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
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