The Invisible People: How the US Has Slept Through the Global AIDS Pandemic, the Greatest Humanitarian Catastrophe of Our Time

  • Greg Behrman
Free Press, 2004 339 pp,. hardcover, $25.00 ISBN 0743257553 | ISBN: 0-743-25755-3

By 1981, when AIDS was first diagnosed in the US, it had been spreading silently for years, perhaps decades, in central and eastern Africa. The newly recognized disease was soon described in the Congo (then Zaire) and in Uganda, and by the late 1980s it was clear that AIDS was taking a far greater toll in Africa than in the United States, and that the entire world was threatened by a rapidly growing epidemic. AIDS was already being compared to the great late-medieval plagues.

How did the world's richest and most powerful nation respond to this great humanitarian crisis? After a slow start (documented in Randy Shilts' And the Band Played On), and after vigorous prodding from activists, the US government devoted substantial resources to combating the domestic AIDS epidemic, funding prevention, care and research. In contrast, the far more devastating epidemic raging beyond US borders was largely ignored by successive American administrations, from Reagan to Clinton. US spending on global AIDS rose slowly to a modest $120 million by the early 1990s and then remained at a standstill for seven years as the disease ravaged large parts of Africa and gathered momentum in other regions—and as careful analyses established that an effective global response would cost billions of dollars a year, not millions. Greg Behrman seeks to explain how this happened in his new book The Invisible People: How the U.S. Has Slept Through the Global AIDS Pandemic, the Greatest Humanitarian Catastrophe of Our Time.

To his credit (and in spite of his book's somewhat overwrought title), Behrman doesn't settle for a single explanation. His analysis attributes American inaction to a shifting interplay of personalities, institutional factors and larger political forces. The relatively low priority accorded to African problems (and African lives) surely played a role. Bureaucratic jealousies among the Centers for Disease Control and Prevention, the US Agency for International Development, the Office of National AIDS Policy and other sectors of the US government contributed to paralysis. Lack of leadership from the affected countries themselves deterred greater involvement (and provided a ready excuse for inaction). Disarray within the United Nations system after the forced departure of Jonathan Mann from the World Health Organization in 1990 wasted crucial years. Even American AIDS activists, portrayed by Behrman as slow to widen their focus to include the epidemic abroad, come in for a share of the blame. Ultimately, in the absence of sustained pressure from the news media and the public, and without persuasive evidence that AIDS in Africa posed a clear threat to American interests, politicians and high officials were never compelled to move global AIDS ahead of what seemed the more urgent crises of the day, whether the war in the Balkans or Monica Lewinsky. There are few real villains in this narrative, with the possible exception of Senator Jesse Helms, whose hostility to all foreign assistance was a formidable obstacle to progress during the later years of the Clinton administration.

Behrman recounts this long series of bureaucratic impasses, missed opportunities, and shortsighted choices in great detail, giving us a sometimes week-to-week chronicle of meetings and conversations among officials, activists and public health experts. This approach, built on an impressive list of interviews, is both a strength of the book and a serious weakness. The reader is left with a rich appreciation for the many factors that contributed to US inaction, and for the numerous exceptional people who fought to end it. But the emphasis on personalities obscures the larger forces that determined these events, and Behrman does little to draw out these larger themes. The book ends abruptly, after bringing us nearly to the present, without attempting a synthesis and without offering ideas for how such a debacle could be avoided in the future.

Moreover, Behrman's book neglects to place its subject, American inaction on global AIDS, in its larger context. It tells us almost nothing about how other developed nations responded to the crisis. More importantly, Behrman fails to explain how America's lack of generosity on AIDS fits in the shameful larger pattern of declining aid to the developing world. In 2003, the US ranked last among industrialized nations in overall foreign assistance as a fraction of national income. Many of the forces that have brought us to this pass are the same as those that drove decisions on AIDS spending. Behrman's exclusive focus on AIDS presumably stems from his conviction that the AIDS epidemic is an unprecedented, unique catastrophe—at times he seems to lump concern for the other pressing health needs of the poor with other forms of obstruction and shortsightedness. Yet such a single-minded focus on AIDS, understandable during the long years of denial and delay, is now becoming an obstacle to what the world desperately needs: a comprehensive, integrated assault on the causes and manifestations of poverty—hunger and environmental degradation as well as disease; poor governance and unfair trade as well as insufficient aid; malaria, tuberculosis and maternal mortality as well as AIDS.

Such a broader perspective would have been particularly useful in the book's final section, which recounts the events leading up to the Bush administration's stunning announcement of the $15 billion President's Emergency Plan for AIDS Relief. Whether or not the promised sums are actually allocated and sensibly spent—it is still too early to judge—they are unlikely to result in lasting progress unless they are part of a long-term strategy of development assistance, coordinated with our allies and aimed at building national capacity as well as bringing immediate relief. By considering American AIDS policy in isolation, Greg Behrman's well-researched and readable book has missed an opportunity to inform development of such a strategy.