Article

The Global Challenge of HIV/AIDS

International Film and Television Exchange And Congressional Human Rights Caucus

Gayle Smith
Gayle Smith

Presentation by Gayle Smith
Senior Fellow, Center for American Progress

Let me begin by thanking the International Film and Television Exchange and the Congressional Human Rights Caucus for focusing on this critical issue. Five years ago, the Clinton administration declared the global HIV/AIDS pandemic a national security threat, generating new interest in some quarters and disdain from many others. But as the Washington Post reported at the time, the threat was real: “Interagency Intelligence Memorandum 91-10005, distributed in classified channels … foretold one of the deadliest calamities in human experience. Titled simply, “The Global AIDS Disaster,” the report projected 45 million infections by 2000 – inexorably fatal, the great majority in Africa. The numbers begged comparison. There were not that many combatants killed in World War I, World War II, Korea and Vietnam combined.”

Today, there is widespread agreement that the HIV/AIDS pandemic does, in fact, threaten the security of countries throughout the developing world and indeed our own. The numbers are staggering, and the resources pledged over the last five years – including through the President’s Emergency Program for AIDS Relief – make clear that the world is paying attention.

But staggering as they may be, the numbers fail to convey the real and much more horrifying structural dimensions of this crisis. AIDS not only kills people, it also hollows out the core of societies, weakening the ability of communities, states and entire regions to forge and maintain the social, political and economic institutions necessary for peace and security.

AIDS kills off the most productive members of society, the able-bodied men and women who work the land and man the factories. It decimates the structure of the extended family by killing off those who care for the young and for the old. It thins the ranks of the lawyers, doctors, nurses, teachers, financial managers and planners who allow states to function.

Its impact is even more severe in situations of conflict, where surveillance is uneven if undertaken at all. No one really knows what HIV prevalence rates are in the Democratic Republic of the Congo, and even in post-war Angola, the ravages of conflict continue to undermine surveillance and treatment regimes. In war zones, HIV is spread, unrestricted, by soldiers and the civilian victims forced to flee their homes. Where predatory movements reign, it is impossible to provide sustained and consistent care and treatment, and even in cases where opposing armies might allow AIDS programs, implementation is rendered uneven.

In essence, the HIV/AIDS pandemic weakens stable and productive states, and undermines efforts to render weak or post-conflict states more secure.

Tackling the structural impact of HIV/AIDS will require more than awareness and an increased budget. This morning I would like to focus on seven key challenges and briefly comment on how we can begin to meet them.

First, we need to turn the conventional paradigm on its head. The HIV/AIDS pandemic is rightly regarded as an emergency, but this designation should not cause us to fashion a response that is more characteristic of relief than long-term development. Looking to the world’s experience in responding to other “humanitarian” disasters, like famines in Africa, we see that while the international community rallies to provide emergency food aid, water and life-saving medical care, it is less able – or inclined – to make the long-term investments required to reverse structural food deficits. I believe that we are at risk of making the same mistake in dealing with the HIV/AIDS pandemic=

It is no coincidence that HIV prevalence is greater in the world’s poorest and weakest countries, for it is in these places that there is little with which to counter the spread of the disease – infrastructure is limited in scope and poorly maintained; health services and educational facilities are limited; budgets are constrained by debt, a reliance on primary commodities, and the skewed terms of global trade.

If we want to avoid the “relief trap” and prevent the state weakness and insecurity that the HIV/AIDS pandemic can sow, we must be prepared to make major new investments aimed at reducing poverty and strengthening the capacity of governments and communities to manage an epidemic that will, tragically, likely be with us for generations to come. This demands that we consider an increase in the overall aid budget and a redoubling of our efforts to erode the gains of global poverty. In particular, it requires that we invest in infrastructure – a sector that the United States has turned away from over the last 15 years. Infrastructure is expensive, but think of the impact – the same physical infrastructure needed for the delivery of vital medicines also serves local trade, the expansion of health and educational services, the investment that these countries desperately need, the movement of humanitarian goods and services in times of crisis, and the basic supplies upon which people depend. It is expensive, but it is a wise investment.

The United States is well placed to take a lead in this regard by endorsing and acting upon the recommendations of the report of Prime Minister Tony Blair’s Africa Commission at the G8 Summit in July.

Second, we must also avoid looking at and responding to global HIV/AIDS as an isolated issue, for by its very nature, the disease has a direct impact on governance, economic development, security, the provision of social services and even basic food production. At present, the HIV/AIDS pandemic is weakening states and communities faster than we can strengthen them.

We are all aware of the threats posed by weak states, as no one can forget that it was from Afghanistan that the al Qaeda network mounted its attack on the United States almost four years ago. And though there are many more Afghanistans out there, few countries are confronting this threat head on, with perhaps the UK’s Department for International Development being the primary exception.

President Bush rightly pointed to the threat posed to America by weak states in his 2002 National Security Strategy, but three years later we have no plan, no dedicated resources, and no evident political commitment to making the investments necessary to counter this threat. Important as it may be to invest in countries that are functioning well, the new Millennium Challenge Account is not the answer, as we must not only invest in capable states, but also invest in making more states more capable.

I would like to here refer you to the report and recommendations of the bipartisan Commission on Weak States and National Security, a project of the Center for Global Development of which I was proud to be a member. As our report demonstrates, the threat is real but the options for tackling it are many.

Third, we need to reconsider our enthusiasm for selectivity. Often, because aid budgets are limited and we want to demonstrate impact, we select individual countries to be aid recipients. As well, and particularly in the world’s poorest regions, we provide little other than humanitarian aid to countries ruled by authoritarian regimes. Though these choices may reflect a particular logic, however, they contradict the logic of AIDS – a disease that knows no borders and threatens equally democracies and dictatorships. We cannot afford to pursue an AIDS strategy that overlooks countries that may threaten entire regions, and where our failure to respond will only ensure that future democratic change is impeded. In light of this fact, I would strongly recommend that future deliberations on PEPFAR include consideration of an expanded and comprehensive focus rather than a country-specific approach.

Fourth, we need to reduce the additional burdens we impose by our failure to coordinate donor assistance, harmonize our policies and standardize our requirements. The Global Fund for AIDS, TB and Malaria was created, in part, to address this problem, and to reduce the management demands of donors upon countries that have limited capacity – and where that capacity is being further eroded by the AIDS crisis. If we really want to help governments tackle the challenges they face, the United States should be doing more, not less, to support the Global Fund, and should use PEPFAR as an instrument for forging greater donor coherence.

Fifth, and in countries at war or emerging from conflict, we should incorporate AIDS strategies into our conflict resolution efforts. During the civil war in El Salvador in the 1980s, for example, UNICEF successfully negotiated “Days of Tranquility” to allow for the implementation of vaccination campaigns. While managing HIV and AIDS requires more than the limited access provided by that model, negotiating “peace corridors” could, for example, allow for AIDS education and treatment along transport routes, within militaries, or among refugee or displaced populations. Similarly, incorporating AIDS programming into immediate post-conflict efforts can allow for the prompt resumption of surveillance efforts while also serving as a non-controversial confidence building measure.

Sixth and finally, if we want to have an impact, we need to use as our guide good science and not ideology. I hope that those of you in attendance have read the recent report from Human Rights Watch entitled “The Less They Know, the Better.” The report chronicles the extraordinary story of how Uganda – the country that proved to the world that a comprehensive approach to HIV and AIDS could reduce prevalence rates by pursing what has been called an “ABC” strategy – “Abstinence, Be Faithful, Use Condoms” – has now issued a draft “AB” policy. The report refers to interviews with Ugandan teachers who report that USAID-funded trainers are encouraging them to omit information about condoms from their educational messages. Combined, the policies being pursued by the Ugandan and U.S. governments are likely to result in a national condom shortage.

Abstinence is a legitimate moral and personal choice – but it does not constitute a health strategy. And for literally millions of women around the world, it is not even a choice. If we really want to win the war against AIDS, and if we believe that it does pose a threat to our national security, then we must use every means available to conquer it. To do less is to condemn millions to death.