by Robert Lalasz

Calling HIV/AIDS "probably the greatest human tragedy of our time," Dr. Helene Gayle of the Centers for Disease Control and Prevention (CDC) predicted that India may be the key to the epidemic's global course.

Gayle, director of the CDC's National Center for HIV, Sexually Transmitted Disease, and Tuberculosis Prevention, addressed "Contagion and Stability," a two-day simulation conference
co-sponsored by the Environmental Change and Security Project and the University of Michigan Population Fellows Program and hosted by the U.S. Army War College in Carlisle, Pennsylvania. High-level representatives from the U.S. government, foreign embassies, and nongovernmental organizations joined leading scientists, scholars, and researchers to explore and negotiate through a scenario of plague epidemic in India and its consequences for regional and global security.

HIV/AIDS, the Developing World, and India

Gayle's speech highlighted the perniciousness of HIV/AIDS and its strains on the health infrastructures of developing countries. She said that AIDS has risen in the last twenty years from a virtually unknown disease to the fourth-largest cause of death worldwide and the leading cause of death in Africa. Perhaps even more significantly, the virus most often attacks people in their period of highest economic productivity. Gayle noted that many African countries are already seeing significant declines in important macroeconomic indicators because of AIDS. The epidemic is also taxing health care services that are already overburdened with such diseases as tuberculosis, cholera, and malaria.

India may be a bellwether for the future of AIDS worldwide, said Gayle. Approximately four million Indians are infected with HIV, which is only one percent of the country's population. But Gayle pointed out that more than 50 percent of some high-risk populations in India are infected, and that the factors that contribute most to the spread of HIV (population mobility, high rates of sexually-transmitted diseases, and gender inequality) are widespread there. "I think a lot of people actually would say that India, in many ways, may be the country that most influences the global epidemic in the long run," said Gayle.

But there is reason for hope. While India's society and leaders were in denial about the impact of AIDS eight or nine years ago, Gayle said that the Indian government has now made HIV its highest public health priority. There is also intense interest in the problem from overseas donors such as the World Bank and the U.S. Agency for International Development. But while praising the Indian government and its international partners, Gayle argued that there are still not enough resources being devoted to fighting HIV/AIDS either in India or globally. "Although there is a clear understanding [about the problem]," Gayle said, "the level of activity, the level of focus, is still not what it should be."

Besides calling for an increase in funding, Gayle outlined a multifaceted approach to address HIV/AIDS worldwide. Keys to the effort are a high-level political commitment to destigmatizing HIV and allowing those affected to seek services without fear of retribution or ostracization. Other steps are: widespread distribution of and education about condoms; private-sector involvement; quality assurance of generic anti-retroviral therapies; and the recruitment of men to HIV prevention.

"We often talk about how, in a society where women's roles are not appreciated, it is important for women to become empowered," said Gayle. "But unless we have the other side of the equation working with it, getting men involved, we are not going to be able to do the job that is necessary in India as well as in other societies."

Disease and Stability in South Asia and the World

Gayle, who starting this fall will be on detail from CDC to the Bill & Melinda Gates Foundation, then joined the other attendees in the "Conflict and Stability" simulation. Participants divided into teams (representing India, the United States, international organizations, and nongovernmental organizations) to formulate and negotiate responses to a scenario of massive plague outbreak in the Indian state of Andhra Pradesh.

In the scenario, international tensions are high. India has suggested that both Pakistan and the United States were involved in the outbreak. Some countries either refuse to accept flights from the region or quarantine passengers from the region. A typhoon on India's western coast forces migration, which threatens to spread the contagion. Meanwhile, a software engineer from Andhra Pradesh's largest city flies to San Francisco, where he is hospitalized with signs of plague.

In essence, the scenario emphasized the global interconnections among issues of population, health, environment, and security: what happens in an Indian village one week can easily affect California the next. Mindful of this, the simulation teams first negotiated a response to the immediate crisis that allowed India to take the lead in managing the outbreak, as the international community provided supplies and funding and tried to open channels of regional communication.

The teams then developed long-term policy recommendations both for prevention of another such crisis and for U.S. action. All teams agreed that strengthening South Asian health care infrastructure—with an emphasis on HIV/AIDS care and prevention as well as enhanced delivery at the local level—was essential. Other consensus recommendations included: the easing of trade barriers between the United States and the region; the development of international early crisis warning systems; and a recommitment to education for women and access to family planning as a strategy for poverty alleviation.