DEATH WATCH: The Global Response to AIDS in Africa

By Barton Gellman
Washington Post Staff Writer
Wednesday, July 5, 2000

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

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

Interagency Intelligence Memorandum 91-10005, distributed in classified channels the following July, foretold one of the deadliest calamities in human experience. Titled simply, "The Global AIDS Disaster," the report projected 45 million infections by 2000--inexorably fatal, the great majority in Africa. The number beggared comparison. There were not that many combatants killed in World War I, World War II, Korea and Vietnam combined.

Unlike the Black Death in 14th-century Europe, which took half as many lives, the means of controlling AIDS were known. Yet African and foreign governments, the report said, were making no more than a "modest level of effort." This would "have only a marginal effect."

The same might have been said for IIM 91-10005. The document landed near the top of the pile of incoming intelligence at the White House and Cabinet agencies. The reaction, said principal author Kenneth Brown, was "indifference--that's the right word." The authors prepared for the flurry of briefings that accompanies release of a major intelligence product. Save for then-Surgeon General C. Everett Koop and a Pentagon medical unit, no one asked.

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

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

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

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

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

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

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

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