AIDS in Africa: why the West is interested
How the UN donor countries are distorting the extent of AIDS, and using safe sex messages to push African societies around.
- The discussion about HIV / AIDS in Africa invites visions of apocalypse. But how much does it tell us about the extent of the disease?
- The most recent estimates from UNAIDS suggest that 34million people worldwide are either living with AIDS or infected with HIV, with a cumulative 19million deaths since the beginning of the pandemic. The vast majority of these numbers derive from Sub-Saharan Africa.
- But the numbers should be treated with caution. One concern is the low number of sites collecting data in urban areas and the variability in rural regions. Another is that there is no information as to the quality of the data collected from any of these sites.
- The international focus on HIV/AIDS seems to be less a result of a concern about public health than it is about Western nations using the issue as a way to justify more intervention into, and control over, African societies.
- African populations are being coerced into seeing themselves as the victims of their own backwardness, and African leaders encouraged to act as if they are liberals living in Southern California.
- Twenty years into the AIDS pandemic, the one thing that is still sorely missing is a detached scientific enquiry.
There are six diseases that cause 90 percent of the total infectious disease deaths worldwide: measles, malaria, TB, diarrhoreal diseases, acute respiratory infections, and AIDS. All but AIDS are curable, at least to some degree.
Yet measles, malaria, TB, diarrhoreal diseases, and acute respiratory infections have routinely killed millions of people in the developing world without special sessions of the United Nations being called, and without any expectation of continental collapse, talk of extinction or international assemblies to mobilise preventative and treatment measures. Why the level of interest in AIDS?
On 25 June 2001, the United Nations General Assembly opened its first special session devoted to a disease. The aims of the three-day meeting were to set health goals and HIV infection targets for countries to meet over the next few years and to establish a global fund for AIDS. Representatives attended the meeting from most countries, including secretaries of state Colin Powell for the USA, and Clare Short for the UK, and a host of African presidents and other heads of state.
Western leaders vied with their African counterparts to present the problem in the most frightening language possible. US ambassador to the UN Richard Holbrooke stated that, ‘of all the major problems we face today – wars, famines, racial conflict, terrorism, nuclear weapons – the greatest threat comes from AIDS’. With allusion to the bubonic plague, he added: ‘[AIDS is] the most serious health crisis in 700 years [and] a direct threat to social and political and economic stability.’ (1)
Dr. Peter Piot, executive director of UNAIDS, went one better and brushed past the plague: ‘We are facing the most devastating epidemic humanity has ever known.’ (2) Little wonder that Pakalitha Mosisili, prime minister of Lesotho, said his government had declared HIV/AIDS ‘a national disaster’.
Writing in the New York Times, Mozambique prime minister Pascoal Mocumbi voiced his concerns about the consequences of losing a generation or two of people and the possibility that over a third of 16-year-olds would die before the reaching the age of 30 (3). Speaking at the UN General Assembly special session on AIDS, President Olusgean Obasanjo of Nigeria suggested that ‘the prospect of extinction of the entire continent looms larger and larger’ (4).
As a call to action against AIDS, these apocalyptic visions are certainly effective. But how much do they represent the true impact of AIDS in Africa?
Just over five years ago I wrote a series of articles examining the AIDS pandemic (5, 6). In some I criticised the Global Programme for AIDS (GPA, superseded by UNAIDS in 1996) and the World Health Organisation (WHO) for exaggerating AIDS figures in their projections and relative to other infectious diseases (6). In the summer of 1994, WHO estimated that 16million people worldwide were infected with HIV and that figure was expected to increase to 40 or 50million by 1999, with 90 percent in developing countries (7).
The numbers today are not as high as those predicted in the early to mid-1990s, but they are startling nonetheless. The most recent estimates from UNAIDS suggest that 34million people worldwide are either living with AIDS or infected with HIV, with a cumulative 19million deaths since the beginning of the pandemic (8). The vast majority of these numbers derive from Sub-Saharan Africa, which is home to 24.5million of those currently living with AIDS or infected with HIV and which has suffered some 16million of the total death toll.
With an estimated 2.2 million deaths from AIDS in 1999, AIDS now exceeds the annual death toll from malaria in Sub-Saharan Africa and far outstrips those deaths from other infectious diseases such as TB. (Although it is still some way from challenging the 3.3million annual deaths from diarrhoea.) (9)
However, the numbers should be treated with caution, and put in perspective. The World Health Organisation (WHO) provides figures for African countries (10, 11) based, not on the total population of each country, but on the population of ages 0-49 years. This immediately makes the figures difficult to interpret and provides a false sense of the extent of the infection.
In Mozambique, for example, the adult rate of HIV infection is reported at 13.2 percent based on the proportion of adults aged 15-49 who carry the infection (10). This is an important demographic, being the most productive section of society. But it is a misrepresentation to report that headline figure as being the rate of HIV infection in Mozambique, which is what consistently happens. The actual rate of HIV infection is six percent when calculated for the total population, and the adult rate is 10.1 percent when calculated for the total adult population (everybody over 15) (12).
The representation of the statistics is an issue, but the way these statistics are derived is critical. A large number of surveillance centres for AIDS have been put in place across Africa since 1995, meaning that we can have a lot more faith in the numbers than previously. Even so, there are substantial difficulties in collecting good disease data in a country as impoverished and underdeveloped as Mozambique.
Despite the best efforts of an army of AIDS investigators, there are only two surveillance centres in urban areas and six outside major urban areas. Data at all sites is only collected from pregnant women and suggest an adult prevalence rate of 11.2 percent in urban centres and 17 percent in rural areas. This latter figure is at the upper end of a wide range across the six sites, from a reported prevalence of five percent to 18.3 percent.
One concern is the low number of sites collecting data in urban areas and the variability in rural regions. Another is that there is no information as to the quality of the data collected from any of these sites. We have no information on the numbers of patients tested or the reliability of the test used. We do not know if these women were self-selecting based on their fear of infection, because they were carrying a secondary sexually transmitted disease or because of some other health problem. Any one of these factors could inflate the estimated number of HIV infections. (On the other hand, the complete absence of men from testing may be artificially deflating the rate of HIV infection, because men may be more likely to become infected.)
There is also concern about what information has not been collected. There is no information on infections in prostitutes, injecting drug users, blood donors or gay men. How the disease is being transmitted and where health resources should be directed, therefore, is impossible to judge. These problems are not considered in press reports that simply repeat the mantra that HIV in Africa is heterosexually transmitted. To what extent this is true has never been established.
Reports from Nigeria suggest a much lower infection rate than Mozambique, with an adult (15-49 years of age) rate of 5.1 percent (11). Again, this figure inflates the total population rate, which is 2.5 percent. The data from Nigeria is much more reliable, however, based on surveillance data from 10 urban and 63 rural sites. The average rate of infection reported from urban areas is 4.5 percent and from rural areas 4.9 percent. As for Mozambique, the range is greater in rural areas (0.54 – 21 percent), implying that rural collection is less reliable. The range in urban areas (2.7 – 8 percent) is much tighter, but still not insignificant.
Without details of the quality and mechanisms of data collection it is difficult to offer much further interpretation. Again, there has been no collection of data from men or the general population through blood donation, rendering the population extrapolations made by UNAIDS and other groups an educated guess based on the sampling of pregnant women.
Discounting the potential problems with the UNAIDS figures and accepting them at face value, it remains difficult to justify the suggestions of apocalypse now. Five percent of the Nigerian adult population at risk of death is certainly tragic, but it is hardly the basis for expecting extinction. Moreover, the developing world is no stranger to disease and pestilence and continues to be ravaged by a myriad of illnesses.
Measles kills one million children a year but can be easily prevented with vaccination. Rotavirus causes severe diarrhea in 125million children a year and kills 600,000 of them, yet it can be easily treated with oral rehydration or intravenous fluids. Hepatitis B kills more than a million adults a year and can also be prevented by vaccination. Worms like hookworm and schistosomiasis infect 1.3billion people a year, mostly through working or playing in fields that double as latrines or swimming in infected lakes and streams. Three hundred thousand of these infections lead to death and for those that survive repeated infection and reinfection can stunt growth and produce years of discomfort. Each worm can be treated with one or two pills costing $1.
So it is worth asking again, why is so much international attention given to AIDS, and so little given to these other diseases? Beyond the hyping of a tragedy into a catastrophe, at the United Nations General Assembly special session on AIDS there was a more pernicious agenda coming into play. The international focus on HIV/AIDS seems to be less a result of a concern about public health, than it is about Western nations using the issue as a way to justify more intervention into, and control over, African societies.
The tone of the discussion was set by a draft document, The Declaration of Commitment on HIV/AIDS, prepared by the session’s co-facilitators, ambassador Penny Wensley of Australia and ambassador Ibra Deguène Ka of Senegal:
‘Noting with grave concern that Africa, in particular Sub-Saharan Africa, is currently the worst affected region where HIV/AIDS is considered as a state of emergency, which threatens development, social cohesion, political stability, food security and life expectancy and imposes a devastating economic burden and that the dramatic situation on the continent needs urgent and exceptional national, regional and international action.’ (13)
The only hint at controversy during the three-day session erupted over the question of whether prevention or treatment should be the main focus of international efforts against the disease. Declarations and statements from the donor countries – the rich Western nations – indicated a preference for money being spent on AIDS prevention rather than retroviral drugs.
Understandably, with Sub-Saharan African leaders being told that 22million of their citizens are already infected and that their economies will collapse and their society descend into anarchy as these people become sick and die, African leaders expressed a desire for free retroviral drugs.
The argument over treatment v prevention provided some exposure of the political agenda behind the meeting. In one of the few outright derogatory comments, Andrew Natsios, head of the Agency for International Development, told the Boston Globe that Africans lack the concept of time required to take a complicated regime of retrovirals and that, therefore, most money should go towards prevention and not cure (14). His comments caused a predictable storm of condemnation, with letters declaring him a racist and calling for him to be sacked.
It was the New York Times, however, that set Natsios straight. An editorial argued that treatment should be made available to Africans because, ‘the availability of treatment gives people a reason to get tested for AIDS and draws them into a health clinic, where they can learn how to practice safe sex’ (15).
It is apparently okay to suggest blackmailing Africans into attending a clinic for treatment and ambushing them with a condom and a banana – as long as you don’t suggest that they are too stupid to use a watch. So long as you get the language right, it seems that safe sex is the new politically correct way to push Africans around.
African heads of state who are prepared to pepper their populations with moralising messages about sex, civil liberties and treatment of women are lauded by those in the West – but heaven help those who haven’t quite twigged the new sexual order. Colin Powell put it bluntly, citing President Yoweri Musevini of Uganda as his example: ‘[Musevini] says “This is what is causing it…irresponsible heterosexual sex.” It kind of jars when you hear it but that is the kind of leadership message that has to be given.’
Other world nations are encouraged to follow suit by providing AIDS education to children: ‘drilling it into them just like we do here with anti-smoking and other types of campaigns.’ (15) (Sadly, African leaders forgot to ask Powell just how successful that anti-smoking campaign has been, and why on Earth he thinks it might work in their countries.)
The session ended with publication of a document: The Declaration of Commitment, which calls for nations to ‘address the epidemic in forthright terms; confront stigma, silence and denial; address gender and age-based dimensions of the epidemic; eliminate discrimination and marginalisation’ (16). Such statements suggest more of an attack on societies’ values than an attack on a disease. Dr Peter Piot, executive director of UNAIDS, called the document an ‘instrument for accountability’. Countries will be pushed to put cultural mores aside. ‘It is our job to push the edges now’, said Dr Piot (17).
At one point the declaration makes clear that ‘harmful traditional and customary practices’ should be eliminated, and Kofi Annan told the press that the United Nations will follow countries to ensure they are setting and meeting the targets of the declaration. Those that are failing will be ‘chastised’ (18).
As a result of this discussion, African populations are being coerced into seeing themselves as the victims of their own backwardness and African leaders encouraged to act as if they are liberals living in Southern California. They are supposed to let it all hang out in public, talking about condoms and shagging on the radio and TV. Men will be taught to respect women, to abandon their old-fashioned views of patriarchy and stop visiting brothels. Members of the armed forces will be nice to the wives of the husbands they are killing. The police will take a more active role in pursuing rapists, the state will clamp down on child abuse, and courts will become woman- and child-friendly.
The virtues of fidelity will be championed and the population warned of the dangers of mixing alcohol with one-night stands. Women will be taught about the use of female condoms and how to enjoy using one. If all this still fails to change behaviour, then people may be manoeuvered into counselling and testing. Counselling centres could be set up in the workplace, on the farm and in schools, and employment made conditional upon attendance.
All of these ideas are to be found within the pages of the UNAIDS report on the global HIV/AIDS epidemic (19), and variations on the theme were ever-present during the UNAIDS special session. No aspect of life is to be untouched in the developing world. From the classroom to the bedroom to the workplace to the courts to the army, all will be interfered with and encouraged to reform under the banner of eliminating HIV and encouraging safe sex.
No doubt many will say that attempts by Western nations to alter African behaviour are justified if it saves the continent from collapse. But this badly misses the point. Western governments used the AIDS issue to moralise to their own populations, regardless of the facts or health benefits – and it seems likely they will try to adopt the same tactics abroad (20). Very little of what is happening has much to do with saving lives in Africa or anywhere else.
The hysterical expectations of African disaster have little basis, but they encourage the notion that African nations cannot approach their health problems using their own ideas and plans. Even though Africans are where it is happening, and although there is little reason to expect that an intervention useful in New York City to have any relevance on the African Savannah, the only interventions likely to be put into action will have their motivation anywhere but in Africa. The consequence will be a creeping but definite controlling reach from the outside in, with African sovereignty and independence the victims.
If Western nations really wanted to be helpful they could cancel third world debt, refrain from complicating the internal politics of Africa through interference, provide medicines, and provide money to develop clean water supplies and efficient farming, industrial and pharmaceutical practices. This is so far from not happening that it is just not funny. The proposal to cancel third world debt has been around for decades but carries so many strings that in practice, if it ever happens, many countries might be better off keeping the debt.
Medicines that could right now save millions of lives are not provided and have not been for decades. There is little reason to expect this to change, and the advanced industrial practices of the West are jealously guarded from the developing world lest they start to cut into profits at home.
UN secretary general Kofi Annan has said that the global fund for AIDS and health needs to raise $7billion to $10billion to be effective. But enthusiasts for the campaign against AIDS in Africa seem less keen when it comes to hard cash. Bill Gates stated that, ‘there is no higher priority than stopping transmission of this deadly disease’, before pledging $100million to the fund. (21). The USA could barely do better than the Gates Foundation with a pledge of $200million, widely expected to be provided at the cost of other aid programs. The UK pledged $100million, but then the UK is quite possibly less well off than Bill Gates. Coca-Cola, Volkswagen and Daimler Chrysler have also pledged money and assistance. In a move bound to produce disappointment, Coke trucks will apparently be used to deliver condoms instead of soft drinks.
If Africa is lucky, Kofi Annan will get no closer than the current $500million or so – but I suspect that once word gets around that the AIDS fund will be used to bring Africa to heel, the donations will start to pour in.
Twenty years into the AIDS pandemic and the one thing that is still sorely missing is a detached scientific enquiry. Development of effective treatments and a vaccine would, if made available, be of enormous benefit to Africans and everyone. In the meantime, epidemiological investigations that reported disease trends without resorting to hyperbole and that located the reasons for different patterns around the globe might provide important insights into the disease.
An honest appraisal of breakthroughs and trends absent of the ideology and politicking that inevitably follows AIDS is to be encouraged. AIDS is not the wrath of God, nature’s revenge or the new bubonic plague; it is a nasty infectious disease that requires clear thinking and investigation to overcome. Bill Gates should stick to building computers and Coke to delivering Coca-Cola, while those that may provide real assistance do their work unhindered.
Stuart Derbyshire is an assistant professor in the University of Pittsburgh Department of Anaethesiology. He is a contributor to Animal Experimentation: Good or Bad?, Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).
The AIDS panic in perspective, Dr Michael Fitzpatrick
(1) New York Times, 19 June 2001
(2) Download the The Global Strategy Framework on HIV/AIDS in .pdf format
(3) New York Times, 20 June 2001
(4) New York Times, 26 June 2001
(5) Derbyshire, S.W.G. (1995) ‘Duesberg and AIDS’, Nature, 377, 672; Derbyshire, S.W.G. (1996) ‘Infectious AIDS: Have we been misled?’ British Medical Journal, 312, 1236; Derbyshire, S.W.G. (1997) ‘Those who believe in alternative theories of AIDS have little room to maneuver’, British Medical Journal, 314, 607-608
(6) ‘WHO criticized for “inflating” AIDS figures, AIDS Analysis Africa, December 1995: 4-5. ‘AIDS is less of a health threat than other diseases in Africa’, British Medical Journal 1995; 311: 633
(7) Weekly Epidemiological Record, 26 July 1994; Guardian, 17 November 1994
(8) Report on the global HIV/AIDS epidemic, June 2000
(9) WHO factsheet No 112
(10) Epidemiological Fact Sheet: Mozambique – 2000 update
(11) Epidemiological Fact Sheet: Nigeria – 2000 update
(12) Population statistics
(13) UN declaration of commitment on HIV/AIDS
(14) Boston Globe, 7 June 2001
(15) New York Times, 24 June 2001
(16) Revised Draft Declaration of Commitment on HIV/AIDS, 11 May 2001
(17) New York Times, 28 June 2001
(18) New York Times, 28 June 2001
(19) Report on the global HIV/AIDS epidemic, June 2000
(20) The AIDS panic in perspective, Dr Michael Fitzpatrick
(21) New York Times, 19 June 2001
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