DEATH WATCH: The Global Response to AIDS in Africa

DEATH WATCH: The Global Response to AIDS in Africa



Washington Post- Wednesday, July 5, 2000-



By Barton Gellman


First of three articles


From a seventh-floor office in Langley some 13 years ago, Katherine J. Hall kept vigil on the unraveling of societies and states.


As national intelligence officer at large, Hall supervised the CIA's taxonomy of upheaval overseas. What signs forecast a government's collapse, an economy's ruin, a civil war? Hall and her staff had a hunch that conventional indicators, heavy on politics and money, were missing something. In 1990, after three years of frustrated lobbying, she and colleague Walter L. Barrows got permission to study the burgeoning growth of AIDS.


Interagency Intelligence Memorandum 91-10005, distributed in classified channels the following July, 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 number beggared comparison. There were not that many combatants killed in World War I, World War II, Korea and Vietnam combined.


Unlike the Black Death in 14th-century Europe, which took half as many lives, the means of controlling AIDS were known.

Yet African and foreign governments, the report said, were making no more than a "modest level of effort." This would "have only a marginal effect."


The same might have been said for IIM 91-10005. The document landed near the top of the pile of incoming intelligence at the

White House and Cabinet agencies. The reaction, said principal author Kenneth Brown, was "indifference--that's the right word." The authors prepared for the flurry of briefings that accompanies release of a major intelligence product. Save for then-Surgeon General C. Everett Koop and a Pentagon medical unit, no one asked.


Nine years later, a highly public awakening plays out in the Clinton administration, Congress, foreign capitals, the United Nations system and the offices of drug manufacturers. The premise of their new commitments on AIDS is that they are confronted for the first time with the magnitude of the disaster.


Yet for a decade, the world knew the dimensions of the coming catastrophe and the means available to slow it. Estimates ranged widely, but the World Health Organization in 1990 and 1991 projected a caseload, and eventual death toll, in the tens of millions by 2000. Individually and collectively, most of those with power decided not to act.


How and why they made their choices is the subject of this series of articles. It is a story of authentic doubts for a time because the disease concealed itself in years of latency and layers of social taboo. It is also a story, by turns, of willful ignorance and paralysis in the face of growing proof. Its direction is marked by wealthy nations' loss of interest once they understood they had escaped the worst, by racial undercurrents, and by poisonous turf battles among the multinational bodies charged with marshaling a response. At nearly every level, the process featured what some participants now see as shameful "demand management": reluctance to take available steps for fear of prompting still greater claims on time and money.


"The first reaction is, 'That's impossible. We could never spend those kinds of resources,' " said William H. Foege, who directed the federal Centers for Disease Control and Prevention (CDC) until 1983, speaking of 1990s estimates that it would take as much as $3 billion a year to fund global AIDS prevention. "Then you have to remember, that's how much we spend on health care in the United States every day. It makes you wonder what's wrong with us, and how will history judge our response."


If today marks a turning point, it is too late for nearly all the 34.3 million people now living with HIV and AIDS, and for the many who will follow. Fewer than 2 percent of them have access to life-prolonging therapies of antiretroviral drugs, or even basic treatment for secondary disease. "They're all dead already," said one despairing U.S. health official. "They're just still walking around."


Nor has the wave begun to crest. The number of new infections with HIV, the human immunodeficiency virus that causes AIDS, is estimated at 15,000 a day--and still growing. The United Nations has set a goal to cut new infections by 25 percent by 2005, but even that improbable feat would not stop the toll from doubling and doubling again.


"We are at the beginning of a pandemic, not the middle, not the end," said Sandra Thurman, director of the White House Office of National AIDS Policy. "We certainly know before we're able to stop this pandemic we'll have hundreds of millions of people infected and dead, and that's the best case scenario."


James Sherry, director of program development for the Joint United Nations Program on HIV/AIDS, or UNAIDS, finds it difficult to speak of the wasted lives without bitterness.


"I can't think of the coming of any event which was more heralded to less effect," he said. "It still hasn't changed. It hasn't changed. In terms of real redeployment of resources, it hasn't changed. The bottom line is, the people who are dying from

AIDS don't matter in this world."


'Under Their Noses'


The 1990 CIA projection turned out to be optimistic. Less than 20 years after physicians first described its symptoms, HIV has infected 53 million people. So far, 19 million have died, roughly the population along the Amtrak route from New York to

Washington. Especially in Africa, but also elsewhere in the developing world, basic measures of well-being are marching backward. AIDS, by itself, is reversing decades of slow improvement in child survival, adult longevity, educational attainment and economic growth.


When Brown and Hall first proposed to study the phenomenon in 1987, they could not obtain CIA approval for use of personnel and computer modeling resources. Internal critics declared global AIDS an unfit subject of intelligence, or said the impact on U.S. interests would be benign.


Speaking of one military colleague at the National Intelligence Council, Brown said, "His penetrating analysis was, 'Oh, it will be good, because Africa is overpopulated anyway.' Others were saying, 'It may be big, but what are you going to do about it?' " Still others, Brown recalled, discounted the likelihood of damage to allied militaries. If officers began dying of the disease, they said, "That boosts morale, because there's more room for advancement."


Another security official, recalling those debates, said critics reasoned that Africa's limitless pool of unemployed men left armies with plenty of reinforcements. "If you have one 18-year-old with a Kalashnikov [rifle] and he dies, you find another 18-year-old," he said. "The cold truth was that the impact on military stability was minimal."


But the chairman of the intelligence council, Fritz Ermarth, saw a winning argument in the AIDS pitch. "I said, 'This is one of those new-age issues, and nobody else is doing it,' " he recalled.


Ermarth's only hesitation, shared by William H. Webster, then the director of central intelligence, involved the "propaganda liabilities of associating this painful topic with the CIA." Soviet era disinformation charged the CIA with brewing the virus for germ warfare. Barrows remembers anxieties that "somebody would try to imply that we're only monitoring our own dastardly deeds."


In the end the CIA agreed to undertake the work and let the State Department publish unclassified portions as a white paper.

In that form in 1992, it reached a wider readership with predictions of "life expectancy at birth reduced by 15 years or more" and infection rates of "10 to 30 percent of the sub-Saharan African population," both of which closely match today's reality.


By any account, little or no fresh response followed the report.


"You've got to have a critical mass of people that are primed to see a problem like this in strategic terms," Ermarth said. "Just to put the words under their noses . . . doesn't get their attention. It's kind of remote, it's distant, it's not obvious what you do about it anyway. And here you're talking 1991, and that critical mass didn't exist."


In the first U.S. budget submitted after IIM 91-10005, appropriations for AIDS control overseas measured $124.5 million, just over half of what Americans pay annually for baldness therapy. Spending remained flat at that level for seven years. And those budgets, in global context, were considered high. The combined assistance from Europe, Australia and Japan barely surpassed them. The Bush and Clinton administrations entertained no proposal to increase the funding.


Over that seven-year period, as best can be calculated from U.N. data, 17,873,939 men, women and children--three-fourths

of them in Africa--contracted an infection that has or will soon cut short their lives.


Discovery, Doubt, Denial


Summoned by improbable theory, a small team of foreign scientists touched down in Kinshasa, Zaire (now Congo), on Oct.

18, 1983. People were dying mysteriously at Mama Yemo Hospital, the 2,000-bed facility named for the president's mother.

Bila Kapita, chief of internal medicine there, had followed medical reports of a new immune disease identified in San Francisco

and New York. He wanted to know whether he could be seeing it in Zaire.


Peter Piot, a 34-year-old Belgian who had co-discovered the Ebola virus in his twenties, led the team of specialists from the

CDC and the National Institutes of Health. He had been to Mama Yemo in the Ebola days, and he saw at once how much had changed.


"In 1976, there were hardly any young adults there except for traffic accidents in orthopedic wards," Piot recalled.

"Suddenly--boom--I walked in and saw all these young men and women, emaciated, dying."


There was not yet an antibody test for the AIDS virus. It took three weeks of makeshift laboratory work--counting T-cells and lymphocytes in blood samples, confirming secondary infections associated with the new disease--to validate Piot's snap diagnosis. There were some three dozen AIDS cases in the hospital, and they were divided almost evenly between women and men.


The implications staggered Piot and his American colleague, Joe McCormick.


"There were so many women, it said to me it's heterosexual," Piot said. "That means everybody's at risk.. . . Until then I never thought a whole country, a whole population, could be involved."


Few believed the report from Zaire. The illness had been known since 1981 as Gay-Related Immunodeficiency Disease. Only homosexual contact, apart from direct exposure to infected blood, was thought to transmit the virus.


Piot, Kapita and McCormick found their submission rejected by a dozen medical journals. Peer reviewers asserted adamantly that the team must have overlooked some alternate path of transmission. At the first international AIDS conference two years later in Atlanta, "people came up to us and said this is nonsense," Piot said. "Denial has been a characteristic of this epidemic at all levels."


Governments shared much of the same disbelief. The first reports of AIDS closely followed the inauguration of President

Ronald Reagan, whose "family values" agenda and alliance with Christian conservatives associated AIDS with deviance and sin.

"AIDS is God's punishment," Rev. Jerry Falwell said in a famous 1983 television sermon, paraphrasing liberally from Galatians

6:8. "The Scripture is clear: We do reap it in our flesh when we violate the laws of God."


McCormick, Piot's CDC colleague on the Kinshasa trip, asked the Reagan administration for funding to return to Zaire to conduct a larger study. According to Laurie Garrett, author of "The Coming Plague," political appointees turned McCormick down, refusing to believe his finding that "AIDS can be, and is, a heterosexual disease."


The Fears of the Rich


Projet SIDA, after the French acronym for AIDS, went forward in Kinshasa without White House help, despite McCormick's plea. Leading it, fresh from a public health surveillance post in New Mexico, came a young American doctor who would transform the global AIDS campaign.


Jonathan Mann, then 37, brought passion and meticulous energy to the job. From 1984 to 1986, his small team traced widening circles of infection, without apparent social boundaries, in Zaire. "The harder Jon and his team looked for identifiable risk factors, the more they came to realize the worst," Robert W. Ryder, who took over the project from Mann, wrote later.

"The risk factors for HIV infection in Kinshasa were being young and sexually active and living in Kinshasa."


One unknown variable stood out when scientists gathered in Bilthoven, Netherlands, in 1986. "You need to know who is having sex with whom," but few human interactions are so bound up in concealment and taboo, said Bernhard Schwartlander, now chief of epidemiology at UNAIDS. "The big problem is that we had no idea of the mixing patterns."


This much was clear: With heterosexual transmission established, AIDS might go anywhere. Mann became convinced the disease had "transcendental importance" and compared it to tectonic forces shaping a continent. He was a persuasive salesman, and two years of evidence gathered in Zaire pierced the complacency of many governments.


Early in 1986, the World Health Organization in Geneva still regarded AIDS as an ailment of the promiscuous few. Halfdan

Mahler, the organization's Danish-born director general, enraged Piot with a casual suggestion in one early meeting that other diseases were far more important than AIDS.


Fakhry Assaad, Mahler's chief of infectious diseases, was beginning to disagree. He knew Mann's research, and the two men made common cause at a conference that year in Bangui, Central African Republic, where the din of a tropical downpour on a sheet iron roof broke up the proceedings and gave them time to talk. Assaad brought Mann to Geneva in November. In a two-hour conversation, the charismatic American upended Mahler's view of the world.


AIDS was not merely another infectious disease, Mann argued. It seemed to flourish in--and reinforce--conditions of poverty, oppression, urban migration and social violence. It therefore could not be solved as a biomedical problem. Women who feared a beating would not ask their husbands to use condoms. Street children and widows without rights of inheritance could not reduce the number of their sexual partners if they depended on sex for subsistence.


In an interview with filmmaker Robert Bilheimer before Mann's Sept. 3, 1998, death in the crash of Swissair Flight 111, Mann said discrimination "isn't just an effect, it's actually a root cause of the epidemic itself."


Mahler later described himself as transformed by Mann's analysis. On Nov. 20, 1986, less than three weeks after meeting

Mann, the WHO leader flew with him to New York for a news conference. A few minutes before 1 p.m., they walked together into Room S-0226 at U.N. headquarters.


"We stand nakedly in front of a pandemic as mortal as any pandemic there has ever been," Mahler declared. "In the same spirit that WHO addressed smallpox eradication, WHO will dedicate its energy, commitment and creativity to the even more urgent, difficult and complex task of global AIDS prevention and control."


Those were stunning words from a man who had helped make the smallpox program the organization's greatest achievement, then or since. Back in Geneva, he put Mann in charge of a special program on AIDS that bypassed WHO's chain of command.

Mann's operation grew headlong from a single room and secretary to one of the organization's biggest programs.


"It was such an incredible turnaround," recalled Kathleen Kay, an Australian who became Mann's first hire and longtime deputy. The first year, 1987, brought a crescendo of political and financial commitments, including a special session of the U.N.

General Assembly. January 1988 saw the largest gathering of health ministers ever assembled, 118 in one room.


"We went into that meeting at minus $500,000 and we left with $37 million," said Kay, who is now writing her doctoral dissertation on the period. The program grew as fast as it could absorb people and cash, and often faster. Contributions from the U.S. Agency for International Development--the largest of any nation--began at $6.6 million in 1987 and more than doubled in each of the next two years.


But the seeds of Mann's undoing, and the program's, had already been sown. Abundant resentments in the WHO secretariat began to surface after Mahler's surprise decision to retire in 1988. Mahler's replacement, Hiroshi Nakajima, had been director of Pacific operations for the WHO and shared general displeasure at Mann's privileged status and unorthodox style. A master of back-room maneuvering, Nakajima began to clip the AIDS program's wings.


By 1990, the sense of urgency about AIDS in wealthy nations had also started to dissipate. "In the '90s it became clear we were not going to have a major heterosexual epidemic in the States," said Michael Merson, who would succeed Mann at the

WHO program. AIDS "was no longer a threat to the West."


Foege, the former CDC director, now teaches at Emory University. He has a maxim for his public health students: "Tie the needs of the poor with the fears of the rich. When the rich lose their fear, they are not willing to invest in the problems of the poor."


'Like a Slow Torture'


Albina du Boisrouvray, a French countess who auctioned off a Renoir and tens of millions of dollars' worth of jewelry at

Sotheby's to fund her philanthropy against AIDS, remembers traveling to Geneva to confront Nakajima early in his term at the

WHO. "I said, 'Aren't you worried about AIDS?' He said, 'Ah, don't talk to me about AIDS; I have malaria, which is a much

bigger killer of people, on my hands.' "


And for a time, malaria was. But AIDS was growing exponentially; malaria was not. As a scientist, Nakajima understood the implications. But a U.S. official who worked with him then said Nakajima concentrated on the constituency politics of reelection. That meant providing money for popular programs, not drawing attention to a problem that few nations wished to acknowledge.


"It was all demand management," the U.S. official said.


Inside Nakajima's secretariat, institutional rivals of the AIDS program told him that Mann's program was excessive for the tiny number of AIDS cases that could be proved, according to WHO senior manager Marjory Dam. Nakajima set out to "normalize" the special program's status, cutting resources and subjecting it to layers of unsympathetic management.


A week or so before the first World AIDS Day summit on Dec. 1, 1988, Mann obtained an advance transcript of an interview

Nakajima had given to the French newspaper Le Monde. He was appalled. Among other things, Nakajima implied the need for balance between the rights of AIDS patients and the interests of society at large. Mann saw that as a green light for the kinds of bans on immigration and employment of people with AIDS that WHO experts said were driving the pandemic underground.


According to Kay, Mann's deputy, Mann made urgent efforts to reach Nakajima, who was traveling. The director general's new aides rebuffed him, pointedly. Kay, who witnessed what came next, said Mann then delivered an ultimatum: If Nakajima's remarks were published, Mann would quit--in his keynote address to the coming summit. Nakajima could not afford such a spectacle. He retracted and rewrote his remarks to Le Monde, and Mann never mentioned them again. But Nakajima would not forget.


Mann found himself excluded from meetings. The legal authority to spend his budget sat unsigned on Nakajima's desk. His travel requests were denied, anonymously and without explanation, or granted too late to matter.


"The WHO's AIDS program pretty much fell apart," said Thurman, the White House AIDS director.


On March 16, 1990, Mann took defiant leave of the scene. At the very hour that Nakajima unveiled six ceremonial stamps for the fight against AIDS--an apt symbol of the director general's priorities, Mann believed--Mann convened his staff just across the hall. He told them he was quitting. His letter to Nakajima cited "great variance between our positions on a series of issues which I consider critical for the global AIDS strategy."


Nakajima did not return telephone calls seeking an interview for this article. His wife, Martha Nakajima, reached at the couple's summer home in Chauvigny, France, said he was not "particularly interested in rehashing things with Jonathan Mann.. . . He's retired now. He doesn't owe anybody anything on that."


Kay, who quit the program with Mann, recalled those years as "just soul-destroying." She added: "To see the structures

grinding to a halt. Just dreadful. All those years lost! It was like a slow torture."


Mann intended to depart in June, but on March 23 Le Monde published an interview in which Mann accused Nakajima of

obstruction that "paralyzed our efforts completely." He was ordered to clear his desk by the end of the day.




The World Health Organization was not the only agency trying to protect its resources from the demands of AIDS. Most major contributors to global health and development followed the pattern.


Throughout the early and mid-1990s, the Clinton administration debated the merits of paying for AIDS testing and counseling of vulnerable populations overseas. Among gay men in the United States, such programs had been credited with causing substantial change in risky behavior--increasing condom use and marginalizing the culture of promiscuous "bathhouse" sex.


The CDC and U.S. Agency for International Development (USAID) held out for years against paying for AIDS tests overseas. The only exception was traditional "surveillance" to track the pandemic's growth, but those results remained anonymous. Individuals who tested positive were not informed.


"The argument was that testing was too expensive, and it led to things that were more expensive," said Gregory Pappas, a physician and Health and Human Services official who took part in the debate in those years. "The philosophy in development circles was, don't create demand. The implications of a lot of people knowing that they have HIV, instead of just dying of it, is [that] it creates demands on the development assistance agencies. It's a calculation that they're trying to postpone paying for interventions that they don't think they can afford."


Beaten down by years of congressional attacks on foreign assistance, and on family planning especially, USAID did not propose budget increases to contend with AIDS. In international forums, participants said, the agency concentrated on limiting the U.S. contribution to 25 percent of the global total. Other countries, and U.N. agencies, were spending so little on AIDS assistance that the American share climbed as high as 47 percent by 1997.


In truth, the principal U.S. foreign aid agency was trying to disentangle itself from mandatory funding of AIDS programs. Mann, who had taken his charismatic advocacy to Congress in the late 1980s, had persuaded appropriators to earmark portions of the agency's budget for his Geneva-based program. According to interviews and internal memorandums made available to The Washington Post, USAID focused much of its legislative energy on eliminating or reducing the earmark in order to recapture control of its budget.


Duff Gillespie, who oversaw AIDS assistance as director of USAID's programs on population, health and nutrition, argued that overpopulation was overwhelmingly the most important problem for Africa. "Duff was very much worried about not letting the population budget be used for AIDS," said Merson, who succeeded Mann as chief of the WHO program.


In a revealing memorandum composed in March 1998, Gillespie tried to explain "the lack of political will and resources to combat the spread of HIV." He emphasized the importance of remembering that "decisions made by policymakers and program administrators are almost always based on a rational process." It would be wrong to suppose that such decisions were "based on gross ignorance, or morally bankrupt." Most commonly they were "simply the product of a different world view and set of priorities."


When decision makers divided their available funds for foreign aid, he wrote, the AIDS pandemic had many disadvantages.

There was no tool available that "directly and invariably" prevents transmission. There was no cure. Costs of AIDS programs were high, and the afflicted populations often lacked "an inherently sympathetic 'victim.' "


Nor, in the view of Gillespie and many other foreign aid professionals in the 1990s, were AIDS interventions cost-effective. To save the life of a dehydrating child with diarrheal disease required little more than a foil packet of salts. Antibiotics cured an otherwise fatal case of tuberculosis. What USAID and other agencies craved were programs that would demonstrate efficacy in congressional audits.


"Do we enter into fields where our interventions have the biggest bang for the buck?" asked Dennis Aitkin, a British career administrator at the WHO. "If tomorrow there was disease out of the blue that you could cure with a hundred million dollars per person, would we focus on it at all?"


At UNICEF, the U.N. children's agency, the health division fought a bitter rear-guard battle from 1992 to 1994 to avoid involvement in AIDS. Sherry, the director of program development at UNAIDS, was then a senior health administrator at

UNICEF, and used the post to expand UNICEF's traditional early childhood mission to include teenagers contracting a sexually transmitted plague.


In a small sign of things to come, Sherry's secretary quit because he was asking her to handle correspondence mentioning condoms. Then UNICEF's child immunization department organized a mass threat to resign. "Why are we jeopardizing our relations with the Holy See?" one angry colleague demanded of Sherry, referring to Vatican opposition to birth control.


At the World Bank, an internal study found what South African economist Alan Whiteside ridiculed as a "silver lining" in the plague. "If the only effect of the AIDS epidemic were to reduce the population growth rate, it would increase the growth rate of per capita income in any plausible economic model," said the June 1992 report by the bank's population and human resources department. Exactly that had happened in the 14th century, the report said, with the bubonic plague. The report did not conclude that AIDS would be a benefit to Africa, even in strictly economic terms, but it hardly marked a clarion call to action.


"Only the World Bank would put that on paper," Whiteside said.




By the middle 1990s, two new trends took shape. In the wealthy industrialized nations, effective drug therapies against AIDS became available--AZT as early as 1987, then combinations of antiretroviral agents in 1996. The new drugs offered hope that fatal complications might be staved off and AIDS rendered a chronic condition. In theory, the drugs gave authorities their first plausible lifeline to AIDS victims overseas as well. In practice, they diminished the urgency of the enterprise by convincing the developed world that it would escape the pandemic without grave effects.


Until the advent of these therapies, said David Nabarro, then chief of health programs for the British Department for

International Development, one obstacle to AIDS assistance was "the notion that if you got the virus, there was [nothing] that could have been done for you." Now that effective prevention and treatment had come of age, the wealthy nations had to decide what they thought a life saved in Africa was worth.


"The bottom line," Mann told his filmmaking partner, Bilheimer, "is that the epidemic could rage on in Africa and we could control it here. . . . We're the rich United States. Do we need Africa?"


Policymakers did not contemplate attempts to bring the expensive new drug cocktails to Africa, in part because of the pharmaceutical cost and in part because most of the continent lacked the health care apparatus to dispense them.


"Transplantation of Northern interventions to the South," Gillespie wrote, would "siphon off resources" with "limited or no impact on the course of the pandemic."


Mann's departure from the WHO, meanwhile, had not halted the AIDS program's slide. Although he tried to be a good soldier, Mike Merson was as frustrated as his predecessor had been.


To open the ninth international conference on AIDS in Berlin on June 7, 1993, Merson unveiled new research--based in part on work at the London School of Hygiene and Tropical Medicine--that calculated for the first time what it would cost to prevent half of the 20 million new infections projected by 2000: $2.5 billion a year, or about 20 times the global AIDS budget.


"The world can find this kind of money when it wants to," Merson said.


Such sermons tended to be preached to the faithful. Who else attended AIDS conferences? In many governments, officials of the era still professed to be unaware of the pandemic. "From the U.K. perspective, there was absolutely no sense that AIDS would become the critical emergency it has become at the moment until 1994, 1995," said Julia Cleves, who worked for the

British Department for International Development.


In Geneva, epic struggles were underway to control the bureaucratic turf around AIDS. The U.N. Development Program, in particular, attacked Merson's program as hopelessly focused on biomedical needs, ignoring the roots of AIDS in underdevelopment. Kathleen Cravero, a Merson aide, became his intermediary with officials with whom he was not on speaking terms.


In 1994, donor governments began pushing for creation of a joint U.N. AIDS program. Two years passed in further acrimony over control of its funding and administration. The WHO spent many months, for example, attempting to impose language saying it would "administer" the program rather than offer "administration in support" of it--at bottom, a question of power.


The World Bank, one of six cosponsors of the joint program, emphasized that it would "assume no liability" for UNAIDS and wished to have "as little involvement as possible" in the new unit, according to memos in 1995 from legal adviser Louis Forget and human development director Richard Feachem.


When UNAIDS was finally established on Jan. 1, 1996, its ostensible partners cut back sharply on the resources and personnel they devoted to AIDS. World Bank loans dropped from $50 million to less than $10 million, WHO spending dropped from $130 million to $20 million, UNICEF from $45 million to $10 million, and so on.


Inside UNAIDS, advisers to Peter Piot--the Belgian virologist, who had become its first director--were speaking of a "syndrome of abdication."


The summer of 1998 brought a new director general to WHO, former Norwegian prime minister Gro Harlem Brundtland. In early speeches and her first two reports on the state of health in the world, she emphasized tobacco and tuberculosis and seldom mentioned AIDS.


In an interview at her headquarters, Brundtland said AIDS had already been identified by U.N. member states as a global health priority, and in any case Piot's UNAIDS program operated side by side with her in Geneva. "If I had announced that my major priority for WHO would be AIDS," she said, everyone would have assumed she planned to refight her predecessor's battles with the program. "I was absolutely certain that to create a stir-up which would be interpreted as infighting would be the last thing we should do," she said.


Last year, HIV/AIDS reached a long-expected milestone in the WHO's surveillance of disease and death: It surpassed all other causes of death in Africa. That fact was nowhere mentioned in the text of Brundtland's 1999 World Health Report.


At UNAIDS, officials drafted a press release and urged the WHO to publish it.


Schwartlander, the senior epidemiologist at UNAIDS, also prepared a briefing slide on the new mortality data for use by his sister organization. Brundtland's organization released neither document, and mid-level officials said new prominence for AIDS would bring pressure on other health budgets in rival departments.


Today, in a secretariat of 2,000, the WHO has nine professionals who work full time on AIDS.


Black and White


The CIA updated its AIDS projections in two major studies after 1991. National Intelligence Estimate 95-5 largely reaffirmed the earlier results and noted that the world spent 10 percent of its AIDS prevention budget "in developing countries, where 85 percent of all infections occur." That report had no more impact than its predecessor, except on military planners who learned of the disease's implications as "a potential 'war-starter' or 'war-outcome-determinant.' "


The next major AIDS study came in National Intelligence Estimate 99-17, released in unclassified form in January. That one resulted from, and intensified, a sudden urgency in the Clinton administration to act. No important feature of the epidemic had been discovered in a decade. What mobilized the government, after seven years of modest effort, has been difficult for its policymakers to identify.


Nowadays Treasury Secretary Lawrence H. Summers and national security adviser Samuel R. "Sandy" Berger often speak publicly about AIDS, and both have pressed for increased resources. In January, the U.S. ambassador to the United Nations,

Richard C. Holbrooke, orchestrated a special session of the U.N. Security Council to discuss AIDS.


Holbrooke announced his plan to focus on Africa late last year. Arriving on the continent for a preparatory visit, Holbrooke said in an interview, "it occurred to me we were going to have the presidency of the Security Council in January, the first month of the new millennium. We needed a theme."


Looking around the policy landscape, Holbrooke came to see AIDS as "the most important problem." He found an ally in Leon Fuerth, national security adviser to Vice President Gore. Holbrooke proposed a visit by Gore to the council to "really dramatize" American urgency. It did not hurt his proposal, other officials said, that Gore had been tormented by AIDS activists in his campaign for the Democratic nomination for president.


On Jan. 10, Gore strode into the 4,086th meeting of the Security Council and spoke of the world's moral duty to "wage and win a great and peaceful war" against AIDS.


"Today, in sight of all the world," he declared, "we are putting the AIDS crisis at the top of the world's security agenda. We must talk about AIDS not in whispers, in private meetings, in tones of secrecy and shame. We must face the threat as we are facing it right here, in one of the great forums of the earth--openly and boldly, with urgency and compassion."


Thurman, the White House adviser, attributed some of the new energy to the emotion of visits to Africa by executive and legislative delegations in 1999. Gillespie, who acknowledges past skepticism on the severity of AIDS, said the calamity's impact on policy is inevitably greater than any hypothetical prediction. "In a policy position you learn a healthy skepticism for all the [projected] numbers," he said in an interview. "If you look at all the studies on [ideas for] reducing mortality and you add them all up, you've saved every life about three times over."


In the wealthy nations, many AIDS authorities suspect, the place of Africa at the center of the pandemic accentuated such skepticism or muffled the urgency of the response. In and out of Africa, it is seldom possible to discuss the matter without touching the question of race.


James Love, an authority on global drug markets, imagines a " '30 million white people' test" by which to measure the urgency of the wealthy nations. "You'd move, kind of like it was an emergency," he said.


Piot, the UNAIDS chief, said he has no doubt that "if this would have happened in the Balkans, or in Eastern Europe, or in

Mexico, with white people, the reaction would have been different."


Sometimes the analysis is more conspiratorial. Last month, the International Labor Organization recruited Namibian President

Sam Nujoma to unveil new measures to combat AIDS. The official record reflects a sober package of proposals prepared for

Nujoma's June 8 speech in Geneva. In fact, Nujoma angrily set the sheaf of papers down on the lectern without reading them.


What he actually said was this: "We in Namibia are the sufferers of this dreadful disease. It is also a historical fact that

HIV/AIDS is a man-made disease. It is not natural. States that produced chemical weapons to kill other nations are known, they are probably represented here, they know themselves, too." Those countries unleashed the plague, he said, and they should cure it.


A Magic Bullet?


Global AIDS has reached a moment of unaccustomed prominence. Heads of state speak its name, and Piot--once unable to publish his Kinshasa results in professional journals--is now the subject of admiring notice in the pages of Vanity Fair.

Pharmaceutical companies are deep in talks with African governments over discounts they may offer for HIV drugs.


The Clinton administration, which added $200 million to global AIDS prevention last year, is preparing proposals to add another $250 million, according to knowledgeable officials. Half a dozen proposals in Congress, representing Republicans and Democrats both, contemplate still higher spending. President Clinton plans to press allies at the G-7 summit of industrialized countries later this month to give major new emphasis to the pandemic as well.


Will the belated awakening bring real change? The answer, according to many experts on the disease, depends in part on abandonment of the quest for what Merson--now dean of public health at Yale--calls "a magic bullet."


Governments in Africa and elsewhere repeatedly have pinned their hopes on a technical fix for AIDS--a vaccine, or a natural plateau in infections, or an effective pharmaceutical cure--that would enable them to sidestep the more painful measures that authorities say are required.


But among AIDS experts there is a near-consensus that combating the disease requires governments to interpose themselves into controversies of sex, injected drugs and other taboos. It also requires costly change in economies and national cultures.


"We know what works," said Piot, who has spelled out the program in increasing detail since taking his UNAIDS post in 1996.

"We know what to do."


The job is first of all for Africans to undertake, said Malegapuru Makgoba, president of South Africa's Medical Research

Council. "I am tired of hearing that the international community is slow when governments on this continent are irresponsible," he said. Nearly every authority believes, even so, that those governments will need outside help.


In some respects, experts say, addressing AIDS demands a new set of considerations in the effort to build modern economies.

Pressures from international lenders to forge the institutions of an export-driven market, for example, have sometimes led to cuts in social spending in Africa and to patterns of urban migration that spread the disease.


"Why are there still truck routes from Durban to Johannesburg, instead of breaking them up?" demanded Paul Pronick, a Canadian volunteer physician in South Africa's rural Northern Province. "Why are we still allowing three or four thousand men to live in barracks [around mining sites] with no social life?"


A multibillion-dollar prevention program in sub-Saharan Africa, according to plans now under preparation by the White House, World Bank, USAID and UNAIDS, would include hundreds of millions of dollars in youth-focused education, intensive counseling of sex workers, provision and "social marketing" of condoms and much more aggressive treatment of lesser venereal diseases, which speed transmission of AIDS. Other programs would provide low-cost drugs to slow transmission of the virus in childbirth, blood testing and improvements in blood bank quality controls.


Each of these methods has been validated in test programs, and most of them are features of Africa's two exceptional successes: Uganda and Senegal.


But until recently, none of this was contemplated on a scale large enough to make a difference--not by most African governments and outside donors, many of whom persisted in hoping for a technological fix.


Gillespie, the USAID official, summarized American policy in a memorandum in December 1998: to "buy time until a vaccine or some other yet-to-be-identified tool becomes available." Frank Dobson, the British secretary of state for health, expressed similar views the same year. The hope dates back even farther. AIDS research pioneer Robert Gallo and HHS Secretary

Margaret Heckler spoke optimistically of an AIDS vaccine within two years. That was April 23, 1984.


A vaccine would, of course, make a difference. But many authorities still regard it as a mirage, even if the science and mass production problems were solved. Few countries in the developing world have the records, roads, facilities and trained personnel to locate, much less inoculate, all their citizens. That kind of infrastructure does not spring up quickly, even with money.


By way of analogy, Daniel Tarantola at the WHO cites a massive effort since the 1970s to inoculate every child against such common killers as measles. "Immunization efforts have been going on 20 years and you still have countries with 40 or 50 percent coverage," he said.


The world's great vaccination triumph is smallpox. Edward Jenner, the 18th century Gloucestershire physician, demonstrated in

1796 that a weakened strain of the virus extracted from cows would build immunity in humans. He published his findings two years later.


In time the smallpox vaccine came into wide use, and a mass killer was expunged from humankind. It was 1979 when the world reached that milestone, 183 years after Jenner solved the problem in his lab.


Staff researcher Robert Thomason contributed to this report.


About This Series


A decade after an unprecedented health crisis was forecast for Africa, AIDS has killed millions of Africans and threatens to kill tens of millions more. Meanwhile, from policymakers in the world's richest capitals to leaders of the most affected countries, the response to the disease has been marked largely by inaction, indifference and self-interest. This series examines the decisions--and missed opportunities--at the international, national and community level that have shaped the advance of AIDS across the continent most affected by the disease.


A Difference of 15 Years


In 16 countries, all in sub-Saharan Africa, more than one in 10 adults is infected with the HIV virus. In seven of those nations, one in five carries the deadly virus.


The worst affected


Adult infection rate as of December 1999


Botswana 35.8%


Swaziland 25.3


Zimbabwe 25.1


Lesotho 23.6


Zambia 20.0


S. Africa 19.9


Namibia 19.5


Malawi 16.0


Kenya 14.0


Cent. Afr. Rep. 13.8


Infection rates elsewhere for comparison:


U.S. 0.61%


India 0.70


Thailand 2.15


Brazil 0.57




Population 109 million (50.7 million adults)


2.7 million people infected (5.06 percent of adults)


Most West African nations show relatively low infection rates, but experts worry that the virus could spread rapidly among Nigeria's huge population. Some urban areas show much higher infection rates.




Population 9 million (4.1 million adults)


870,000 people infected (19.95 percent of adults)


There are early signs that Zambia is following Uganda in fighting the epidemic. The HIV rate among pregnant 15- to

19-year-olds in Lusaka, the capital, has dropped by almost half from 1994.




Population 1.6 million (775,000 adults)


290,000 people infected (35.8 percent of adults)


The country has a well-developed road system and is a hub for truckers from across southern Africa. This high mobility of people facilitates the spread of HIV. Although relatively prosperous, Botswana has spent little on anti-HIV programs.


South Africa


Population 39.8 million (20.6 million adults)


4.2 million people infected (19.94 percent of adults)


More people are infected with HIV in South Africa than in any other nation, and the infection rate is among the fastest growing in the world. Anti-AIDS programs are mired in controversy.


Uganda Population 21.2 million (9.2 million adults)


820,000 people infected (8.3 percent of adults)


Uganda was the first African government to respond aggressively to the danger of AIDS. A prevention drive cut the infection rate from 14 percent in 1990.




Waking Up to Devastation


U.N. epidemiologists predicted in 1991 that by the end of the decade, 9 million people in sub-Saharan Africa would carry the HIV virus, which causes AIDS. Current figures are 21/2 times that high. Unless a large-scale anti-HIV/AIDS campaign is launched, experts fear that 50 million people worldwide could be living with HIV by 2005. Industrialized donor countries contributed about $350 million last year to fight AIDS overseas, half of it U.S. money.


Cost of treatment


The U.N. AIDS office has estimated that at least $1 billion is needed to establish an effective HIV-fighting program in sub-Saharan Africa. U.N. epidemiologists estimate that it would cost between $1,400 and $4,200 a year per patient in sub-Saharan Africa to treat the infection and the disease effectively with antiretroviral drugs.


Funds available


In 1997, the United States spent $7 billion in development aid overseas, with $121 million of it going toward fighting AIDS.

Only last year were appreciably more funds allocated. U.S. funds to fight the epidemic now make up about half of all donor nations' contributions.


NOTE: All infection rates are based on estimates. The vast majority of sub-Saharan Africans are never tested for HIV and do not know if they carry the virus. The only basis available to UNAIDS are tests from prenatal clinics and tests administered to

people in high-risk categories, such as sex workers.


SOURCES: UNAIDS, USAID, private foundations


AIDS in Numbers




In sub-Saharan Africa, a higher proportion of women than men live with HIV infection or suffer from AIDS. The infection rate

is particularly high among girls.*


Number of people living with HIV/AIDS, in millions


Women Men Children under 15


Sub-Saharan Africa 12.9 10.6 1.0


Total: 24.5 million


Worldwide 15.7 17.3 1.3


Total: 34.3 million


* Male to female infection is more likely than female to male, particularly among girls who are physically not fully developed.

Also, young girls often have sexual relations with men in their 20s and 30s who often already are infected.




5,500 people die of AIDS in sub-Saharan Africa every day -- the equivalent of almost half the student body of Howard University or American University. By 2010, about 13,000 people will die daily of AIDS.


Sub-Saharan Africa Elsewhere


People who have died since the start of the epidemic: 11.5 million 7.3 million


18.8 million total


People now living with HIV/AIDS: 24.5 million 9.8 million


34.3 million total




AIDS has created 13.2 million orphans, most of them in sub-Saharan Africa. By 2010, UNAIDS estimates, there may be 42

million orphans -- the number of children in the United States living east of the Mississippi.


Number of orphans*


12.1 million in sub-Saharan Africa


1.1 million in rest of world


* Children who have lost their mother or both parents to AIDS


Life expectancy


Life expectancy, already cut by AIDS in many sub-Saharan countries, is expected to fall further by 2010.


SOURCES: UNAIDS, staff reports


The Impact of AIDS


Population structure


HIV will change the composition of populations in countries with high infection rates. AIDS deaths will radically shrink the proportion of women older than their early 20s and men older than their early 30s.


Labor Cost


The cost to government and private employers of the labor force is rising because of higher insurance premiums and costs of training new workers, faster turnover and absenteeism due to HIV and AIDS.


Distribution of the added cost in Kenya, in percent


52% Absenteeism due to HIV/AIDS


23% Labor cost*


13% Absenteeism due to funeral attendance, burial costs


12% Health care


*Includes extra training, recruitment costs, productivity loss of new employees and other labor turnover costs


Work Force


Some companies in sub-Saharan Africa have begun to hire two or three employees for the same position, fearing that workers in key positions may be lost to AIDS. By 2020, the labor force in some of those countries will have shrunk by more than 20 percent because of AIDS.


Estimated percentage of labor force lost to AIDS in 2020 based on current infection projections


Namibia 22%


Botswana 21


Zimbabwe 21


Mozambique 19


S. Africa 17


Kenya 15


Malawi 13


Uganda 12


SOURCES: U.S. Census Bureau's World Population Profile, UNAIDS, International Labor Organization, U.S. Census

Bureau's World Population Profile 2000


2000 The Washington Post Company