The world's failure to control the HIV/AIDS epidemic is one of the greatest scandals of our times. The global HIV epidemic is spiralling out of control. Since the advent of the virus some 25 years ago, 20 million people have died of AIDS caused by HIV infection. Today, more than 40 million people worldwide are infected with the virus. Each year, some 3 million people die from AIDS infection.
For two decades the infection has travelled steadily from its African origins to Europe, the Americas, South-East Asia and the southern Pacific. Each month, the epidemic spreads further, especially in the developing world, it is also sweeping unchecked across Russia and the territories of the former Soviet Union, and poised to emerge in both China and India, hitherto largely untouched.
Over this time the world has lost to AIDS a population the size of Australia's. In the next 25 years, thanks to what we might otherwise call the miracle of compound interest, the global death toll from HIV/AIDS infection might exceed 100 million.
But even this estimate might be conservative if the virus mutates into more virulent and infectious forms as it infects larger populations. By any measure, the HIV epidemic ranks alongside the great epidemics of history – the Black Death, the European diseases that destroyed the indigenous civilisations of the Americas after the Spanish conquests and the great influenza epidemic of 1919-20 that killed more people than the Great War.
Like these earlier epidemics, HIV/AIDS poses an immense threat to social stability and economic development across much of the globe. Yet, in 2005, the sobering truth is that the developed world has come to accept it. The figures no longer excite horror or fear, much less indignation or even firm resolve to change the way we manage the epidemic.
Complacency and fatalism have replaced determination and activism as the hallmarks of the institutional and governmental response to the disease. The developed world believes that new HIV infections can continue to be suppressed through education alone, and that the situation is broadly under control.
Developing countries that now bear the brunt of rising infection rates are nonetheless also confronting other more pressing challenges to their populations' health, security and development. International and multilateral effort and funding are concentrated on providing cheaper drug therapies for the infected, while prevention activities and education programs are increasingly under-funded, ineffective and badly targeted.
What is missing from the global response is any sense that the spread of HIV can be controlled, much less eradicated. Yet experience and evidence strongly suggest that both these goals – control and eventual eradication – are still achievable. After all, between 2002 and 2004, the much more infectious and virulent SARS virus was detected, contained and eliminated.
IN REVIEWING THE HISTORY OF THE EPIDEMIC, the central, unanswered question remains: why was HIV/AIDS not stopped in its tracks when the world had both the opportunity and the knowledge to do so? And why, when we know so much about what works to control it, does the global response remain paralysed and incoherent in the face of so much avoidable suffering and death?
By the mid-1980s, science had discovered the major pertinent facts about the HIV virus. Its properties, nature, modes of transmission and susceptibilities to preventive measures were more or less fully understood. Many jurisdictions, including Australia, translated this knowledge into policies and programs that were breathtakingly effective in changing the sexual, drug-taking and other behaviours that carry with them the risk of HIV infection.
These programs were generally based around frank, truthful information about sex and drugs, the widespread distribution of condoms, the establishment of needle and syringe exchanges and the building of information and support networks and institutions to sustain the education programs and to deliver HIV/AIDS services and treatments.By 1990 at the very latest, we had the information, the tools and the experience to know how HIV/AIDS could be suppressed. Yet when it came to making global policy, the evidence of success was ignored or disregarded in favour of policies and programs based on religious faith, quackery and superstition.
Nowhere in the developed world was the failure of evidence-based policy making greater, and the triumph of religion more complete, than in the United States. The scale of America's spectacular failure to prevent its citizens from HIV/AIDS infection is revealed in the statistics: in 2003, the rate of HIV prevalence per 100,000 was 69 in Australia, 200 in the United Kingdom and 600 in the US; the incidence of AIDS per 100,000 was 1.5 in Australia, 1.4 in the UK and 15 in the US.
America politicised HIV/AIDS in a way that destroyed any hope that its government would adopt sane and rational prevention policies. The root causes of the present problem can be found not in the properties of the virus but in the politics of how the American religious right exploited the emergence of HIV/AIDS to pursue its political objectives.
It was the world's bad luck that the emergence of HIV coincided with a dramatic political upheaval in the US, the growth of the political power of the religious right and the beginnings of what have become known as the culture wars. Had HIV been dealt with like SARS, there was every possibility that over a few short years, it could have been contained, isolated and eradicated. This opportunity was lost.
IN THE US, HIV FIRST INFECTED GAY MEN AND DRUG USERS. It therefore transcended its humble origins to become a symbol of liberation and oppression, a metaphor for illness and redemption, and an opportunity to make large profits – all of which paralysed any hope of a swift, scientifically sound political response to the problem.
Twenty-five years later, and as a direct consequence of the American mismanagement of the politics of HIV/AIDS, the world's response remains paralysed and misguided. The malign consequences of the American religious right's success in defining HIV/AIDS have spread around the world.
Uniquely among diseases, HIV is still defined not in terms of what it is, or how it spreads, but whom it infects. Empirical data, scientific method and established facts have counted for much less than they should in determining national and international AIDS policies and priorities.
Religious extremism, conspiracy theories from the left and the right, bigotry and plain stupidity that should long ago have been suppressed still paralyse the global response. In the developed countries, with the glaring exception of the US, HIV infection has for the moment been contained. Public concern has ebbed as advanced medical treatments have been developed to stem the onset of AIDS and to keep those with the disease alive and in relatively good health. Although there are signs of lessening commitment, preventive education campaigns have dramatically reduced rates of new infection, especially among the young.
It is the developing world that faces the full impact of HIV/AIDS. Yet the worse the epidemic becomes, the less interested people are in it, joining global warming, the US budget deficit and the fate of refugees as issues that generate immense coverage but little action. It has become an issue that, in the developed world at least, no longer generates public fear or apprehension – a manageable malady, unfortunate for those who contract it, but not the out-of-control killer that it was feared in the mid-1980s.
Our attitudes to HIV demonstrate the paradox of prevention – success is achieved when something does not happen. The more people are persuaded to protect themselves, the fewer the cases of infection. But the fewer the cases of HIV infection, the less obvious is the case for undertaking prevention and the less public concern about the problem. Thanks to a combination of preventive education and development of combination drug therapies to treat people, in the developed world HIV infection rates have either remained steady or, as in Australia, fallen considerably in the past decade.
In the developing countries, things could not be more different. These countries lack the basic health infrastructure to treat most diseases, let alone HIV/AIDS. They lack the budgets to provide their HIV-infected populations with expensive retroviral therapies that delay conversion to AIDS. In many cases, these countries are constrained by culture and religion from openly discussing the sexual and drug-taking behaviours that are most likely to facilitate the spread of the virus.
The longer the HIV virus is established in a population, the less effective preventive education campaigns are in stemming its spread. Western experience demonstrated conclusively that swift, frank and widespread HIV education programs undertaken before the virus took hold in vulnerable groups were able to bring about modification of sexual and drug-taking behaviours.
In Australia, for example, we were able to stop the transmission of HIV from gay men and intravenous drug users into the general heterosexual population. We did this through targeted education, and not by sanction, isolation and quarantine. In Australia, new annual HIV diagnoses peaked at 1371 in 1989, declining to 926 (1994), 693 (1999) and 782 (2003). New annual diagnoses of AIDS peaked at 953 in 1994, declining to 290 in 2003.
More than 85 per cent of new HIV infections result from transmission from sexual contact between men. HIV prevalence remains at below 1 per cent in people using needle and syringe exchanges, prison entrants, among men and women attending sexual health clinics who report a history of heterosexual contact and women with a history of sex work.
Broadly, and with some significant variations, the Australian experience reflects that of the developed world, excluding the US. The key to checking the spread was timely, frank and widely disseminated education, complemented by the availability of condoms, needle and syringe exchanges and anonymous testing. But in most of the developing world, education campaigns lagged well behind the first appearance of the HIV virus. These campaigns have been under-funded, hobbled by political and religious pressures to avoid controversy and largely useless as a means of bringing about sustained behaviour change. In the absence of both the political will and the resources to check its spread, HIV will continue its remorseless spread.
Now the world views HIV/AIDS with a combination of complacency and fatalism – developed countries assume that their relative success in containing new infection rates will continue indefinitely and that the development of the long-promised vaccine is imminent while developing countries seem to have confined their political agitation to pressing for the provision of generic anti-retroviral drugs, while paying lip service to effective education and prevention programs.
Globally, conventional wisdom has come to view HIV/AIDS as a fact of life and an act of nature. Like a slow-moving storm, HIV is increasingly seen as something that can be detected, measured and perhaps avoided, but beyond human powers of control or suppression.
NOTHING ABOUT THE HISTORY OF HIV/AIDS, OR THE NATURE OF THE VIRUS itself, warrants either fatalism or complacency. The infection can be controlled, wherever governments marshalled the will and resources to contain HIV/AIDS, it was contained. Wherever governments succumbed to political and religious pressures to abandon effective prevention campaigns, or to deprive their populations of the means to protect themselves from infection, HIV and AIDS caseloads spiralled out of control.
In many ways, the fight to contain HIV/AIDS has been a victim of the so-called culture wars – the epic struggle between the political expression of resurgent fundamentalist religion and the values of scientific rationalism. In the US in particular, HIV was seized upon by the combatants in the culture wars to further their political goals with disastrous consequences for the control and suppression of the disease.
In mid-1980s America, science and religion battled for control of the HIV epidemic, and religion won. The architects of the rise to power of the American religious right included Jerry Falwell, Pat Robertson and Ralph Reed. Skilfully using the reach and power of new communications technologies – cable television, call centres and computer-organised databases – over two decades these politicians disguised as preachers built the Christian right into the largest single voting bloc in America. The Christian right was crucial in the Republican presidential election victories of 1980, 1984, 1988 and, above all, in George W. Bush's election in 2000 and 2004.
Perhaps even more importantly, the Christian right's ability to mobilise its core supporters was the major factor in the demolition of Democratic Party supremacy in the American Congress to the point that the Republican Party has virtually permanent effective majorities in both the Senate and the House of Representatives, and most state legislatures.
Robertson, Falwell and Reed, and their minions and acolytes, mobilised their voting support by conjuring up a dark and satanic liberal conspiracy that threatened the values of mainstream Americans. They and their institutions profited greatly as they summoned their supporters to arms to repudiate the values of secular, humanist liberalism. From the earliest days of the emergence of the evangelical Christian right, they defined the cultural struggle in terms of abortion, school prayer, the activism of the liberal courts, feminism and, significantly from the point of view of HIV/AIDS control, homosexuality.
The Christian fundamentalist resurgence had its origins in the white southern backlash to the Democratic Party's support for the 1965 Civil Rights Act giving southern blacks the vote. Southern whites deserted the Democrats and switched to the Republicans.
Over the next two decades, the Christian right repaid the Republican Party for giving it a home by remoulding the Republicans in its image. American Christian fundamentalism is thoroughly inculcated with the anti-black racism out of which its political power grew. The world view of the Christian Right was perfectly expressed by Pat Robertson in The New World Order in 1991: "How can there be peace when drunkards, drug dealers, communists, atheists, New Age, worshippers of Satan, secular humanists, oppressive dictators, greedy moneychangers, revolutionary assassins, adulterers and homosexuals are on top?"
Robertson's perspective had not changed 10 years later when he and Falwell discussed the reasons for the al-Qaeda attack in a 700 Club telecast two days after 9/11. Falwell said, "The ACLU [American Civil Liberties Union] has got to take a lot of blame for this. And I know I'll hear from them for this, but throwing God ... successfully with the help of the federal court system ... throwing God out of the public square, out of the schools, the abortionists have got to bear some burden for this because God will not be mocked and when we destroy 40 million little innocent babies, we make God mad ... I really believe that the pagans and the abortionists and the feminists and the gays and the lesbians who are actively trying to make that an alternative lifestyle, the ACLU, People for the American Way, all of them who try to secularise America ... I point the thing in their face and say, ‘You helped this happen'. Robertson said, "I totally concur, and the problem is we've adopted that agenda at the highest levels of our government, and so we're responsible as a free society for what the top people do, and the top people, of course, is the court system."
The political template for the Christian and radical right was best summarised by Pat Buchanan in his 1992 speech to the Republican National Convention that renominated President George H.W. Bush in his ultimately unsuccessful bid for re-election against Bill Clinton. "The agenda Clinton and Clinton would impose on America – abortion on demand, a litmus test for the Supreme Court, homosexual rights, discrimination against religious schools, women in combat – that's change, all right. But it is not the kind of change America wants. It is not the kind of change America needs. And it is not the kind of change we can tolerate in a nation that we still call God's country ... My friends, this election is about much more than who gets what. It is about who we are. It is about what we believe. It is about what we stand for as Americans. There is a religious war going on in our country for the soul of America. It is a cultural war, as critical to the kind of nation we will one day be as was the Cold War itself. And in that struggle for the soul of America, Clinton and Clinton are on the other side, and George Bush is on our side. And so we have to come home, and stand beside him."
LIKE ABORTION, HOMOSEXUALITY WAS HIGH ON THE LIST OF THE SINS committed by the liberal establishment. But with the arrival of HIV/AIDS, homosexuality was swiftly characterised by the Christian right as especially deserving of the punishment of a stern God. For two decades, the Christian right's interpretation of the causes of HIV/AIDS has permeated every level of American government and society. Scientific and empirical evidence about the nature of HIV spread and how to control it has been ignored and disregarded, and its proponents vilified as creatures of the secular, liberal establishment.
In state after state, the political ascendancy of the Christian right has meant that frank HIV education campaigns, condom distribution and needle and syringe exchanges have been curtailed or abandoned. In their place, the Christian right has imposed HIV prevention education campaigns based solely on promoting abstinence from sexual activity and monogamous sex within marriage, and strict enforcement of punitive anti-drug laws to stop needle and syringe sharing.
Internationally, the Christian right exerted its political dominance in the George W. Bush Administration to attempt to bend to its will the policies of the global institutions combating the HIV epidemic. In 2004, the Bush Administration exported to the world the HIV/AIDS containment policies that had been such a spectacular and catastrophic failure within its own borders. In announcing its commitment of $US15 billion ($20 billion) to international HIV/AIDS programs, the Bush Administration made it clear that its aid would be delivered bilaterally and not through multilateral institutions. The bulk of the funding would go to the provision of anti-retroviral drug therapies (and so constitute an indirect subsidy to manufacturers of these therapies) while prevention campaigns would concentrate on sexual abstinence and suppression of drug trafficking as the policy responses to be recommended in the developing world. Failure was immensely rewarded.
Globally, the ascendancy of scientific method, empirical observation and reasoned policy making on HIV/AIDS now faces the same determined adversary that triumphed in the US. Religious fundamentalism poses a direct and immediate threat to the international consensus about how best to contain the epidemic. We must learn from the failure of American scientists and activists to sustain political and public support for effective policies. Empirical evidence about what works and reasoned policy recommendations are sufficient, but by no means necessary, conditions for winning the public policy battle.
The religious right succeeded in America because it did not fight on the same terms and intellectual grounds as science. The religious right spoke in terms of values, morality and the protection of children and families from threat and danger. Science and secular liberalism simply could not match the emotional intensity and political simplicity of the religious right's arguments about HIV/AIDS and its claims about its links to homosexuality.
If science, and its Enlightenment fellow traveller, secular humanism, are to maintain political ascendancy in the fight against HIV/AIDS, much less in such areas as genetic engineering, stem-cell research, cloning and biological sciences, then they will also have to reconnect with the deepest wellsprings of human values and emotions.
Religious fundamentalism must be engaged and defeated at the source of its power, emotional strength and ideological appeal. The American experience of HIV/AIDS demonstrates that whatever their professional achievements, scientists and doctors are lousy politicians. The liberal left has forgotten that politics is not a science but an art.
Art is the distillation of emotion. And politics without emotion, values and ideology cannot succeed. Religious fundamentalism of whatever complexion – Christian, Jewish, Islamic or Hindu – is simply the rebadging of the totalitarian impulse that has plagued all of human existence.
There can, in the end, be no intellectual or political compromise with totalitarian fascism. By its nature, totalitarianism seeks total control, total subservience and total victory while the lovable, but almost terminal, flaw at the heart of liberal humanism is tolerance. But, as 20th-century history demonstrates, totalitarianism and liberalism cannot co-exist.
In this, I agree with Buchanan's analysis. The sooner we understand that we are engaged in a cultural and political war for the future of civilisation, the better. The sooner we rip away the "religious" mask of resurgent totalitarianism and cease to pander to the ludicrous claims of its high priests to represent anyone's will other than their own, the better. The sooner we reject the perverted science of religious totalitarianism, the better.
To triumph over religious totalitarianism, science and liberalism must reassert the values of the Enlightenment remove all priestly influence from politics, confine religion to the churches, synagogues and mosques and strip from these extremists the privileged taxation and other concessions that they have so skilfully abused to promote their political objectives.
The fight to contain the physical virus of HIV is deeply intertwined with the struggle to defeat the political virus of religious totalitarianism. Too many people have already perished because we engaged the physical virus without realising the deadly threat posed by the political one. In the name of those numberless millions who can be saved from HIV infection and avoidable death, the global fight to contain HIV must become part of the larger struggle to engage with, and defeat, religious totalitarianism. ♦