New York, N.Y.
LAURIE GARRETT: Good afternoon. It’s a pleasure to see so many people here talking about global health. It’s a new agenda that we’re bringing to the Council. I’m very pleased to be the Council’s first senior fellow for global health, trying to insert global health into the national security agenda. And I want to thank each and every one of you that showed up today. And I think you’re in for— well, I’m not sure I would say a treat, because the subject area we’re going to be dealing with is a bit grim. But I am incredibly pleased and honored that Dr. Alan Whiteside was able to find time in his extraordinary schedule to come from Durban, South Africa, to be with us today.
And some of you might not be completely familiar with Alan’s work. So let me just say by way of background that Alan is running a unique social-economics program dedicated to looking at the impacts of HIV at the University of KwaZulu-Natal in Durban, South Africa. He has already been the author of countless invaluable papers, studies, and this book, which I cannot strongly enough recommend. It’s a little hard to find in the United States, but we have included in your handouts an order form, should you be inspired to get a copy for yourself. The amount of data in this comparatively slim volume is dizzying. You’ll find that if you do pursue this area further, you’ll be using this as a reference guide for quite some time.
I have been trying to understand how and why it is that the global community can’t seem to appreciate what the scale of HIV really is, cannot seem to understand how it’s affecting government, how it’s affecting whole entire societies, and even how it’s affecting the nature of discourse in the world today about matters that seem not directly related to HIV at all.
It’s a little surprising to me that this hasn’t been immediately obvious, but this fall I was fortunate enough to be in Florence and to have permission to see some of the original vellum documents maintained during the Great Plague of the 14th century, when Florence lost 80 percent of its population to the Black Death in about 18 months’ time. And what struck me as I went through these documents is that people were moaning about poor sales; one wine merchant [said], “I went to San Gimignano and nobody bought a darn thing, and then I went down to Siena and nobody bought a darn thing.” Never mentioning that everybody was dying. There was nobody to buy. You’d lost your entire economy.
And it struck me that it’s very, very hard in real time, when you are in the middle of such an absolutely staggering and seemingly hopeless catastrophe, to be reflective and to really see the scope of it in real time. But this is what Alan is trying to do, and we have to thank him for each and every effort he makes in this direction.
I want to say by way of rules for the day, we’re going to have a brief discourse and then open it up for your questions. And everything’s on the record. You can run away and quote every darn thing either of us says to your heart’s content.
Alan, let me start off. You were born in Kenya but raised in Swaziland, and you’ve worked most of your career in Africa— Botswana, South Africa now— but you’ve also done some research work in Ukraine and certainly in the U.K. and traveled all over the world. Because of your race, most people assume you are European, but as I’ve come to know you better and better over the years, there’s no doubt that you are an African and you think as an African. What does it mean to think about economics in African terms?
ALAN WHITESIDE: Well, I think that looking back at where I came from and growing up in Swaziland, there were a number of things which perhaps were absolutely central to who I am and what I do and why I do it. And the first thing is the awareness of the huge poverty that there is. If you look around the continent and around particularly Swaziland, South Africa, you see immense poverty. And there’s a burning injustice in the fact that there are so many people who are so impoverished.
I think the second thing about African economics is the dignity; that people may not have very much, but they are an extraordinarily dignified and sharing people. And I think for me, a memory that sticks in my mind was when I was in my late teens, going to churches in the African community in Swaziland and seeing people putting in a two-cents coin and taking one cent worth of change because that’s as much as they could afford. So for me, African economics is around poverty.
But there’s something else which I also have, and I think it’s really important to share it with an audience like the one you’ve got here, and that’s a sense of optimism. And that’s perhaps not so much economic as political. When you look at Africa, I think a lot of the time it’s being written off as a continent without much hope, but if we think back 10 years, we were facing civil war in South Africa, and [now] here we are, we’ve had our third election. So that’s this fundamentally African thing that I have, a sense of real optimism.
And Laurie, we were talking earlier and I said to you in the election, the first election, three elections ago, it was a civil war state. People were killing each other. In the last election, there were a few deaths— in the second election. In the third election, some people tore down posters that belong to other parties. And if that’s not progress, then what is it?
GARRETT: Well, I wanted to pick one country to focus on a little bit to try and get our hands around the issues here, and I decided on Zimbabwe. I think it’s a fair argument to say it’s the most politically unstable society in the region of east Africa, southern Africa, at this time.
There was just a study released last week from the Zimbabwean— a major university in Zimbabwe that says that 2 million people in Zimbabwe are HIV-positive. And the startling data point is that 60 percent— six zero— of them are female. The urban prevalence in women aged 15 to 24 in Zimbabwe is now 40 percent, which is absolutely startling. The overall combined all-adult, male-female rate is 33 percent. So if you were in a room of adults like this in Zimbabwe, one out of three of you would be infected with HIV right now.
It’s— in addition, the country’s now in its fifth year of famine, and as much as the [President Robert] Mugabe government tries to jury-rig the data, there’s no doubt they’re going to go into their sixth year of famine. And by all accounts, Robert Mugabe has driven that country into absolute hell. He has reversed every single development marker, every single dime of investment, going back to colonial days. And it’s certainly one of the greatest disappointments on the entire continent.
How much of this, how much of the willingness of that population to tolerate this man and this regime for so long, can be ascribed to a sort of mass psychosis induced by absolutely everybody going to funerals absolutely every week?
WHITESIDE: Well, I think the thing about Zimbabwe and the data that you’ve just quoted is that it has been revised downward. The best data source we have there is from the antenatal surveys, which are assisted by the [U.S.] CDC [Centers for Disease Control], and they have brought their data down. But we also know that there are parts of Zimbabwe where HIV presence is up to 70 percent among women of childbearing age.
GARRETT: Seven oh percent?
WHITESIDE: Seven zero percent. There have been— some of the data points have shown HIV presence levels of that magnitude— some of the border towns, some of the so-called growth points.
And I think what you’re asking— how far has the epidemic [gone] and is the despair in the country driven by HIV/AIDS? --is a very difficult one to answer. It’s something that we’re beginning to look at, at the University of KwaZulu-Natal— we’ve had very generous support for a democracy and governance research fellow— because what we’re trying to disentangle is to what extent is the epidemic being --to what extent is the problem in the country being driving by climatic change? Because that’s part of it. To what extent is it being driven by debt? Because that’s part of it. To what extent is it being driven by environmental crises? Because that’s also part of it.
And in effect, I think what we’re seeing in a country like Zimbabwe is almost a perfect storm. There are waves of events, there are waves of drought, there are waves of bad governance, there are waves of debt, there’s waves of deindustrialization, and you add into that— but it’s also driving it— AIDS, and then you’ve got the crisis.
I think that if you look at what’s happening in Zimbabwe, then what we’re looking at is a society where people are just no longer engaging with the government, and they expect nothing from the government. And they— I think psychosis, the term you use, is very important.
If we talk for a minute about the food crisis, I was on the BBC [British Broadcasting Corporation] website just a few minutes ago, and there is a quote from Robert Mugabe on the website where he says, “We don’t need food.” Today, in an interview with Sky News, he said, “We don’t need food.” He also said that [Nobel Peace Laureate] Archbishop [Desmond] Tutu is an evil little man, so we will take neither of those comments as having much value.
But if you look at these food crises, what you see there is the AIDS epidemic writ large because effectively to grow food you need a number of things. You need a number of inputs. You need land, and I don’t believe that land is an issue in Zimbabwe anymore. You need labor, and here we’re talking about quantity of labor and we’re talking about quality of labor.
What does AIDS do? It takes away people who would be in the field, cultivating. It takes away people, not just because they’re sick, but because those people who would be there cultivating are off looking after other people. And it’s also affecting the quality of labor because effectively you’re losing the intergenerational transfers of knowledge. So Joe Mkomo who’s sitting out in Matabeleland and would have known not to plant that bit of field because it floods every year doesn’t know that because dad died. So we’re losing the major input into the agricultural process. So you’ve got land, you’ve got labor, and then in traditional economic terms you’ve got another set of inputs, which is capital. But let’s call it seed, let’s call it fertilizer, agricultural extension officers. Let’s call it markets. And all of that is faltering and failing.
So effectively I think that the Zimbabwean famine is caused by the HIV epidemic, and the inability of Zimbabwe to recover its agricultural processes will be cause by HIV/AIDS.
GARRETT: You coined the term “new variant famine.” What did you mean by that?
WHITESIDE: Well, I have to admit that the term “new variant famine,” which has upset an awful lot of people, which it was designed to do— and I may— if I may just say, watch this space because the next article that [writer and activist] Alex de Waal and I are writing is called “AIDS: A Darwinian Event?” So we are hoping that that will also cause a certain—
GARRETT: Don’t tell the creationists anything about this.
WHITESIDE: [Laughs.] Maybe we’re on their side. We haven’t finished the article yet. No, I can assure you that won’t be happening. [Laughter.] No, that won’t be happening. On the record, that won’t be happening. No, we called it “new variant famine” because at that moment, when the audience we were aiming for was predominantly the readers of The Lancet [medical journal], there was a lot of discussion about new variant CJD [Creutzfeldt-Jakob Disease]. So the terms “new variant” seemed to be good.
GARRETT: Referring to Mad Cow Disease.
WHITESIDE: Yes. Seemed to be a good idea to catch the leaders. And a lot of people wrote to us and said, “Love the argument, hated the title.”
GARRETT: OK. Well, what is it, anyway?
WHITESIDE: The argument is quite simple. What you’ve got is a situation where there is a food crisis, there is a famine where you are, as I’ve just outlined, losing productive capacity, and basically it will be very much harder to recover from that. So it is a “new variant famine.” It isn’t the old famine where it doesn’t rain, you do something to survive that period when your production goes down, and when the rain comes back you bounce back.
What happens with “new variant famine” is, it doesn’t rain, your production goes down, the rains come but you haven’t got the skills, you haven’t got the inputs. So at the very best your production goes up ever so slightly, but more likely it just carries on going down. So famine becomes a state of permanency rather than something which happened this year because it didn’t rain.
GARRETT: And how much— you know, it’s always been my observation that all over sub-Saharan Africa, agricultural labor is female labor. Men don’t do agriculture unless they’re white or they are employed by a white farmer. So the fact that the HIV rate is skyrocketing and becoming more and more female in that region, how does that affect the situation? I assume the women are also the caretakers and the ones expected to take care of the sick so that those who are not ill are less likely to be able to devote time to farming.
WHITESIDE: I think that the use of labor there is from culture to culture and also from job to job, so you wouldn’t find the women plowing. You’d find the men plowing, but the women doing the weeding. So it’s going to vary from agricultural system to agricultural system. Having said that, the basic point that you make, that the bulk of subsistence agriculture is from women, is absolutely correct. And what it means— AIDS means is that you’re losing those inputs. You’re losing those inputs in a number of ways. First of all, the women are— there are fewer women because they are dying. Let’s not pretend it’s— we’ve got data from the Medical Research Council which shows that mortality rates among women between I think it’s 15 and 30 have risen 150 percent in the last 12 years, and that’s in a society where the epidemic is still in its early stages.
So we’re losing the labor because women are dying. We’re losing the labor because women are sick. And that’s a really important problem because women are just unable to get out into the fields. But we’re also losing the labor because women’s labor is having to be used for other things. Using— if we take our hypothetical person, Joe Mkomo in Matabeleland, if he’s lying in bed sick, his wife will be expected to take care of him. So that time is lost from productive output. If his— the children are sick, she’s in the queue at the clinic, that time is lost from productive output.
So effectively this is a disease which increasingly has a female face. There are more women infected than men, and the burden is being carried by the women of Africa.
GARRETT: Before I go to Botswana, another case example I want to look at, how much of everything we’ve talked about so far do you see applying to your experience in Ukraine, and how much do you think we are already able to quantify some economic impact from HIV in Ukraine?
WHITESIDE: That’s a very interesting question. Again, I think there the problem is you have a society which, until very recently, was in decline, so trying to sort out the AIDS impact was extremely difficult.
And one of the realities that we have to face is that people like the World Health Organization [WHO] do calculations that we’ve got this many people who are HIV-positive, therefore it will cost this much for the government to treat them. But it isn’t axiomatic that they’re going to get treated. So if you decide not to treat them, then you’re not spending the money. And who actually cares about that, apart from the poor souls who are infected and their families have to bear the burden? What happens with this epidemic— and I’ll come back to Ukraine in a minute— but what happens with this epidemic is that the burden of care gets shifted from the private sector to the government, from the government to the community, and then when the community can’t bear it any longer, from the community to the family and to the women in the family.
Now coming back to Ukraine, we don’t know because we don’t know whether or not this epidemic is going to spread beyond the drug users and the people who have sex with drug users in Ukraine, or in Russia, or indeed in any of the former Soviet Union states. If it does, then I suspect it will have a severe economic impact because it’s a society which has already seen a contraction in the working-age population. At the moment there’s unemployment, but five, 10 years from now, they’re going to face the same sort of crisis of human resources as Western Europe is facing.
GARRETT: Demographer Murray Feshbach at the Woodrow Wilson [International] Center [for Scholars] estimates that Russia, in particular, is already in an acute labor shortage and that in a decade’s time, the combination of outflow, declining fertility rate, and HIV will mean that they will have no choice but to allow huge Asian immigration into what is now almost all-white Siberia; otherwise, all industrial capacity and everything will entirely collapse.
WHITESIDE: You see the same thing happening with medical staff going to Africa, where many of the medical institutions in the state system are staffed by Cuban, Indian, and other doctors because there is simply not the capacity there and we’re not creating it and we’re losing it. So I don’t think that’s an impossible scenario at all for Ukraine and for Russia. And that’s going to be particularly serious in the countries which have just joined the European Union [EU], because of course their young labor has access to Britain, France, and Germany at very much better wages.
GARRETT: Let’s look at Botswana. You did a number of studies looking at what’s happening in the diamond industry in Botswana already and how that’s associated with HIV in Botswana. Botswana has either the highest or the second highest, depending on the Zimbabwe data, HIV rate in the world. So could you summarize what you saw with the diamond industry?
WHITESIDE: Yes. If we look at HIV prevalence rates, at the moment the highest is Swaziland, where we’ve got 2002 data, [at] 38.6 percent. Botswana has been higher than that. Currently on the 2003 data, they’re just a little bit below that, 38 percent. But, you know, what’s .6 percent between friends? So, basically they have a very serious situation. They also have an epidemic which is a lot more mature than Swaziland’s. In Swaziland, we see that; Botswana we see that. You see, I need a tablecloth or a flip chart here. [Laughs.]
GARRETT: He always wants to draw what he’s saying. OK, so you see a plateau.
WHITESIDE: Yes, we do indeed.
GARRETT: But a high plateau.
WHITESIDE: A very high plateau. Now, what happened with the diamond company, Debswana, there is that in 1991-92, they put in place all the prevention thoughts, all the prevention methods that were the best practice at that time. They had peer education, they had condoms, they had theater, they had everything that they were told they should put in place if they were a responsible company in order to prevent this epidemic from moving through their workforce.
By about 1997-98, they were beginning to see deaths. And they were beginning to see rather more deaths than they were expecting and more deaths than they were comfortable with. And what happened is that they then went and they did a survey among their workforce, a seroprevalence survey using saliva. Basically, the workers just spat in a test tube, and this was tested to see if they were HIV positive or not. It was done anonymously. All you did was put your age and your job band on the test tube.
And they found that the prevalence in the diamond mine was 28 percent, which was absolutely horrific. They thought it was going to be 11 or 12. The worst of it was that it was pretty uniform across the job grades. So [among] the least skilled, it was 33 percent; but [among] the most skilled, it was coming in at 18 percent. So the diamond company came in and said to myself and my colleague, [London School of Economics Professor] Tony Barnett, what do we do? And we said, “Well, we don’t actually know what you do. But let’s talk about this. Let’s have a discussion about what you might do.”
And what they did was what we call an institutional audit. And this is available on the UNAIDS website, the case study we wrote up, where we basically said, what does this epidemic mean for this company in terms of its labor force, in terms of its critical posts? Which jobs are the most important, where are we likely to see impact? What does it mean for this company in terms of its market? What does it mean for this company in terms of its pension plan, in terms of its training?
And on the basis of that institutional audit— which they did— and this is really important: Debswana, the people in the diamond company went and did this, and so it was wholly owned by them— on the basis of that institutional audit, they put in place a whole lot of policies which I think are among the best in the world. Things like— ones which people won’t like— they test people before they give them scholarships for overseas training. If you’re not a member of the company already, and you want to go and be trained as a geologist in Newcastle or as a doctor in New York, then you have to have an HIV test, and if you’re positive, you’re excluded from that scholarship.
They put in place AIDS compliance for their suppliers. They said, “We’re taking this epidemic seriously, and if you want to do business with us, whether you’re a supplier of air conditioning equipment or whether you’re the accountant or the lawyer, we expect you to be AIDS-compliant.” And they put in place free antiretroviral therapy for their workers and for their workers’ spouses. Any member of the work force at the diamond company can get access to free antiretrovirals, and the company doesn’t need to know about it; it can be done through another route.
So Debswana is, to my mind, a model employer, a model company. But let’s be clear on this: It is also the richest company in one of the richest countries in Africa, and that is not replicable and nor will it be replicable, particularly by the company, which is a textile company, which is taking advantage of the AGOA [African Growth and Opportunity Act] opportunities, that is based in Lesotho.
GARRETT: Well, that leads to— one of the things you spend a lot of time on in your book is looking at how HIV is affecting productivity and the bottom-line revenues for all sorts of sectors of industry and individual businesses. I mean, you know, it’s not just that people are dying, but you’re losing your labor force. Can you go through some of the key points that you think contribute the most, where HIV is affecting the bottom line?
WHITESIDE: I think there are two which I would pick up on. The first one is that HIV impacts sooner than we expect, and the second is— I’m just making a note here for myself --
GARRETT: So you remember what you say? [Laughs.]
WHITESIDE: So I remember what I wanted to say. We have— one of the things that’s really hard to do is to identify how HIV actually impacts on productivity, because how do you measure a person’s productivity up to the point they’ve died of AIDS? I mean, most of us are in jobs where, frankly, it would be very hard to measure our productivity and to measure an impact in whether or not the pace goes up or down. [Laughter.]
GARRETT: [Laughs.] Let’s be perfectly frank!
WHITESIDE: I’m sorry— let’s be honest. [Laughs.] If you have a bad day, it doesn’t matter. You can probably catch up tomorrow. But there is one group of people where my colleagues up at Boston University were able to get good, solid data, and that is among the tea pluckers in Kericho— I think it’s Kericho— in Kenya, and basically, those are people who are paid per kilogram of tea that is plucked. And what these colleagues did was they tracked deaths from AIDS, and they looked at people who died in service in the tea estates, and they were able to, by various methods, say, “Well, this is TB [tuberculosis] and also thrush, and therefore we are going to…” And then some cases it said AIDS on the death certificate.
So they could identify workers who died of AIDS for certain, and they could identify workers who died of other causes. And what they found is that the actual production started declining 18 months before those workers died, and that is something which we really didn’t expect to see. So I think what we’re looking at is a real impact on productivity in terms of actual output. What we desperately need to do is to get those sorts of measures in other locations, because it is such a powerful tool for advocacy.
The second area where I think we’re looking at impact is around morale. What you see is that in workplaces where people are sick and where people are going to funerals and where women, particularly, are at home, taking care of kids, there’s a huge impact on employee morale. And I know of workforces where— small workforces where there are one or two people sick, and I can see the impact it’s having on those workforces.
And then there’s a third thing, which I think we also have to be brutally honest about, and that is that the private sector adapts. When there’s a problem, the private sector finds a way to solve it. So we’re not going to see an impact on pensions. We’re not going to see an impact on the company share of resources going to medical aid. What we are going to see is the burden being shifted onto the state, and then again to the community and the household. I think the private sector is infamously resourceful, and I think that’s what we’re going to see.
GARRETT: So it’s just cost-shifting?
GARRETT: And you had mentioned to me earlier that you’ve been startled by findings in the mining industry regarding tuberculosis and HIV.
WHITESIDE: Yes. There’s a very recent issue of the journal AIDS— it’s the last issue, I think, which has just come out. Basically what they have found— and this is the first time I’ve seen good, hard data for this— that, as you would expect, the TB rates were coming down. In the mining industry it’s a totally controlled environment, so you can actually put in place DOT. In fact, they parade the miners—
GARRETT: [DOT stands for] directly observed—
WHITESIDE: Yeah. Sorry, yeah, yeah.
GARRETT: --for— of course, yes— for Tuberculosis.
WHITESIDE: They actually paraded the miners. So if you were TB-positive and you needed treatment, you had to go on parade before you could go to work. And if you didn’t, then you didn’t go to work and you didn’t get paid. Now, that’s what’s coming down, and TB was, to some extent, under control in the mining industry. And with the changes, with the ending of apartheid, living conditions were improving.
So— I’m not saying— I’m not a defender of the mining industry, but TB was coming down. Then HIV came along and now we’ve seen an increase in HIV among— I mean, in TB among HIV-positive miners. But what the article in AIDS shows is that, among HIV-negative miners, you’re also seeing an increase in TB.
So if we put this in biological terms— and as a biologist, you know more about this than I have— you’ve forgotten more about this than I’ll ever know— the herd is getting sicker.
WHITESIDE: The entire cohort is becoming less well. And I think if you look at African communities— and there isn’t the research on this— that same pattern would be true. And again, a large part of the reason, I think, is that Mum is not there to take care of the kids.
GARRETT: But that overall the burden of disease is rising with HIV and affecting not only the HIV population but the society as a whole.
WHITESIDE: Absolutely. And again, what you have is the double whammy of here is a disease with associated diseases, which is creating a disease— growing diseases burden. Here is your supply of health care workers and your health resources, and they’re being diminished by this disease. So we have this double whammy, which is this double insult to African health.
GARRETT: When we look back and we read the histories of the black death of the 14th century— and certainly [writer and historian] Barbara Tuchman’s, you know, penultimate book on that, “Distant Mirror,” is instructive— we can see that the ultimate outcome of the black death, when Europe lost 50 percent of its population, roughly— some places, more than 80 percent— was that not only were there suddenly fewer workers to— serfs to send out to farm the fields, so of course you got famine, but that the priests had been unable to explain why it happened and to pray it away, and many of them, in their terror, refused to give last unction to dying victims of the plague, so that the whole control that the Catholic Church had over the populace was undermined. And never again did the Holy Roman Church have the same level of control and grip over Europe as it had had before the plague. And entire institutions of fiefdom and serfdom collapsed, because suddenly there was a desperate need for labor, and you had to actually pay for it. Labor had real value. And this ultimately completely changed the whole relationship between the aristocratic classes and the working classes of Europe. Can you see anything on that scale occurring either now or in near future, in any endemic countries in sub-Saharan Africa?
WHITESIDE: I fear so, and in a way, this is the next article which I’m writing—
GARRETT: After Darwin.
WHITESIDE: Yes, that’s right. And the reason is, there are a couple of statistics which we need to be aware of. One is that if you look at societies like Botswana, the cohort mortality for a 15-year-old boy at the moment, unless there’s a real change, is that that child has an 80 percent chance of dying of AIDS— a 15-year-old boy. This is the data which was published in the 2002 UNAIDS review, the 2002 UNAIDS world AIDS report.
You know, one thing which people don’t know is, they didn’t publish the data for girls, because it would be too depressing.
GARRETT: That would be?
WHITESIDE: More than 80 percent chance of mortality from HIV.
The second thing which I think we need to have in our minds is that we’re talking about life expectancy in the worst-affected countries falling to below 40, in some cases perhaps to 30 years. And if you look at a simple thing like life expectancy, I think that’s enormously instructive in understanding what this epidemic is going to do, because life expectancy is not just about how long you’re going to live; it’s also about what you expect from life.
And I think if we were to look around this room and if anybody in this room is below 30, if we said to you, “You’re going to only live another five years,” would you buy that condominium, would you buy that car? If you were a parent and you thought your kids are not going to reach their 30th birthday, will you invest in that college education?
So I think that in a society where there is this perception that things are falling apart— if I could quote [Nigerian author] Chinua Achebe’s book— then I think there’s a real disempowerment, a lack of engagement as to the future. It’s something which we’re seeing, I believe, increasingly. And it may be part of the reason why we’ve got this complete state failure in Zimbabwe, why in Malawi the election results are being contested, because there isn’t that belief in a future.
GARRETT: What is the state, then? One of the things you point out that so many people observing the epidemic have failed to notice is that Africa, and we could say the same now of the former Soviet nations, these are places where the state is a new invention. And in many cases, when HIV arrived, the state was still being invented, the notion of statehood, the notion of governance, of the basic systems of governance. So now the situation you describe, that sense of hopelessness, of no future, what does that mean that the society expects of the state? And how is the security of the state affected by that expectation?
WHITESIDE: Well, I think in most instances it means that the society, which had very little expectation of the state, is having those expectations endorsed. They didn’t expect much from the state, and they’re not getting it. And I think there’s less of a willingness to buy in. And we’re looking at this at the moment using data from Afrobarometer, which is a very useful tool for looking at African society.
But there is the converse of this, and I think it’s possible in this room to not leave a picture of complete doom and gloom. There are places where the society has come together. There is Uganda, where the epidemic has turned around. There is Senegal and the Gambia— we often forget about little Gambia— where the epidemic never took off. And there is South Africa, where, despite the problems we have, we’ve had a political transition. And if we can grasp AIDS, then maybe we’ll make a difference.
There’s even Swaziland, where there’s some amazing initiatives going on. One of them is where the National Emergency Response Committee on HIV/AIDS— NERCHA, for short— goes out and they plow fields in the [inaudible], and they say, “These are the fields to feed the orphans. Will you, the community, cultivate them?” And the communities do cultivate them. And then they’re providing the storage capacity, the feed, and so on and so forth.
So there is— I think we’re at a cusp. We either fall apart or we come together. And of course, it will be different in different societies, but that’s really where I think we are with this epidemic.
GARRETT: I just want to ask one more question and then open it up for everybody here in the audience. And that is, if I were sitting in leadership in one of the so-called second-wave countries, as identified by our National Intelligence Council, the countries most likely to be the next great waves of HIV— that being Russia, China, India, Nigeria, and Ethiopia— I would argue Ethiopia’s already way past being a second wave; it’s totally locked in. But at any rate, with the others, if I were in power right now I might very well argue, looking at what— how the world has responded to Africa’s epidemic, that the last thing in the world we want is to be transparent about our HIV numbers. We want to downplay it for external consumption as much as possible, because just look at how the world has responded to Africa’s pandemic. It has said, “Whoa, don’t invest there. That’s a loser continent. Man, walk away from that one.” And I’m in national security meetings where they say the same thing about Africa as a foreign policy issue: “Total mess, just stay away from that continent. Man, it was already a mess. AIDS comes along, destroyed.”
And so I might very well say, if I were in [Russian President Vladimir] Putin’s administration right now, in particular, or in the new administration of [Prime Minister Manmohan] Singh in India, or talking to [Premier] Wen Jiabao in China, I might very well say let’s do our level best to externally appear cooperative and honest, but by all means keep the view of this epidemic and certainly any indication of it actually having impact on our society as quiet as possible, because we don’t want to follow how the wealthy world has viewed Africa. We don’t want that happening to us.
WHITESIDE: --they are.
GARRETT: You think they are already?
WHITESIDE: Well, I mean, are they being open about their epidemics? I mean, what you’re saying is very interesting. I think we are seeing a denial around HIV/AIDS in these countries. In China there is definitely a denial, and there are people in the audience who will probably say things when we open it up for questions. In Russia, I think it’s— well, in all these settings, it’s tied up with people and practices which are considered undesirable by the people in power. It’s tied up with commercial sex work. It’s tied up with drug use. It’s tied up with the caste system. So I think there is a real denial around that.
For me, the question is will it bridge beyond the drug users and the people who have sex with drug users in places like Russia? I don’t know. In India and China, the question is will the people really care, the people in power care enough about the many millions of people? Will they react in the same way as we might about those people who are falling ill? And that’s a question which I would really pose. I don’t know.
The question, though, is, do we try to put the lid on this epidemic because we don’t want to scare away our investors and we don’t want to scare away our tourists? Well, my province, KwaZulu-Natal, I think is taking an incredibly material attitude towards them. And this isn’t a commercial, but it’s the reality. They have said, “We have to face this epidemic because in KwaZulu-Natal we have the highest prevalence in South Africa.”
GARRETT: What is it right now?
WHITESIDE: It’s about 36 percent among our antenatal clinic attenders. Where I live, in Durban— and friends in the audience have been there— I can take you to a clinic which is less than three kilometers from my home and my office where prevalence is about 40 percent.
So what we’ve done in our province is we’ve said, “OK, this is the reality. How are we going to make it work for us? What are we going to do with AIDS that will turn it from a dire, dire threat into an opportunity?”
And it may be around treatment. It may be around being open and honest about it. It may be around providing care for orphans. There are a whole series of things that we might have to do. But if we ignore it, it isn’t going to go away. So let’s rather face it.
GARRETT: Well, you now brought something up— and I know I promised that that was going to be my— but I have to ask one last question, because this will be nice and controversial. I think I know what you’re going to say in answer to this, and there will probably be people in the audience that will be agitated, shall we say.
Again, hypothetically, I’m a head of state in a country that is incredibly resource-scarce and has an HIV prevalence that means that in the reproductive age, my productive age population, about a third or more are already infected. I know that I only have, in my entire society, two cardiac surgeons. I only have, in my entire society, four foreign-trained generals in my full armed forces. I have only one individual who can run an air-traffic control center from my capital airport, and one meteorologist to forecast famine conditions and so on.
Along come antiretrovirals. I can make a choice to do what probably the West wants me to do, or probably the people in this room want me to do, which is to, in a total democracy sense, make those antiretroviral drugs available to as much of my population that’s infected as possible and expend huge resources to create an infrastructure that will be designed to get those drugs out as broadly as possible, as quickly as possible.
Or I can say, “I must target these very valuable individuals with skills that spill way beyond way beyond the epidemic, get them fully treated, and get them started training their successors.” In other words, I’m doing rationing, knowing that I’m dooming much of my population to die that might survive longer with these drugs. What would your decisions be?
WHITESIDE: The reality is, we will be rationing drugs. If you take South Africa, for example, where probably at this point— and the data is there, and I don’t have it off the top of my head— but in South Africa, probably 200,000 people would benefit from going on treatment now, including, I might say, someone who works directly for me in a personal capacity.
Our government has said we will treat 53,000 through the state system. So, inevitably, we are not going to roll out treatment to everybody who needs it. So then the question is, how are we going to ration? And the question is, is it going to be explicit, as boldly put as you do, saying we will give it to the people who are most productive in the society, the ones we can least afford to lose, or is it going to be implicit in the way we do it? And the answer is, it’s going to be implicit. You are more likely to get treatment if you’re in an urban area. That immediately addresses people who will keep the economy rolling.
It’s going to be implicit in the sense that we might put in cost recovery. We’ll give you treatment, but we expect you to pay a contribution towards it. And that immediately cuts out people who can’t afford that contribution. It’s going to be implicit in very many ways.
And let’s also be realistic about this. Even if we recount every person on treatment at midnight on the 31st of December in 2005, we are not going to reach these ridiculous targets which have been set by the World Health Organization.
GARRETT: Well, that should give food for discussion. If you could just raise your hand and— do we have the microphones? I think we have somebody right here. Please identify yourself when you ask a question.
QUESTIONER: Hi. I’m Katrina Kuai from UNDP/CSO, [United Nations Development Program] Civil Society Organizations division. And my question to you, doctor, is, one, I’d like to dwell a moment longer on the Uganda story, because it is a phenomenal story. And I’ve heard a bit about the political will that went into it, the leadership, as well as the civil society— the strength of civil society there. But I wonder if you can mention a little bit more about maybe the economic side of it that I don’t know too much about, and how much that configured in— or maybe the government’s ability to manipulate the economy or the existing nature of the economy that maybe provided an easier way of— some aspect of that.
And then my second question was about— it was just trying to clarify a point— when you mentioned the example of the Botswana diamond company, whether you’re suggesting that— well, should government— ideally, would government be able to implement the same conditionalities? Because, I mean, the— obviously not, in reality. But I mean, how do you implement those kinds of conditionalities, unless you have a totally controlled situation? And besides, what’s the government— it doesn’t have the mandate to do that, because it does violate some civic rights as well. So those are my questions.
WHITESIDE: Well, I think the first question— there’s a very good article just been published, a very accessible article, by Rand Stoneburner and Daniel Low-Beer. And I’m not certain if it’s Science or Nature—
GARRETT: Actually, one in each.
WHITESIDE: --one in each; right, OK— very recently published, which looks at the story of Uganda, the ABC [program to control the spread of HIV/AIDS]. And I’m sorry to disappoint our colleagues down the road in the White House; it is ABC. And the—
GARRETT: Abstinence, be careful, and use condoms—
WHITESIDE: That’s right.
GARRETT: --be faithful, and use condoms when not.
WHITESIDE: Yeah. Yeah. So effectively, what we’ve got is a situation where it is combination of those things. But what’s really interesting from the Low-Beer and Stoneburner article is that what has made the difference is where people have got the messages from. It’s getting the message from their peer group, and it’s also being aware of the mortality around them. And undoubtedly delaying onset of sexual debut has been tremendously important in keeping prevalence lower among young women. So the A part is important, but so are the other two.
In terms of the economic impact, I think that what this really tells me is that, in a society in transition, where you’ve got an economy that’s growing, you can do things that will be really important in terms of making a change, where people are more hopeful of a future. If you’re hopeful about the future, then you’re more likely to invest in all the behaviors that are going to prevent HIV from spreading.
The other part of your question, about the economic input— and I think this is a tremendously important one— is if you look at the data on how much was spent in Uganda, there were domestic resources mobilized. And I think this is really important. It’s the real message that we need to have for the global community and for Africa as well. If you go into a country and say, “You’ve got an AIDS problem and we’ve got the money and we’ll solve it,” the president, the minister of finance, and everybody in that country is going to say, “Oh, good. That’s one less thing on the list that we have to deal with.” And that’s not going to solve the problem.
The second part of your question, just remind me, was on?
WHITESIDE: Oh, Botswana, testing and so on and so forth. Well, the Botswana government won’t employ you without being tested if you’re a foreigner. So the government is doing that. But let’s not get hung up on that, because that’s a particular response to a particular issue. I think what’s more important is the fact that the company, and indeed the government, has been prepared to say, “There are some things which may not be popular, but we’re going to actually make sure that we deal with them, because the future of our society is at risk.” And I would love to see some of the ethicists and the philosophers engaging around the HIV debate— which they don’t do— you know, what are the rights of the group as opposed to the rights of the individual?
GARRETT: Let me throw a question at you that I’ve thought of many times and I don’t have an answer for. You know, it takes 20, 30 years to train a general. And to reach general, you have to have had life experience that may not come in any given soldier’s life. And so I could imagine as a head of state, if I have a finite number of generals and I know that the HIV rate among my officer corps is 20 percent, I could imagine quite definitely deciding, “Well, I will preferentially make sure that top of the line treatment goes to my generals.” But what if my infantry knows this and they are not getting antiretrovirals? Then why the hell should they obey their generals? What is to result in tremendous resentment in the rank and file?
And then as you extend that out to the society as a whole, if [South African President] Thabo Mbeki’s government is going to give roughly 50,000 out of a needed 200-plus thousand people antiretrovirals in South Africa, and it’s going to go through a somewhat chaotic process of selection— but clearly the elite already is— let’s be clear. In South Africa the elite— cabinet members who are HIV positive, members of parliament who are HIV positive— have been getting their antiretrovirals for quite some time. So, at what point do we reach the level where the disparity of access to drugs becomes destabilizing in and of itself to the social order?
WHITESIDE: That’s a very good question. A couple of points, though. First of all, in South Africa if you’re in employment, you’ve probably got access to drugs. If you’re in the civil service, you certainly—
GARRETT: But the unemployment rate is—
WHITESIDE: Yeah, for 30 percent. If you’re in the civil service, you certainly get access to drugs. Not the case in the rest of Africa, but we have medical aid programs. If you work for my university, you get access to antiretrovirals, and now if you’re a student at the university— which is a real incentive for keeping your grades up, I guess— or for failing every year for many, many years. [Laughter.] I don’t know; I haven’t thought that one through.
So then the second question, of course, is around the military, where we do know HIV prevalence is high. Well, this is maybe an opportunity to demilitarize, because as some of my colleagues once said, why do we need that army anyway?
But seriously, I think there are real issues about who will get access. And if you go to Johannesburg or Nairobi, you will see people flying in from all over Africa to get treatment in the private hospitals. In Nairobi, in Johannesburg, that treatment is available.
I think it’s going to be a really interesting thing to look at, and I hope that it might be something which you’ll look at over the next year, because it’s one of those topics which needs to be picked up.
QUESTIONER: I’m wondering, Alan, how do you think is the best way to get the attention of policymakers and government leaders to take the long-term impacts of HIV/AIDS on development issues seriously and not just be looking at prevention and treatment, but be looking at the effect on the civil servants, looking at the security issue, impact on the military? I mean, there’s some research going on, but what is the strategy to try to get these long-term societal impacts of AIDS on the agenda of policymakers?
GARRETT: I’m working on it, I’m working on it! [Laughter.] Give me a break, I’ve only been here nine weeks. [Laughs.]
WHITESIDE: She’s working on it. I really— if I knew the answer to that, I would— maybe the question is: where people have taken it on board, what has it taken? And in Uganda it was [President Yoweri] Museveni being told by [Cuban President Fidel] Castro, “Listen, your soldiers are going to die.” In Botswana, it was [President] Festus Mogae seeing the death rates climb. In Thailand, it was an awareness of what the science meant, I think.
GARRETT: It was also in Thailand the military impact.
WHITESIDE: Right. In Senegal, it was a confluence of fortunate events around very important people and around good science. In fact, there’s a very good paper being written on this by a gentleman called James Putzel at the London School of Economics, who looks at what it is that makes a difference. But I don’t think any of us know.
GARRETT: I think— I have to say, I think the question I asked in the beginning— the inability to be in the middle of a plague and really sense what’s happening around you— clearly plays a role. I’m often stunned by the way people talk about HIV in Washington— well-meaning people, people whose hearts are right bleeding on the table. And yet they’re not seeing it. They’re not really seeing it. And to have an idea of what it would mean if— just look at the numbers; figure what’s the percentage of sub-Saharan Africa; look at the prevalence levels and extend out 10 years— all those people will be dead. And it’s more people will be dead than all the people that all our investment with development aid since World War II has been about. We’ve reversed the entire development investment. I just don’t think that people can see it, because it’s almost impossible to imagine something this horrible. It’s almost outside of our consciousness, even when you’re in the middle of it, as you are.
WHITESIDE: No, I think that’s true. I mean, one of the things you can do is to— well, UNAIDS has got a scenario activity going on at the moment, and maybe that’s one way to look at it. I mean, these are things we’re grappling with, and, you know, it’s a case of watch this space, I’m afraid.
QUESTIONER: Evan Lieberman from Princeton University. And Professor Whiteside, I’m wondering if you could talk a little bit about some of the social forces in societies which have constrained these responses to AIDS because there’s so much— I mean, we assume that there’s this positive demand, which there is, within societies for a government response to AIDS. And then when we don’t see a response, it’s just the kind of narrow thinking of some unenlightened leader. But there are vast segments of societies— we know certainly in this society— but in many African societies, where there are church leaders going around saying don’t use condoms; the pope coming to Africa and saying all sorts of quite negative messages, but—
GARRETT: The United States Congress saying don’t use condoms.
QUESTIONER: Exactly. And I think that it seems to me that these are— politically, these are important forces to reconcile with. And I wonder— you know, we might talk about them as being moral conservatives in the U.S. If you use— if there’s any type of language or how you might identify those groups in some of the societies in which you’ve worked with, and how big of a problem you think they really are politically for having strong and aggressive responses to the AIDS crisis.
WHITESIDE: Well, it’s a difficult one to answer, because if a society is a society which abstains from premarital intercourse and is faithful within marriage, then you don’t have an epidemic. So there is an argument for the moral conservatism, if it works. So what you have to do is to say, in an ideal world, this is something that works, but we aren’t in an ideal world. And I guess what you’re trying to do is to get those people in that society to say this is what we want for ourselves and for our children, and indeed, for the society, but we recognize it isn’t going to work for everybody, therefore we have to have Plan B and Plan C, and Plan B and Plan C are very appropriate.
I don’t have— you see, also, I’m really not able to answer it too well because I’ve always worked in a setting where people understand the need for condoms. Our problem isn’t around faiths and condoms; our problem is around culture and condoms, the fact that they’re not accepted in a cultural sense. People do not like using condoms. There is a section in some societies that if you take the used condom, you can take it to the m’ganga or the sangoma, the witch doctor, and there you’ve got some body fluid which you can use for nefarious purposes.
GARRETT: Put a curse on someone.
WHITESIDE: So for me it’s not really been around that responsibility. The other thing which is a major problem, and it’s not a conservatism of culture, it’s around the culture of entitlement to sex, which seems to be very prevalent among many African men; that if I’m away from home, I need to have sex. And that’s another big issue. So those are the things which I think we have to address, as well as this moral conservatism.
GARRETT: If I can follow up on that, this whole thing— going back to the point that the state itself is a recent invention in much of this world, and of course, now we’re dealing with failed states all over the world, to what degree have these pseudo-states, these weakened states themselves been an obstruction to being able to effectively get HIV under control?
WHITESIDE: Well, absolutely they have been, because if you’re not delivering— well, in the book we talk about the need for development in order to create an environment. It’s necessary but not sufficient. You’re not going to be AIDS control without development. You’ve got to have it if you’re going to have the environment where people can change their behaviors, where they’re empowered to. And I think failed states is an example where you just have no ability to deliver anything.
But equally, the Western state— there was something there before it, and there is something there now. And in Swaziland in particular, we’re looking to the traditional leaders. I mean, we may not agree with everything that they stand for, but they are the safety net. And that’s what [the government funded emergency response committee] Nurture is doing in Swaziland, is saying we’ll use the traditional society to provide that safety net. So I think—
GARRETT: Yeah, but then the king has that annual festival where all the naked virgins are paraded out.
WHITESIDE: Oh, that’s not true. They aren’t naked. They just wear— they don’t wear any tops.
GARRETT: They’re topless. [Laughs.] There’s a prime example for you.
GARRETT: In the back here.
QUESTIONER: Patrick Slavin from UNICEF. First I’d like to thank Ms. Garrett for “The Coming Plague.” I read it in grad school recently. Dr. Whiteside, can you comment on the state of the vaccine trials, in particular the ones at or one at UCT [University of Cape Town]? There are occasional press reports about them in this country. Secondly, could you comment more on your criticism of the WHO’s 3 by 5 program [to provide AIDS treatment to 3 million people by 2005]?
WHITESIDE: I can’t comment on the vaccine trials, and it’s just such a pity that Seth Berkley [of the International AIDS Vaccine Initiative] walked out because—
GARRETT: --he’s running them and he just left.
WHITESIDE: Yes. I can’t say anything. Is there anybody else in the audience who could? I don’t know.
GARRETT: Sorry. But after all, you don’t ask an economist to tell you what’s going on with vaccine trials.
WHITESIDE: No, absolutely not.
GARRETT: But do tell us the second. That’s an important—
WHITESIDE: OK. The 3 by 5— well, basically, if you look around the world and you add up what each country says they’re going to have on treatment— South Africa, with 4 million infections, maybe 53,000. Mozambique was I don’t know how many; I think they’re aiming for 21,000. What you’re finding is that when— and I wear a 3 by 5 button, by the way. I’m a— I also vote Liberal Democrats in Britain and Patricia de Lille [leader of the Independent Democrats] in South Africa. So I’m into losing causes.
GARRETT: He told me he supports [presumptive Democratic nominee Senator John] Kerry’s election in the United States.
WHITESIDE: [Laughs.] That’s right. Oh, God, I hope that’s not a losing cause.
Anyway, so I think if you add up all the things that people have said they will do, you’re not going to get anywhere near 3 by 5. Now— and maybe a comment—
GARRETT: Do I need— do people know what 3 by 5— let me back up one moment. This is a problem those of us in the field, we get too into our lingo and forget to define. The World Health Organization has set a target, and their target is to have 3 million people in developing countries on anti-HIV medication, antiretrovirals, by the end of 2005. This is the goal they have set, though they had no committed finances whatsoever behind this goal when they announced it. And the new director general just last week, in the annual WHO report, reiterated that this is the prime goal of the entire institution of the World Health Organization at this time, though they still have no resources to implement it.
WHITESIDE: Let me make it clear I want people to go on treatment. That’s absolutely fundamental. I think it is a right that people should have access to treatment. But I think for an organization to stake their reputation on this— because I take commitment seriously. If you say that this is what we will do, what happens when we reach that point and there aren’t those people on treatment? And that, for me, is the problem, not the fact that we’re trying to put people on treatment, because I think that’s absolutely fundamental.