Nicholas N. Eberstadt
volume 81, number 6
HIV/AIDS is a
disease at once amazingly virulent and shockingly new. Only a generation
ago, it lay undetected. Yet in the past two decades, by the reckoning of
the Joint UN Programme on HIV/AIDS (UNAIDS), about 65 million people
have contracted the illness, and perhaps 25 million of them have already
died. The affliction is almost invariably lethal: scientists do not
consider a cure to be even on the horizon. For now, it looks as if AIDS
could end up as the coming century's top infectious killer.
At present, the
HIV/AIDS pandemic, though global, is overwhelmingly concentrated in
sub-Saharan Africa. Although this situation has exacted a terrible human
cost, the rest of the world has been largely unaffected by Africa's
tragedy. Things will be very different, however, in the next major area
of HIV infection. Eurasia (which for the purposes of this essay is
considered to be the territory encompassing the continent of Asia, plus
Russia) will likely be home to the largest number of HIV victims in the
decades ahead. Driven by the spread of the disease in the region's three
largest countries -- China, India, and Russia -- the coming Eurasian
pandemic threatens to derail the economic prospects of billions and
alter the global military balance. And although the devastating costs of
HIV/AIDS are clear, it is unclear that much will be done to head off the
Today HIV/AIDS is
decimating sub-Saharan Africa. According to UNAIDS, as of late 2001 more
than 28 million of the world's roughly 40 million HIV carriers lived in
that region, and about 9 percent of all sub-Saharan inhabitants between
the ages of 15 and 49 were HIV carriers. (In parts of the continent, the
rate is far higher: adult infection exceeded 30 percent in four
countries last year, and in Botswana it was near an almost unimaginable
40 percent.) UNAIDS' best guesses put AIDS-related mortality in
sub-Saharan states at over two million in 2001 -- suggesting that the
disease accounted for every fifth death. So far perhaps 20 million
sub-Saharan people have perished in the pandemic.
catastrophe is a humanitarian disaster of world historic proportions,
yet the economic and political reverberations from this crisis have been
remarkably muted outside the continent itself. The explanation for this
awful dissonance lies in the region's marginal status in global
economics and politics. By many measures, for example, sub-Saharan
Africa's contribution to the world economy is less than Switzerland's.
In military affairs, no regional state, save perhaps South Africa, has
the capacity to conduct overseas combat operations, and indeed
sub-Saharan governments are primarily preoccupied with local troubles.
The states of the region are thus not well positioned to influence
events much beyond their own borders under any circumstances, good or
ill -- and the cruel consequence is that the world pays them little
rather different in the world's other area of rapidly spreading HIV
infection. Eurasia is home to the great majority of the world's
population; five out of every eight people on the planet live there. It
has substantial economic weight -- its combined GNP in 2000 of $15
trillion exceeded that of either the United States or Europe.
Militarily, it is home to four out of five of the world's million-strong
armies, and four of the seven declared nuclear states. Thus, unlike in
sub-Saharan Africa, unexpected shocks there -- such as the unfolding
HIV/AIDS epidemic -- will have major worldwide repercussions.
terms, HIV/AIDS is already firmly established in Eurasia. According to
conventional estimates, more than 7 million of the region's inhabitants
were HIV carriers in 2001. And according to those same official
estimates, it took less than a decade for sub-Saharan Africa's HIV
population to leap from 7 million to 25 million.
It must be
emphasized that there is currently no reliable method for accurately
forecasting the long-term trajectory of the HIV/AIDS pandemic.
Nevertheless, the prospect of tens of millions of Eurasian HIV cases --
and AIDS deaths -- in the decades ahead is by no means fanciful. To the
contrary, absent a cure or a vaccine, it is quite possible that the
center of the global HIV/AIDS crisis, in terms of absolute numbers, will
shift from Africa to Eurasia over the coming generation.
uncertainty about the future direction of the disease, a number of basic
facts are already clear. First, even without approaching the infection
rate of sub-Saharan Africa, HIV/AIDS is poised to exact a staggering
human toll over the next quarter-century in the region's three pivotal
countries -- Russia, India, and China. Second, the economic costs of the
disease in these three countries will be vastly larger than they have
been in sub-Saharan Africa. Finally, given how the disease spreads, some
key Eurasian populations will be harder hit than others -- and some
regional governments will prove less competent than their neighbors (and
competitors) in handling the crisis that ensues.
The spread of
HIV/AIDS through Eurasia, in short, will assuredly qualify as a
humanitarian tragedy -- but it will be much more than that. The pandemic
there stands to affect, and alter, the economic potential -- and by
extension, the military power -- of the region's major states. And the
disease will do more damage to some big countries than to others. Over
the decades ahead, in other words, HIV/AIDS is set to be a factor in the
very balance of power within Eurasia -- and thus in the relationship
between Eurasian states and the rest of the world.
THE NEW RUSSIAN
To assess the
implications of HIV/AIDS for Russia, India, and China in the years
ahead, one must begin by getting a clear sense of the situation today.
Unfortunately, the available data on HIV infection in these countries
are somewhat tentative, in large part because the highest authorities in
Moscow, New Delhi, and Beijing are unable (and unwilling) to monitor
their respective HIV epidemics closely and continuously. Even UNAIDS
figures are vetted by host governments, raising the possibility that the
results have been negotiated downward. Nevertheless, thumbnail sketches
of the HIV situation in each country are still possible.
By all accounts,
Russia's HIV/AIDS epidemic has exploded in recent years; the only
dispute is over how much. Over the past 15 years, Russian medical
authorities have registered a cumulative total of about 200,000
HIV-positive patients. Independent estimates, however, are much higher
-- ranging from a UNAIDS figure of 700,000 carriers in 2001 to the
Russian Academy of Medicine's total of one million in mid-2002, to U.S.
intelligence sources' approximation of one to two million carriers
today. These latter figures imply an infection rate two to three times
that of the United States.
first HIV infections within the Russian Federation occurred before the
end of communist rule, the demise of the Soviet state set the stage for
the disease's rapid spread. The upheavals of Russia's ongoing transition
-- economic and social dislocation, increased poverty, new freedoms
(including greater opportunities for geographic mobility, extramarital
sex, prostitution, and drug use) -- transformed the country into a far
more conducive setting for the spread of HIV/AIDS. Health authorities
first noted HIV in port cities such as Kaliningrad and St. Petersburg,
but the infection apparently then rapidly made its way to other urban
centers, including Siberian cities such as Irkutsk. Current indications
are that it is now a truly nationwide phenomenon.
epidemic can be understood by looking at those groups at highest risk.
As in most Western countries, there is a homosexual component to the
spread of the disease, with men who have sex with other men emerging as
an identifiable vector of HIV transmission. There is also a drug-use
vector, in which intravenous (iv) drug users contaminate other users or
their own sexual partners. This method of transmission appears to be
particularly important in Russia: current press reports, for example,
suggest that Moscow alone may contain almost one million drug users,
including perhaps 150,000 needle-using heroin and cocaine addicts.
appears to be spreading rapidly through these populations, but the scope
of an HIV/AIDS "breakout" into the general population will depend to a
large degree on risk behavior in the non-drug-using heterosexual
population. Although accurate figures about sexual practices are hard to
procure, basic demographic data suggest that previous constraints on
behavior are eroding: the proportion of out-of-wedlock births, for
example, has soared since the collapse of communism. Russia has also
experienced an explosive increase in the incidence of curable sexually
transmitted infections: official figures point to a 33-fold jump over
the course of the 1990s. (This figure should not be taken literally,
owing to the unreliability of both past and present health reporting,
but it is nonetheless indicative.) Beyond this, Russia's flourishing
level of prostitution factors importantly in the spread of HIV/AIDS
among heterosexuals, particularly due to the substantial overlap between
commercial sex workers and iv drug users.
transition from communism to capitalism has also coincided with a
tremendous increase in criminal activity, a trend with important
implications for the future of the HIV/AIDS epidemic. One factor is the
spread of behavioral risk through small-scale crime, such as
prostitution and iv drug use. At least as important, however, is the
Russian Federation's prison system. Currently Russia incarcerates almost
one million convicts at any given moment. Public health care, however,
is notably absent in the Russian penal system; prison camps are
consequently virtual incubation dishes for diseases such as
drug-resistant tuberculosis and HIV. Unlike under the communist-era
gulag, moreover, nowadays prisoners are released on a regular basis: in
2000, about 300,000 convicts were granted liberty. Most of them head
back to their native towns, and a significant proportion of these former
convicts are HIV positive. Russia's prison system, in other words,
functions like a carburetor for HIV -- pumping a highly concentrated
variant of the infection back through the general population.
prognosis for the Russian HIV/AIDS epidemic depends largely on the
preventive policies the government pursues. Unfortunately, it is only a
slight caricature to say that Moscow seems to have settled on a posture
of malign neglect toward the gathering problem. The Russian government
is spending only $6 million a year of its own resources on HIV/AIDS
programs. That sum pales in comparison to the more than $6 billion the
United States devotes each year to its HIV problem, and surreal as this
may sound, the Russian total is less than a third of the $20 million
that Moscow pledged just this past summer to the un's worldwide campaign
against HIV. Much of the anti-HIV work in Russia today is being funded
not by Russians, but by foreign nongovernmental organizations such as
Medicins Sans Frontieres and George Soros' Open Society Institute.
Beyond its own
seeming lack of interest in tackling HIV/AIDS, the Russian government
has also prevented outside organizations from financing related health
activities -- most conspicuously, World Bank-proposed programs to combat
tuberculosis, a disease associated with HIV infection that is now
endemic throughout the country. Further complicating the struggle is
Moscow's insistence that legal authorities have access to HIV test
results. People who test positive for HIV and are thought to have
contracted the illness through illegal drug use are subject to
prosecution. This rule creates a powerful incentive among citizens to
conceal and misrepresent their HIV status -- and further fans the spread
of the disease.
A TRYST WITH
In India, as
elsewhere, current numbers are uncertain. UNAIDS has suggested that
about four million Indians were HIV positive in 2001 -- a figure that
squares with New Delhi's official estimates. In August 2002, however,
Health Minister Shatrughan Sinha publicly warned that the true numbers
might be much higher, owing to the sketchy disease-surveillance
capabilities of several large Indian states. This view is corroborated
by a U.S. National Intelligence Council estimate that India has between
five and eight million HIV sufferers.
HIV was first
diagnosed in India in the mid-1980s. As in Russia (and in most other
countries), HIV first emerged in India's urban centers; Mumbai (Bombay),
Chennai (Madras), and Bangalore were among the early high-risk cities.
Studies suggest that the disease has spread through two geographic
pathways: first, along the main trunk roads that serve as the transport
network for this enormous country, and second, along the border regions
near Burma, where drug use is widespread.
are difficult since epidemiological surveys (which calculate the
incidence, distribution, and control of disease) are still very limited
in scope and scale in India. In most of the country, moreover, people
are still reluctant to discuss behavior that contributes to the spread
of the disease. Homosexual sex, for instance, is an apparent vector for
HIV transmission in India, but public sensibilities preclude a
discussion of this factor. Drug use has also grown over the past decade,
but is mostly confined to the border with Burma. Reports indicate,
however, that most of the Indian HIV/AIDS epidemic today is heterosexual
-- and is transmitted by commercial sex workers and commercial truckers.
(Prostitution in India appears to be widespread: in the early 1990s,
Indian social scientists estimated that 2 million prostitutes were at
work in the country, and demand has only grown during the intervening
decade.) Furthermore, if current accounts are accurate, many monogamous
women in India are being infected by husbands having extramarital
affairs. And given the high levels of illiteracy among women in India
and the taboos concerning sexually transmitted diseases more generally,
very little information seems to be available to India's adult female
population about HIV risks.
government has responded to the country's HIV epidemic unevenly. New
Delhi announced a National AIDS Control Program in 1987, but
follow-through was haphazard and the government's own anti-AIDS
organization devoted a considerable portion of its energies to arguing
that outside groups were overestimating the prevalence of HIV in India.
India is currently in the second phase of a ten-year government program
for combating the spread of HIV. India's federal system, however, grants
wide latitude to states, and these have shown varying levels of interest
(and competence) in dealing with the problem. In April 2002, New Delhi
announced a nationwide target of "zero ... new [HIV] infections by
2007." But barring a miracle cure, that goal is utterly fanciful -- and
only raises questions about the seriousness of the effort overall.
Of the three
countries under consideration, the uncertainties are greatest for China.
The overwhelming majority of HIV cases in the country are undocumented
and untreated: as of 2001, a cumulative total of only 30,000 HIV cases
had been registered. Consequently, estimates of the total current cases
and the number of new cases of HIV in China rely heavily on guesswork.
In August 2001,
health authorities in Beijing announced that 600,000 Chinese were HIV
positive as of 2000. A little later, in July 2002, UNAIDS estimated that
the total number of people living with HIV/AIDS in China was 850,000 --
a figure with which Beijing, at the time, concurred. Just two months
thereafter, however, the Chinese Health Ministry raised the official
estimate to one million.
suggest that the total may be even higher. (Indeed, according to some
claims, the province of Henan alone might already have 1.2 million HIV
carriers.) A June 2002 un report suggested that China's HIV population
was between 800,000 and 1.5 million people. The U.S. intelligence
community, for its part, estimates that China has one million to two
million HIV carriers. Nor is this the upper boundary of informed
guesswork. In June 2002, an unnamed un official told The New York Times
that there could be as many as 6 million HIV cases in China today; if
that claim proves accurate, China would currently have the largest HIV
population of any country in the world.
enormous population, these huge HIV numbers still translate into
relatively low rates of prevalence: a million HIV carriers would mean a
rate of about 0.13 percent; 2 million, about 0.25 percent; and even with
the astronomical figure of 6 million, China's HIV prevalence rate would
be only somewhat higher than the current 0.7 percent rate in the United
States. But whatever the true rate is, there can be no doubt that totals
are rising swiftly. Chinese authorities and UNAIDS, for instance, both
suggest that the prevalence of HIV in China has been increasing recently
by about 20-30 percent per year; the U.S. Centers for Disease Control
and Prevention also note that at current rates the number of victims
could double in 30 months.
HIV is currently
transmitted in China by three main routes: extramarital heterosexual
intercourse (abetted by the ongoing expansion of China's commercial sex
business), illicit iv drug use, and the sale of unsafe blood. This
latter factor is in many respects particular to China and reflects the
realities of China's ongoing economic transition. With the demise of the
rural commune system and the attendant disintegration of public health
care in the Chinese countryside, both patients and doctors needed new
means of financing rural health care. One such method was the sale of
blood or plasma by impoverished farmers to pharmaceutical concerns,
clinics, or unregulated agents called "blood heads." These transactions
typically took place without the benefit of fresh, disposable needles.
Officially encouraged through the early 1990s, this trade in blood was
outlawed in 1998 -- yet it still continues.
The Chinese HIV
epidemic appears to be predominantly heterosexual in nature, and the
risk of HIV infection is disproportionately high among the rural poor.
High-risk subpopulations include iv drug users, buyers and sellers of
blood, and commercial sex workers. Larger at-risk groups may include the
so-called floating population (the more than 100 million migrants from
rural areas seeking opportunity on the fringes of Chinese urban life)
and the "unmarriageable males" (the rising number of young men in China
who, due to the country's growing gender imbalance, have no realistic
prospect of finding a bride). Although epidemiological data on HIV risk
factors for China are spotty, there is also no doubt that behavioral
mores are rapidly changing. One telling indication is that between 1985
and 2001 the registered incidence of sexually transmitted infections in
China soared by more than a hundredfold.
recently, Beijing's response to the mounting HIV crisis was, at best,
peripheral. Despite many warnings from public health experts, China's
political leaders seem to be in denial. In September 2002, news reports
revealed that the Chinese Communist Party's Central Committee had
ordered a study of the nation's HIV situation (apparently the first ever
such study initiated by the government). This past summer the Chinese
government also began cooperation with the U.S. National Institutes of
Health to monitor the epidemic. But open discussion of HIV in China is
still not officially permitted. In particular, the issue of HIV-tainted
blood remains taboo -- perhaps because of the regime's arguable
complicity in the gathering tragedy. Research on the blood problem
continues to be discouraged; activists who bring the problem up continue
to be jailed. Unfortunately for the government, an epidemic cannot be
censored -- and unfortunately for China, suppressing information about
HIV/AIDS only makes matters worse.
THE BOTTOM LINE
For all the
shortcomings of available information about HIV in Eurasia, several
facts are clear.
of the sources one prefers, enormous numbers of people are already
infected with HIV in Russia, India, and China. If one trusts UNAIDS
estimates, the total for the three countries already exceeds 5.5
million; if one prefers the U.S. intelligence community's statistics,
the collective figure may be as high as 12 million.
Second, in each
of these countries the continued rapid transmission of HIV is assured
and is poised to "break out" into the general population. Russia and
China in particular seem to have special potential "epidemiological
pumps" for exposing broad segments of their populations to HIV risk --
in the former, the national prison system, and in the latter, the
prevalence of HIV-tainted blood transfusions combined with the newfound
mobility of the rural poor.
Finally, none of
the governments in question has pursued effective public health measures
to prevent the spread of HIV. To the contrary, each of these governments
has taken at best a halfhearted approach to stemming the HIV epidemic.
Taken together, these facts strongly suggest that the HIV/AIDS crises in
Russia, India, and China are only just beginning. But how far will these
crises go -- and what will be their economic and political consequences?
In seeking to
predict the future course of HIV/AIDS, there is much we still do not
know or understand. Although scientists have exhaustively analyzed the
genetic makeup of the virus, the public health community knows far less
about its spread -- the very human demographic, sociological, and
behavioral factors that account for its grim progress through the world.
Indeed, as The New York Times medical correspondent Lawrence Altman M.D.
noted in early 2001, "HIV's toll has vastly exceeded the most
pessimistic report issued earlier in the epidemic, and the misjudgment
largely reflects gaps in knowledge about HIV and AIDS." For now,
modeling the future of the HIV pandemic is at least as much art as
science; intuition counts no less than technique.
To consider what
may yet happen in Eurasia, we need to be able to explain what has
already befallen sub-Saharan Africa. Twenty million deaths into Africa's
AIDS catastrophe, the medical and public health literature remains
curiously vague -- even euphemistic -- about exactly how HIV spread so
fearsomely fast through the region. In broadest outline, however,
Africa's HIV disaster is evidently due to a collision between ecological
risks (prevalent malnutrition and a heavy preexisting burden of
infectious diseases, both of which impair the body's ability to fight
disease) and behavioral risk (more specifically, sexual transmission
patterns and specific sexual practices that raise the odds of
Conversely, it is
worth noting why HIV has made relatively limited inroads into the
populations of wealthy Western countries. This seems to be due to their
favorable "ecological" advantages (better nutrition and minimal endemic
disease fortify their residents' immune systems), their particular "behaviorial"
dispositions (risky practices, such as drug use and prostitution, have
not proliferated catastrophically), and public health infrastructures
that have successfully contained potentially lethal risk factors.
Given what is
known about the ecological and behavioral HIV risks in Eurasia, it seems
safe to suggest that China, India, and Russia today are susceptible to
distinctly greater HIV/AIDS risks than are the aÛuent Western countries
-- but distinctly lower risks than those in much of sub-Saharan Africa.
Where Eurasia will fall between these two poles is not yet clear, but
expert opinion has already hazarded some predictions. China's health
minister, Zhang Wenkang, warned last year of 10 million HIV infections
by 2010; the head of UNAIDS, Peter Piot, has set the figure at 20
million. The former figure would correspond with an HIV prevalence of
1.3 percent among adults; the latter figure would suggest 2.5 percent.
For India, the U.S. intelligence community has predicted 20 million to
25 million HIV carriers by 2010 -- numbers consistent with a prevalence
rate of 3-4 percent. And in Russia, that country's leading AIDS
authority, Dr. Vadim Pokrovsky, expects 5 million HIV sufferers by 2005,
corresponding to an HIV prevalence rate of 6 percent among adults. U.S.
intelligence estimates run as high as 8 million by 2010, implying a
virtually sub-Saharan infection rate of 11 percent.
figures in mind, it is possible to map out prospective paths for
HIV/AIDS in Russia, India, and China over the next quarter-century,
using demographic and epidemiological modeling techniques. The
assumptions behind any model drive its results -- and so any projections
can only be illustrative. And from what we know about the record of past
HIV/AIDS projections, no one should expect this exercise to be
profoundly prescient. But such modeling can nonetheless help to clarify
thinking, for it has the virtue of internal consistency.
At the risk of
making eyes glaze, let me briefly review the components of this "model."
After all, I do not want to seem to be pulling results out of a magical
First, I needed a
"baseline" to describe the expected demographic trends in the absence of
HIV/AIDS: for this baseline, I chose the U.S. Census Bureau's most
recent population projections for the period from 2000 to 2025 for
China, India, and Russia. Then, I had to make some basic presumptions
about the nature of the local HIV/AIDS epidemics themselves.1 These
particular assumptions affect all subsequent calculations -- but the
only truly critical one was that the epidemics would be essentially
"heterosexual" in nature. (As the previous discussion showed, that view
is not the least bit unrealistic.) I assumed the HIV-positive population
to be one million as of 2002 in Russia, two million in China, and four
million in India -- necessarily arbitrary figures, to be sure, but ones
well within the range of informed assessments today.
Finally, I had to
make conjectures about distinct future HIV "prevalence scenarios" for
each of the three countries. That is to say, how bad would the epidemic
become over time? Clearly, this was the trickiest -- and most arbitrary
-- facet of the effort. I identified three "families" of scenarios for
the disease, which I termed "severe," "intermediate," and "mild" --
corresponding to high, medium, and low levels of HIV infection.
("Severe" is taken here to mean adult HIV prevalence by 2025 reaching as
high as 10 percent in Russia, 7 percent in India, and 5 percent in
China; "intermediate," 6 percent, 5 percent, and 3.5 percent,
respectively; and "mild," 2 percent, 1.5 percent, and 1.5 percent.)
These different scenarios, though quite arbitrary, fall well within the
expectations of informed independent observers today.
The model lays
out a series of specific and staggering implications for the spread of
HIV/AIDS in Russia, China, and India.
The magnitude of
infection. First, the absolute magnitude of the Eurasian HIV/AIDS
epidemic over the coming quarter-century will match or exceed that of
the entire worldwide HIV crisis up to now. For example, under the
assumptions of even a mild epidemic, the cumulative total of new HIV
cases in China, India, and Russia from 2000 to 2025 would be about 66
million, compared to UNAIDS estimates of about 65 million infected
worldwide to date. The other scenarios predict even higher HIV totals:
an intermediate epidemic would suggest nearly 200 million new HIV cases
in the next 25 years, and a severe epidemic would lead to more than 250
million new cases (see Table 1).
Cumulative New HIV Cases, 2000-2025
Note: All figures
in this table and the ones that follow are projections based on the
The death toll.
In each scenario, the cumulative death toll from AIDS over the next 25
years for Russia, China, and India vastly exceeds the total number of
people killed by AIDS globally so far. UNAIDS estimates that AIDS --
from its onset to the present day -- has taken about 25 million lives.
By contrast, a mild epidemic would project a cumulative total of about
43 million AIDS deaths for these three countries from 2000 to 2025. And
the other projections look far worse. During an intermediate epidemic,
for example, the hypothetical toll would be about 105 million, more than
four times as many as have died to date (see Table 2).
Cumulative AIDS Deaths, 2000-2025
On an annual
basis, the numbers are equally astonishing. According to UNAIDS, the
current annual aggregate death total from AIDS is about 3 million people
per year. By comparison, the mild epidemic scenario suggests that
Russia, India, and China would suffer a collective total of nearly 1.7
million deaths a year in 2010, and 2.3 million by 2015. In an
intermediate-epidemic family of scenarios, deaths would top 3 million in
2010 and would approach 6 million in 2025.
New AIDS cases.
In every scenario considered here, Russia, India, and China would each
have to contend with massive numbers of new AIDS cases in the decade
2010-20. That result follows simply from the long incubation period
between HIV infection and the onset of AIDS, and the large number of HIV
carriers that each country is projected to accumulate between 2000 and
2015. The discussion also presumes that a cure for AIDS will not be
found during this time frame.
illustrative calculations, for example, suggest that China experienced
"only" 30,000 new AIDS cases in 2000. By 2015, assuming just a mild
epidemic, new AIDS cases in China erupt at a pace of nearly 100,000 per
month. In India, the projected numbers are equally shocking. In 2000,
according to these estimates, India was facing a significant burden of
100,000 new cases of AIDS a year. But even under a mild epidemic, the
total would exceed one million a year in 2015, and would rise still
higher for every year between 2015 and 2025 (see Table 3).
Table 3: New AIDS
Cases in 2015
changes. The HIV/AIDS epidemics modeled here could significantly alter
population dynamics in these Eurasian countries and might substantially
reduce the future size of certain economically important population
cohorts. Under the milder epidemic, for instance, the aggregate
populations of India, China, and Russia would be almost 90 million lower
in 2025 than Census Bureau projections (the baseline) currently
anticipate (see Table 4). Worse, the cohort often labeled the
"economically active" population -- persons 15 to 64 years of age --
would be about 44 million fewer than currently projected (see Table 5).
Under less optimistic scenarios, the demographic impact is
Population in 2025
Working-Age Population in 2025
projections, Russia is hit especially hard demographically. This trend
occurs not simply because the model posits somewhat higher HIV rates for
Russia than for India or China but also because Russia's population is
projected to decline over the coming quarter-century -- even in the
absence of any worsening of its HIV crisis. Under the conditions of even
a mild epidemic, however, that decline is projected to accelerate
expectancy. Finally, and in some ways most portentous, all of the
scenarios point to either a stagnation or a reduction in national health
levels as reflected by life expectancy at birth. This decline is an
inescapable arithmetic consequence of the expected surge in mortality.
In many ways, the future looks bleakest for Russia. For instance, under
the severe epidemic scenario, Russian life expectancy would be a full
decade lower a generation hence than it is today. The projections for
China and India, although not as dramatic, are still deeply troubling
(see Table 6).
Table 6: Life
Expectancy in 2025
exercise can be faulted in a number of respects -- modeling exercises
always can. What these separate scenarios commonly highlight, however,
is this: reasonable, historically grounded assumptions about the future
course of HIV/AIDS suggest the real possibility, and perhaps even the
likelihood, of an unprecedented cost in human lives for Russia, India,
and China in the years just ahead.
CONSEQUENCES OF THE DISEASE
HIV/AIDS epidemic will clearly have far-reaching economic ramifications
in the coming decades. The number of dead, to begin with, threatens to
be absolutely enormous. Furthermore, AIDS typically does not kill its
victims immediately but subjects them to a prolonged period of gradually
mounting debility and incapacity. This is a period, often extending for
years, during which the victim's needs grow while his or her own ability
to attend to them steadily diminishes. And AIDS does not kill randomly
but instead tends to strike people in their prime reproductive ages --
years that coincide in most populations with the highest rates of labor
productivity. Given this combination of factors, what sort of impact can
we expect an HIV/AIDS epidemic to inflict on the economies of Russia,
India, and China?
This question has
received surprisingly little rigorous consideration. Two decades into
the epidemic, the state of economic thinking about this complex set of
interactions can still be described fairly as introductory and
exploratory. The emerging economic literature on the subject has
identified some of the potential macroeconomic repercussions of
AIDS-related illness and death. Population growth, labor supply, and
savings rates all will be hurt -- indeed the more comprehensive the
framework employed, the more negative the conclusions seem to be.
Even so, a number
of important potential economic ramifications of an HIV/AIDS epidemic in
a low-income setting have as yet received little consideration. Two in
particular deserve mention here. First, by curtailing adult life spans,
a widespread HIV epidemic seriously alters the calculus of investment in
higher education and technical skills -- thereby undermining the local
process of investment in human capital. Second, widespread HIV
prevalence could affect international decisions about direct investment,
technology transfer, and personnel allocation in places perceived to be
of high health risk. These factors suggest that HIV breakout could have
lasting economic consequences -- in effect, cutting aÛicted countries
off from globalization. The long-run economic impact of these effects
could be even more significant than the constraints the epidemic could
impose on local labor supplies or savings.
calculating the prospective economic cost of HIV/AIDS for a society
would be a highly exacting task (it would essentially require figuring
out how much less a population would earn due to HIV, how much more it
would be obliged to devote to covering the needs of AIDS victims, and
the present value of the differences in those two amounts). This
exercise would require detailed data that are simply unavailable today
for any country. There is, however, an extremely simple alternative
approach to thinking about the possible economic implications of these
HIV/AIDS epidemics, one that may promise a serviceable first
approximation of the macroeconomic impact. We might call this the
"health-based productivity" approach.
development has seen an important and well-documented shift in patterns
of global economic performance: a continuing move away from
natural-resource-based wealth and toward wealth generated by human
knowledge and skills. Put another way, "human capital" has become a
predominant and increasingly important factor in overall economic
potential. In modern times, this trend has made for a robust link
between health and productivity at the national level. This association
holds both across nations at any given point in time, and also within
particular countries over time.
simple patterns do not capture the complexity of the health-productivity
relationship, nor do they indicate causal directions. On the one hand,
wealth is an instrument that helps people afford lifestyle patterns that
lead to better health. On the other hand, improvements in health can
boost productivity by extending potential work-life, enhancing physical
capacity, and facilitating learning. Regardless of these complexities,
for any country, at any point in time, life expectancy is a fairly good
predictor of per capita economic output.
THE HEALTH OF
What would these
HIV/AIDS projections for Russia, India, and China imply for each
country's economic performance if we relied solely on a simple
health-based productivity model? The answers can be computed by using
World Bank data to estimate the recent (circa 1999) correspondence
between national life expectancy and output per member of the "potential
work force" (i.e., persons 15-64 years of age), and then combining these
figures with the simulations of national life expectancy and potential
work force size from the various HIV scenarios.
By this method,
Russia's GNP per "person of working age" would be projected to rise by
about 50 percent between 2000 and 2025 without HIV. Health-based
productivity predictions, however, indicate that an HIV epidemic could
radically reduce per capita productivity under any of the scenarios
discussed earlier. Even with a mild epidemic, Russia's predicted output
growth per working person would be less than half as great as under the
"no HIV" baseline scenario. And if there was an intermediate epidemic,
the predicted level of output would actually be lower in 2025 than it
was in 2000.
For India, this
method predicts about an 80 percent increase in GNP per working-age
person over the next 25 years assuming the absence of AIDS. All of the
HIV scenarios, however, would reduce that growth significantly. A milder
epidemic, for example, would depress predicted growth by about
two-fifths; under the intermediate epidemic scenario, output per working
person would be no higher in 2025 than it is today.
AIDS would, by this method, experience a predicted increase in output
per working-age person of more than 50 percent during the next 25 years.
But even a mild epidemic would cut that growth by half -- or, to put it
slightly differently, even an epidemic with a peak HIV prevalence rate
of 1.5 percent would cut more than half a percentage point a year off
China's long-term economic growth rate. Under an intermediate epidemic,
output per working person would barely rise between 2000 and 2025. And
under the most pessimistic of the scenarios, Chinese productivity over
that same period would actually decline.
This method also
permits the prediction of national levels of output, a set of figures
that merits examination. In Russia, for instance, even though the model
predicts a baseline increase of more than 50 percent in output per
potential worker, national output would increase only by about 33
percent in the "no AIDS" case. This discrepancy results from the decline
in the absolute number of Russians between the ages of 15 and 64. The
HIV scenarios reduce Russia's future GNP not only by reducing predicted
output per worker, but also by cutting the size of the 15-64 cohort.
Thus, under conditions of a mild epidemic, Russia's national output
would remain completely stagnant between 2000 and 2025. And under the
intermediate epidemic scenario, Russia's GNP would be a shocking 40
percent lower in 2025 than it is today. Indeed, the model suggests that
HIV/AIDS in Russia might, under a variety of scenarios, prevent the
Russian economy from experiencing any growth in the years ahead.
For India, the
model suggests that GNP absent HIV would be almost 170 percent higher in
2025 than in 2000 -- with growth driven both by a larger work force and
by increasing worker productivity. Under the mild epidemic scenario, GNP
would still rise substantially -- but by about a third less over that
quarter-century than the "no AIDS" baseline would have predicted. If
there was an intermediate epidemic, predicted GNP in 2025 would be 40
percent lower than in the baseline scenario; national output would still
grow, but growth would be cut by three-fourths over the next 25 years.
As for China,
health-based predictions of economic output suggest relatively modest
output growth of 80 percent between 2000 and 2025. The mild epidemic
scenario would be predicted to cut that growth by more than a third; an
intermediate epidemic, by much more. The more pessimistic scenarios
would suggest even more dramatic economic repercussions for the Chinese
predictions of future economic output are admittedly an overly
simplistic measure for assessing the prospective performance of
extraordinarily complex societies. Even so, health and wealth are
closely connected in the modern world. To the extent that HIV/AIDS
compromises national health prospects, it also compromises economic
A GATHERING STORM
In the decades
ahead, the likelihood of HIV breakout into the general population in
Eurasia will depend on the extent to which local Eurasian populations
can avoid replicating the risk factors that led to such a breakout in
sub-Saharan Africa. Fortunately, Eurasia enjoys some ecological
protections that sub-Saharan Africa lacks. Nutrition in India, China,
and Russia is generally superior to that in sub-Saharan states, and the
burden of endemic disease is also distinctly lower. With respect to
behavioral risks, we know very much less about the situation in China,
India, and Russia than we would like. Sexual transmission patterns, the
prevalence of risky sexual practices, and the extent of other dangerous
practices (such as iv drug use) will do much to determine the future
trajectory of the HIV/AIDS epidemic in these three countries. Amazingly,
neither local nor international health studies have examined in any
sustained manner these potentially deadly risk factors.
limits of our knowledge, available information suggests that major HIV
epidemics are already underway in China, India, and Russia, and that
local social mores and behavioral practices are set to further spread
the disease. The precise trajectory that HIV/AIDS will follow in these
three countries cannot be foretold at this time. But as the hypothetical
scenarios show, even fairly mild epidemics (by sub-Saharan standards)
could have a tremendous impact on long-term health and mortality trends
in all of these countries. Indeed, China, India, and Russia together
could experience more HIV infections and AIDS deaths over the coming
quarter-century than the entire planet has thus far.
From a purely
ecological standpoint (that is, focusing on nutrition and endemic
disease), India probably stands a greater risk today than either Russia
or China for an HIV/AIDS breakout. Yet in the simulations, the country
whose economic prospects seemed most threatened by the disease was
Russia. Two factors largely account for this result: the country's poor
health performance, entirely irrespective of HIV, and, relatedly, the
country's prospect for long-term population decline. In HIV/AIDS
scenarios well within the realm of current informed expectations,
Russia's economy 25 years hence might be no larger than it is today. In
a world characterized by general economic growth, such a result would
only increase Russia's marginalization both within the world economy and
on the world stage.
limited future economic prospects seem to be established already by a
host of other factors that have nothing to do with HIV. From a
geopolitical standpoint, then, the most pertinent question is whether
the unfolding HIV/AIDS epidemics in China and India will be sufficiently
powerful to alter the future economic or political balance between these
two rising and ambitious states. To judge by these simulations, it is
possible that HIV/AIDS could play such a role in the years ahead -- and
again, relying on these simulations, the balance of risks presently
appears to weigh more heavily against India than against China.
On the other
hand, and somewhat paradoxically, China may have more difficulty
mounting an effective response to an emerging HIV crisis than would
either Russia or India. The reasons have to do with constraints on
anti-HIV/AIDS policies in China. In contemporary Eurasia, perhaps the
most successful HIV-control campaign thus far has been Thailand's. The
Thai campaign relied on cooperation between the government and civil
society to educate the public about HIV and to intervene with high-risk
groups. Analyses of the program by the World Bank and other groups have
stressed the value of civil-society participation, as well as the
importance of popular trust in the government in lending credibility to
the state's massive public education effort. Whether China could
replicate Thailand's approach is by no means clear. A public health
campaign premised on the independence of nonstate actors and the
population's confidence in its government could be rather more difficult
these constraints, the prospects of a Thai-style campaign doing much for
Russia or India still look grim. When Thailand inaugurated its muscular
anti-HIV campaign, adult HIV prevalence was lower there than it is today
in Russia and India. And even after Thailand's policies went into
effect, the estimated number of HIV carriers more than doubled over the
subsequent decade -- the grim arithmetic of the disease being that newly
diagnosed infections will add to the patient pool for some time, even if
an effective program is diminishing the stream of newcomers.
responses to their respective HIV crises may also be circumscribed by
economic considerations. For now, the most effective medical
intervention for prolonging HIV patients' lives is the complex "drug
cocktail" of anti-retroviral drugs. It is true that many people with HIV
in the advanced industrialized West have been given a new lease on life
by taking these drugs, and that this has made the disease less of a life
sentence than it was before. The problem with thinking that this advance
represents a solution to the developing world's HIV/AIDS problems,
however, is that the cocktail is extremely costly -- typically $15,000
or more per patient per year. Even the generic versions of the drugs, a
year's supply of which can be manufactured for $600, are not affordable
by most countries for most of their people with AIDS. And even if they
had the money, the unfortunate fact is that they would probably not
spend it on this cause, because the cost of distributing the treatment
(even assuming that the drugs were given away free) would often be more
than the economic value to governments of the lives thus saved. The
tragic truth is that until some kind of actual cure is discovered, most
people with HIV/AIDS in the developing world are essentially doomed.
awful reality, there are still things states can do to at least contain
the risk of contagion within their populations. Governments can
competently monitor the spread of the disease and warn their citizens
accordingly. They can engage in public education campaigns to apprise
their people of the deadly risks they face with HIV, urging them to
alter specific behaviors. They can attend to the explosion of curable
sexually transmitted infections, since these have proved to be a leading
indicator for HIV transmission. And they can intervene with groups at
high risk of HIV to encourage lifestyles that will court fewer dangers.
But governments in Eurasia are not yet doing enough of these things.
HIV in the region
may be likened to a gathering tempest, and the governments in Moscow,
New Delhi, and Beijing to captains of vessels in its path. The storm,
already within sight and rapidly advancing, is enormously powerful and
capable of untold tragedy and destruction. From the captain's deck,
however, officers continue to regard the approaching squall with curious
detachment, unconcerned about its implications for their ship. When they
come to their senses, the tempest will be even nearer than it is now --
and they may discover that their ability to navigate out of harm's way
is more limited than they would have supposed.
technically inclined, I assumed that 1) each epidemic got underway
around 1985; 2) in each country, the median incubation period for HIV
carriers between infection with HIV and the onset of AIDS is nine years;
3) life expectancy after the onset of AIDS averages two years; and 4)
HIV epidemics in Russia, China, and India are all subject to the
"standard heterosexual" distribution between the sexes and over age
groups that has been witnessed in other low-income countries (especially
those of sub-Saharan Africa). For computing demographic and
epidemiological results, I selected the spectrum software package
developed by the Futures Group International for the U.S. Agency for
Eberstadt holds the Henry Wendt Chair in Political Economy at the
American Enterprise Institute and is Senior Adviser to the National
Bureau of Asian Research. This essay draws on a longer study prepared
with the assistance of Lisa Howie; for more detailed results see
Copyright (c) 2002
by the Institute for International Economics.