Convinced that the global spread of AIDS is reaching catastrophic dimensions, the Clinton administration has formally designated the disease for the first time as a threat to U.S. national security that could topple foreign governments, touch off ethnic wars and undo decades of work in building free-market democracies abroad.
The National Security Council, which has never before been involved in combating an infectious disease, is directing a rapid reassessment of the government's efforts. The new push is reflected in the doubling of budget requests--to $254 million--to combat AIDS overseas and in the creation on Feb. 8 of a White House interagency working group. The group has been instructed to "develop a series of expanded initiatives to drive the international efforts" to combat the disease.
Top officials and some members of Congress contemplate much higher spending levels. The urgency of addressing AIDS has also touched off internal disputes over long-settled positions on trade policy and on legal requirements that aid contractors buy only American supplies.
The new effort--described by its architects as tardy and not commensurate with the size of the crisis--was spurred last year by U.S. intelligence reports that looked at the pandemic's broadest consequences for foreign governments and societies, particularly in Africa. A National Intelligence Estimate prepared in January, representing consensus among government analysts, projected that a quarter of southern Africa's population is likely to die of AIDS and that the number of people dying of the disease will rise for a decade before there is much prospect of improvement. Based on current trends, that disastrous course could be repeated, perhaps exceeded, in south Asia and the former Soviet Union.
"At least some of the hardest-hit countries, initially in sub-Saharan Africa and later in other regions, will face a demographic catastrophe" over the next 20 years, the study said. "This will further impoverish the poor and often the middle class and produce a huge and impoverished orphan cohort unable to cope and vulnerable to exploitation and radicalization."
Dramatic declines in life expectancy, the study said, are the strongest risk factor for "revolutionary wars, ethnic wars, genocides and disruptive regime transitions" in the developing world. Based on historical analysis of 75 factors that tend to destabilize governments, the authors said the social consequences of AIDS appear to have "a particularly strong correlation with the likelihood of state failure in partial democracies."
Another mobilizing factor is American politics. African American leaders, such as former representative Ron Dellums (D-Calif.) and Rep. Jesse L. Jackson Jr. (D-Ill)., have adopted the cause of AIDS in Africa. Their interest is converging with that of long-standing AIDS activists in the United States and Europe, where the course of the epidemic has been slowed by preventive efforts and life-saving combinations of anti-retroviral drugs. They are angry at policies that price those medicines beyond the reach of the developing world.
In June, those activists disrupted Vice President Gore's presidential campaign announcement in Carthage, Tenn., and two other speeches that week--"blindsiding us completely," as one senior adviser put it. The activists, and several senior Clinton administration officials, say that pressure accelerated the White House's response.
There is no recent precedent for treating disease as a security threat. So unfamiliar are public health agencies with the apparatus of national defense that one early task force meeting was delayed when Co-chairwoman Sandra Thurman, whose Office of National AIDS Policy is across the street from the White House, could not find the Situation Room.
For all the stakes they now describe, Clinton administration officials do not contemplate addressing them on a scale associated with traditional security priorities. Gore's national security adviser, Leon Fuerth, freely acknowledged that the 2001 budget request of $254 million to combat AIDS abroad--a sum surpassed, for example, by drone aircraft in the Pentagon budget--provides "resources that are inadequate for the task." He called the work of the task force "an iterative process" aimed at slowing the plague's rate of increase and alleviating some of its effects. Before this year, federal spending on AIDS overseas remained relatively flat.
Other officials noted that the United States has endorsed U.N. Secretary General Kofi Annan's declared five-year goal of reducing the rate of new infections by 25 percent. That falls close to the CIA's best-case, and least probable, scenario. Because such a turn of events would demand resources from U.S. allies and multinational bodies, the new White House group has been instructed to "develop a series of expanded initiatives to drive the international efforts."
Fuerth, a member of the "principals committee" that takes up the most important foreign policy questions, told representatives from 16 agencies on Feb. 8 that the panel wanted a package of proposals for Clinton within a several weeks. The working group is scheduled to finish drafting its proposals in May. Fuerth said the government is looking for "the kind of focus and coordination on this issue that we normally strive for on national security issues."
"The numbers of people who are dying, the impact on elites--like the army, the educated people, the teachers--is quite severe," he said. "In the end it was a kind of slow-motion destruction of everything we were trying, in our contact programs and our military-to-military programs, to build up, and would affect the viability of these societies, would affect the stability of the region. . . . In the world that we're facing, the destiny of the continent of Africa matters. And it isn't as if this disease is going to stay put in sub-Saharan Africa."
Twenty-three million people are infected in sub-Saharan Africa, with new infections coming at the rate of roughly 5,000 a day, according to World Health Organization figures. Of 13 million deaths to date, 11 million have been in sub-Saharan Africa. In the developing world, the disease spreads primarily through heterosexual contact.
The intelligence estimate portrays the pandemic as the bad side of globalization. Accelerating trade and travel--along with underlying conditions favorable to the disease--are pushing much of Asia, and particularly India, toward "a dramatic increase in infectious disease deaths, largely driven by the spread of HIV/AIDS," the intelligence report said. "By 2010, the region could surpass Africa in the number of HIV infections." The number of infections now is relatively low, but the growth rate is high and governments have been slow to respond.
Infections are also growing rapidly, and largely unchecked, in the former Soviet Union and Eastern Europe. The intelligence estimate said this growth will "challenge democratic development and transitions and possibly contribute to humanitarian emergencies and military conflicts to which the United States may need to respond." The report also anticipates that "infectious disease-related trade embargoes and restrictions on travel and immigration also will cause frictions among and with key trading partners and other selected states."
"The thing that's most staggering, and people are just beginning to grasp, is that Africa is the tip of the iceberg," Thurman said. "We are just at the beginning of a pandemic the likes of which we have not seen in this century, and in the end will probably never have seen in history."
Senior administration officials, some of them apparently frustrated, said that the government does not dispute estimates by the Joint United Nations Program on HIV/AIDS that it would take nearly $2 billion to fund adequate prevention in Africa, and a like sum for treatment. What the United States has been spending, by contrast, "is a rounding error for county budgets" in Fairfax and Montgomery counties, said one disgusted official.
"I don't have a fantasy that we're going to go to the Hill and get $5 billion to build Africa's health care infrastructure," said one senior Africa policymaker. "We're trying to determine effective steps that need to be taken, and can be taken, right now."
After initial resistance from U.S. Trade Representative Charlene Barshefsky, the government has agreed in principle to encourage cheaper access to life-saving drugs by relaxing hard-line positions that protect U.S. drugmakers' intellectual property. Gore has said publicly that the United States does not rule out the use by afflicted countries of locally made or imported generics of drugs under patent by American companies. Assistant Trade Representative Joseph Papovich has written to the governments of Thailand and South Africa with new formulas for resolving intellectual property disputes on such medicines.
But several participants in the government effort said the practical meaning of the change, if any, will have to be decided at the Cabinet level or by Clinton personally. An early test comes in May, when Barshefsky's office decides whether South Africa should be removed from the "watch list" of countries facing potential trade sanctions. South Africa is on that list because it passed a law the United States initially described as threatening to the intellectual property of American drug manufacturers.
With the prospect of substantial new spending, agencies ranging from the Centers for Disease Control and Prevention (CDC) and National Institutes of Health to the Labor Department are fighting over the allocation of funds. Undersecretary of State Frank Loy, meanwhile, is said by participants to be resisting the emerging consensus that the international AIDS effort should be centered in Thurman's office.
The task force has also battled over proposals to amend the Foreign Assistance Act, which requires all taxpayer-funded aid to come from American suppliers. Public health agencies want exceptions for condoms and AIDS test kits, which can be acquired more cheaply overseas. Congress willing, the task force is likely to recommend that change.
The high-profile attention from the top is "raising this issue in ways that leaders [of afflicted nations] can't ignore it," one White House official said. Richard C. Holbrooke, the U.S. ambassador to the United Nations, used his rotation as Security Council president in January to declare a month on Africa. He made AIDS the subject of the first Security Council meeting of 2000 and invited Gore to speak. When Clinton traveled to India in March, he successfully pressed the government to issue a joint declaration on AIDS.
Pervading the recent U.S. effort is a strong sense among participants of time misspent. The virulence of the pandemic was accurately foreseen, and "the United States didn't exactly cover itself with glory," said one close adviser to Clinton.
"We saw it coming, and we didn't act as quickly as we could have," said Helene D. Gayle, a physician who directs AIDS prevention at the CDC. "I'm not sure what that says about how seriously we took it, how seriously we took lives in Africa."
Peter Piot, a virologist who heads the United Nations AIDS efforts in Geneva, said "the good news is that the U.S. government is mobilizing. The bad news is that it took so long. This is not a catastrophe that came out of the blue. It has been clearly coming for at least 10 years."
Asked about those comments, Thurman looked pained.
"Oh yeah," she said softly. "It's very late. But better late than never. You rarely ever get a second chance in an epidemic."
Staff researcher Robert Thomason contributed to this report.
THE IMPACT OF AIDS
More than 16 million people have died from AIDS since the 1980s, 60 percent of them in sub-Saharan Africa. Not since the bubonic plague ravaged Europe in the Middle Ages has there been as devastating a disease. U.S. officials have reached the conclusion that the impact of AIDS will be so vast that it has become a threat to U.S. national security.
Percentage of adult population infected with HIV or suffering from AIDS. Selected countries
South Africa: 12.9
Central African Rep.: 10.8
Ivory Coast: 10.1
AIDS already has significantly shortened life expectancy and will cut more years off people's lives by 2010.
Life expectancy without AIDS (years): 70.1
Life expectancy with AIDS (years): 38.9
Change: 44.5% drop
Life expectancy without AIDS (years): 69.5
Life expectancy with AIDS (years): 38.8
Life expectancy without AIDS (years): 66.3
Life expectancy with AIDS (years): 37.8
Life expectancy without AIDS (years): 63.2
Life expectancy with AIDS (years): 37.1
Life expectancy without AIDS (years): 56.8
Life expectancy with AIDS (years): 34.8
Life expectancy without AIDS (years): 60.1
Life expectancy with AIDS (years): 37.8
Life expectancy without AIDS (years): 65.9
Life expectancy with AIDS (years): 44.7
Life expectancy without AIDS (years): 68.2
Life expectancy with AIDS (years): 48.0
Life expectancy without AIDS (years): 60.7
Life expectancy with AIDS (years): 46.1
AIDS has left about 9 million children without their mothers or both parents, the vast majority in sub-Saharan Africa.
Number of 15-year-olds per 10,000 of that age group who have lost their mothers or both parents to AIDS.
Ivory Coast: 380
U.S. assistance to combat AIDS has stayed around $120 million for the past seven years. But officials believe much more is needed to halt the disease and treat those infected.
2001 budget request: $264 million
SOURCE: World Bank, WHO, UNICEF, USAID