Voices of the Invisible People

Author Greg Behrman asks why the richest and most powerful country in the world has responded so feebly to the AIDS pandemic.

August 16, 2004
 |  During the past 20 years, more than 65 million people across the globe have become infected with HIV. Around the world, 25 million have died – more than all of the battle deaths in the 20th century combined. By decade’s end there will be an estimated 25 million AIDS orphans. If trends continue, by 2025, 250 million global HIV-AIDS cases are a distinct possibility.

According to Greg Behrman, author of “The Invisible People: How The U.S. Has Slept Through The Global Aids Pandemic, The Greatest Humanitarian Catastrophe Of Our Time,” the pandemic is reshaping the social, economic, and geopolitical dimensions of our world. Decimating national economies, creating an entire generation of orphans, the disease is generating pressures that will lead to instability and possibly even state failure and collapse in sub-Saharan Africa. Poised to explode in India, China, Eastern Europe and Russia, AIDS will have devastating and destabilizing effects that will reverberate throughout the global economy and the international political order.

Despite all this, Behrman points out the United States has consistently failed to act decisively.

Terrence McNally: A few years ago you were working at Goldman Sachs in Manhattan. What led you to focus your attention on the global AIDS crisis and the US response?

Greg Behrman: I was studying at Oxford and was very interested in the idea of new security threats. People were starting to talk about enormous health crises in terms of national security. I came across stories on the global AIDS pandemic and I was absolutely shocked. I had no idea of the magnitude, had no idea what it was doing to Africa, and it seemed so underappreciated. The question began to emerge – “What have we done about it?” and evolved into “What has the US done about it?” What has the world’s wealthiest, mightiest, most advantaged country done to address one of the greatest threats now known to mankind?

I was supposed to go back to Goldman Sachs, but I told them that I had to stay with this, to answer this question, to tell this story.

As someone who was neither a published writer nor an AIDS expert, where did you go from there?

In the preface of ‘The Best and the Brightest,’ David Halberstam wrote that when he was a young writer, he went up to a major author at a cocktail party, and asked him “What makes for a best-selling and important book?” The writer told young Halberstam, it’s a book that you feel has to be written.

For me, that was the case with this. I have come to think that this issue is the defining moral challenge of our time. Maybe once a generation or once every 50 years, a crisis comes along that is so enormous, that you can take the measure of our humanity by how we respond.

I had a burning passion to tell the story. There was a time when I thought that publishing this would mean going to the local Kinko’s and cranking out 20 copies and giving it to family and friends. I had the good fortune to find a great agent and a great publisher who really got behind it, and I’m now able to share the book with a lot of people.

Bush mentioned global AIDS in his state of the union. What has been the Bush administration response so far?

In January ’03 President Bush announced a $15 billion emergency plan for AIDS relief – a huge step up over past US policy. We’re in the first year of that five-year plan, and the administration has so far released about $2.4 billion.

Now $15 billion over five years implies $3 billion per year. In fairness to them, they never said $3 billion a year. They’re saying they need time to ramp up, and that the funding commitment will be a bit back-ended. They’re short of the $3 billion this year, so it has to be watched carefully. Perhaps because I have an historical perspective, I’m inclined to give them the benefit of the doubt.

How does it compare to what we were spending before that announcement?

It’s a big step up. $2.4 billion is five or six times what we were spending in President Clinton’s last year, and $3 billion or more would be six or seven times.

I’ve heard that it can only be spent on US pharmaceuticals. Are there any such limitations that we should be aware of?

In past there have been concerns about a few things. One was the issue of drug procurement. There was the sense that the US would only buy pharmaceutical company drugs. Even though prices have come down considerably, they still cost several times what similar generic drugs cost. The administration has recently said that they would do their best to pursue generics. Again we have to watch.

You are also author of the 25-page report of the Council on Foreign Relations Roundtable on Improving U.S. Global AIDS Policy, which has been submitted to the administration and to Congress. What are your recommendations and what has been the response?

With the President’s initiative we have an emergency plan, and it could do much good, but we still need so much more. We need a long-term global strategy. We have never had a viable long-term global strategy to combat one of the greatest threats now known to mankind.

When you say a global strategy, I assume you mean not just that the US needs its own global strategy, but that the US needs to enter into a sharing of ideas and resources globally – that this has to be a global effort.

That’s exactly right, and it’s an important criticism of the administration’s approach because there’s a strong inclination to pursue a go-it-alone approach, saying “We have our own goals…We’re going to use our own institutions and our own methodologies to try to pursue a US plan.”

But this is a global problem. The US can’t defeat it alone, and we shouldn’t have to. What is much more judicious is an integrated global approach where we work in concert with other countries, as well as international institutions and mechanisms that have been set up and which are working. A true strategy to defeat this pandemic calls for us to outline big goals in terms of impact, strategic approaches to getting there, and a budget that can be financed and is sufficient to meet the goals. I also think we have to invest billions more upfront. It’s going to take a recalibrated level of diplomatic and political will and engagement.

Much of your book deals with the various ramifications of the pandemic and the consistently inadequate US response under both parties. Can you offer a quick history starting with the Reagan administration?

It’s a great question and, in a sense, it’s the one that the book tries to answer. What’s our history? What have we done? What haven’t we done? What lessons can we learn? I profile presidents, public health officials, diplomats, and I tell their stories. We learned that there was a global dimension to this pandemic during the Reagan administration, and essentially nothing was done about it. Very little was done during the Bush #1 administration as well. There was a huge burst of hope when Clinton became president because in his very first inaugural speech he addressed the world’s AIDS crisis. He said we have to get ahead of it, in his words, “lest it engulf us.”

On Charlie Rose recently Clinton said that he was focused on three or four areas where he felt his influence could make a difference. One was global AIDS. What is Clinton’s role at this point?

President Clinton in his post-presidency has done some wonderful work, pressuring pharmaceutical companies to lower their prices, getting some equipment for Africa, and also in helping South Africa to devise a strategy. He’s been active and his advocacy’s had a big impact, but during his presidency, he was essentially inert on this issue. I found that for seven years even after what he said at his first inauguration and after being briefed by officials, President Clinton did essentially nothing, and US funding remained flat at about $120 million for seven years, even as the pandemic exploded abroad.

When you speak about his doing nothing, you don’t mean in terms of AIDS within US borders, but in terms of taking on the global crisis?

During that time there was great leadership in terms of battling the pandemic domestically, and great strides were made. Donna Shalala was a great leader and President Clinton did some wonderful things. But, consider this – in our history, there have been about 1.3 million people infected with HIV in the US. There have been 65 million people infected worldwide. When you consider how it’s changed our culture and the impact HIV/AIDS has had at home, then you consider what’s happening in Africa and elsewhere abroad, and how resource-starved and under-equipped they are to deal with this problem.

I suspect many Americans feel – accurately or not – that AIDS is coming under control in the US, and that, among the various problems that they have time to focus on, global AIDS is not one of them; it won’t directly affect us, it’s more a moral issue than a security issue. Are they wrong on either or both counts?

I think there is a tremendous moral obligation for us all, and that should be enough to draw us in. I think of this as the holocaust of our time. There are countries in southern and central Africa nearing adult infection rates of 40 percent, where soon two in five adults will die of AIDS. Adult infection rates of 20-25 percent are the norm throughout the subcontinent. I think this presents a huge moral obligation and a huge moral opportunity.

But it’s even more than that. There’s a strategic imperative as well. This is crushing economies. It’s beginning to explode in Eurasia, in India, China and Russia, huge economic partners and collaborators of ours. It’s becoming an enormous threat to African stability and security because it’s crushing key state institutions. It’s believed some African militaries have infection rates of 40-50 percent.

Who will keep the peace? When you look at the social, economic, and political pressures, state collapse becomes a real possibility. We know that terrorists operate in eastern Africa. Our embassies were bombed in 1998 in Kenya and Tanzania. Osama bin Laden operated in Sudan for the better part of the nineties. We see increasing instances of conflict and terrorism in western Africa.

In creating pressures on states, AIDS will help provide refuge and sustenance for these terrorist elements. If you’re not compelled by the moral argument, which I think we should be, then certainly there’s a very strong strategic interest in engaging the pandemic. The great and heartening news is that we really can do so much to curb it.

Besides coming up with money, what can the US and these global alliances do? Let me observe that Africa has certainly lagged behind other continents in terms of development, and just at the point perhaps when the rest of the world would have begun to pay attention to their economic growth, AIDS has become the thing which keeps them lagging further and further behind. Correct?

It’s one of the horrifying and torturous dimensions that this disease is taking its greatest toll in a part of the world that’s already been so crushed by poverty, colonialism, famine, and other health crises. It’s really important to consider that western developed economies spend $2,000-4,000 per person per year on national health. In Africa, it is often $5 per person per year. Ethiopia spends $1 per person per year.

These countries have only the shells of national health systems, and that’s one of the things that we can do. In addition to moving in an emergency capacity, we can work with other international partners to help build health infrastructure. It doesn’t have to be things like very sophisticated health centers with cutting edge technology. It can be basic clinics and delivery systems, and, very importantly, the human capacity – training people to staff these systems. Africa really lacks that. It’s not rocket science. We know that if we do those basic things, we can save millions of lives. We simply need to devote the resources and the will to doing it in a sustained way. We can also empower those populations to run, manage and operate that infrastructure. We can build a platform for these countries to move forward in a long-term fashion.

People hear about Africa. You also mentioned Southeast Asia, India, China, and Russia, areas not on most people’s radar screens. What is the status in those countries, and contrast it with SARS if you will?

All of those countries are on a huge steep upward trajectory. India will soon overtake South Africa as the country having the highest number of infections. AIDS is growing fastest in the world in Russia. It’s projected Russia now has around a million people infected, and could have between 5-8 million people infected by 2010.

Now think about all the attention SARS got, and its effects on tourism and industry. All the people combined who have died of SARS – that many people die of AIDS every two hours. We’re a bit numb to it because it’s been with us for a while, but that doesn’t mean the toll is any less punishing. Because of its latency, the lag time between infection and when you will be affected and die, we are now beginning to see millions of deaths happen in increasing numbers. The pandemic is not abating.

What has been the role of the US and European pharmaceutical industries – among the largest political donors, certainly in the US and I assume overseas?

They’re among the world’s largest political donors, and the US pharmaceutical industry is also the most profitable industry in the world. What’s phenomenal is that with billions of dollars of research and development, some of which is government funding, these pharmas have developed drugs which though not a cure for the disease, have proven very effective as treatments, extending people’s lives for quite a while.

We’ve certainly reaped the benefits of that, but they’re priced such that they are essentially unaffordable in the developing world. The pharmas have been very averse to lowering those prices in the developing world for fear that it will set a precedent.

The tragic dimension of that is that, even now as they really do begin to lower their prices enormously in response to political pressure and popular pressure in protests, they could have done it six years ago. They could have begun to make these drugs available abroad where they were so desperately needed.

Had they acted six years earlier, would that have merely been ameliorative for those already suffering with AIDS or would it have done anything to prevent the growth of AIDS?

It certainly would have been life-extending and maybe life-saving.

A few less orphans a little later….

You’re talking about mothers who could live longer to see their kids grow up, so that a 12-year-old boy wouldn’t have to head his household and take care of himself and his siblings. We’re also finding now that treatment is very important to prevention, because when you realize that this disease is not necessarily a death sentence, you’re more inclined to get tested. You’re more inclined to come into contact with people who can counsel you regarding how to not spread the disease. They’re really interlinked, and that amplifies the tragedy of not having these drugs earlier. Now that there’s a sense that the drugs are more reasonably priced, it’s galvanized political leadership to say “Okay, we can do a lot more. Let’s get moving and put some resources behind this.”

In other words, there’s leverage in turning individuals and even nations from desperation and resignation toward a different attitude and a different psychology that says, “This is a disease I’m going to live with for a few years.”

…to a sense of possibility.

What can readers do right now?

The problem is so big and so much is needed, that governments have to lead. When you look at a global strategy and what it’s going to cost, the World Health Organization spends about $30 billion per year. Consider that based on the US’s share of global wealth, that would call for about $10 billion per year from the US. When you boil that down, and think about ways to finance it, that might come to two or three movie tickets per American.

WHO says that could begin to save 8 million lives per year. So a global strategy is possible and affordable, and people can speak up about this. Go to rallies and ask political leaders and candidates what they’re doing and why they’re not doing more. Write to elected officials.

The US has spent something more than $150 billion so far on its invasion of Iraq, and here you’re saying that it would take maybe $10 billion a year from the US to shift the whole AIDS paradigm?

And save 8 million lives. It’s a huge opportunity. I feel people are hungry for a big idea, hungry for a great mission, and there’s no mission more needed. I think this would be an extraordinary vision to set our aspirations on.

One other thing that people can do: the proceeds of my book are being donated to a great organization in South Africa called Heartbeat, that works with AIDS orphans and vulnerable kids who are heading their households. People can go to the website, theinvisiblepeople.com, and learn more about Heartbeat, and if they’re inclined to make a donation, it would have a great impact.

Greg Behrman is the coordinator for the Council on Foreign Relations Roundtable on Improving U.S. Global AIDS Policy. He graduated from Princeton and received his M.Phil. in International Relations from Oxford University. He is a member of the Brookings Council and serves on the Board of Directors of Heartbeat, a non-profit organization in South Africa that cares for AIDS orphans. For more information and a list of Greg Behrman’s speaking engagements, visit theinvisiblepeople.com.

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