Professor JONATHAN MANN, director of the International AIDS Centre at Harvard School of Public Health, delivered an address on the Global Effects of AIDS at Sydney's Prince of Wales Hospital on March 5. This is an abridged version of his talk.
This is a critical time in the history of our global confrontation with AIDS. Today, faced with an expanding pandemic, we can see — more clearly than ever before — the limits of our current national and global response. The course of the pandemic within and through global society is not yet being influenced in any substantial manner by current efforts.
In 1980, an estimated 100,000 people worldwide were HIV-infected; during the 1980s, the number of infected people increased 100-fold; today, over 15 million people, including over 13 million adults and over 1 million children, have become infected. Of the over 13 million HIV-infected adults, nearly 9 million are in Africa, over 1 million in North America and Latin America, from 1 to 2 million are in Asia, and over 500,000 are in Europe. Of the world's HIV-infected adults, over 7 million are men and over 5 million are women, and the ratio of women to men has been steadily increasing.
The pandemic remains highly dynamic and volatile.
Thus, HIV is continuing to spread in every community and country which has thus far been affected. In the United States, from 120,000 to 240,000 new HIV infections are anticipated in the next three years; in Europe, an estimated 75,000 new HIV infections occurred last year. There is no country in which the HIV epidemic has yet peaked.
In addition to continuing spread in already infected areas, HIV is spreading — sometimes quite rapidly — to communities and countries little affected just a few years ago. Nigeria, once considered an area of minimal HIV activity between the west African and central African epicentres, now estimates it has at least 500,000 infected people.
Reports from Paraguay, Greenland and various Pacific Island nations all illustrate the continuing broad geographical range of HIV introduction and spread. Yet it is in south-east Asia, in India, Burma and Thailand, that the volatility of the pandemic is most dramatically seen. In India, HIV seroprevalence among commercial sex workers has literally exploded; in Burma, the latest seroprevalence among injecting drug users exceeded 60%; and the Thai epidemic continues to expand and, affecting over 500,000 Thais, is already more than 10 times greater, on a population basis, than the epidemic in the United Kingdom.
Projections into the future are only estimates. The Global AIDS Policy Coalition — an independent international research group based at the Harvard School of Public Health — projects that nearly 20 million people will become HIV infected by 1995, and that by the year 2000, between 40 and 110 million adults, in addition to at least 10 have been infected worldwide.
The second major fact about the pandemic is that its major impact is yet to come. As of January 1, 1993, over 500,000 AIDS cases have been officially reported to WHO (World Health Organisation); yet a more realistic estimate is that over 2 million adults and over 600,000 children have developed AIDS since the beginning of the pandemic.
From 1992 to 1995, we estimate that an additional 3.8 million people will develop AIDS, so that more people will be developing AIDS during the current three-year period than the total number during the entire history of the pandemic until now. This also means that the number of children orphaned by AIDS will more than double in the next three years: from approximately 1.8 million today to 3.7 million by 1995.
Yet an analysis of the pandemic alone is not enough — for our individual and collective response is the determining factor in this global epidemic. In examining the global response to AIDS, four phases can be readily identified.
The first, from the mid-1970s until 1981, was silent and illustrated clearly the modern world's vulnerability to global spread of infectious agents.
During the second phase, from 1981 to 1985, the response to AIDS occurred mainly within communities and was expressed through community organisations; few nations and no international organisations had responded.
Then, 1986-90, we witnessed an extraordinary period of global mobilisation. A global AIDS strategy was developed, the UN system and official development assistance agencies were activated, virtually every country in the world created its own national AIDS program, and community and non-governmental organisations became ever more active and numerous. Thus, during this extraordinary period of global mobilisation, the gap between the expanding pandemic and efforts against it was starting to narrow.
During this period, at the community level, remarkable successes were achieved in HIV prevention. Our analysis of programs around the world, whether involving homosexual men, or injecting drug users, or commercial sex workers, or adolescents, shows that three key ingredients are necessary for successful prevention programs. These three elements — information/education, health and social services, and a supportive societal environment — must be present for prevention to succeed, yet each must be adapted to local culture and circumstances.
First, information and education are needed, and the details of this work are critical. Most important is the involvement of the people to be reached in the program design and implementation. This has been a particular problem in programs for young people. We must remember that just because we are ex-youth does not make us experts on what youth today think and how they react.
The second key ingredient for successful prevention involves health ked — at the local level in very practical ways — to the information messages.
The third ingredient — more complex but just as important as the other two — is a supportive social environment. This means that people are supported, not coerced, and that active steps are taken to prevent discrimination and to promote rights and dignity. Again, this is not a luxury; it is a necessity for effective prevention.
When these three are combined — as they have been in creative, innovative and courageous ways by community organisations around the world — then HIV transmission has been markedly slowed.
Yet, since 1990, the world has entered a new phase in the confrontation against AIDS: a period in which the national and global response has stalled — is failing to keep pace — and is falling dangerously behind the pace of the pandemic. Global mobilisation is being replaced by complacency and a lack of coordinated and strategic leadership. As a result, there is a widespread and growing sense of concern about how best to proceed, the gap between the rich and the poor is widening (not only rich and poor countries, but the rich and poor within countries), and a global ethic of caring has not been developed.
Let us consider some of the evidence of this "levelling off" and some of the fundamental problems within the global response.
During the period 1985-91, the industrialised nations provided a global total of about US$850 million for HIV/AIDS prevention and care in the developing world. This seven-year total is less than the total spent in New York on AIDS last year.
In 1991, for the first time, resources available to the WHO for global AIDS work declined. The resources for AIDS are levelling off, and even declining, in most if not all countries. Resources are certainly not keeping pace with the pandemic.
In addition, our analysis revealed the depth of global inequity in prevention and care.
Of the $1.5 billion spent on prevention in 1991, only 6% was for the developing world — which has over 80% of the world's HIV infections. Last year, about $2.70 was spent per person in North America, compared with only seven cents in sub-Saharan Africa and only three cents per person in Latin America.
Similarly for care: about 90% of the world's spending was for the approximately 25% of the world's people with AIDS in North America and Europe.
There is also a failure of leadership — and of strategic thinking.
Industrialised nations are turning away from coordinated and multilateral efforts, showing a growing preference to work independently and bilaterally with chosen developing countries. Thus a "popular" country like Kenya or Uganda may have five or more donor lp, while many others have only one or even no "rich friends".
Major international organisations, with mandates and responsibility for global action, are having difficulty reaching agreement on allocation of responsibilities and coordination of their efforts.
A large number of "pilot projects" have been tested, and many are successful — yet curiously, they have not been amplified and applied in large-scale prevention programs.
What is wrong here? Why, despite the courage, passion, and commitment of many individuals and communities, is the social response — the political response — faltering? How can we explain the paradox of plateauing resources and commitment at a time when the pandemic is expanding and intensifying worldwide?
AIDS will require that we deal with what we have not thus far been willing to address: the key, underlying pre-existing issues — deeply embedded in the status quo of societies worldwide — which fuel the spread of HIV. An analysis of AIDS epidemiology and the global response shows that the pandemic flourishes by exploiting societal weaknesses, and the major societal weakness it exploits is inequality and injustice, that is, discrimination — not in the abstract, but in its specific and concrete manifestations.
A decade of work against AIDS has shown us that the central societal lesion which underlies AIDS and ill health worldwide is discrimination.
An obvious example: the role and status of women worldwide is fundamental to HIV prevention. Women cannot say "no" to unwanted or unprotected sexual intercourse unless they have the economic and social power to mean "no". In several studies in Africa, women monogamously married to a man who has several sexual partners are becoming infected with HIV, and they have no risk factor except their powerlessness to influence their husband's behaviour.
Therefore, reforms of laws governing property distribution and divorce may be much more important in helping to prevent HIV infection than increasing the distribution of brochures or condoms. Of course, this problem is not restricted to the developing world. Among adolescents and young adults in Western society, men are dominant in deciding the "when, where and how" of sexual intercourse.
An analysis of the relationship between gender and AIDS — and a broader look at gender and health — including maternal mortality, sexual violence, sexually transmitted diseases and failures of family planning — shows clearly that male dominated societies are a threat to public health.
Similarly, belonging to any marginalised or stigmatised social group results in an increased risk of AIDS infection. This is because fewer resources, less information and less social support translate into increased risks of exposure to HIV, or to a decreased ability to put into practice the implications of prevention messages. ossession of their human rights and dignity are best equipped to contribute to HIV prevention.
Social discrimination creates and amplifies vulnerability to the spread of HIV. On the basis of a societal analysis, the Global AIDS Policy Coalition recently identified 57 countries at high risk for an explosive HIV epidemic — probably in the next few years — including countries which have thus far been little affected by the pandemic, such as Bangladesh, Egypt, Indonesia and Pakistan.
We can see also that individual, national and global vulnerability to further HIV spread is really a microcosm of vulnerability to ill health, disability and premature death. For analysis of other global health issues — maternal mortality, street children, sexually transmitted diseases, cancers, injuries — shows that like HIV/AIDS, they are inextricably linked with marginalisation and other expressions of societal discrimination — in other words with neglect of basic human rights.
What, then is to be done? The old vision of AIDS, as a separate, unique and isolated health problem, has now become a straitjacket. Today, recognising the limits of our current approach, we can start to define a new approach, building upon lessons grounded in the real experience and the knowledge gained in communities around the world.
We must launch a forthright assault on the basic problems — the underlying societal conditions — which create and magnify our vulnerability to AIDS. This means that we must confront the many forms of discrimination — based on gender, race, religion, national origin, sexual preference or social class — which makes societies vulnerable to further spread of the pandemic. This is not only the basis of a strategy for AIDS; it is a strategy for health — community, national and global.
In speaking to different people around the world, I have been struck by three reactions to these ideas. First, there is universal agreement that our current work on AIDS is necessary but not sufficient. Second, there is widespread agreement that respect for human rights, and related societal change, will be needed for control of the pandemic. Yet often there is also a sense of hopelessness, of being overwhelmed by the scope of the problem.
Here we confront a fundamental paradox. People in all countries are deeply concerned about their health, the health of their families and children. In every society, their is a proverb which goes something like: "So long as you have your health ..." Yet if health is really a central concern of all peoples, why is it that health has not become a central, defining principle of local, national and global purpose?
Paradoxically, we health workers have contributed to this problem. For we have generally been silent, or at least very well behaved. We have not spoken out boldly about the central importance of health; we have been timid in our expectations. Thus, we have accustomed ourselves to playing a secondary, reactive and minor role in community , national and global life. We have trained ourselves to expect and to accept second-class political attention for health concerns.
The political impotence of health aspirations may also be due in part to the fact that throughout history, people have experienced disease, disability and death as individuals confronted by personal tragedies. Yet today when people lose their jobs, they can recognise the connection with national policies, the national economy and the global economy.
However, in health, people are only slowly realising that the same connections apply: that individual tragedies of preventable disease or disability, or premature death, are also linked to community, national and global policies, action and inaction. Only when the personal is linked with the global can health take its proper place in the societal and political realm.
The enormous disparity between what people are seeking in health and what they receive is a global phenomenon, and the second-class political attention given to health aspirations is not limited to AIDS. This is not a problem we can simply allow ourselves to blame on others, on the so-called decision-makers or on politicians. We must now take responsibility to help give voice to the basic desires of people for better health.
It has become increasingly clear that to work against AIDS — whether in the laboratory, the clinic or the streets — is to become, to some extent, a revolutionary — or, if you prefer, an activist. A revolutionary because in order to achieve the goals of our work — whether to make a vaccine which could be accessible to the entire world's population in need, or to ensure care for all those who need care, or to prevent infection through education of young people — in all these ways, our goals will require change in our societies.
Thus, our new global AIDS strategy is about more than AIDS — it is part of a deeper, more fundamental struggle: whether health will now become a central, defining principle guiding national and global purpose. This is not a modest aspiration — but please, why should we be modest?
Just imagine what we could do if health and human rights were placed at the centre of debates about community, national and global purpose. Just imagine what real global health leadership could mean for problems like drug use, the environment, and AIDS.
When the history of AIDS is finally written, this may yet be the most precious contribution we could have made — a vision of health, solidarity, rights and peace: now we must work — each of us and together — to ensure that it becomes an active vision and a reality — strong enough, wise enough and humane enough to protect and ensure our global future.