A Conversation with Greg Behrman, author of The Invisible People:
How the U.S. Has Slept Through the Global AIDS Pandemic, the Greatest
Humanitarian Catastrophe of Our Time (Free Press; June 2004)
What inspired you to tell the story of the U.S. response to the global AIDS
When I first learned of the magnitude of the crisis, I was absolutely stunned.
Tens of millions of people were dying of a preventable and treatable disease. I
have always been deeply struck by the Holocaust. It seemed to me that this was
the defining moral challenge of our time - our Holocaust. I had to do my part.
Most Americans feel that AIDS is coming under control at home so global AIDS
won't directly affect them. Are they wrong?
They are dead wrong. This disease has already killed 25 million people. By 2010,
it is expected to have infected 100 million people. In Africa, an entire
generation of adults is under siege. Mankind has never seen anything like it.
For starters, our sense of morality won't allow us to abide such needless
devastation, when there is so much that we can do to prevent or mitigate it. In
addition, our security at home is now bound to global stability, at large, as
never before. The disease is crushing communities and societies; it is
eviscerating national economies and it is destroying state capacity. It is now
quietly sowing profound instability. AIDS will reverse trends in
democratization; it will give rise to warlords, rogue leaders and conflict. In
Afghanistan we saw the danger of a failed state, in Africa we confront nothing
less than the potentiality of a failed continent. Terrorists will find refuge
and sustenance in the debris. We are profoundly vulnerable.
Shouldn't America focus on addressing AIDS within our own borders and let
other countries do the same in their own countries?
It is one of the saddest conditions of the global AIDS crisis, that it is
striking most brutally the world's populations least equipped to handle it.
Africa, Southeast Asia, and now populations in India, China and the former
Soviet Union suffer from poverty and other health challenges. Leadership in
these countries has generally been abysmal. But, because of our wealth, our
might and even our economic and security interests in these parts of the world,
we have both a moral and strategic obligation to provide resources, will and
How do you expect the global AIDS issue to play out during the election
Global AIDS will definitely be a hot issue in the election. Bush considers his
$15 billion initiative a great strength, a historic example of American humanity
and generosity. He speaks of it often, as he did during his mid-April press
conference, which most expected only to be on Iraq. But, Kerry has been strong
on the issue for some time and is very critical of Bush's unilateral and
abstinence-centric approaches, as well as the speed at which the effort is
moving. Richard Holbrooke is Kerry's key foreign policy advisor, and he has said
publicly that this issue is second to none in importance.
What good will it do us to look back at past mistakes and missed
opportunities? Shouldn't we be focused on the present AIDS crisis?
We are at a very fragile and seminal juncture in the world's response. Africa is
in desperate need of resources for prevention and now treatment and care for the
tens of millions who are infected. The disease is poised to explode in India,
China and the former Soviet Union with the potential to needlessly infect
hundreds of millions. It is imperative that we take inventory of our response --
what we've done well, and perhaps more glaringly how we've failed. The history
of our response provides us with critical lessons that help point towards a much
more constructive and effective path forward.
How did you get access to such top policymakers as Donna Shalala and Richard
Holbrooke for your research?
I found that policy makers cared deeply about this issue and very much wanted to
do their part to get this story out there. They were thrilled that someone
wanted to tell this important story and took pains to provide me with tremendous
access. To be sure, sometimes it took a little bit of persistence and work on my
part as well.
Were American policies complicit in helping AIDS flourish?
The world shares complicity for the devastation AIDS in now wreaking across the
globe. There is much blame to go around. But, American wealth, might, reach and
advantage makes us the undisputed world leader. By and large, as went the U.S.
response to global AIDS, so went the global response. The book reveals that
there is so much we could have done -- for so little, really - at so many turns.
As this pandemic exploded worldwide in the 1990s, U.S. funding was flat at
around $120 million until the very end of the decade. That is one of the most
mind-boggling statistics in recent history. Our response has consistently been
10 years behind where it should have been. We cannot afford to keep letting this
disease wash over us. It is essential to get ahead of the curve now. Literally,
hundreds of millions of lives are at stake.
What were the greatest missed opportunities, when America could have acted
effectively on knowledge?
There have been so many. We recognized that this was a global disease in the
Reagan administration. That's when our response should have begun. Around 1990
in the Bush I administration, the National Intelligence Council predicted, with
eerie precision, the number of infections that there would be in 2000. No one in
the government noticed or took action. Clinton mentioned global AIDS and the
need to respond in his very first inaugural address but did nothing for more
than 6 years, as the disease exploded across the globe. And towards the end of
his administration there was finally an effort to devise a real global plan,
what some called a "war plan" -- the first and only real strategic
effort initiated in U.S. history -- but tragically it fizzled amidst egos and
bureaucratic turf wars. It has been a tragic history of missed opportunities.
But those episodes demonstrate what was possible, and what is still possible.
Why was there so much resistance to recognizing that AIDS was global?
Until ARV drugs (the drug treatments that have dramatically prolonged life
amongst AIDS patients in the United States) became available in 1996 and were
proven efficacious on a wide-scale around 1998, people were focused on what was
going on domestically. The cause also lacked effective spokespeople from the
international community and domestic political constituencies. Everyone was
focused on his or her own issue. And global AIDS fell through the cracks. The
disease was also taking its most punishing toll on Africa, which is perennially
overlooked. There was a confluence of factors creating a sort of "perfect
storm," a recipe for neglect.
How much has "passive racism" played a role in U.S. neglect of the
global AIDS crisis?
It's difficult to measure. But, think about it this way: imagine that 25 percent
of adults in Western Europe or South America were about to die gruesome,
premature deaths in the next few years, while we had it within our means and
competency to stop it. It is inconceivable to think that our response would be
the same. A policy maker I interviewed said it perfectly. It's not that
Americans wished death upon black Africans; it's just that it made it easier to
Why should America be expected to take the lead in fighting global AIDS?
Our peerless wealth and might make us the world's leader. Our sense of moral
purpose and mission and the strategic stake we have in this issue compel us to
lead. This is a global threat, and we must demand that the rest of the
international community play its part. But, we have vital moral and strategic
interests at stake. Whether we like it or not, all eyes in the global community
are upon us -- we must not shrink from leadership.
How does the U.S. response to the global AIDS crisis compare to how we have
responded to other global issues like terrorism?
Leaders like Bill Clinton, Colin Powell and Richard Holbrooke have all said
unabashedly that there is no global crisis as serious or as deadly as global
AIDS. Yet, there is a profound disconnect -- a chasm, really -- between the
rhetoric and the resources and the will. When you cut through the numbers, the
U.S. is spending around $2 billion per year on global AIDS; it has designated a
relatively small Office at the State Department to carry out U.S. policy, and it
has not mustered nearly enough political and diplomatic will. The good news is
that winning the war on global AIDS would take only a fraction of the resources
that the war on terrorism will require. The bad news is we're still way short,
way too slow and unwilling to finally get ahead of the curve.
Bush's $15 billion plan for AIDS relief seems like a sign that the U.S. is no
longer sleeping through the global AIDS crisis. Aren't we now doing enough?
We cannot discount the President's initiative. It is historic, and if executed
well, it will help save millions of lives. However, the incredible thing is that
because the disease is continuing to explode, even if the initiative achieves
all of its goals -- which will be very difficult -- the crisis will still be
much worse at the end of 5 years than at the beginning. We continue to be 10
years behind the curve and we will pay an ineffable price.
What will it take to do better in the next decades so AIDS doesn't further
escalate out of control?
We need a 5-pronged plan on top of the President's $15 billion initiative.
First, we need to lead an international initiative to build broad-based
sustainable health infrastructure in the developing world. Developing countries
will not be able to make real, sustainable progress because of their staggering
deficit in physical infrastructure and human capacity. The key will be building
that infrastructure. WHO estimates that for $10-12 billion from the U.S. and
with the rest of the world paying its share, 8 million lives per year might be
saved! We must start immediately. Second, we've got to step-up our vaccine
research and development effort in funding and priority. Third, we've got to
increase technical and financial aid for, and diplomatic engagement with, India,
China and the former Soviet Union -- the so-called "next wave"
countries -- where the disease is poised to explode to unprecedented
proportions. Fourth, we've got to work with international partners both at the
country level and multilateral organizations. This needs to be a global effort
with strong international collaboration. Finally, everyone must exercise his or
her voice. People can make a big difference by contributing to organizations on
the ground or pressing their representatives to up-grade U.S. policy. Tens of
millions are dying of HIV/AIDS. It is their crisis. But, it is ours too. If all
these elements coalesce, the U.S. will finally have a real global strategy to
combat the deadliest threat facing mankind at the turn of the new millennium.
Have we learned, and do we have better policy in place now so that we will be
better prepared for the next new disease?
This is the "next" disease. Consider the attention that SARS got in
the media. As many people die of AIDS in a few hours as all those who died of
SARS combined. We can't afford to take our eyes off the ball. The disease is on
a steep upward trajectory in important African countries like Ethiopia and
Nigeria. And most ominously the storm clouds are gathering in the next wave
countries -- we are going to see an entirely new dimension to this pandemic, and
unprecedented levels of devastation in the disease's next phase.
Global problems can overwhelm individuals. Is there anything that individuals
can do to help address the AIDS crisis?
I just returned from a trip in South Africa where I was volunteering in some of
the townships, working with AIDS orphans and children heading their households.
After I returned people remarked, "that must have been so sad." It was
certainly difficult to see all the needless suffering. But, it was also
extremely energizing. When you spend time on the ground, you meet and come to
know wonderful people who have tremendous compassion and commitment. They are
willing to do anything and everything possible to combat this disease, to save
lives. You see how much can be done for so little. People can play a big role by
contributing to some of the organizations that are doing this work. They can
contact their political representatives to let them know that they care, and
that they want more funding and more priority for global AIDS. (This information
is available at www.theinvisiblepeople.com). That's the thing about democracy:
if we want to know who is really responsible for fighting global AIDS we need
only look into the mirror. To be sure the crisis is enormous and the challenge
is daunting. But, the opportunity is electrifying.