The Atlantic Monthly | December 2006

The Agenda
Foreign Affairs

Containment Strategy

Iran. North Korea. Uganda? Why the Pentagon ranks Africa’s AIDS crisis as a leading security threat

by Stephan Faris
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In a dark-green shipping container outside a Ugandan military hospital, a visiting Tanzanian general and four of his colonels encircle a desk. On the desk sits a green plastic paper tray. And from the tray rises a polished wooden dildo. “This weapon,” a Ugandan warrant officer tells them, “I’m sorry for exposing it to you. This is one of the weapons we have used in fighting HIV and AIDS.”

In the Ugandan military’s program for AIDS prevention and treatment, the dildo is used to demonstrate condom use. It is part of the first line of defense in a larger conflict that very much involves American forces: the fight to prevent countries from collapsing into failed states that can foment armed conflict, chaos, and terrorism beyond their borders. In fact, the United States Department of Defense funds a good part of the Ugandan military’s AIDS program. It trains doctors and clinicians, helps support AIDS orphans, and stocks labs with instruments and supplies. And it has donated thirteen prefabricated HIV-testing labs and AIDS-counseling centers, including the one in which the officers were sitting on a summer afternoon out at the Bombo Barracks, about an hour’s drive from Kampala.

The impact of AIDS on Africa’s health and well-being is a matter of grim statistical record. By 2010, USAID estimates, the epidemic will have cut the life expectancy in Botswana to twenty-seven years from what would have been at least seventy years. Some countries expect to lose half a generation. “When you have countries where you have 40 percent of the adult population affected, where teachers are disproportionately infected, where we’re creating a generation of orphans, you can see the stress on the social fabric,” says Ambassador Mark R. Dybul, the U.S. global AIDS coordinator.

But what was once seen as a humanitarian catastrophe is viewed increasingly as a security threat—an important reason behind the $15 billion Emergency Plan for AIDS Relief that President Bush announced in January 2003. A study of 112 countries by Susan Peterson, a political scientist at the College of William and Mary, and Stephen Shellman, a political scientist at the University of Georgia, found that countries with severe AIDS epidemics had correspondingly high levels of human-rights abuse and civil conflict. “Does AIDS make war or civil strife more likely?” asks Peterson. “The answer is yes.”

Even in countries that don’t collapse, AIDS deaths can threaten security in the form of AIDS orphans, who are desperate, disenfranchised, vulnerable to radicalization, and projected to reach 25 million worldwide by 2010. “Where do you think the breeding ground for terrorism will be?” asks General Charles Wald, the former operational head of European Command, which also oversees U.S. military operations in most of Africa. At a recent conference, Wald listed the biggest threats to U.S. security. After terrorism and weapons of mass destruction came AIDS.

High on the list of the Pentagon’s concerns about AIDS is its impact on African militaries; for many, it has become the biggest killer. Young, often far from home, and with cash in their pockets, soldiers who must live under fire cultivate a sense of invulnerability that can kill them when they come back to the barracks. The epidemic accounts for seven out of ten military deaths in South Africa and kills more Ugandan soldiers than any other cause, including a brutal twenty-year insurgency and two wars in Congo. AIDS deaths have reduced Malawi’s forces by 40 percent. Mozambique can’t train police officers fast enough to replace those dying of the disease. “As we fight the enemy, the HIV is also fighting us,” John Amosa, a forty-five-year-old AIDS-afflicted Ugandan sergeant, told me. “We have two front lines.”

Uganda kicked off the fight that became a model for AIDS prevention in 1986, after President Yoweri Museveni sent sixty of his top officers for training in Cuba, where eighteen tested positive for HIV. At a conference later that year, Fidel Castro took the Ugandan president aside. “He said, ‘You’ve got a big problem on your hands,’” recalled Sam Kibende, a deputy director of Uganda’s national AIDS research center. “That’s when the president woke up and realized his fighting force was going to be decimated.” With national infection rates leveling off somewhere between 6 and 7 percent after peaking at 15 percent in the early 1990s, the Ugandan army plans to hold every officer responsible for AIDS education. “Behavior change needs sustained fire,” says Dr. Stephen Kusasira, who runs the Ugandan military’s anti-AIDS efforts. “We want it to be a command problem. It should only become a medical situation when they are sick.”

Unfortunately, AIDS hampers the ability of Uganda and other African nations to maintain not only their own security but also that of their neighbors. Asked to send troops to the troubled Darfur region of Sudan, South Africa couldn’t field a complete battalion of uninfected troops; an estimated 17 to 23 percent of its military is HIV-positive, and tests in 2004 on two battalions found infection rates as high as 80 percent. “They had to kludge together units to get enough healthy troops to send,” says Wald, who retired from his post at European Command in July. Because African Union members contribute 37 percent of all United Nations peacekeepers, the shortage of healthy manpower has rippled out through the world’s hot spots and is of growing concern to the United States, which leaves peacekeeping duties mostly to other nations. “AIDS is a readiness issue,” says Richard Shaffer, a retired Navy commander who runs the Defense Department’s HIV/AIDS Prevention Program. “It’s not just having your weapon. It’s not just knowing how to use it. It’s being healthy enough to use it.”

Perhaps the only thing worse than having few peacekeepers ready to send is the risk to those who actually go. Eighty-one percent of UN peacekeepers are on missions in Africa, home to 60 percent of the world’s people living with AIDS. A 1999 study by the head of Nigeria’s medical corps found that the longer Nigeria’s soldiers were deployed as peacekeepers in Sierra Leone, the greater their chance of contracting HIV. Infection rates increased from 7 percent after one year abroad to 10 percent after two years, and to more than 15 percent after three years.

It’s not hard to see why. During a short stay in the Congolese city of Goma last year, I was shown a dozen or so children allegedly fathered by soldiers from the UN mission, including two light-skinned boys whose fathers were said to be Moroccan. One visitor to Bunia, where the fighting is most brutal, said that she had seen women stripping in the headlights of vehicles of soldiers on night patrol. “The United Nations has helped me a lot,” Bibishe, a twenty-five-year-old prostitute, told me. “They bought me the mattress I’m sleeping on. They bought me clothes.” In the courtyard of her brothel waited a drunken South African sergeant. It was about ten o’clock in the morning.

Since its beginnings in 1981, AIDS has infected about 65 million people worldwide, and killed more than 25 million of them. Yet in parts of Africa, the first waves of death are just beginning. Andrew Price-Smith, a political scientist at Colorado College, cites Zimbabwe, where the epidemic accelerated a general slide into chaos, as a warning of what might happen in other countries. “We’ve already peaked in terms of infections,” says Price-Smith. “Now we’re starting to see the mortalities crest. The subsequent wave will be the wave of economic and political disruption that follows.” Nigeria is another focus of concern, not so much because of its infection rate (which, at between 4 and 6 percent, is relatively low) but because of its general instability and its importance as an oil supplier. “When AIDS affects a large portion of a population, that creates instability,” said General William “Kip” Ward, who took over Wald’s position. “That instability can lead to conditions that are right for terrorist exploitation as they seek to recruit new followers.” While the security threat that AIDS poses is for now largely confined to Africa and Southeast Asia, stirrings of epidemics in Russia and India (which happens to be the third-biggest contributor of UN peacekeepers) are, given their size, strength, and strategic importance, more worrisome still.

As the U.S. military pivots to confront these risks, it’s starting to have to think preventively. The Navy—whose Naval Health Research Center is a leader in military research on behavioral issues—oversees and funds prevention and treatment programs in sixty-seven countries. In Vietnam, U.S. forces teach AIDS prevention to the army they once fought. In Ukraine, they’re setting up testing and counseling centers. In India, they’re providing clinical training and lab support. “We can’t just sit back and wait until the crisis is fully blown and treat every problem like it’s the nail and we’re the hammer,” says Wald.

The spectacular rollout of antiretroviral medication may be stopping the gap across Africa, but treatment programs will remain hostage to donor funding and vulnerable to viral resistance to drugs. Future military missions may increasingly be like the AIDS-vaccine research project in western Kenya, where the Walter Reed Army Institute of Research helps care for 2.5 million civilians on the tea plantations around the city of Kericho and in the neighboring Southern Rift Valley. The Army provides 6,500 patients with antiretroviral drugs and supports a youth center along with church-based counseling and in-home care. It has renovated the district hospital and brought in more staff and doctors. To teach AIDS sufferers the basics of nutrition and feed them in the meantime, Walter Reed has even planted a model farm, complete with rows of maize and grazing areas for three cows and their calves. “The main mission is [vaccine] development for the American war fighter,” says Colonel Samuel Martin, commander of Walter Reed in Kenya. “This just helps us put a more human dimension to our operations.” In the leafy hills around Kericho, the Army is hoping to keep Americans safe by helping Africans to stay alive.

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