveled widely.