November 26, 2004

The greatest moral issue

In ten years, HIV will have infected more people than have died in 2,000 years of war. How will history judge our response?

by Earl Pike
and Tracy Jones

By the end of the 15th International AIDS Conference in Bangkok last summer, one thing amid the mountains of truly dire reports and predictions was clear: Rarely before have we had a chance to do so much, for so little.

That�s not an exaggeration. In 2003 nearly five million new people around the world were infected with HIV, the virus that causes AIDS. Three million died. As the World Health Organization pointed out, the numbers are not going down; they�re growing at an alarming rate in the U.S. and across the planet.

It�s time to put the epidemic in perspective: Within ten years, we will reach an accumulated 150 million HIV infections around the world. A combined toll of 150 million in what will be, by then, an epidemic that has lasted but 35 short years.

By comparison, the combined death toll from all wars, everywhere in the world, since the first century, is approximately 149 million. A period of 2,000 years, including all the European wars, the Hundred Years War, the Wars of the Roses, the American Revolution, the Napoleonic wars, the War of 1812, the U.S. Civil War, both World Wars, the Korean War, all the Arab-Israeli wars, the Vietnam War, the Persian Gulf wars, and every conflict, uprising, civil war, war of independence, invasion and revolution, everywhere, in every country and territory, since the days of the Roman Empire.

By another comparison, if one added up all the deaths in the 20th century from weapons of mass destruction, and multiplied that number by ten, it would still not equal the number of people with AIDS who will die in the next 12 months.

As a matter of moral equivalence, it comes down to this: Imagine that we had the ability to prevent, and to care for those wounded from, every armed conflict over the last two millennia.

We do.

As a crisis, AIDS is now beyond comprehension, and it will only grow worse over the coming years. Millions upon millions will die; tens of millions of children will be orphaned; whole countries will virtually disappear. In Swaziland, a small nation of 1.2 million people in southern Africa with an adult HIV seroprevalence rate of almost 40%, the country�s leader said bleakly, �The world is letting my country die.�

As a moral opportunity, the crisis of AIDS presents us--and by �us,� it should be understood to mean the Western nations, especially the United States--with the prospect, on some elemental level, of saving the world.

It would cost each of us, American taxpayers, about 22 cents a day. That much would pay for the medications, the treatment, the prevention needed.

But didn�t President Bush already take dramatic steps to combat global AIDS?

No.

On January 28, 2003, in his State of the Union address, Bush said, �I ask the Congress to commit $15 billion over the next five years, including $10 billion in new money, to turn the tide against AIDS in the most afflicted nations in Africa and the Caribbean.�

It seemed historic. But before the end of the year, the President�s budget has whittled the implied $3 billion a year down to $2.1 billion for 2004--a 30% reduction. The president, it turned out, had not allocated the money; he had merely authorized the government to spend up to $15 billion.

Of the money authorized, only $1 billion was earmarked for the U.N. Global Fund for AIDS, Malaria, and Tuberculosis, still the best and most effective venue to combat global AIDS.

The rest was earmarked for fourteen countries on a pre-set list determined by the White House--countries, it turns out, where the United States has strategic interests beyond AIDS. The selection of countries wasn�t governed by pure science; it was tainted by political considerations.

Heavily emphasized in the Bush plan was support for the so-called �ABC� approach: Abstinence first; then, Be faithful; and only at the end, Condoms. Bush has pointed to Uganda�s dramatic success in reducing the nation�s HIV rate by employing the ABC approach, implying that abstinence was the key. But more recent evidence suggests that widespread condom use had more to do with Uganda�s success than abstinence.

Finally, of the $15 billion pledged, only $350 million, or less than 3%, has been released so far. In fact, since the president made his January 2003 announcement, over seven million new cases of HIV infection have occurred around the world; millions more have died.

No, the tide isn�t turning. It grows wider, and longer, and deeper with each passing day.

No more politics. What does it take to save the world?

� As the lessons of numerous countries make clear, leadership is essential. Presidents, prime ministers, and other national leaders; governors and provincial heads; mayors across the United States and throughout the world must make a clear, unhesitating, science-based, long-term commitment to ending the crisis. Leadership is the first moral imperative in AIDS, and it must come from the top.

� Resources are the second moral imperative. We in the United States should commit to $10 billion a year for the next five years to combat AIDS globally, and direct those funds toward the United Nations Fund. It sounds like a large commitment, but it comes out to about 22 cents a day for every American taxpayer. And we should do it because we can, because if we are to stand as a moral light to the nations, we should seize the opportunity to help end the worst epidemic in human history.

� Maintenance of support for domestic AIDS is the third moral imperative. In over a dozen states, people with AIDS are currently on waiting lists to access life-saving AIDS medications; some have already died while waiting. We must commit to fully funding the Ryan White CARE Act, America�s primary dedicated support system for people with AIDS, and to ensuring that inequities in care based on race, gender, and geography are eliminated.

� A true commitment to the ABC approach, which means not shying away from the reality that condoms save lives, is the fourth moral imperative. While we continue to debate whether availability of condoms leads to increased sexual activity--a contention that has been thoroughly disproved--young people continue to have unprotected intercourse.

� Justice is the fifth moral imperative, and justice is an ethic set by example, once again, by leadership from the top down. It will not do, as some religious conservatives who have latched onto AIDS as �their� issue have implied by their actions, to be concerned about AIDS among African women and children, while entirely neglecting the reality that gay and bisexual men--especially men of color--are still dying in major cities and small towns across America. Just as right-wing conservatives have attempted to divide us along lines of gay versus straight, Black versus White, and so on, there is a move afoot to resuscitate the idea that some people are �innocent victims,� and others are morally tainted. Such divisions ought to be roundly condemned by political leadership at the highest levels.

� A truly collaborative, international effort to develop an effective vaccine is the sixth moral imperative. Turf wars between researchers and corporations must end, and scientists working separately must work together, sharing information and ideas. In the end, only an effective vaccine will truly bring the epidemic to a halt; and in the end, only coordination and collaboration will create the necessary conditions for vaccine development.

As Sen Patrick Leahy of Vermont put it: �When future generations look back at this time and place, I believe they will judge us, more than anything, on how we responded to AIDS. It is the most urgent, the most compelling, moral issue of our time.�

And lest anyone think that such awareness is partisan, Leahy�s words are echoed from the other side of the aisle, by Sen. Bill Frist, a Republican: �History is going to record what we do when we face the terrible waste of life and hope that is the global AIDS epidemic today. Our grandchildren will ask us what we did to fight it.�

There is only one acceptable answer: Everything we could, and more.

Earl Pike is the executive director of the AIDS Taskforce of Greater Cleveland, and Tracy Jones is the associate executive director.