Progress in Fighting AIDS in Africa?

With the decline in AIDS among the white population in the United States, the advent of effective treatment (the antiretroviral drugs), and the slowing in the growth of the international epidemic, Americans' interest in the disease has waned. Only about a third of one percent of the U.S. population is infected by the AIDS virus (HIV), and half of those are black (thus the per capita prevalence of the disease is roughly four times as great as its prevalence among whites). Among whites, the principal means of transmission are homosexual sex; among blacks, heterosexual sex and needle-sharing drug use.

The international epidemic is undiminished, indeed growing, though at a diminished rate. Some 40 million people worldwide are infected by HIV, up from 8 million in 1990. But the international distribution of the epidemic is remarkably skewed. In North America and Western and Central Europe, it is only.3 percent, and in most of the world it is no higher than 1 percent. In the Caribbean countries, however, it is 1.2 percent (which is the approximate prevalence among U.S. blacks) and in sub-Saharan Africa it is at least 6 percent and perhaps as great as 10 percent. Because antiretroviral drugs are available to only about 20 percent of the infected population in sub-Saharan Africa, the death rate is much higher than elsewhere, and indeed about two-thirds of the world's AIDS-related deaths occur there. The ratio of total infected persons to annual number of deaths is about 10 percent in sub-Saharan Africa versus 1 percent in the United States.

Even within sub-Saharan Africa, there are vast differences in the prevalence of the disease among the different countries. Most of the West African countries, including Nigeria (Africa's most populous country), have prevalance in the 5 to 7 percent range. But there are a number of countries in East Africa, notably the Republic of South Africa, where the prevalence is in excess of 20 percent (it is 24 percent in Botswana, for example). The overall prevalence of the disease in sub-Saharan Africa seems, however, to have peaked, so that the continuing increase in worldwide prevalence is being driven by increases in other countries, mainly in Asia.

The disease is a principal focus of foreign aid by wealthy nations, multinational groups such as the United Nations, and private foundations such as the Bill and Melinda Gates Foundation. The total amount of money spent fighting AIDS in other than the wealthy countries has been estimated at $8.3 billion a year, of which $2.6 billion is spending by the affected countries themselves and the rest represents donations--so a total of about $5.7 billion in foreign aid. The money goes for such things as buying condoms, educating people about the disease, training health workers, and buying antiretroviral drugs. There is, of course, a great deal of waste. The United States devotes a significant fraction of its assistance to preaching sexual abstinence and requires that all the condoms it supplies be purchased from U.S. manufacturers, which charge much higher prices than Asian manufacturers.

I am dubious that the foreign donations are money well spent, compared to alternatives. This is not because HIV-AIDS isn't a ghastly disease, and economically very harmful because of its debilitating effect on the working-age population, to which most of the victims belong; it is because the causes of its prevalence in those countries in which it is prevalent are social and economic conditions, or political decisions, that must be changed before there can be any real hope of significantly reducing the prevalence of the diseases, and that are unlikely to be changed by foreign money. The causes include profound ignorance about the disease (due in part to superstition and in any event an aspect of much broader deficiencies in education and literacy), miserable living conditions and short life expectancy which reduce aversion to risky behavior, migrant male labor that increases the demand for paid sex, cultural traditions of male promiscuity, female circumcision (a risk factor for HIV), and the extremely low status of women that drives many of them into prostitution and reduces their ability to bargain effectively with men over safe sex, to which men are more averse than women. Underlying all these things is the extreme poverty of most sub-Saharan countries, which in turn stems, in major part anyway. from the dreadful legal and political infrastructure of most of these nations. And, by the way, these awful conditions are not the legacy of colonialism, as is often charged. These countries were better administered when they were colonies, at least those that were French or British colonies; and many other former colonial nations, such as India, Singapore, Malaysia, Tunisia, and Trinidad, are prosperous relative to sub-Saharan countries, while Liberia, a sub-Saharan African nation that has never been a colony, remains profoundly disordered and impoverished.

Because of the inadequate legal and political infrastructure in sub-Saharan countries, giving money to these countries for any purpose is likely to be a poor investment. This is dramatically shown by the case of South Africa, which has one of the highest rates of HIV-AIDS of any country in the world. Because of its mineral resources and its substantial white minority, South Africa is by African standards a wealthy country. Its GDP is almost $200 billion. Its leaders have been in a shocking state of denial concerning AIDS. Any money given to South Africa to fight AIDS is likely simply to replace the money that South Africans spend on AIDS. This of course is a general problem of charity, such as food stamps in the U.S.--if charity, even when earmarked for a specific expenditure, is less than the recipient would spend on the item anyway, his consumption of the item will be unaffected. So if a person spends $2,000 of his own money every year on food, and then is given $500 worth of food stamps, he will not eat more (unless having a larger total income increases his demand for food), but rather will spend $500 less out of his own pocket. The same may be true in the case of foreign assistance for fighting AIDS in Africa.

An interesting contrast to South Africa is presented by Uganda. Unlike South Africa, Uganda is very poor; its annual GDP per capita is only about $1,500, compared to more than $12,000 for South Africa. Yet its HIV-AIDS prevalence dropped steeply in the 1990s, from 15 percent to 5 percent. Although its prevalence has been increasing somewhat since and there is dispute over the accuracy of the government's statistics, it is generally believed that the prevalence of the disease in Uganda has indeed declined substantially--and has done so as a result of an inexpensive (only tens of millions of dollars) government campaign to educate people in the danger of AIDS. It is the kind of campaign that virtually any country could afford, without need for foreign assistance. In contrast, the antiretroviral drugs are expensive (even though sold at very low prices for use in poor countries) when the cost of the health-care infrastructure required for their effective administration is taken into account. Yet the drugs, unlike a vaccine (which has proved thus far impossible to develop, because of the extreme mutability of the virus), do not eliminate the disease; a person on the drugs can still transmit the virus.

The South African and Ugandan cases suggest that political will rather than huge foreign charity holds the key to reducing the prevalence of AIDS in poor countries. HIV-AIDS is a disease readily preventable by financially inexpensive behavioral changes, such as the use of condoms, once people are alerted to the character and gravity of the disease. A government that communicates effectively with its people and makes condoms cheaply available to them will go far toward reining in the epidemic.

One comment in particular merits a response: that Botswana, one of the best-governed countries in sub-Saharan Africa, and one of the most prosperous (its GDP per capita is about $10,000, and thus close to the Republic of South Africa's $12,200), has one of the highest AIDS rates in Africa (24 percent), and therefore I am wrong to suggest that bad government and poverty are the roots of Africa's disproportionate incidence of HIV-AIDS. I had pointed out, however, that the factors that influence a country's AIDS rate are multiple. One of them is migrant labor, which facilitates prostitution and casual sex. Botswana sends many of its workers to South Africa, and also sits astride major north-south traffic arteries. In addition, its relative prosperity has led to rapid urbanization, and cities provide greater opportunities for casual sex than rural areas. Another factor that has undoubtedly influenced the AIDS rate in Botswana is that the AIDS epidemic started in southern Africa, which is probably why the highest African AIDS rates are in the countries of southern Africa, which include Botswana. The epidemic had already spread widely before preventive measures, including education in the danger of the disease, were taken. But that of course cannot explain why Botswana's AIDS rate is higher even than South Africa's.

A further point about Botswana is that although its average income is high, because of its diamond mines and tourist attractions, the income is very unevenly allocated. Most of the population is very poor (30 percent are below the poverty level) and 20 percent are illiterate. However, a wealthy country with many poor can pay for public health, and in fact Botswana has an advanced program for combating AIDS by education, free condoms, etc., and has had it for a number of years, so it is a puzzle why the overall incidence of HIV-AIDS remains so high.

I want to emphasize two other factors that did not receive adequate attention in my original post. One is that short life expectancies reduce the cost of risky behavior: a 25 percent risk of dying from AIDS is very high, but the expected cost of death that is generated by that risk is lower the higher the probability of dying young from some other disease, a probability much higher in sub-Saharan Africa than in the United States. Another factor is the prevalence of other sexually transmitted diseases, such as syphilis, which increase susceptibility to infection by the AIDS virus. Both of these points are discussed in an early article by Tomas J. Philipson and me on AIDS in Africa--"The Microeconomics of the AIDS Epidemic in Africa," 21 Population and Development Review 835 (1995)--and in a more recent article by Emily Oster, "Sexually Transmitted Infections, Sexual Behavior and the HIV/AIDS Epidemic," 120* Quarterly Journal of Economics* 467 (2005). We note in our article the curious positive correlation in Africa of AIDS with education, and suggest that educated Africans are likely to be urban and therefore have more opportunities for casual sex. On the economics of AIDS generally, see also Philipson's and my book* Private Choices and Public Health: The AIDS Epidemic in an Economic Perspective *(1993).