The African AIDS crisis now claims the lives of about 5,000 Africans daily, making up around 80% of the world’s AIDS deaths. This continent also bears 95% of the world’s AIDS orphans, 70% of new HIV infections and 90% of the world’s children living with HIV/AIDS (1). The amount of human suffering behind these figures is almost unimaginable.

The burden of this pandemic is an economic nightmare for an economy already in distress, where approximately 50% of the people live in extreme poverty. Africa’s only hope is that other nations come to her aid, acting out of concern, respect for human dignity or whatever moral code.

Over the years, however, the AIDS situation in Africa has worsened to catastrophic levels, without much being done to arrest it, because many in the affluent world “looked upon assistance to Africa as charity that [they] had a right to offer or withhold” (2) and not their moral duty. The 1990s have seen the commitments of many donors decline and become increasingly sporadic reducing to only a trickle (3). Aid levels have dropped relative to the growth of HIV; lack of finance is now said to be the primary constraint against progress against AIDS (3). With four-fifths of the world’s wealth, and only 5% of the world’s HIV cases, the question is: how do developed nations continue to allow such great human suffering, without doing anything that could significantly reduce it?

One can only speculate about the reasons behind this inaction. ‘AIDS, Africa and indifference: a confession’ reveals an attitude which may be behind some, if not most of this indifference – the perceived security afforded by political borders. The author writes:

I have never been to Africa. I am not black. I do not have HIV…By virtue of my work, I have cared for people – transiently – who have HIV/AIDS. But, as politically incorrect as it may sound, I am not connected to the tragedy that is AIDS in Africa. And, as crass as it may sound, I do not have to be. Perhaps, as part of my effort to be reasonably well-informed about the world, I cannot avoid hearing about it…But I can avoid doing anything about it, and no one will call me to account for my inaction…tragedy is not an easily exported commodity, and we prefer that it be handled behind national borders. In wealthier nations, we look after our own…(4)

This paper seeks to examine this attitude and to further explore its ethical dimensions.

The future of AIDS

Globalisation is a phenomenon that has not only affected trade and finance, but has also changed the nature of health challenges facing people the world over (5). It has brought nations closer to each other, creating close international contacts so that the traditional distinctions between nations’ domestic and international health problems are now, in the words of the US Institute of Medicine, “losing their usefulness and are often misleading.” (5)

With the number of international travelers now reaching three million people daily, microbes including HIV are being transported across the world (5). Also traveling with these people are values, ideas and lifestyles (5), some of which could potentially fuel HIV transmission rates if adopted in destinations across the world.

Sexual risk-taking behaviours by travelers, for instance, mean that HIV can be literally imported from highly affected areas to those with low infection rates. Studies investigating such behaviours are small scale and may not be applicable to the general population (6). But there is cause for concern. Only recently, one such study concluded that “substantial numbers of individuals visiting international resorts have unprotected sex with people they meet while abroad” (7), a theme also echoed by other studies (8). Coupled with the growth of sex tourism and the absence of specific interventions targeting these behaviours, a climate is created for cross-country HIV transmission.

Given these considerations, the suggestion cannot be dismissed that for HIV, physical borders separating nations are arbitrary and irrelevant human constructs. The birth and growth of HIV/AIDS itself should be a reminder of how border-less the microbial world is. From a handful of reported cases in the US, HIV has now become a global problem with mobility a major factor accounting for this spread (9). With such a background, in today’s world, any country seriously aspiring to protect itself or its people from HIV/AIDS and its consequences needs to not only look within but also across its own borders. With the failure of affluent countries to show this understanding, the future of AIDS is bleak. A compelling forecast notes:

Despite uncertainty about the future direction of the disease [AIDS], a number of basic facts are already clear. First, even without approaching the infection rate of SSA, HIV/AIDS is poised to exact a staggering human toll over the next quarter century in … 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. (10)

Are developed countries going to wait for this shift of the AIDS epicentre from SSA to Asia before they feel threatened enough to act?

The ethics of seclusion in the face of harm

Acting now could dramatically change the future trajectory of AIDS and reduce its potential undesirable consequences; inaction represents a serious moral misjudgment, a state of inactivity in the face of a foreseeable harm.

Many would agree that it would be morally right to avoid or minimise the effects of, for example, a foreseeable national TB epidemic if it could be done by the decisions and actions of governments. It would be hard to justify reactions which do not deliberately act to prevent such harm and human suffering, both on consequentialist and non-consequentialist grounds; most non-consequentialists also hold that what is bad has to be avoided or prevented and good promoted (11).

Even if the seclusion by those with extra resources was to somehow turn out to be less damaging than is being suggested here, other considerations would still demand their unconditional action against the epidemic. First, a global HIV epidemic of the magnitude predicted here would not be in the best interest of their children’s future world. The increased misery and frustration in the developing world caused by AIDS could result in increased terrorism and insecurity around the world. As often seen with other disasters, people with AIDS may flee their homes to seek asylum or force their way into the developed world to settle there in their pursuit for a dignified human existence. Corporate giants and companies with ‘sister’ companies in Africa and Asia face an economic threat, as those dying are the economically active workforce. The threat of AIDS in China and India, the most populous nations on earth, would inevitably have negative implications for their markets and the world economy at large. It is presumably for some of these reasons that the US in 2000 declared HIV/AIDS a great threat to international security (12).

Conclusion

AIDS is a threat to everyone in the world, either directly or indirectly. The response so far has not reflected this understanding. The moral responsibility for action against it belongs to all humanity, not only to those currently worst affected. In a globalised world, it is in everyone’s best interests to fight it wherever it currently dominates, and in multilateral coalitions. The deceptive feeling of safety behind national borders must be overcome. Indeed, as Eberstadt so eloquently puts it,

HIV in the region [China, Russia and India] may be likened to a gathering tempest, and the governments in Moscow, New Delhi [,] …Beijing [and ultimately to Washington, London etc, ] 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. (10)