The Foreign Service Journal, December 2004

toll as originally feared, it is still a real threat in Asia. Meanwhile, malaria is resurgent in areas where it had been eradi- cated for decades. Newly drug- resistant strains of tuberculosis and other diseases continue to con- found modern science. The West Nile virus is now endemic in parts of North America, as is dengue fever. A newly mutated strain of influenza emerges every year, rais- ing the specter of a return of the 1918 Spanish influen- za virus that killed at least 20 million worldwide. (The recent news that much of the U.S. flu vaccine supply is contaminated and unusable has already led to calls for rationing, and harbors the potential to fuel genuine panic in the event of an epidemic.) Even such obscure pathogens as Mad Cow Disease (BSE) and avian influenza threaten our delicate food chain with disrup- tion if not collapse. All of these diseases, once obscure and confined to remote, isolated corners of the world, are now either present in the United States or just a short plane ride away from our international airports. But all these newly emerging microbial threats pale before the mother of all pandemics: HIV/AIDS. While malaria, cholera and tuberculosis all erode the ability of developing nations to provide for their peo- ple’s needs, HIV represents a quantum leap in the nature of the threat, as it incorporates all the inherent dangers of an epidemic outbreak as well as those of a chronic attrition of populations. Preying upon our most innate of drives — repro- duction — HIV threatens to depopulate the globe the way the Black Death did Europe 650 years ago. Globally, 38 million people are infected with HIV, with 25 million living in sub-Saharan Africa. In 2003, near- ly five million people were infected with HIV world- wide — three million in sub-Saharan Africa. This rep- resents the highest yearly infection rate since the beginning of the HIV pandemic — sobering evidence that we have not yet begun to effectively control this plague. While sub-Saharan Africa remains the epicen- ter of HIV infection, with four southern African coun- tries experiencing adult infection rates over 30 percent (Zimbabwe, Botswana, Lesotho, and Swaziland), evi- dence indicates that in the near future, the focus will shift eastward toward the popula- tion behemoths of China and India, and northward into Eastern Europe and Russia. These regions are currently experiencing the highest increases in HIV infection rates globally, and repre- sent the potential for startlingly large numbers of newly infected persons by 2010. As dire as these statistics are, we have only begun to experience the turmoil and disruption associated with the HIV pandemic. With an incubation period of between seven and 10 years, we are well into the HIV infection phase of the pandemic, as current infection rates show. However, we have not yet begun to see these astro- nomic infection rates translate into deaths — a cer- tainty in three to five years, as those infected in the late 1990s see their HIV infection evolve into AIDS. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that 68 million people will die globally from AIDS between 2000 and 2020. This rep- resents a threefold increase in the rate of death from 1980-2000, the first 20 years of the pandemic. Failure to target rising infection rates with effective preven- tion programs will ensure that this rapid rise in mor- tality rates will increase past the UNAIDS target of 2020. The future of an unrestrained HIV pandemic is one of wildly escalating mortality and increasing social, political and economic instability. HIV is an attrition epidemic (like malaria or TB) during its infection stage, when it lies within the body, building its numbers and weakening its victims. During this seven-to-nine-year period, victims suffer gradual weakening and diminished capacity to provide for family and contribute to society. In its final stages, when HIV evolves into AIDS, it manifests the attrib- utes of an outbreak epidemic (like bubonic plague or influenza), imposing extreme and costly demands on the medical system and causing panic and social dis- ruption. This combination of outbreak and attrition effects makes HIV/AIDS unique among infectious diseases. As such, it constitutes an important case study of the implications of all infectious epidemics for global sta- bility and security. F O C U S 24 F O R E I G N S E R V I C E J O U R N A L / D E C E M B E R 2 0 0 4 A government that cannot secure the health of its people has failed its most fundamental responsibility.