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Authors: Laurie Garrett

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In the spring of 1994 the U.S. Census Bureau delivered the most horrible prognosis to date. Based on up-to-the-minute seroprevalence data, the Bureau predicted that by 2010 there would be
121 million fewer human beings
in sixteen countries than would have been the case in the absence of AIDS. The countries—Brazil, Burkina Faso, Burundi, Central African Republic, Congo, Côte d'Ivoire, Haiti, Kenya, Malawi, Rwanda, Tanzania, Thailand, Uganda, Zaire, Zambia, and Zimbabwe—were expected to also experience radical reductions in overall population growth rates and increases in infant mortality, child mortality, and premature death rates.
55
Life expectancies for several countries were expected to plummet: Uganda, without AIDS, would have had an average life expectancy of 59 years by 2010. With AIDS, that was forecast to drop to a mere 32 years. Haiti's life expectancy would decline from a projected 59 years to 44. Meanwhile, premature death rates, already climbing in the early 1990s because of AIDS, were expected to have doubled, compared with 1985 levels.
Hope had to rest with the children of Africa, the continent's next generation of potential bankers, lawyers, economists, farmers, business financiers, and planners. But studies in Zambia, Zaire, and Malawi revealed
that many AIDS orphans died shortly after their mothers' demises, even though the children were not themselves infected. The causes of death were numerous, usually falling under the pediatric catchall “failure to thrive.” Many of the children hadn't been fully vaccinated against measles, polio, and other common diseases. Most were malnourished. And many languished without their mothers, lacking the love and attention of any alternative adult.
“There is no doubt, AIDS threatens to alter the economic and social fabric of many societies, which may affect the development process,” Uganda's United Nations representative James Baba said in December 1991. “The major problem AIDS presents today is the factor of creating an increasing number of orphans which traditional societies are beginning to fail to cope with. The traditional extended family systems that once absorbed and catered for such orphans are being stretched to the limit by the sheer enormity of the problem. As a result, the extended traditional family system is breaking down. The social and economic cost it imposes is simply too demanding.”
56
The U.S. Agency for International Development used mathematical models to estimate the impact of orphans in East Africa. In the year 2015 alone, the agency scientists predicted, 2.4 million mothers would die of AIDS, each leaving an average of three orphans. Thus, it was possible that in a
single year
in East Africa 7.2 million AIDS orphans would be generated.
57
Other studies forecast 355 million AIDS orphans in Central and East Africa by the year 2000, or up to 11 percent of the region's entire population of children up to the age of fifteen.
58
Meanwhile, the U.S. Census Bureau predicted dire upturns in infant and child mortality in several African nations, due both to direct AIDS deaths and to neglect of children orphaned by the deaths of parents who succumbed to the disease. Hard-won improvements in those two key measures of national development were expected to evaporate. By 1994, the Bureau said, Zambia had already experienced a staggering 15 percent increase in infant mortality, compared with 1984, and Malawi, Uganda, and Zaire had suffered nearly comparable increases.
59
“The concept of a war on AIDS with its goal to stop HIV is seriously flawed and should be discarded,” Decosas wrote.
60
“Most regions in the world have a well-established epidemic of HIV. This epidemic requires a social response ranging from a review of legislation to a rethinking of the national industrial development plans. It also urgently requires new programmes, new approaches, and some radical reforms in health care and public health.”
For the exhausted few adults of Kanyigo all the forecast and debated numbers for Africa's future AIDS toll, loss of productivity, and abandoned orphans were just so much hand-waving by abstract people living in even more ephemerally imagined places, like Washington, London, and Geneva. But there was nothing surreal about AIDS or the tragedy it had created.
What was harder to imagine every day, Kanyigo elder Cosmos Bilasho said, was the future: How could there be a future if no one was here today to raise the children?
As the train pulled out of the Rome station Subhash Hira made another quick scan about the floor, making certain that he and his Indian colleagues were still in possession of all the suitcases, valises, shopping bags, and carryalls they had already toted over so many thousands of miles. It was the natural reflex of an experienced Third World traveler.
Physically, Hira had changed little over the years. He sported the same—or identical—round wire-rimmed glasses that had been perched upon his nose thirteen years earlier in 1978 when he had first arrived in Lusaka to head up Zambia's sexually transmitted disease program. Aside from some gray hairs, Hira hadn't aged much; he still possessed boundless energy.
But inwardly Subhash Hira was a very different man. Keeping track of Zambia's horrific AIDS epidemic had taken away a bit of his soul, left scars on his spirit. He sighed a lot and didn't seem to notice it until someone asked, “Hira, what's wrong?”
“People born in the post-plague era never could imagine what it had been like then,” Hira said, speaking above the chugging train's din. “People said to me when AIDS started in Zambia, ‘You are looking at the bubonic plague in the Middle Ages, and ten years down the line you will see the same kinds of mass deaths.' And I thought it was exaggeration. How could we even be thinking of thirty to forty percent HIV seropositivity? Six years ago, in 1985, it was only three percent in pregnant women in Lusaka.”
Hira looked out the window at the spectacular countryside of Tuscany, but seemed not to see anything. His mind's eye was on the wards of Lusaka's University Teaching Hospital. As he spoke, Hira's Indian colleagues eavesdropped, worried expressions filling their faces. They were all on their way to the Seventh International Conference on AIDS in Florence, where they hoped to spark discussion of HIV's emergence in Asia.
“I am moving home soon, to Bombay,” Hira said with a hedged smile. There was no escaping the homesickness he had felt all those years in Lusaka. The circumstances of his return were less than ideal. But when he glanced at his four colleagues, two sari-adorned women and two men wearing Western-style suits, Hira's face lightened up. Obviously, he was content with the notion of working with his own people.
But his smile soon evaporated and his voice was muted when he explained, “AIDS has come to India. I must do everything in my power to ensure that what I have witnessed this last decade in Lusaka does not occur
in Bombay or Calcutta or Delhi or Madras. HIV is emerging all over India. It may even be too late already. It may even be too late.”
It was. By 1991 HIV had already appeared in several Asian populations. Dr. I. S. Gilada, secretary-general of the Bombay-based Indian Health Organization, estimated that 100,000 female prostitutes in his city were infected, 2 million nationwide, with the highest rates—up to 70 percent —seen among India's Tamil women who worked as prostitutes in Bombay. Dr. Jacob John, of Christian Medical College in Vellore, reckoned that a third of the female prostitutes in that Indian city were HIV-positive, as were 6 percent of the men tested in sexually transmitted disease clinics.
WHO's Jim Chin estimated in 1991 that about 250,000 Indians were infected in toto, but characteristically added, “That's a lowball guesstimate.”
In Asia's most prosperous countries AIDS remained a stranger. A nationwide 1991 survey of blood donors in Japan, for example, found that the infection rate was less than 0.002 percent; Japan seemed virtually free of HIV. Similarly, Singapore had by mid-1991 seen only eighty HIV infections, according to Dr. Roy Chan of the Singapore AIDS Commission.
But wherever poverty was high, HIV seemed to have made its entry into Asia well before 1991.
Shortly before the opening of the Seventh International Conference on AIDS in Florence, during June 1991, Representative Jim McDermott, a physician and Democrat from the state of Washington, released the results of an AIDS investigation he conducted for the House of Representatives. The report drew appalling conclusions about the Asian pandemic, prompting many fellow politicians to discreetly voice concerns that McDermott was deliberately exaggerating the situation to skew foreign aid commitments. As time would show, however, McDermott's report underestimated the scope of the Asian pandemic.
61
After touring India, Thailand, and the Philippines at the request of Speaker Tom Foley, McDermott reached the conclusion that “Asia is the sleeping giant of a worldwide AIDS epidemic.” He estimated that as of June 1991 some 1 million Indians were already infected with HIV and in the year 2000 India and Thailand combined would have 12 million infected citizens. McDermott predicted that Asia's epidemic would, within perhaps just five years' time, outstrip that of Africa.
With all the prior warnings, prognostications, and clear evidence of the devastation AIDS was inflicting upon Africa, how could the microbe have so overwhelmed Asia? Why hadn't humanity succeeded in preventing HIV's emergence on the continent? As late as the fall of 1989 valid surveys of Thai drug users and prostitutes revealed infection rates below 0.04 percent—seemingly negligible. Yet within a mere twenty months that 0.04 percent infection rate among Chiang Mai prostitutes had soared to more than 70 percent. In just twenty months the virus emerged, spread in an epidemic fashion, and became endemic among key population groups in
Thailand. That constituted the most rapid HIV emergence in the history of the global epidemic.
How could this have happened? In retracing the virus's pathway across Asia, scientists and public health experts gained greater evidence supporting the GPA's earlier theories that human rights violations, poverty, and the behavior of
Homo sapiens
played crucial roles in the emergence of disease. Indeed, the
only
way to comprehend Thailand's astonishingly rapid HIV emergence was to recognize the intimate coupling of social, political, biological, and economic factors.
African history, tragically, repeated itself in Asia. Lessons went unlearned. As had many African societies, most Asian countries initially tried to legislate away the virus by restricting the activities and movement of potential carriers. When that appeared to fail, governments simply refused to acknowledge the virus in their midst, penalizing physicians and experts who raised public alarm about AIDS. Official AIDS figures reported to the World Health Organization reflected attempts by most governments to downplay the impact of AIDS.
62
During the last weeks of 1987 a meeting on AIDS in Asia was convened in Manila, under the partial sponsorship of WHO. Few cases of the disease had, at that point, surfaced in any Asian nation except one, and that country was populated predominantly by Caucasians: Australia. Though Australia was geographically in the Pacific Rim, most Asians considered the country, and its epidemic, European. But Dr. John Dwyer, the avuncular director of AIDS research at the University of South Wales in Sydney, did his best to convince those in attendance at the Manila conference that the pandemic was coming, and it would hit Asia not in the manner of its attack upon Europe but as it had Africa.
Dwyer pointedly reminded his colleagues that incidences of syphilis, gonorrhea, and other sexually transmitted diseases were rapidly rising throughout Asia; that female prostitution was rampant in almost all of the continent's sprawling centers, and male prostitution in several cities; that opium smokers were abandoning that drug and their pipes in favor of heroin and syringes; and that many parts of Asia were suffering levels of poverty and malnutrition comparable to those seen in Africa.
India's first AIDS cases included recipients of contaminated U.S. blood products manufactured by Cutter Biological, a California-based company, and of anti-RhD vaccines made by Bharat Serums and Vaccine, Ltd., an Indian firm.
63
During 1985–89 the Indian Council of Medical Research tested more than 2 million people, finding 764 who carried the virus; half of them were female prostitutes. By the end of 1989 the infection rate was soaring. A Bombay survey revealed that 4.9 percent of the city's female prostitutes were infected.
64
As evidence of HIV's presence in India mounted, proposed legislation outlawing sexual intercourse with foreigners was introduced into
the Maharashtra state legislature. Though it was defeated, the proposed law reflected a strong mood at that time in Indian society.
So poor were educational efforts that a 1989 survey of a sampling of India's AIDS patients revealed that even they hadn't heard of the disease. Only 4 percent professed to have heard of AIDS before contracting it; most, long after their diagnosis, still had no idea what the disease was. An important factor contributing to ignorance was illiteracy—94 percent of those who were interviewed were unable to read the few AIDS brochures or news articles that were published in India.
65
By mid-1990 the infection rate among Bombay's prostitutes had risen to 10 percent and 5.6 of every 1,000 blood donors in the city carried the virus. The director of the Indian Medical Research Council, Dr. A. S. Paintal, estimated that Bombay's infection rates had reached such proportions that every day 100,000 sexual acts were performed with HIV-positive female prostitutes.
66
One Bombay STD clinic was finding infection rates among prostitutes of 40 percent.
At the same time, blood donor infection rates rose to 1 percent, and India saw its first cases of HIV involving injecting drug users. Sixty-two heroin users in Manipur were cited in government notices in April 1990. Concern about the blood supply grew when a government survey uncovered 510 HIV-positive blood donors in the state of Gujerat. Among them, 430 were “professional donors,” individuals so poor that they subsisted off the meager funds earned by regularly selling their blood. Despite such clear evidence of the microbe's presence in the national blood supply, by the Indian government's admission less than 5 percent of all commercial blood was screened for HIV in 1991. That figure wouldn't budge much in 1992.
Data on HIV infection rates grossly underestimated India's crisis because most high-risk individuals were by 1991 actively avoiding testing. Their reluctance stemmed from widespread knowledge that in Manipur some 100 HIV-positive people were placed in permanent seclusion, chained to their beds, and barred from further social interaction.
67
That drove other potentially infected people underground, away from the public health system.
One group that was able to penetrate the mistrust was the government's cholera program, which enjoyed widespread respect among India's poor. Their 1991 survey in Manipur revealed that an astonishing 80 percent of heroin injectors were HIV-positive.
The microbe had been handed another bit of good fortune. Beginning around 1987, when Burma, once the richest nation in Southeast Asia, was given the World Bank's least developed country status, the traditional opium trade was transformed into a heroin market. It was no longer necessary to ship raw opium paste to Marseilles or other European locales for processing into heroin, thus reducing Burmese profits. But with the shift in opiate processing, heroin was suddenly available for local consumption. Within the so-called Golden Triangle—Burma, southern China, and Laos—opium,
and now heroin, production outstripped the 1960s market share held by Turkey and Afghanistan.
In Manipur, which bordered Burma, the sudden availability of the far more powerful heroin drew opium users like bees to honey. Needles, however, were in short supply.
HIV appeared in Manipur riding the crest of the heroin wave. Former opium smokers clumsily experimented with tourniquets, cookers, and syringes, clustering in groups to share not only the knowledge of how to get high but the equipment with which to do so. In less than sixteen months opiate users went from less than 10 percent heroin injectors with under 1 percent HIV seroprevalence to more than 95 percent heroin addicts, mainlining the purest and most powerful smack in the world. And 80 percent of them had within that time also mainlined HIV.
68
Stunned by the rapidity of HIV's march across India, the World Health Organization mustered $20 million and the World Bank $100 million for the most aggressively funded AIDS education campaign ever planned. But from the start the effort seemed doomed, as political leaders throughout India failed to lend their support, some states refused to participate, and allegations of impropriety, even embezzlement, buzzed about the health system. For example, reluctant to face the political flak that would shower down from all over India's business community if the foreign aid millions were spent outside the country, the government purchased more than a billion defective condoms from a local manufacturer and raised prices on quality imported products.
“We're sitting on a volcano. We won't be able to cope,” Maharashtra AIDS researcher Geeta Bhave declared. When all the hundreds of thousands of HIV cases progress to AIDS, she predicted, India's health care system would collapse.
Even HIV-2, previously found almost exclusively in West Africa, emerged in India. By June 1993, STD clinics in Tamil Nadu, Bombay, and Goa reported that 2 to 3 percent of their clients carried the second species of AIDS virus.
German researchers studied the genetics of HIV-1 and HIV-2 viral strains found in various parts of India, finding further evidence for quite recent emergence of the viruses in the country and extraordinarily rapid spread. No matter where they looked, they found infected Indians, and there was no sign that the viruses' spreads were concentrated geographically, as they were in North America and Europe.
BOOK: The Coming Plague
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