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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 crisis?

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 vision: leadership.

How do you expect the global AIDS issue to play out during the election season?

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 turn away.

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.