Global Policy Forum

By Richard G.A. Feachem

Most of what we once thought we knew about global health has been proven wrong by the relentless advance of HIV/AIDS, tuberculosis and malaria.

People like myself who have worked for decades in international health have long believed in our ability to overcome challenges. We have worked in an era of enormous progress in human health. In countries that have done well economically since World War II, life expectancy has soared. Even in poorer countries, there have been huge gains driven by increased education and effective programs for disease prevention. Smallpox has been eradicated and polio will be soon. We have ridden a tide of optimism based on evidence. As a result, we have come to have faith in the public health paradigm: Confront an infectious disease with the right questions and the right tools, and you will conquer it.

But this paradigm hasn't worked for HIV/AIDS. We understand the disease's cause, transmissions and effects on the human body in exquisite detail. Yet the global epidemic -- the pandemic -- continues unabated.

Even as this realization sets in, people have maintained a distressing complacency about the HIV/AIDS pandemic. The battle against this disease has acquired the traits of a distant, low-intensity conflict -- distasteful, lethal and a cause for genuine concern, but ultimately remote, difficult to solve and something you learn to live with. This is a dangerous attitude. The HIV/AIDS pandemic will get much more dire before it gets better, even in Africa. Worldwide, it will not peak for another 40 to 50 years. It cannot be contained; our armory is ineffective. In country after country, it will devastate populations, especially the urbanized skilled and educated classes, much as the Khmer Rouge did in Cambodia. However, whereas the killing in Cambodia stopped after several years, the killing from HIV/AIDS will go on and on, racking nations with the ferocity of half a century of Khmer Rouge rule.

Still, many people discount the global threat from HIV/AIDS and hide behind comfortable myths about AIDS, as well as tuberculosis and malaria. Myth: Malaria might happen to travelers but is easily treated. Fact: Malaria, a threat to anyone visiting, working or living in tropical areas, is often drug-resistant and can be hard to treat. Myth: Though we are hearing more about the resurgence of TB, those clever folks at the Centers for Disease Control can get a grip on it. Fact: TB is spreading rapidly in the United States and Europe, due partly to importation from Latin America and Eastern Europe respectively, and drug-resistant TB is both difficult and expensive to treat.

Concerning HIV/AIDS, we don't hear so many scary stories anymore. Myth: It appears to be under control in the United States. Fact: The domestic epidemics in the wealthy countries continue to grow and increasingly afflict poor, heterosexual women. We do hear that HIV/AIDS is causing lots of deaths in Africa, but Africans have always died in large numbers from infections. Myth: If Africans would only get a grip on their political and economic systems, they could sort this out as we have. Fact: Even a well-governed African country would be unable, if unassisted, to mount the scale of response necessary. Indeed, even we haven't been able to do that.

Tuberculosis and malaria kill more than 3 million people per year, and AIDS kills another 3 million. These numbers are growing rapidly, dwarfing the number of people who could conceivably die from terrorism or conventional warfare. These three diseases are taking many countries backward, back to life expectancies and mortality rates the world hasn't seen since the early 1900s. Each of them can be prevented, if not cured. Yet we spend billions trying to prevent terrorism and pennies on fighting these much bigger killers. In 2001, for every person who died of war and violence, seven people died of one of these three diseases, nearly all of them children or young adults.

The worst-hit countries are in Africa. In parts of southern Africa, one out of every three adults is infected with HIV; without access to modern drugs, most will be dead within five years. Ten million children have been orphaned by AIDS, enough to populate a country the size of Belgium and the figure will quadruple in this decade. Teachers in parts of southern Africa are lost to HIV/AIDS at twice the rate they are trained. Disease and premature death among farm workers is contributing to famine and starvation. Economic growth and foreign investment are stunted by the lost productivity of local companies. And the ranks of health-care workers and the military are being depleted in even the wealthiest African states.

Horrifyingly, the worst is still to come. The presidents of Botswana and Malawi have predicted the demise of their countries if much more is not done. Further north, the most populous sub-Saharan African countries, Ethiopia and Nigeria, are in earlier stages of their epidemics. These countries have yet to see the virus wreak its full devastation. Meanwhile, the epicenter of the disease is moving east. Within a decade, India and China will have half of all the HIV-positive people in the world. The denial that we have seen in Africa is now happening in Asia, a denial fed by the myth of cultural immunity and by the naive belief that "it can't happen to us."

I have seen many of the faces of denial:

• The senior official leaning back in his office chair on a hot afternoon in an East African capital and saying, "What you don't realize is that malaria is part of being African. We have always had it and we always will; although it would help if rural people would tidy up their villages and have less puddles and mosquito-breeding sites around."

• The hard-nosed U.S. politician -- committed to seeing that taxpayer dollars are well-spent -- saying, "What can we do? Increased aid to those countries will only be misused or stolen. They have to get their house in order before we can do more."

• The urbane lady at a comfortable dinner party in Mumbai, India, saying, "Well, we now accept that India will have an HIV/AIDS problem -- but nothing like Africa. Our culture is completely different. In any case, the HIV problem in India will be among them [meaning the poor, the lower-caste, the underclass], not among us."

If we continue at the current level of denial and inaction, the largest Asian countries will experience HIV/AIDS epidemics that will dwarf what we see in Africa.

The CIA, recognizing AIDS as a national security issue, projects HIV infection rates for India that indicate that HIV will kill many more people than would a full-scale war with Pakistan. These projections are being branded as alarmist, but perhaps it's time to be an alarmist. Despite years of work among gay men in San Francisco, sex workers in Calcutta and long-distance truck drivers in Africa, we have failed to make a serious dent in the crisis. Yes, there is good news about some local communities changing their destiny by effective action. Yes, new drugs are widely used in rich countries. But overall, the passage of HIV around the world has continued roughly as if we had done nothing.

U.N. Secretary General Kofi Annan, former South African president Nelson Mandela and Secretary of State Colin L. Powell understand the gravity of the threat. Powell called HIV/AIDS "a catastrophe worse than terrorism." He said, "One threat that troubles me perhaps more than any other does not come out of the barrel of a gun, it is not an army on the march, it is not an ideology on a march. It's called HIV/AIDS."

We must develop new, larger and more effective responses. The Global Fund to Fight AIDS, Tuberculosis and Malaria, where I am executive director, is a first step. A public and private partnership, the fund has agreed to support programs worth $1.5 billion over the next two years in over 80 countries. Countries must show that the money is used to make real gains: that more women and babies are sleeping under nets treated with insecticide; that more AIDS patients are getting drugs that will improve and prolong their lives; that more teenagers are learning how to protect themselves against AIDS; and that more families in rural areas and urban slums are receiving early diagnosis and treatment for tuberculosis. Countries that can show they have made a difference will get more funds; those that cannot, will not.

For the Global Fund to continue its support for these fighters on the front line, it still needs an additional $2 billion in 2003 and $4.6 billion more in 2004. The world's failure to fully fund our efforts -- or any comparable effort -- is yet another indication that people lack the sense of urgency this crisis demands.

Much more is required. Above all else, the world needs leaders in the countries most affected to rally their people to the fight. Leaders in wealthy countries must make sure that their citizens realize the global consequences of inaction and mobilize the money and expertise needed to stem the tide.

But leaders are influenced by their followers -- and politicians are sensitive to their electorates. The lethal mix of ignorance, apathy and denial that is widespread among the educated citizens of both rich and poor countries is at the heart of our collective failure to act. Citizens believe that peace, law and order, and protecting the environment are important. It is time for citizens to believe that HIV/AIDS, TB and malaria are important, too, and to be vocal about it.

There can be no more urgent cause facing us today. In Africa, the enemy is already among us. In Asia, the enemy is at the gates. The future course of these deadly pandemics hangs in the balance.

Myth: We're starting to win the war against AIDS, tuberculosis and malaria. Fact: The war is just beginning.

Richard Feachem is the executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. He was director of health, nutrition and population at the World Bank (1995-99) and dean of the London School of Hygiene and Tropical Medicine (1989-95).

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