Cape Town workshop on the security aspects of HIV/AIDS

On 7-9 February 2004, Pugwash Meeting no. 291 was held in Betty’s Bay, near Cape Town, South Africa.

Threats without Enemies: the security aspects of HIV/AIDS: An exploratory workshop

Co-Sponsored by Pugwash Conferences on Science and World Affairs and the South African National Pugwash Group

Workshop Report

Following the success of the Pugwash focused workshop series on Intervention, Sovereignty, and International Security, which was an innovation by Pugwash, the South African Group proposed, and the Pugwash Council authorized, the convening of two exploratory workshops on a similar model. Their purpose is to explore potential concrete “multiplier” Pugwash roles in the enlarged security agenda where there are many threats but fewer (or in this case, no) enemies, of which HIV/AIDS is a prominent case in point. “Multiplier” means using the unique authority of Pugwash to identify and then to promote leading edge topics for development by others. These workshops may stand in a similar relationship to larger planned research and policy development on the question of AIDS and security, as the Pugwash study group on Intervention, Sovereignty, and International Security did to the work of the International Commission on Intervention and State Sovereignty.

As is customary with Pugwash meetings, the workshop was held on a non-attribution basis. Therefore the workshop report is the sole responsibility of the author and has not been endorsed by any of the participants: it records his impressions.

Pugwash is very grateful to the South African Pugwash Group for facilitating and subsidising the meeting. A total of 10 South African and international participants accepted, of whom 9 eventually attended the workshop. Disciplines represented included medical physiology and biochemistry, development economics, political sociology, military sociology, historical epidemiology (all these with specialist knowledge of AIDS issues), political science, mathematical operational analysis and research administration. Pugwash would also like to thank the London School of Economics, the Centre for the Study of AIDS at the University of Pretoria, the University of KwaZulu-Natal, QinetiQ plc and the South African Military Academy, Saldanha, for travel and other support provided.

Background to the workshop

The meeting began with a discussion of the reasons why the security dimensions of AIDS have hitherto received rather limited systematic attention. Part of the reason, it was suggested, was that this strange and malevolent medical condition has naturally been first addressed in medical terms. This may appear to be an odd remark, but is not so. A repeated theme in the workshop was of the over-emphasis on somatic, medicalised interventions to the detriment of others; for the inevitable and therefore earliest arrival of a political dimension in any public health intervention is as necessary in this case as in 19th century infectious epidemics. John Snow did not stop the 1859 cholera epidemic at Golden Square in London by treating sick patients: he had not the means: he could not. He treated the epidemic by developing a medical model that led him to remove the pump handle from the Broad Street pump that was the source of infected water.

In the present case, as will be reported below, the workshop formed the view that this necessary engagement with the domestic political economy of AIDS has been surprisingly fragile to date. Even more so, this has been the case with the security dimension. From the outset, the workshop adopted a fairly stringent definition of security. It discussed briefly, but made little use of, the fashionable but intractable concept of “human security”. Instead it went to first principles. It was suggested that as humanity confronts the known successive waves of the AIDS pandemic that are about to break (west Africa, Ethiopia, Russia, Ukraine, India, China), societies where adult life expectancy drops as precipitately as it has for high prevalence South African societies (Botswana from 63 to 36; South Africa from 60 to 47; Zimbabwe from 59 to 43 within a decade) will face great difficulty in social and cultural, let alone political reproduction. This will have a range of potentially large security consequences in the old-fashioned sense of the concept. Yet the manner in which HIV/AIDS interacts with other solvents of social and state coherence is little studied as yet. The purpose of the workshop was to explore how this might best be done.

AIDS and the AIDS debate in South Africa

The first of three presentations in this session described the physiological and biochemical processes attendant upon infection and the progress of the disease thereafter. The workshop was grateful to have been set off with a medical paper which reminded us of some of the grounding points of the epidemic. The specific point emphasised was how, within the cruel hi-jacking of the immune system, the body rapidly depletes its own muscle tissue in order to furnish amino-acids needed in its response. This makes the general nutritional status of the patient especially important and sets a context for the cost/benefit of different forms of intervention, some of which are complex and expensive in the Southern African context (for example ARVs).

A second presentation then placed the medical model in the wider Southern African context. It reviewed the epidemiological and statistical data in detail. It was argued that, contrary to the repeated assertions of President Mbeki and the AIDS Denialists, time series data from antenatal clinic blood tests confirm a real and rising epidemic curve from near zero in 1990 to 26.5% HIV Positive in that group (converting to circa 19.94% in the adult population) in 2002. The Southern African epidemic has now reached a point where we may expect soon to see large numbers of deaths: transition to the “death phase” in the epidemic cycle. The key actuarial finding is that relative to age group specific deaths in 1985, young South African women, aged 25 to 29 (the highest risk group demographically and physiologically) face a risk of death today 3.5 times greater. It was noted that if, as President Mbeki has often said, poverty is the cause, then the arrival of democracy has been a very bad thing indeed for the health of black (overwhelmingly) South Africans. But that is not the most obvious, sufficiently powerful and proximate cause, with an applicable aetiology. That cause is AIDS.

Why has the South African epidemic become so bad, so quickly? It was argued that there had been too heavy a focus upon issues of sexual behaviour – the primary transmission mechanism without question – to the exclusion of micro-environmental and macro-environmental determinants. These – the domestic political economy of AIDS – include greater attention to issues of mobility, urbanisation, women’s rights and status and unequal exposure to levels of violence as well as larger determinants such the capacity and quality of governance, and (indeed, for Mbeki is right if the point is placed in context) gross poverty. The case was made powerfully that as a consequence of an unequal emphasis favouring biomedical intervention and attempts to change sexual behaviour in isolation, the Southern African epidemic promises several grim features which will have directs impacts on security. From having no AIDS orphans in 1995, South Africa must plan to cope with two million by 2010. There will be higher, possibly disproportionately higher, mortality in skilled and professional groups (on evidence from the mining industries) which will greatly strain social security. While it was not suggested that South Africa’s political integrity was certain to be compromised, the risk was acknowledged; and the grim reality of the recent ruining of Zimbabwe was thought to be quite likely impacted by the scale of its AIDS crisis. Impact mitigation was vigorously promoted for South Africa.

The thrust of this prescription was firmly endorsed in a third presentation which argued that the South African epidemic had been worsened by the use of the wrong analytic tools. Race, class and gender are all uncontroversially, if painfully, indicated in a robust understanding of what has happened. But, equally it was argued that “coping” strategies alone would fail. A range of strategies for positive living were described. The essential value of such strategies is that they break the “victim mould”. In ensuing discussion, the workshop underscored the importance of this by noting the scale of hitherto under-exploited sources of initiative in afflicted South African populations. The history of resourcefulness of people under oppression includes much insufficiently recognised evidence of often heroic innovation to maintain micro-economic viability and psychological balance and a sense of dignity. These may be harnessed again to this unanticipated new cause.

However, the debate in South Africa is currently obscured by two unfortunate influences. The first is well-known and is the wish to deny the reality of the AIDS epidemic. Denial is a natural psychological defence against personality breakdown; but when exercised in the manner and on the scale that has been endorsed by President Mbeki in particular, it has set back the national capacity to combat the affliction. There was some debate about the perverse fact that President Mbeki’s reluctance may have delayed the large-scale introduction of ARV therapies to precisely that point in the career of the South African epidemic where it is least appropriate. But there is another source of confusion currently disturbing the national debate, which does not deny the fact of AIDS in South Africa, only its scale. The journalist Rian Malan has recently become celebrated for two articles in, respectively, the South African investigative magazine “Noseweek”, and internationally in The Spectator. There he proposes that for some reason or other the scale of the South African epidemic has been continuously over-estimated in AIDS statistics. He suspects malign, conscious and self-serving reasons among the “AIDS establishment” which he sees as variously hysterical and ‘skilled at the manipulation of fear for advancement in terms of money and power’. He has promoted this view with a detailed discussion of the work of the Actuarial Society of South Africa surveys and his opinion has been eagerly embraced by the AIDS Denialists. In an interview published during the holding of the workshop, President Mbeki expressed views which, without attribution, could have been taken almost word for word from Mr. Malan’s article. In a closely comparable way, Mr Malan occupies in relation to the South African AIDS debate a similar position to that which the Danish statistician Bjorn Lomborg does (or rather, did) to the issue of global warming. In both cases, the use and abuse of statistics is the chosen ground of contention.

Mr. Malan was the tenth person who accepted an invitation to attend the Pugwash workshop. His articles, and papers analysing them, were pre-circulated to all to inform a discussion. However, without explanation Mr. Malan did not appear and accordingly, in the scheduled session, the workshop proceeded to a consideration of his work in his absence. Given his unexplained failure to attend, the workshop’s agreed views of his work and the undue prominence which is currently being given to his opinions, the meeting resolved to authorise the Chairman of the South African Pugwash Group to write on its behalf to the newspapers. The letter is reproduced as an annex to this report.

AIDS and security: the Columbia/LSE alliance project plan

A session was devoted to a review and critique of plans to form a lattice-work of international collaboration to fill the gap of understanding about AIDS and security. Tabled papers first explained how the history of approaches to the study of AIDS had omitted this dimension. The first three engagements with AIDS had been respectively, biomedical but attached to stigmatised carrier groups; then – as had been already stressed in the previous session – through a predominantly sexual optic; thirdly, and most powerfully, it was engaged though Denial at the public scale – the approach which had so damaged and distorted responses in the South African episode. Three different lines of approach were advocated (two of which had already been promoted in the workshop). These are, respectively, a study of the geo-politics of the human immune system (where in the world people experience different degrees of deficiency in essential micro-nutrients); a renovated political economy of public health; and, finally, the security perspective.

It was explained how first AIDS was represented by a fragile analogy: “AIDS is as destabilising as any war”. (In the next session it was observed that the only really useful lesson from war is from the medical model of battlefield medicine.) But it took the exposure of the Clinton Administration’s ambassador to the UN, Richard Holbrooke, to the sight of AIDS orphans in Lusaka to propel the issue into the formal purview of the UN Security Council. This occurred at the first meeting of the new century, on 10 January 2000, under the chairmanship of Vice President Gore. With the passing of Resolution 1308 of 17 July 2000, the first link was forged between AIDS and the Council’s primary responsibility for the maintenance of international peace and security. In fact, the granting of status as a formal security issue was quickly attached to the developing concept of the responsibility to protect human rights, the subject of the previous Pugwash focused study group of this type and of the International Commission on Intervention and State Sovereignty. The UN process of 2000-2001 set down markers for the largest scale arena where AIDS may be a driver to direct security threats of the traditional type. At this point the manner in which the US National Intelligence Council (NIC) has structured its framework for the analysis of AIDS as a security issue, was reviewed. The advantages of the scenario “snapshot” were contrasted with the disadvantages of static framing of issues. This led to discussions about better forms of strategic analysis which was the subject of the third session and together they composed important questions that will be addressed in the second workshop.

Finally, reviewing the scope of security problems in the next waves of HIV/AIDS, three important descriptors were proposed. It was noted that the coming waves may differ importantly by aetiology: in particular the blood selling route to infection in China stands out. Secondly, and following the lead of the NIC, it was suggested that differentiation by prevalence rate would quickly help to identify those countries at risk of social and political erosion and those not. On this criterion, despite the high absolute numbers expected for India and China, the low prevalence rates place them in low risk categories. Thirdly, the fact that certain high prevalence regions, notably West Africa, will also have high geo-strategic importance because of forthcoming oil exploitation means that the dangers of sudden wealth acting as a force for evil rather than for good, should be anticipated and pre-empted.

The manner in which these research topics will be investigated in the forthcoming interdisciplinary and interregional project was described and helpfully criticised. Workshop members expressed a hope that they would be informed and where appropriate, engaged.

Current strengths and weaknesses of Operational Analysis and Strategic Assessment techniques

Of capital importance in any attempt on any complex security issue to link credible analysis to efficient joined-up policy-making is the assessment vehicle into which the analysis is placed. The wrong vehicle may either simply fail to carry the issue forward or may abuse its needs and offer radically wrong solutions. The problem of strategic analysis has been rapidly rising in salience since the end of the Cold War. There is now a general awareness of the inadequacy of received methods for complex, synergistic security problems, although, in practice, these former techniques, honed during the Cold War years, continue in wide currency. Thinking in a new way is the essential prime requirement.

AIDS is a classic example of such a problem and a third session of the workshop was devoted to a paper examining answers to the question “what are the appropriate modes of analysis to grip these diverse data and make them tractable for effective policy response”. Three main topics were introduced. First the importance and value of cusps, thresholds and catastrophe theory in these cases. The Zeeman catastrophe machine was demonstrated showing how critically important it is to know where an influence stands on the control surface to be able to judge whether or not a locus will move smoothly in transition or will flip. Secondly, several socio-dynamic models that can apply to epidemics were discussed and the likely limitations on traditional threshold/diffusion models to determine the spreading characteristics of diseases were noted. These were linked, thirdly, to interesting modelling characteristics of socio-sexual networks of importance in the transmission of AIDS. Since sexual networks tend to be scale-free rather than random, it was suggested that the spread of computer viruses on the internet might more closely resemble the spread of HIV than biological viruses of shorter duration, such as SARS. This lead to a discussion of the importance of battlefield medicine in designing response strategies to AIDS under constraints of funding, of cooperation and of time. Thus, given that sexual contact essentially follows a Pareto curve, in constrained circumstances does this not imply targeted interventions at the top-20 group of individual vectors? But triage raises deep ethical difficulties for medical practitioners attuned to value systems which privilege the autonomy of the individual patient’s choice. The relevance of Professor Onora O’Neill’s path breaking recent work on medical ethics for the twenty first century’s context of “low trust” situations, was recognised and signalled for further more detailed consideration.

Most members of the workshop affirmed that this was their first encounter with military operations analysis (OA) and all found it deeply revealing. Considerable discussion ensued on the central political problem of the “data-to-policy” link. The difficulties being currently experienced within strategic analysis as its practitioners wrestle with multi-variate and frequently stochastic interactions were reported. The engagement of that community with the forthcoming Columbia/LSE alliance project was reported also. These discussions were recognised as being preliminary and the issue was placed on the agenda for the next workshop.

Plans for the second workshop

The workshop members devoted time to discussion of what, if any, further useful contribution Pugwash might make. Without foreclosing the agenda, two issue areas were agreed to require further exploration. Both are within the primary Pugwash mission of reconceptualisation of security issues. The first engages the current efforts within the strategic assessment communities; the second continues the explorations begun in the third session of this workshop.
1) Assess the viability of the CIA 10% prevalence rule-of-thumb against data

In its early published work in the last two years, the NIC and CIA have been, as intelligence agencies should be, seeking for a formula to give warnings and indicators of impending social and political fragmentation under stress. It has suggested the 10% prevalence rate. This needs to be interrogated vigorously against case data.

2) What are the costs and benefits of different modes of analysis, specifically formal security analysis?

This methodological question is supremely one which Pugwash was created to attack: to learn to think in a new way: to defeat the intellectual bondage of Cultural Lag.
The meeting adjourned with plans for the second workshop to be held in June 2004, most probably again in South Africa.

Annex: Letter to Editor agreed upon by workshop participants

18 February 2004

Dear Sir

Over the weekend of 7-8 February 2004, near Cape Town, the Pugwash Conferences on Science and World Affairs (Nobel Peace Prize 1995) convened a small private seminar of South African and international researchers on AIDS. The relevant disciplines were represented.

The journalist Rian Malan was invited to attend to debate his much publicised opinion that AIDS statistics have been manipulated to over-represent the scale of the pandemic. In the pre-circulated agenda, a session was announced for this purpose. Mr Malan agreed to attend and agreed to pre-circulation of papers discussing his views, but then, without notice or explanation, failed to appear.

Your readers should know of this, because – quite apart from his impoliteness – it means that by normal academic convention, Mr Malan has conceded his case.

The view of the meeting was that on the evidence of his published work, examined in his absence of course, Mr Malan demonstrates that he does not understand basic principles of epidemiology or data collection. For example he focused too much upon the least informative and least reliable data fields in death certificates. The most reliable and most informative fields (age and gender) show an abnormal and highly significant three and a half times increase over fifteen years in death-rates of young South African women (those aged 25 – 29), for which AIDS is the only sufficiently powerful and specific likely known cause. None other is offered by Mr Malan.

Therefore the meeting concluded that, principally on grounds of a lack of technical competence, Mr Malan is not in a position to promote views on AIDS statistics which merit discussion in their own terms, and certainly not to carry the undue weight being given to them in the South African national debate at this time.

On behalf of the Pugwash Conferences seminar,

Yours faithfully,

Professor M.E. Muller,
Chairman, S.A.Pugwash Group


Participant List

Ms Mary Crewe, Director of the Centre for the Study of AIDS, University of Pretoria; University of Pretoria 0002, South Africa

Professor Nola Dippenaar, Professor and Deputy Chair of SA Pugwash Group;
Department of Physiology, Faculty of Medicine, University of Pretoria, Pretoria 0002,
South Africa

Dr Lorraine Dodd, Principal Strategic C2 – command and control – Analyst
Qinetiq, Malvern, Senior Operational Analysis modeller and mathematician, British Defence Science community, United Kingdom

Ms Lindy Heinecken, Deputy Director, Centre for Military Studies;
Military Academy, Private Bag X2, Saldanha 7395, South Africa

Professor Marie E Muller, Dean and Professor in the Department of Political Sciences, Chair of SA Pugwash Group, Chair of the Pugwash Council;
Faculty of Humanities, University of Pretoria, Pretoria 0002, South Africa

Professor Gwyn Prins, Alliance Professor, Columbia University and London School of Economics and Political Science (LSE); Room V912, Tower Two, Houghton Street
London WC2A 2AE, United Kingdom

Professor Hussein Solomon, Professor and Director of CIPS;
Department of Political Sciences and Centre for International Political Studies
University of Pretoria 0002, South Africa

Mr Gus Stewart, Director: Research Development and Policy Development
London School of Economics and Political Science (LSE), Houghton Street
London WC2A 2AE, United Kingdom

Professor Alan Whiteside, Director, Health Economics and HIV/AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa