The Coming Plague (88 page)
Authors: Laurie Garrett
Still, it seemed at first glance unimaginable that AIDS could make a dent in Asia's economic boom. Only a handful of countries (the Philippines, Papua New Guinea, Burma, and Cambodia) experienced negative GNP growth during the 1980s, and many Asian countries had growth rates that were five to seven times greater than those of the United States and Switzerland.
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Like Africa, however, much of Asia was simultaneously undergoing other disease emergences that could be expected to compound or synergize with HIV/AIDS. These included dengue, hepatitis (A, B, C, D, and E), multiply drug-resistant malaria, tuberculosis, drug-resistant cholera, and virtually every known sexually transmissible microbe. Though no one knew how to calculate the additive or multiplicative economic impacts the interlocking epidemics might have, it was clear, biologically and epidemiologically speaking, that interconnections existed.
In mid-1993 the GPA estimated that 1.5 million residents of South Asia were HIV-positive, most of them Indian or Thai citizens. For Thailand, specifically, WHO estimated that 450,000 people were infected by late 1992.
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But WHO's numbers were surely overly conservative. Newer data demonstrated that the rate of expansion of the country's epidemic, far from slowing as many hoped, was accelerating alarmingly.
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The only hopeful slowdown in Thailand's plague was seen among injecting drug users in Bangkok, who readily snapped up sterile syringes when they were made available.
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The only hopeful slowdown in Thailand's plague was seen among injecting drug users in Bangkok, who readily snapped up sterile syringes when they were made available.
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Mechai Viravaidhya estimated that Thailand's cumulative AIDS death burden by the year 2000 would be 470,000 to 560,000 adults. Based on an average productivity loss of $22,000 per dead worker, that could inflect an indirect loss of $7.3â$8.5 billion on the Thai economy. Direct treatment costs for those people would be between $61 and $167 million out of a total annual Ministry of Health budget of just over $40 million.
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In 1992 a single day of AIDS hospitalization in Bangkok cost an average of $298.73;
Thailand was in the unfortunate position of having reached Western standards of curative medicine and hospitalization while its populace still earned Third World wages. By 1992 Thai officials were predicting that the epidemic would push the nation's health and medical advances backward, as an overwhelmed system collapsed under the economic costs and the sheer load of AIDS cases.
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In 1992 a single day of AIDS hospitalization in Bangkok cost an average of $298.73;
Thailand was in the unfortunate position of having reached Western standards of curative medicine and hospitalization while its populace still earned Third World wages. By 1992 Thai officials were predicting that the epidemic would push the nation's health and medical advances backward, as an overwhelmed system collapsed under the economic costs and the sheer load of AIDS cases.
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Drawing on slightly different estimates of both the forecast epidemic size and indirect costs, WHO predicted a total economic burden from AIDS of $9 billion for Thailand by the year 2000.
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And the GPA told World Bank officials as early as October 1991 to expect a possible economic downturn in South Asia during the latter half of the decade: it was a view shared by the Thailand Development Research Institute in Bangkok.
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And the GPA told World Bank officials as early as October 1991 to expect a possible economic downturn in South Asia during the latter half of the decade: it was a view shared by the Thailand Development Research Institute in Bangkok.
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The U.S. Census Bureau issued dire forecasts for Thailand, based on HIV-prevalence rates as of early 1994. The Bureau predicted that by 2010 Thailand would have experienced such severe devastation due to AIDS that the country's population growth rate would have plummeted toâ0.8 percent (from a pre-AIDS predicted +0.9 percent); there would be 25 million fewer people in the country than would have been the case in the absence of AIDS; life expectancy would take a nosedive from what would have been 75 years to a mere 45 years; child mortality rates would more than triple (reaching some 110 per 1,000 children born); and the nation's crude death rate would soar from about 6 deaths per 1,000 to more than 22 per 1,000.
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Though few analogous economic analyses had been done for India, Burma, the Philippines, or other Asian countries in the grips of HIV, there was a clear consensus in international public health circles by 1993 that the pandemic would, at the very least, exert a Thirdworldization effect upon the health care systems, tourist industries, and government-funded social service sectors of hard-hit countries. Worst-case scenarios forecast sharp declines in both agricultural and industrial productivity with resultant declines in GDPs.
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The United Nations Development Program and the Asian Development Bank predicted in late 1993 that the HIV epidemic would increase general levels of poverty and, by the year 2000, cause local famines in key areas.
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The United Nations Development Program and the Asian Development Bank predicted in late 1993 that the HIV epidemic would increase general levels of poverty and, by the year 2000, cause local famines in key areas.
Such dire economic forecasts, whether they concerned the projected impact of AIDS on Africa, Asia, or Latin America,
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were always intended to draw the attention of wealthy donor states. The nations of North America, Western Europe, and, to a lesser degree, Japan and the Soviet Union had always been forthcoming with cash when a crisis struck, even if the quantities were more symbolic than substantial. If the cash was offered at interest, Africa and Latin America might cringe, but Asia had an excellent debt-repayment record.
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were always intended to draw the attention of wealthy donor states. The nations of North America, Western Europe, and, to a lesser degree, Japan and the Soviet Union had always been forthcoming with cash when a crisis struck, even if the quantities were more symbolic than substantial. If the cash was offered at interest, Africa and Latin America might cringe, but Asia had an excellent debt-repayment record.
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Throughout the world hope for a global AIDS bailout rose as Berliners clawed away at the wall that had physically divided their city for three
decades. What began with dockworkers in Gdansk in the early 1980s built slowly for years in pockets of antiauthoritarian resistance that spanned from Prague to Riga, from Vladivostok to Berlin. Once the Berlin Wall fell there was no turning back: the ideal and reality of communism were dead. And with the end of communism came capitalist dominance and Western victory in the Cold War. Threat of global thermonuclear annihilation suddenly seemed quite remote. Politicians all over the world spoke of a Peace Dividend. And suddenly the world had surplus cash, they claimed, and long-neglected social programs could now be subsidized. For a few moments in history, it seemed, people around the world were remarkably optimistic.
decades. What began with dockworkers in Gdansk in the early 1980s built slowly for years in pockets of antiauthoritarian resistance that spanned from Prague to Riga, from Vladivostok to Berlin. Once the Berlin Wall fell there was no turning back: the ideal and reality of communism were dead. And with the end of communism came capitalist dominance and Western victory in the Cold War. Threat of global thermonuclear annihilation suddenly seemed quite remote. Politicians all over the world spoke of a Peace Dividend. And suddenly the world had surplus cash, they claimed, and long-neglected social programs could now be subsidized. For a few moments in history, it seemed, people around the world were remarkably optimistic.
But no Peace Dividend appeared. People craned their necks looking for it, soon spotting a shadow emerging on the horizon. Excitement yielded to despair and frustration as they recognized the shadowy Dividend for what it was: international recession.
After all the celebrations and dancing in the streets of Prague and Berlin settled down, the West got a good, hard look at what lay behind the Wall, inside the long-sequestered world of communism. And they discovered that Stalinists from Uzbekistan to the Baltics had been juggling the books for decades. The East was broke.
Worse yet, its populations, which had long had nearly every aspect of their lives controlled by the state, were ill prepared to build strong civic societies. With their economies in a shambles, cynicism quickly overcame the brief sensation of elation for most Europeans.
Reunification of the two Germanys was concretized on October 3, 1990, amid fetes and fireworks, but by the end of that year official unemployment in the former GDR had soared from zero to more than 350,000 adults.
Overnight the former Cold War multitrillion-dollar spending became a latter-day Marshall Plan for reconstruction of the ex-communist world. Ten billion dollars shifted from coffers in Bonn to national bank vaults in Moscow in a single day. And that was just one of many West-to-East transfers.
Not only was there no Peace Dividend, there was newfound, long-term structural agony. Even the booming Asian economies felt the pain as demand for autos, electronics, and consumer goods dropped in Europe and North America.
While much of the world watched the demolition of the Berlin Wall during the fall of 1989 with astonishment and elation, Hans Seyfarth-Hermann dashed about Checkpoint Charlie tossing condoms at the crowds of East Germans as they poured through. The bewildered East Germans snapped the packets out of the air and examined what looked like matchbook covers. They read this brightly colored inscription: “You will see many tantalizing things during your visit to West Berlin. Enjoy yourself, but remember, we have AIDS.”
Inside each putative matchbook was a latex condom. Political openness, it appeared, could carry a price tag. If it was true, as the old Stalinist
leaders claimed,
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that AIDS hadn't made its way yet into most of Eastern Europe, the fall of the Wall would surely put an end to the political barriers that had allegedly kept the microbe at bay.
leaders claimed,
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that AIDS hadn't made its way yet into most of Eastern Europe, the fall of the Wall would surely put an end to the political barriers that had allegedly kept the microbe at bay.
Seyfarth-Hermann and fellow AIDS activist Julian Eaves were in a Berlin gay bar called the Dark Cellar the night of November 9, 1989, when they overheard Germans speaking in a startling accent. The two of them realized that the men were from Saxony, part of East Germany, and that they were filled with excitement that night, Eaves later recalled, “trying to enjoy the wild life in the big city.” Eaves and Seyfarth-Hermann recognized that their Saxon gay counterparts knew nothing about AIDS and safe sex. They also were sadly aware that some West Berlin gays, sick and tired of “latex sex,” might take advantage of the Easterners' ignorance.
The two activists spert the following day making hundreds of the special packets which they later tossed at the hordes of Saxons and other Easterners crossing through Checkpoint Charlie.
“Everything that is new is welcome now in East Germany,” Eaves explained. “The old stigmas have been thrown away, and everything is possible. We hope East Germany will achieve a world level in everything, except AIDS deaths.”
No one could imagine that just four months later prostitutes in West Berlin would be on the verge of staging a protest strike over the thousands of competitors that flooded in from the East every Friday night to earn valuable deutsche marks over the weekend. Hungry for hard currency, young women, most of whom didn't really consider themselves prostitutes, would pour into Berlin to turn a few quick tricks, often for as little as five deutsche marks. The regular hookers would be outraged because the newcomers would charge far less than the former going rate, and they wouldn't require that their customers wear condoms.
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Within three years the Eastern prostitutes would be a regular feature of red-light districts all over the wealthier West.
HIV would also ride Europe's new heroin trail. Opening up the formerly secluded states rang bells of opportunity for organized criminal elements on both sides of the former Wall. Poland, in particular, would become both a center for a locally produced opiate called
kompot
and a transfer point for pure heroin imported from other parts of the world and destined for distribution in Central Europe.
kompot
and a transfer point for pure heroin imported from other parts of the world and destined for distribution in Central Europe.
The first serious emergences of HIV in Eastern Europe were not via either prostitution or heroin injection, however. Rather, they came by means that reflected the tragic state of medicine in much of the communist bloc.
Though there had been isolated AIDS cases in Russia for at least four years, HIV really emerged during the early spring of 1988 in Elista, capital of the Kalmyk Republic, located on the Caspian Sea. A baby languished on the pediatric ward of the town's hospital, suffering every imaginable ailment. Doctors were stumped, unable to reach a diagnosis, until one
suggested sending blood samples from the infant to Valentin Pokrovsky, a virologist doing AIDS research in Moscow. Pokrovsky confirmed that the child was infected with HIV.
suggested sending blood samples from the infant to Valentin Pokrovsky, a virologist doing AIDS research in Moscow. Pokrovsky confirmed that the child was infected with HIV.
The child's father, it turned out, had visited the Congo in 1981, where he apparently was exposed to HIV. He passed the virus sexually to his wife, who, in turn, transmitted HIV to the child.
It was tantamount to treason to publicly acknowledge shortages of vital goods during the regime of Joseph Stalin, and forty years after the dictator's death many Soviet citizens remained reluctant to step outside normal bureaucratic channels in order to draw attention to production deficiencies. In 1988, however, prior to news from Elista, U.S.S.R. Minister of Health Alexander Kondrusev publicly decried the country's sorry state of medical supplies. In particular, he warned that the nation needed to use 3 billion syringes per year, but was only manufacturing 30 million annually, and importing none. Simple mathematics indicated, then, that the average syringe was being used 100 times. Kondrusev warned that this syringe shortage could spell disaster.
He would soon prove remarkably prescient.
The AIDS baby at the Elista hospital was treated by staff who used the same syringes to withdraw blood samples from and administer drugs to all the babies on the neonatal ward. For more than three months the nurses unknowingly injected HIV into all of the babies and, in a few cases, their mothers.
As the numbers of AIDS babies mounted, the overwhelmed Elista doctors ordered some of the infants shipped to a hospital in Volgograd. And again, the medical staff reused syringes over and over, soon having infected nearly every child on the Volgograd baby ward.
The incidents were kept quiet until early 1989 when a Russian trade union newspaper,
Trud,
broke the story. According to
Trud,
Health Minister Kondrusev had grossly underestimated the enormity of the gap in the Soviet Union between the number of injection procedures of one kind or another that were performed by health providers and the annual production rate of sterile syringes.
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While leaders in Moscow received single-use sterile injections, the masses living in outlying areas relied on hospitals that suffered permanent supply shortages. So in Elista and Volgograd, for example, health care workers had little choice but to reuse syringes 400 or 500 times, occasionally honing the needles on a whetstone so that they would still pierce skin.
Trud,
broke the story. According to
Trud,
Health Minister Kondrusev had grossly underestimated the enormity of the gap in the Soviet Union between the number of injection procedures of one kind or another that were performed by health providers and the annual production rate of sterile syringes.
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While leaders in Moscow received single-use sterile injections, the masses living in outlying areas relied on hospitals that suffered permanent supply shortages. So in Elista and Volgograd, for example, health care workers had little choice but to reuse syringes 400 or 500 times, occasionally honing the needles on a whetstone so that they would still pierce skin.
It was horribly reminiscent of the events in Yambuku Hospital in 1976, where Belgian nuns used a handful of syringes hundreds of times per week, unwittingly spreading the deadly Ebola virus. That, however, occurred in a remote, impoverished region of Central Africa; the Soviet Union was, allegedly, part of the advanced industrialized world.
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