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Gerald R Ford School of Public Policy ** Integrated Policy Exercise ** January 2003

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Science and Technology: The next wave; AIDS
 

The Economist; London; Oct 19, 2002;
 

The global fund set up to combat AIDS risks running out of money even before it has really got going

PREVENTION is said to be better than cure. It is, however, often hard to get people to act on this sensible advice. On October 11th, the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria, an organisation set up in January to collect and disburse funds to combat these three diseases, met to consider the fund's financial position. The numbers are grim. The fund has pledges of $2.1 billion over the next five years. But next year alone, it will need $2 billion more than it has been promised in order to finance those proposals it has already agreed to.

Though malaria and tuberculosis are serious problems, it is against AIDS that the bulk of the effort is directed. All of the approved proposals, even those aimed at treatment, have been chosen because they involve an element of prevention. Condoms and clean needles will be distributed. Antiviral drugs will be given to pregnant women. Counselling and testing centres will be built. If the money is there. On current projections, though, the fund will run out of cash in the second quarter of 2003. And even if it survives that, the projected shortfall in 2004 is $4.6 billion.

Nor is the drain on its funds likely to diminish. The numbers infected with HIV, the virus that causes AIDS, are rising rapidly. The day before the Global Fund meeting, UNAIDS, the United Nations agency charged with tackling the epidemic, revised its estimate of the amount of money that is needed for the task in 2005, taking poor and middle-income countries together, from $9.2 billion to $10.5 billion.

Furthermore, a report on the likely future spread of AIDS was published on September 30th by America's National Intelligence Council (NIC). It focused on China, India, Russia, Nigeria and Ethiopia, all populous countries, but none of them now in the premier league of infection rates. It concluded that within eight years these five "next-wave" countries will have 50m- 75m cases among them, compared with 30m-35m in central and southern Africa, the part of the world that is now worst hit (see chart). Moreover, it reinforced a point it made in a less-detailed report published three years ago: that AIDS is not only a humanitarian crisis in places that suffer from it, but also a security crisis for America and, by extension, other rich countries too. That point, above all others, might be the one that helps to loosen purse-strings in the world's finance ministries.

Cough up

The funding crisis is real enough. But international agencies are always short of money, rarely reticent about reminding people of the fact, and generally willing to wring any withers that can be wrung in pursuit of an extra dollar. The National Intelligence Council, however, is about as hard-headed an organisation as can be imagined. Yet it, too, is clearly scared. And its report makes disturbing reading.

One striking observation is how different the pattern of transmission is in different countries. That makes off-the-peg solutions impossible. Usually, an AIDS epidemic starts in a vulnerable group, and then spreads to the wider population. The NIC report suggests that in the next-wave countries those vulnerable groups differ significantly from place to place.

In China, for example, one of the main causes of the spread is poor farmers selling blood to illegal brokers. Although only a fraction of this blood is infected, brokers tend to mix what they have bought into large batches before extracting plasma for transfusions from it. One infected donation is all it takes to contaminate an entire batch. In Russia, by contrast, injecting heroin with dirty needles is the main source of infection. That is a common route to an AIDS epidemic. But the authorities are compounding their problem with what looks like a compassionate policy. Prison amnesties are releasing large numbers who have been infected while in jail.

In Ethiopia, meanwhile, the driving force is war--or rather, paradoxically, peace. The demobilisation that followed the end of the war with Eritrea has dispersed infected soldiers and camp-following prostitutes all over the country. Ethiopia has already had one wave of demobilisation-led AIDS after the end of its civil war in the 1980s. Now it faces another.

Although the NIC report predicts that China (10m-15m infected people in 2010) and India (20m-25m) will be the countries with the most cases, they are so populous that the epidemic should not destabilise them in the short term. But they will certainly feel the pinch. In India, for example, AIDS is expected to cut GDP by 1% a year.

About Russia, Nigeria and Ethiopia the report is less sanguine. Nigeria, the most populous country in Africa, is likely to lose a large part of its government and business elite--for although AIDS hits poor countries worst, it rarely spares the rich within those countries, since rich people generally have more sexual opportunities than poor ones. And while the NIC reckons Nigeria's oil industry will escape the worst effects of AIDS, the prospect of the country, which has a large and increasingly assertive Muslim population, being even less governable than it is now is one that must worry America's State Department. Ethiopia will suffer similar problems, though it has no oil.

Russia, too, could be destabilised. The disease will exacerbate the decline of the country's population, reduce its ability to put a decent-sized army into the field and, given that it has not yet abandoned pretensions to have a comprehensive health service, drain its tax revenues.

None of these countries yet shares the plight of southern Africa, of course. There, infection rates in several countries are a quarter or more of the adult population. But that, too, highlights a dilemma. As the report's authors delicately put it, "a debate is likely over how much the Global Fund should focus on heading off AIDS in large, next-wave countries where it is in the earlier stages, and how much to devote to the hardest-hit countries in southern Africa."

This debate will be irrelevant, though, if the fund runs out of money, and other mechanisms are not put in place to compensate. The Global AIDS Alliance, one of the field's numerous lobby groups, has done a few sums. Accepting UN estimates of need, and based on the idea that 90% of the money should come from national governments (with the other 10% coming from foundations), it has come up with a formula that shares the burden in proportion to the GDPs of potential donors. According to this, America should raise its annual contribution from $200m to $1.5 billion. Whether it does so may depend on whether it believes its own spooks.