Without a medical miracle, it seems inevitable that the Acquired Immune Deficiency Syndrome (AIDS) pandemic will become not only the most serious public health problem of this generation but a dominating issue in 3rd world development. As a present-day killer, AIDS in developing countries is insignificant compared to malaria, tuberculosis, or infant diarrhea, but this number is misleading in 3 ways. First, it fails to reflect the per capita rate of AIDS cases. On this basis, Bermuda, French Guyana, and the Bahamas have much higher rates than the US. Second, there is extensive underreporting of AIDS cases in most developing nations. Finally, the number of AIDS cases indicates where the epidemic was 5-7 years ago, when these people became infected. Any such projections of the growth of 3rd world AIDS epidemics are at this time based on epidemiologic data from the industrialized rations of the north and on the assumption that the virus acts similarly in the south as it does in the US and Europe. Yet, 3rd world conditions differ. Sexually transmitted diseases usually are more prevalent, and people have a different burden of other diseases and of other stresses to the immune system. In Africa, AIDS already is heavily affecting the mainstream population in some nations. Some regions will approach net population declines over the next decade. How far their populations eventually could decline because of AIDS is unclear and will depend crucially on countermeasures taken or not taken over the next 1-2 years. In purely economic terms, AIDS will affect the direct costs of health care, expenses which are unrealistic for most 3rd world countries. Further, the vast majority of deaths from AIDS in developing countries will occur among those in the sexually active age groups -- the wage earners and food producers. Deaths in this age group also will reduce the labor available for farming and industry. AIDS epidemics also may have significant effects on foreign investment in the 3rd world as well as negative effects on tourism. The global underclass will be disproportionately affected by AIDS as the blacks and Hispanics already are in New York and Miami. Thus far, the reaction of donor countries to the World Health Organization's (WHO) appeal for funds to fight the battle against AIDS has been excellent. The global strategy of WHO places priority on national campaigns, but none of the national campaigns will be effective unless linked to similar actions in other nations to form a vigorous international program. The US has a special responsibility to provide international leadership on AIDS. The US is the world leader in AIDS research and has the bulk of the virus research capacity. Further, no country can come close to matching US experience in dealing with AIDS through "safe sex" education campaigns.
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