Journal of Medicine and Philosophy 0360-5310/02/2702-163$16.

00
2002, Vol. 27, No. 2, pp. 163±177 # Swets & Zeitlinger

The HIV/AIDS Pandemic:

A Sign of Instability in a Complex Global System
Solomon R. Benatar
University of Cape Town, Western Cape, South Africa

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ABSTRACT

Intense scienti®c work on HIV/AIDS has led to the development of effective combination drug
therapies and there is hope that effective vaccines will soon be produced. However, the majority
of people with HIV/AIDS in the world are not bene®ting from such advances because of
extreme poverty. This article focuses on the pandemic as a re¯ection of a complex trajectory of
social and economic forces that create widening global disparities in wealth and health and
concomitant ecological niches for the emergence of new infectious diseases. While the
biomedical approach to HIV/AIDS is necessary, has prolonged the lives of many individuals
and could offer much at the level of population health, it cannot, in isolation, improve the health
of populations. To achieve the latter will require understanding and addressing the deeper social
causes of pandemics. Broadening the discourse on ethics to include public health ethics and the
ethics of international relations could contribute to reducing the impact of the pandemic and to
preventing the emergence of new infectious diseases in the future.

Key Words: ethics, globalization, health, HIV/AIDS, International Monetary Fund, neo-liberal
economics, population, poverty, sub-Saharan Africa, World Bank

I. INTRODUCTION

In his paper Anton van Niekerk (van Niekerk, 2002) justi®ably focuses on
those issues that can and should be addressed in resource-poor countries faced
with the devastation of the HIV/AIDS pandemic. He argues that diverting
attention away from what can be done in the short-term by addressing longer-
term solutions to complex system effects is potentially disempowering. His

Correspondence: Solomon R. Benatar, M.D., Department of Medicine and Bioethics Centre,

University of Cape Town, Observatory, 7925, Western Cape, South Africa. E-mail: sbenatar@
uctgshl.uct.ac.za
164 SOLOMON R. BENATAR

approach encourages those severely af¯icted communities to do whatever they

can to ameliorate the effects of this plague, and also overcomes the paralysis
that may follow the sense of hopelessness associated with a victim image.
I wish to offer a perspective that complements and extends his approach, by
acknowledging the disempowering effects of the exploitation, discrimination
and imperialism that characterize the current world system (Alexander, 1996;
Gilbert, 1992; Hosle, 1992; Lee & Zwi, 1996). Drawing the attention of
scholars to the complex deeper issues that must be faced when considering the

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implications of HIV/AIDS in an unstable world could also be coupled to
discrediting, through shaming, those nations that believe that their military
and economic strength imbues them with incontestable power. While their
con®dence may be justi®ed in terms of destructive and coercive military and
economic power, they cannot justi®ably claim to be morally superior when
their interests in continuous economic growth and wasteful life-styles take
precedence over the very basic living needs of billions of ``others'' (Aitken &
La Follette, 1996; Dower, 1991; O'Neill, 1992; Unger, 1996). In an era in
which the emergence of severe infectious diseases, the development of bio-
logical weapons and the potential for subversive use of genetic and informa-
tion technology may render military might super¯uous, new concepts of
power and security are required to ensure secure lives for all (Falk, 1999,
2000). The suggestion that HIV/AIDS is one of several signs of instability in
a complex world system at a crucial time in history should not be lightly
dismissed (Garrett, 1995, Benatar, 2001). Working for greater global solidar-
ity holds the key to the future health and security of the majority of the world's
people.

II. CONTEMPLATING THE THIRD WORLD

Rather than taking the ``third world'' for granted and ignoring its plight,
Vitorio Hosle (1992), a German philosopher, has examined the concept of the
``third world'' through its historical origins, and its presumed hierarchical
relation to, and telos towards approximating, the ``®rst world''. He criticizes
the failure to examine the increasing gaps between it and the ®rst world and
argues that unless we address elementary ideas of justice in relation to the
third world, the ecological crisis and the accumulation of weapons of mass
destruction, all other questions regarding our moral behaviour will become
obsolete. In writing eloquently about ``the third world as a philosophical
 THE HIV/AIDS PANDEMIC 165

problem,'' he has explicated how the appalling conditions of life in many

countries are intimately linked to powerful historical forces and to ongoing
discriminatory attitudes, and he has made a cogent case for efforts to
ameliorate third world problems. His ideas are enhanced by Anthony
Richmond's description of the pervasive effects of racism (1994) and Titus
Alexander's analysis of how similar forces to those that have marginalized and
oppressed blacks under apartheid South Africa are operative at a global level,
revealing the pervasive discrimination against vast numbers of people, most

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especially those of colour (1996).

III. GLOBALIZATION AND THE LEGACY OF THE 20TH CENTURY

Globalization is a popular term used to refer to a phase of history character-

ized by the impact of a neo-liberal economic system in which free market
considerations are seemingly closely associated with the propagation of
democracy and human rights. However, in reality over-emphasis on the
market has somewhat eclipsed considerations of democracy and social justice
(Amin, 1997; Barnet & Cavanagh, 1994; Falk, 1999, 2000; Gill, 1990; Gray,
1998; Ralph, 2001; Teeple, 2000). Exploitation, a long-standing feature of
human life, is thus covert because globalization is only super®cially linked to
democracy and human rights. Much has been achieved to promote human
rights since the promulgation of the Universal Declaration of Human Rights in
1948, and many agree that there is no plausible alternative to democracy
(Dunne, 1992). However, it is becoming clear that neither the ¯ourishing of
modern democracy ± even in developed nations ± (Ralph, 2001) nor sincere
propagation of a coherent human rights agenda are features of a world in
which economic globalization is pervasively imposing a set of ideas and
beliefs that favour market transactions above all other values (Falk, 2000;
Heywood & Altman, 2001; Royal Danish Foreign Ministry, 2000).
Globalization, and the exploitation associated with it, are complex and
ambiguous concepts with social and ecological manifestations that re¯ect a
long, interwoven economic and political history in which peoples, economies,
cultures and political processes have been subject to international in¯uences
(Amin, 1997; Barnet & Cavanagh, 1994; Falk, 1999; Gray, 1998; Teeple,
2000; Wallerstein, 1999).
Positive and widely appreciated manifestations of progress associated with
globalization include advances in science and technology; increased life-
166 SOLOMON R. BENATAR

expectancy; enhanced economic growth; greater freedom and prosperity for

many; improvements in the speed and cost of communications and transport;
and popularization of the concept of human rights. About 20% of the world's
population has bene®ted maximally from such progress. The positive impact
of globalizing forces in South Africa has been to promote the demise of
apartheid.
Negative effects of globalization generally include widening economic
disparities between rich and poor (within and between nations) and increases

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in both absolute and relative poverty. At the beginning of the 20th century the
wealthiest 20% of the world's population were 9 times richer than the poorest
20%. This ratio grew slowly to 30 times by 1960, and more rapidly to 60 times
by 1990 and to over 70 times by 1997. World debt grew from $0.5 trillion in
1980 to $1.9 trillion in 1994 and $2.2 trillion in 1997. The `debt trade' (and the
way in which this has been created and its relationship to the arms trade), a
major factor in perpetuating and intensifying poverty and ill health (Sivard,
1996), has been described as the modern equivalent of slavery (Pettifor, 1996).
Most countries that were required by the World Bank to pursue structural
adjustment programs are in greater debt than ever before. Third world debt,
although accounting for a small proportion of total world debt, has reached
obscene levels in relation to income levels in the third world, and is indeed
unpayable (Pettifor, 1996). These adverse effects are felt most severely by
80% of the world's population.
The development of a complex web of material, institutional and ideolog-
ical forces and powerful massive multinational corporations in a globalizing
world has profound implications for the accumulation of capital and for
the way in which resources are controlled. In 1970, 70% of all money that
exchanged hands on a daily basis was payment for work, while speculative
®nancial transactions accounted for 30%. By 1997 massive increases in
speculative exchanges had changed these proportions to 5% and 95%
respectively (Global Exchange, 2001). Such a striking shift in the distribution
of money arguably re¯ects devaluation of the lives and work of most people in
the world, and has particularly serious implications in Africa where unem-
ployment rates are extraordinarily high.
The in¯uence of a shift in the locus of economic power from the nation state
to global corporations alters the balance of power in the world. Boundaries
between states, and between foreign and domestic policies, become blurred ±
in the process undermining small states' control over their own economies,
and threatening their ability to provide for their citizens. Economic disparities
 THE HIV/AIDS PANDEMIC 167

have become so marked and their adverse effects so apparent that a very
signi®cant degree of incompatibility has arisen between neo-liberal economic
policies and the goals of democracy (Brecher, Costello, & Smith, 2000; Gill,
2000; Ralph, 2001).1 This has important implications for South Africa, now
freed of its apartheid legislation but challenged to cope with the power of the
global economy while struggling to become a social democracy (Benatar, 2001).
In addition to progressive widening of the economic divide between nations,
and growing external control over the economies of small countries through the

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`debt trade' and markets that are increasingly global, other powerful forces are
generating new patterns of inclusion and exclusion. Evidence is accumulating
that, associated with globalization, there has developed a large (but little
discussed) illicit global economy comprising: an uncontrolled arms trade,
money laundering, an illicit drugs trade (now an industry worth over $500
billion annually), massive migration and smuggling of people, traf®cking in
endangered species, toxic waste dumping, prostitution, sexual exploitation and
child labour (Bales, 1999; Friman & Andreas, 1999).
The latter half of the 20th century has been characterized by more striking
changes than ever before (Hobsbawm, 1994). The world's population has
doubled from 3 billion to 6 billion. Economic disparities have widened
dramatically with billions of people now living under dehumanising condi-
tions of poverty and squalor. New patterns of war and ethnic con¯ict have
resulted in displacement and migration of millions of people. Changing spatial
dimensions of human relations resulting from war, migration, travel and new
forms of communication have radically disrupted the social lives of many.
Widespread ecological damage is resulting from escalating consumption of
the earth's resources far out of proportion to population growth (McMichael,
1993).

IV. THE EMERGENCE OF HIV/AIDS

It is against this background of rapid and profound change, contributing to the

creation of new ecological niches and to the adaptive evolution of microbes
with resistance to many anti-microbial drugs, that 29 new infectious diseases
have emerged since 1973 to af¯ict humankind. These include Legionnaires
disease, Lyme disease, various forms of encephalitis, bovine spongiform
encephalopathy, Hantaan virus disease, Ebola fever and other haemorrhagic
diseases, new forms of E. Coli and Vibrio cholerae and, HIV/AIDS the most
168 SOLOMON R. BENATAR

extensive and frightening of all. In addition, many other infectious diseases

that had become localized, limited or controlled have recrudesced with serious
adverse implications for all ± for example, tuberculosis, malaria, measles and
others (World Health Organization, 1996).

V. SUB-SAHARAN AFRICA

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Sub-Saharan Africa (home to 10% of the world's population) has been
most severely affected by the temporal relationship of the above-mentioned
powerful social forces to its economic and political development (Davidson,
1992; Lancaster, 1999; Logie & Benatar, 1997; Michaels, 1992; Sandbrook,
2000; Ungar, 1992). It is also the poorest (consuming 1% of the world's
economy), and the most severely affected by the HIV/AIDS pandemic
(bearing over 70% of the global burden of HIV/AIDS). The desperate
condition of Africa, a continent desired, exploited and eventually discarded,
has been reviewed (in the medical literature) from differing but complement-
ary perspectives (Benatar, 1994; Elmore-Meegan & O'Riordan, 1993).
HIV/AIDS has refocused attention on Africa but action has been limited
(Stillwagon, 2001).
Africa has long been central to the aspirations of industrialized nations.
Initially presenting a challenge to circumnavigation, it became a sub-continent
inviting exploration and adventure resulting in a clash of civilizations,
colonization, brutal enslavement of its people and relentless extraction of its
rich resources. After initiation of the process of independence in Africa in the
1960s, powerful nations pursuing their ongoing interests colluded with sel®sh
African leaders who were co-opted into neo-liberal economic policies and
corrupt practices. Economic slavery propagated through covert and sophisti-
cated guises replaced physical slavery and colonial oppression, and will in due
course be recognized as such (Pettifor, 1996).
The tragedy of Africa is now being aggravated by its elimination from the
foreign policy agendas of powerful countries. The withdrawal of industrial-
ized nations from even attempting to deal with the dire condition of the
African continent is re¯ected in the writings of political scientists. ``The crisis
is so diffuse and of such magnitude that the United States and the world at
large shrink from engaging it . . . In fact, history mocks the very idea of an
international coalition to save Africa'' (Michaels, 1992). Economic analysts
noted that after the Cold War ended, Africa lost whatever political lustre it
 THE HIV/AIDS PANDEMIC 169

might once have had. The Association of Concerned Africa Scholars con-
tinues to work towards restoring Africa to an appropriate status within U.S.
foreign affairs (ACAS, 2000).
Africans must clearly take some responsibility for the state of their
continent since post-colonial independence. Poor governance, corruption,
internal exploitation, nepotism, tribalism, authoritarianism, military rule and
overpopulation through patriarchal attitudes and disempowerment of women
have all contributed to its sad state. However, to be fair these shortcomings

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must be seen in the context of powerful external disruptive forces acting over
several centuries to impede progress in Africa (Davidson, 1992; Lancaster,
1999; Sandbrook, 2000; Unger, 1992).

VI. THE ROLE OF THE WORLD BANK AND THE IMF

IN GLOBAL HEALTH

Over the last 20 years the World Bank, and the IMF have held the balance of
power in formulating global health policy (Pauly, 1997). They have encour-
aged liberalization of economies, cut subsidies from basic foods and shifted
agricultural policy to promote export crops to the detriment of home-grown
food production ± all resulting in devastating malnutrition and starvation that
have caused billions to suffer, especially in Africa (Amin, 1997; Lancaster,
1999; Lurie, Hintzen, & Lowe, 1995; UNDP, 1999; Wade, 2001).
It is an indictment of the IMF and World Bank's structural adjustment
programs that they required governments to reduce expenditure on health
care, education and other social services and encouraged privatization, even
within health care. Availability of condoms, STD treatments, anti-tuberculosis
therapy and treatments for co-infections of HIV are subject to user-charges
introduced and still encouraged by the World Bank in many African countries.
The whole Public Health Agenda (information surveillance, epidemiology,
research and behavioural surveillance) has thus been reduced to a skeleton.
Structural adjustment programs, debt repayments, cuts in foreign aid budgets
(especially by the U.S.), discrimination against African trade, increasing
malnutrition and the cold-war activities of the great powers have all played
a signi®cant part in fanning the AIDS pandemic. Illness and death from AIDS
in a family results in loss of breadwinners, substantial funeral and mourning
costs and the removal of children from school to increase household income
(Abbasi, 1999; Nandy, Scott, Logie, & Benatar, 2000).
170 SOLOMON R. BENATAR

Regrettably organizations (such as the World Health Organization) that

promote public health have not adequately acknowledged or discussed these
adverse forces. The somewhat naõÈve surprise that, despite considerable global
attention to HIV/AIDS, so little has been achieved in slowing the pace of the
pandemic in sub-Saharan Africa, re¯ects denial and neglect of the effects of
profound social forces and human behaviour on the environment and how
these have contributed to the emergence of new plagues. Failure to recognize
the pervasive social, economic, behavioural and political aspects of HIV/

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AIDS ± both in terms of its origins and its control ± is self-defeating. The
complexity of the scienti®c endeavour required to understand the pathobiol-
ogy of the disease and to develop appropriate treatment and vaccines is more
than matched by the complexity of understanding and dealing with the social
underpinnings of HIV/AIDS and other plagues locally and globally (Benatar,
2001; Garrett, 1995; Lee & Zwi, 1996; McNeill, 1998).
HIV/AIDS cannot be dealt with adequately unless efforts are made to
ameliorate these underlying conditions progressively. Recognition of the
adverse effects of overt racial apartheid in South Africa, while failing to
recognize the adverse effects of covert economic apartheid at a global level,
regrettably re¯ects a form of `selective moral blindness'. Moreover, it is not
necessary to go beyond considerations of the rational long-term interest of the
world's privileged people to appreciate this (Hosle, 1992).
It is also predictable that unless the conditions that promote the emergence
of new infectious diseases are addressed other new diseases will in all
probability emerge in the future with potentially devastating effects world-
wide (Garrett, 1995). Appreciation of this prospect has led President Clinton
to declare HIV/AIDS a security threat to the industrialized world. In 1999 the
Commonwealth Heads of Government Meeting declared HIV/AIDS a global
emergency. The importance of this insight lies in understanding that more is
needed than the mere development of `drugs as weapons' to combat the
pandemic. Acknowledgement of and attention to both the proximate and
ultimate causes of plagues are essential (Garrett, 1995; McNeil, 1998)

VII. AN EXPANDED CONCEPT OF BIOETHICS AND ITS

RELEVANCE TO HIV/AIDS

Most of the debate about medical ethics generally, and about HIV/AIDS
speci®cally, has focused on ethical issues at the micro level of the doctor/
 THE HIV/AIDS PANDEMIC 171

patient relationship ± most especially con®dentiality, informed decision-

making, individual human rights and the harm/bene®t balances for individuals
involved in clinical research. At this level basic human needs can be identi®ed
as respect for human dignity, and self-determination of individuals conceived
of as rational and autonomous. In this context the physician is viewed as
committed to the care of each individual patient within various models of the
doctor/patient relationship embracing the concepts of contract, respect for
autonomy, covenant and trust in bene®cence.

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At the meso level of ethical considerations, human needs extend towards
such considerations as order and justice within the communities in which
individuals are socially embedded and `constructed' (Doyal & Gough, 1991;
Taylor, 1992). The responsibility of physicians here is viewed more broadly
and includes concern for equitable access to health care, public health and the
common good. Considerations of justice, the `social contract' and utilitarian
considerations necessarily impact on the physician/patient relationship.
Morality here requires an institutional component embracing attention to public
health and the management of resources. Interpersonal relationships are
broadened to encompass the concept of civic citizenship with primary res-
ponsibilities complementing the primary rights of individuals and the corre-
lative duties of others in order to achieve rights in practice.
The justi®ed focus on ethical issues at the micro level that have profound
implications for individuals, and especially those at risk of stigmatization, has
somewhat eclipsed ethical issues that need to be addressed in dealing with
threats to public health. However, the era of genetic medicine and lessons
learned from the HIV pandemic are prompting recognition that some
information about individuals cannot belong exclusively to individuals. The
web of relationships and responsibility extends to family members for whom
knowledge of familial genetics or transmissible disease may be crucial to their
future well being. It is also becoming apparent that research on HIV/AIDS
requires consideration of the ethics of relationships between communities,
trial sponsors, industry, ministries of health and between the private and public
sectors in the process of protecting and promoting public and population
health.
Such considerations raise the perennial problem of how to strike a balance
between the rights and needs of individuals and the common good of societies.
While the focus on individual rights is vital and necessary for the well being of
individual persons and has a high social utility value, such focus is not
suf®cient for the achievement of improved public health. Scholarly debates on
172 SOLOMON R. BENATAR

public health ethics are inadequately developed and require greater attention
(Beauchamp & Steinbock, 1999). Eloquent arguments have been offered in
favour of a language of public health that ``speaks to the reciprocity and
interdependence which characterize community'' (Robertson, 1998).
There is also a need to go beyond advocacy for rights to include con-
sideration of the duties necessary for rights to be widely satis®ed. Lack of
attention to civic responsibilities allows individuals and powerful groups to
place their own needs above those of all others ± and thwarts the achievement

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of such goals as universal access to health care (Benatar, 1996), and curbing
the spread of infectious diseases.
Achieving an improved balance between the needs and rights of individuals
and the requirements for advancing public health will require a shift in
mindset away from exclusive and often sel®sh individualism towards respect
for individuality that is combined with a strong sense of community and civic
citizenship. Essential steps will include: acknowledging the need for a new
balance (Jennings, Callahan, & Wolf, 1987; Margalit, 1998), involvement of
the community to be researched in the design and acceptance of vaccine trials,
reducing stigmatization and promoting admiration of those who are willing to
participate, dealing with con¯icts of interest between communities and trial
sponsors, and seeking longer-term economic and social justice when balanc-
ing the harms and bene®ts of vaccine research. Clearly public debate and
education needs to proceed simultaneously with processes that ensure
accountability and protection of individuals (Benatar, 2000).
In the same way that embarking on vaccine research in developing
countries will require going beyond micro-ethical considerations to include
the meso level of ethics mentioned above, so dealing with global pandemics
requires ethical considerations at the macro level ± that is, at the level of the
global economy and of the relationships between nations that have profound
effects on human health and well being (O'Neill, 1992).
At the macro level human need extends to encompass security and a safe
environment. The desired conception of the individual becomes that of an
autonomous individual sharing equal rights with all other citizens in the world,
in a relationship of interdependence in which the rights of some should not be
acquired at the expense of the rights of even distant others. The level of
complexity here is much greater because of the way in which the foreign
policies of some countries may covertly enhance the lives of their own citizens
through exploitation of unseen persons elsewhere. The role of physicians,
scientists and all health care professionals needs to be broadened further to
 THE HIV/AIDS PANDEMIC 173

include commitment to global professional ideals, to the continuing advance-

ment of knowledge and to concern for the health of populations globally, as
well as the health of future generations (Alberts, 2000; Rotblat, 1997). The
moral perspective is thus extended from interpersonal morality to civic
morality and to an ethics of international relations, that has dimensions
intimately linked to political, military, cultural and economic issues (Benatar,
1998; Dunne & Wheeler, 1999; Elfstrom, 1997, 1998; O'Neill, 1992; Paul &
Hall, 1999).

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Why should we bother to go beyond the micro level of ethics? Modern
communication, transport, methods of money exchange, the creation of
nuclear and other weapons of mass destruction and the emergence of new
infectious diseases have shrunk distances and differences in many senses, and
created common global risks. In this context, and with a deeper understanding
of the impact of historical forces on shaping the wealth and health of nations,
we need to appreciate how we are all implicated in the lives of others, and that
it is increasingly impossible to hide with credibility behind the barrier of
physical distance while billions of people live impoverished lives. Altruism
and reparations aside, the importance of physical and moral interdependence
is so great that self-interest alone should be suf®cient to drive policies toward
sustainable development (Hosle, 1992). Unless such progress is made the
prospects for dealing adequately with the HIV/AIDS pandemic and indeed for
our humanity seem bleak.

VIII. CONCLUSIONS

New infectious diseases such as HIV/AIDS, the recrudescence of tuberculosis

and malaria in multi-resistant forms, ecological degradation, escalating ethnic
con¯ict and persistent poverty and hunger in the midst of plenty are all signs
of an increasingly unstable world at the end of a period of major progress
(Amin, 1997; Falk, 1999, 2000; Hobsbawm, 1994; Wallerstein, 1999). At this
time in history when the dark side of progress is becoming so obvious, old
ways of `linear thinking' about progress, in particular when this is de®ned
only in economic terms, are becoming obsolete. It is unlikely that relying
solely on advances in scienti®c knowledge, free-market forces, simplistic
notions of human rights and interpersonal ethics will provide suf®cient
solutions to problems within an unstable complex system (Homer-Dixon,
2000). Imaginative and creative new practical approaches, associated with the
174 SOLOMON R. BENATAR

wise application of scienti®c and social knowledge using systems theory and
supported by a broader ethics framework are required to ameliorate the
adverse effects of rampant market forces (Dunne & Wheeler, 1999; Elfstrom,
1997; Falk, 2000; Paul & Hall, 1999; Rist, 1997). Averting the potential for
setting back the clock of progress by ensuring better quality of life for all in a
complex interdependent world is the 21st century challenge to human society
(Wallerstein, 1999).

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NOTE

1. Several mechanisms are operative: the in¯uence of transnational corporations on the power
of governments of small/weak nations to pursue development, full employment or other
national goals; lack of corporate accountability at the national level; trade agreements such
as North America Free Trade Agreement and the World Trade Organization; and the
restrictive power of international ®nancial institutions such as the World Bank and
International Monetary Fund over national, state and local governments' control over their
economies; and the complicity of these organizations in the denial of human rights.

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