Global Policy Forum

By Howard W. French

The details may change each year, but when the 14th International AIDS Conference got underway last week in Barcelona, the flood of alarming statistics about the progression of the disease around the world was entirely familiar.

Soon, average life expectancy will dip below 40 years in 10 African countries. Twenty-five million children will be orphaned worldwide by the disease by the end of the decade. In Russia, H.I.V. infection has increased 15-fold in three years. In China, 17 percent of the population has yet to hear of AIDS, even as the disease takes off there in earnest.

Sometime soon, AIDS will have killed more people than all the wars of the 20th century. Yet, in a paradoxical way, the most pessimistic data coming out of the conference may come from the few bright spots, including the United States and a few other rich countries.

People in the United States and Western Europe, where annual treatments may average $35,000 per patient, have begun to think of AIDS as a survivable condition. Each year, moreover, new data seem to feed a growing conviction in the wealthiest countries that the epidemic has been blunted in their own backyards.

In Japan, the world's second-largest economy and a lavish spender on scientific research, there has never been an AIDS epidemic. Search as one might, it was nearly impossible last week to find more than a brief mention of the Barcelona conference in newspapers.

AIDS has always created a chasm between rich and poor. More than ever before, though, the pandemic is carving up the world into islands of affluence, medical prowess and good governance, and vast regions of poverty, imploding institutions and despair.

Perhaps the most glaring symbol of this divide is the tepid Western response to the United Nations' plea for $10 billion a year to fight AIDS. Many experts call this the minimum amount needed to blunt the epidemic and care for the sick and dying. But the world's rich nations, lacking the same sense of urgency that drove them to action in response to Al Qaeda, or in the gulf war, are now offering less than one-third of this sum.

Strong moral objections have long been raised to the West's seeming indifference to the plight of many African societies. And yet the growing magnitude of the AIDS crisis has tested the illusion of invulnerability, prompting a search for more pragmatic solutions.

"The world stood by when AIDS was spreading in Africa," said Peter Piot, executive director of the United Nations AIDS program. "We can't do the same thing now that it is spreading in Eastern Europe, at the doorsteps of the E.U."

Beyond the universe of AIDS experts, however, many people involved in international affairs say appeals to realism like this do not go far enough. For them, the central lesson of the Sept. 11 terrorist attacks is that in today's globalized world there is no such thing as lasting insulation from other people's crises. When entire societies are allowed to collapse and human miseries are permitted to fester, sooner or later those who had the means to help do something about it but didn't will have a steep bill to pay.

TODAY, some people will say, `Why should we care?' " said Joseph S. Nye Jr., dean of the Kennedy School at Harvard University and author of "The Paradox of American Power" (Oxford University, 2002). "Well, in the mid-1990's, many people said pretty much the same thing about Afghanistan: `It is in terrible shape, but what does it matter to us?' On Sept. 11 we found out what it matters to us."

If the challenge from AIDS was limited primarily to Africa, a continent perennially shunted to the periphery of the world's concerns, some might still maintain that wealthy nations need do little more than apply the kinds of Band-Aids and moral salves that are being employed there now. According to yet another statistic issued in Barcelona, although 28.5 million of the world's 40 million people infected with H.I.V. live in Africa, only about 30,000 Africans are receiving treatment with anti-retroviral drugs.

Year by year, however, it is becoming clearer that Africa is hardly alone. In Russia, the rate of infection is growing as fast as anywhere. China and India each acknowledge millions of recent cases, and yet both are thought to be vastly underreporting the crisis. In Indonesia, the disease has been spreading like wildfire.

In the future, the main hotspots highlighted in any new atlas of this epidemic will be major countries (albeit not Western ones) that are the anchors of entire regions. The doomsday scenarios that full-blown AIDS epidemics in all these places imply are almost too extreme to contemplate.

For self-interested Westerners, it is easy to conjure images of the devastation that could visit the more affluent parts of Europe if the former Soviet empire were to be sucked into the AIDS vortex: refugees streaming into Europe, economic collapse, even the outbreak of violence on such a scale that the rich nations might be forced to intervene. But the West is less accustomed to contemplating more distant catastrophes.

In thinking about India and China, Africa may once again serve as the best cautionary model of how a disease can change the course of human history. Africa, with all its problems, had made great strides in terms of life expectancy, and in some countries, economic development as well. Like a century suddenly torn off a calendar, those gains are now being wiped out, and with one-third or more of adults infected with H.I.V., few institutions can remain intact.

In living memory the world has seen mass death in places like China, with its great famine, and the damage has stayed contained. This is a vastly different era, though, one of huge trade and investment linking all parts of the world, not to mention the proliferation of nuclear weapons. And the wholesale collapse of institutions, like China's army — the world's largest — is something mankind has never seen.

Yet these are precisely the kinds of threats that the international conference-goers have been warning of.

Given such realities, it would seem the world is rapidly approaching a critical fork in the road. One way, perhaps, lies death on a scale unseen since the worst plagues of the past. The other way lies a Herculean common struggle against AIDS, of uncertain outcome. Either way, experts from a multitude of disciplines say everyone — rich and poor — will be involved.

"The message of Sept. 11 is that there are no more quarantines," said Ramesh Thakur, a political scientist and vice rector of the United Nations University in Tokyo, "and isolation is an illusion."

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