Globe and Mail (Toronto) - March 14, 2000
THE PLAGUE THAT ISN'T
Poverty is killing Africans, not an alleged AIDS pandemic, says U.S. policy adviser Charles Geshekter
By Charles Geshekter
The United Nations calls it the "worst infectious disease catastrophe since bubonic plague." U.S. Senator Barbara Boxer advocates spending $3-billion to "fight AIDS." And delegates at last month's National Summit on Africa in Washington pleaded for more money to wage war on AIDS. But the scientific data do not support these claims. The whole subject needs a healthy dose of skepticism.
I recently made my 15th trip to Africa to find out more. Let's start with a few basic facts about HIV, AIDS, African record-keeping and socio-economic realities. What are we counting? The World Health Organization defines an AIDS case in Africa as a combination of fever, persistent cough, diarrhea and a 10-per-cent loss of body weight in two months. No HIV test is needed. It is impossible to distinguish these common symptoms -- all of which I've had while working in Somalia -- from those of malaria, tuberculosis or the indigenous diseases of impoverished lands.
By contrast, in North America and Europe, AIDS is defined as 30-odd diseases in the presence of HIV (as shown by a positive HIV test). The lack of any requirement for such a test in Africa means that, in practice, many traditional African diseases can be and are reclassified as AIDS. Since 1994, tuberculosis itself has been considered an AIDS-indicator disease in Africa.
Dressed up as HIV/AIDS, a variety of old sicknesses have been reclassified. Post mortems are seldom performed in Africa to determine the actual cause of death. According to the Global Burden of Disease Study, Africa maintains the lowest levels of reliable vital statistics for any continent -- a microscopic 1.1 per cent. "Verbal autopsies" are widely used because death certificates are rarely issued. When AIDS experts are asked to prove actual cases of AIDS, terrifying numbers dissolve into vague estimates of HIV infection.
The most reliable statistics on AIDS in Africa are found in the WHO's Weekly Epidemiological Record. The total cumulative number of AIDS cases reported in Africa since 1982, when AIDS record- keeping began, is 794,444 -- a number starkly at odds with the latest scare figures, which claim 2.3 million AIDS deaths throughout Africa for 1999 alone.
More reliable, locally based statistics rarely exist. In December, I interviewed Alan Whiteside of the University of Natal, a top AIDS researcher in South Africa and asked for details of the alleged 100,000 AIDS deaths in South Africa in the last year. He laughed aloud. "We don't keep any of those statistics in this country," he said. "They don't exist."
And South Africa is more advanced than most African countries in that it conducts HIV tests in surveys of about 18,000 pregnant Africans annually. The HIV-positive numbers are then extrapolated. But there are two problems with this: The women are given a blood test known as ELISA, which frequently gives a "false positive" result (one condition that can trigger a false alarm is pregnancy). Even the packet insert in the ELISA test kit from Abbott Labs contains the disclaimer: "There is no recognized standard for establishing the presence or absence of HIV-1 antibody in human blood."
Secondly, it's well understood that many endemic infections will produce so much cross-contamination that a single ELISA test is virtually useless. When I asked Thuli Nxege, a 28-year-old domestic worker from a rural Zulu township, what made her neighbours sick, she cited tuberculosis, and added that the lack of sanitary facilities and having open latrine pits adjacent to village homes made it difficult to prepare clean food.
Beauty Nongila, principal of a rural school in north Zululand, insisted that having more toilets would improve the health of her 408 students (her sparsely-equipped elementary school has four). She struggled to provide her underfed kids with a spartan lunch on an allowance of 8 cents a day. When I inquired about the AIDS crisis, she laughed and said that dental problems, respiratory illnesses, diarrhea and chronic hunger were far more vexing.
Figures about children orphaned by AIDS also bear closer examination. The average fertility rate among African women is 5.8 and the risk of death in childbirth is one in three. The African life span is not long -- 50 for women and 47 for men -- so it would not be surprising, on a continent of 650 million people, if there were not even more than 10 million children whose mothers had died before they reached high- school age.
The scandal is that long-standing ailments that are largely the product of poverty are being blamed on a sexually transmitted virus. With missionary-like zeal, but without evidence, condom manufacturers and AIDS fund-raisers attribute those symptoms to an "African sexual culture." Rev. Eugene Rivers of Boston has launched a crusade to change African sexual practices -- a crusade reminiscent of Victorian voyeurs whose racist constructs equated black people with sexual promiscuity.
In South Africa, which will host the International AIDS Conference in July, criticism is on the rise. Some journalists and physicians are challenging the marketing of anxieties and questioning the epidemic.
Late last year, South African President Thabo Mbeki launched an investigation into the safety and benefits of AZT, a toxic and expensive drug that produces abnormalities in laboratory animals; its life- extending benefits remain unproved. South Africa's Minister of Health, Manto Tshabalala-Msimang (a physician herself), told South African television audiences in December that she would not recommend AZT, advice echoed on the same program by Dr. Sam Mhlongo of the National Medical University in Pretoria.
I'd argue that wearing red ribbons or issuing calls to condomize the continent will do little for the health of Africans. By contrast, a 1998 study of pregnant, HIV-positive women in Tanzania showed that simply providing them with inexpensive micronutrient supplements produced beneficial effects during and after pregnancy. The researchers found that women who received prenatal multivitamins had heavier placentas, gave birth to healthier babies and showed a noticeable "improvement in fetal nutritional status, enhancement of fetal immunity and decreased risk of infections."
Once AIDS activists consider the non-contagious, indigenous-disease explanations for what are called AIDS, they may see things differently. The problem is that dysentery and malaria do not yield headlines or fatten public-health budgets. "Plagues" and infectious diseases do.
This means that those who question AIDS in Africa put their own funding at risk. I saw this at first-hand when I visited Swaziland in mid- December at the invitation of their HIV/AIDS Crisis Management Committee. I was driven from the airport to the hotel in a late model 4-wheel drive vehicle. It had been donated by UNICEF and was covered with AIDS posters urging Swazis to "use a condom, save a life." The committee included representatives of the major government ministries, as well as church and women's groups.
After my presentation, an attorney named Teresa Mlangeni acknowledged that she could easily see how malnutrition, tuberculosis, malaria and other parasitic infections -- not sexual behaviour -- were making her fellow Swazis ill. But other committee members confided that if they voiced public doubts, they risked losing their international funding. And I realized that the vested interests of the international AIDS orthodoxy would discourage further inquiries.
Traditional public-health approaches, clean water and improved sanitation above all can tackle the underlying health problems in Africa. They may not be sexy, but they will save lives. And they will surely stop terrorizing an entire continent.
Charles L. Geshekter is a three-time Fulbright scholar who teaches African history at California State University in Chico. He has served as an adviser to the U.S. State Department and several African governments.