VIRUSMYTH HOMEPAGE

FUDGED FACTS ON AIDS
Science does a number on Africa

By Colman Jones

Now 9-15 March 2000

Nelson Mandela's successor says "no thanks" to western drug companies -- just the start of a new made-in-Africa campaign against AIDS orthodoxies

Africa has always been a country of mystery for North Americans. In a more innocent time, it was Tarzan. Lately, it's been war and famine. But in the near future, the panic over a seemingly overwhelming menace -- AIDS -- will overshadow those other images.

As the syndrome recedes as a source of public concern in Canada and the United States, it's becoming the focus of more and more news about Africa. It was the subject of the first meeting of the UN Security Council not concerned with war and peace. Disease is now the main security issue in Africa.

Later this year, the travelling media medical road show heads to Durban, South Africa, for the once-every-two-years international conference on AIDS. No doubt there will be more nightmare statistics about the numbers of people infected with the ticking time bomb of HIV, and the need to send in AIDS drugs ASAP.

But these scribes may find there are things happening in Africa that don't fit into the AIDS-is-rampant, give-us-AZT-quick story they're poised to write, for an unlikely alliance of skeptics -- those who doubt that drugs are the answer, even that all of what is making people sick is HIV -- is on the rise.

The naysayers include not only the usual anti-corporate, anti-medical suspects, but newer members as well -- students of Africa and even the successor to Nelson Mandela.

Mandela earned his stripes by putting his body in front of the military might of the apartheid state. But this is the information age, and the man now in the president's chair, Thabo Mbeki, carries out his radical activities by surfing the Internet, colluding with dissidents whose critique challenges the assumptions about what AIDS is and how it can best be treated. Mbeki and his health minister have done the unthinkable: they have told multinational drug firms they don't want their products, because South Africa will deal with AIDS as it sees fit.

No, it will not be business as usual in Durban.

***

I get a taste of the increasing militance against AIDS assumptions in Africa at York University last week. Charles Geshekter, a California State University professor of history, is in town to talk about what he calls "an abandonment of scientific principles in the fight against AIDS."

African studies program coordinator Pablo Idahosa makes it clear to the assembled group of about 30 curious attendees, mostly people of colour, that he shares concerns not only about some of the numbers of AIDS cases being bandied about, but also about the lifestyle assumptions often made by social scientists in the West.

Geshekter recounts how his training as an economic historian and anthropologist led him to question some of the core concepts that guide public pronouncements about AIDS, HIV and African sexual culture. "You're looking at what I think is going to turn out to be one of the great frauds of the late 20th century."

Hyperbole, perhaps, but it's hard not to choke on the enormous statistical inconsistencies in estimates of African AIDS cases . If one is to believe the media coverage of late, the African AIDS pandemic has mushroomed. The continent is reeling from "an epidemic of biblical proportions," writes Mark Schoofs in one of a series of articles in the Village Voice last fall, "on track to dwarf every catastrophe in Africa's history." Newsweek says the continent is "in the middle of a medieval death grip."

Unverified Data

But the science supporting such claims is surprisingly weak. What little data we have on AIDS in Africa is fraught with unverifiable conclusions -- and numbers marked by discrepancies as wide as the Sahara Desert.

For example, the November 26, 1999 Weekly Epidemiological Record, published by the World Health Organization (WHO), shows a cumulative total of 794,000 reported AIDS cases in Africa, only slightly higher than the U.S. tally of 717,000 cases, out of a 20-year global total of 2.2 million reported AIDS cases so far.

In contrast, the Joint United Nations Program on HIV/AIDS (UNAIDS) 1999 AIDS Epidemic Update claims that there have been some 13.7 million AIDS deaths in sub-Saharan Africa since the first reports of the disease surfaced in the early 1980s, and that an estimated 23.3 million sub-Saharan Africans are now infected with HIV.

The prevalence of HIV in a given area is assessed from small surveys of pregnant women who visit health/STD clinics. The number is then extrapolated using complex mathematical models to estimate the actual death toll -- models based on the unquestioned assumption that an HIV test accurately predicts sickness and death a decade later.

Another difficulty in measuring AIDS in Africa is mere definitions. What counts as an AIDS case there would not be included here.

In October 1985, the WHO published a checklist of AIDS symptoms for use by developing-world doctors. Under the rather elastic Bangui definition (named after the Nigerian city where it was first proposed), the syndrome can be diagnosed based on a cough, diarrhea and fever that lasts for more than one month. No HIV test is necessary, nor is a person's HIV status even included on health or death-reporting forms in many African countries.

Diagnosing AIDS this way, exclusively on the basis of symptoms, is problematic, especially because this is a disease with "no typical symptoms," in the words of HIV discoverer Luc Montagnier.

But even in places where HIV tests are used to diagnose AIDS, there remain major questions about the reliability of a positive result, the criteria for which differ from country to country, and even from lab to lab.

Most HIV tests detect antibodies, not the virus itself, and these antibodies have since been found to show up during the course of other, unrelated conditions. These include many tropical infectious diseases suffered by African populations, certain vaccinations, blood transfusions and even pregnancy.

The typical doctor in Africa is confronted with very sick patients and no sure way to know if they're suffering from TB, malnutrition, cholera or malaria. As Francis Kasolo, head of virology at the University Teaching Hospital in Lusaka, Zambia, tells NOW, "If you look at the clinical settings in the district hospitals, they do not have the facilities to say a patient has HIV infection."

Quite Confident

There are those who feel that among those diagnosed with AIDs are those suffering from something else. "I am quite confident in my own mind that many cases identified as AIDS (according to their symptoms) are not AIDS," says professor Daniel J. Ncayiyana, deputy vice-chancellor at Capetown University. "The numbers given must, of necessity, include people who possibly have other conditions," he says, although he has no idea how many. "Who knows?"

Uganda has incorporated this confusion into its professional procedure. As a matter of course, it includes TB under the umbrella of AIDS.

Further spiking the number of AIDS cases is the use of cumulative numbers -- all cases since the beginning of the 1980s.

And, in Africa as elsewhere, there are questions about the relationship between HIV -- the virus thought by conventional researchers to cause AIDS -- and the illness itself. No conclusive link has been proven.

Regardless of what we call it, there's no denying that too many people in Africa are dying. And people in support work here in Toronto don't have a lot of interest in quibbling over statistics when they're trying to save lives.

Richard Bedell, medical consultant for Medecin Sans Frontiers (Doctors Without Borders) admits that "some of the potential sources of error in terms of estimating the burden of HIV disease in Africa are worth examining.'' But he's very clear that "there's enough evidence that the pandemic is one of enormous scale.''

It's hard enough to pry funds out of governments that are not elected by sick people in Africa. AIDS is a better lever than most.

"Funds are hard to come by," Geshekter says, "so when the World Bank, the UN and the World Health Organization all say that fighting AIDS is the number-one issue facing Africa, you've got to follow the money. If you're working at the ministry of health in Uganda or Botswana, would you be inclined to give lower, declining numbers of AIDS cases or higher numbers?"

In the short term, an AIDS diagnosis may extract short-term aid cash from well-to-do countries. But it also puts in place a medical paradigm that limits local choices on how to confront the problem.

To AIDS dissidents like Geshekter, the focus on HIV tests, vaccines and drugs for Africa ignores a host of other factors that contribute to the epidemic. He says what he calls the "medicalization of poverty" is overriding any sense of African history and political economics.

"If you look at African states in the late 1970s you find spiralling indebtedness, and the imposition of structural adjustment programs in the early 1980s. One of the key points of all the privatization schemes and adjustments was to cut back on what were called 'bloated' state-structure agencies like education and public health," he notes, which resulted in cutbacks to medical interventions for diarrhea, TB drugs and the like.

Meredith Turshen, who has been studying AIDS in Africa since the 80s and now teaches public health policy at Rutgers University in the U.S., says that in an earlier time she saw family planning soak up all the resources from general health care. "I now see exactly the same thing happening with AIDS."

To Turshen and other observers, the real threats to Africans can be found in famine, civil war, rural poverty, urban overcrowding, migratory labour and the breakdown of state institutions. Very little, for example, has been done to monitor the contamination of the African blood supply, Turshen notes.

"I have been in enough African hospitals to know that there are no autoclaves (for the sterilization of medical instruments). There isn't even chlorine bleach to clean needles. And even if there were, there's no time to do that, because you're using two needles on a ward of a hundred people."

But such nitty-gritty stuff "will not get a quilt made or get anybody wearing red ribbons," says Geshekter.

On the other hand, the cost of treating all those tagged with an AIDS diagnosis would be so enormous that governments are balking. At their forefront is South Africa's president Mbeki, who chose World AIDS Day last December to publicly challenge the western pharmaceutical approach to AIDS and to reaffirm his government's decision to withhold AZT from pregnant women -- the mainstay of efforts around the world to prevent the birth of HIV-positive infants.

Price Cuts

The main reason, of course, is cost. Providing AZT to the estimated 3.6 million South Africans (of a total population of 44 million) who are infected with HIV would have Pretoria forking out nearly 288 billion rand ($47 billion U.S.) a year, and $15,000-a-year-per-person protease-inhibitor "cocktails" are similarly off the radar.

An adviser to the South African health minister, who declined to be identified when contacted by NOW, vehemently defends her government's actions. "We already have 4 million people who are HIV-positive," she says, "so the cost effect on our economy would be absolutely enormous."

She dismisses price cuts offered by makers of anti-HIV drugs like AZT. "When drug companies like Glaxo Wellcome tell you they have made the drug afordable, that is absolute nonsense. They have a roughly 800-per-cent markup on the manufactured price of AZT. They then say they will sell it to us at a seventh of its price -- but that's still a 100-per-cent markup."

That there is a certain confusion surrounding the AZT issue is evident from the further response of South African health ministry officials. Early yesterday morning, the ministry faxed me a "draft" by a Dr. S.P. Reddy dated this past Sunday. Reddy concludes, in contrast with the president's public pronouncements, that "we would all like to give HIV-positive mothers AZT/nevaripine,'' but the "full ramifications must be carefully researched and costed."

This AZT-positive statement notwithstanding, the president has made it clear that he has a medical problem with the pharmaceutical. Credible scientists have raised "monumental" concerns about the toxicity of AZT, Mbeki said in a speech to South Africa's second chamber of Parliament, the National Council of the Provinces, prompting a furious denial from Glaxo Wellcome.

Questions about the drug's safety have been around for a long time. The Concorde study, the first major study of AZT not underwritten by the drug's manufacturer, found that patients who received it had a 25 per cent higher death rate than those on a dummy placebo.

At GlaxoWellcome Canada, medical director Anne Phillips insists the drug is both safe and efficacious. "We're talking about a life-saving intervention, and you have to look at the costs in the future to that nation of allowing children to be born infected and to die.''

But Mbeki's new-found opposition to western-style AIDS solutions appears to be catching on. Health officials from the dozen-plus African countries making up the Southern African Development Community issued a joint statement last November indicating that they are "gravely concerned over the possible side effectss as a result of the toxicity of (anti-HIV drugs)."

Combo Therapies

Of course, AZT has been supplanted by a host of new, allegedly safer and more effective combination therapies that are credited with saving lives left and right.

But now they, too, have been found not to be the sure thing they were first thought. Michael Saag, an associate professor of medicine at the University of Alabama and director of the university's AIDS outpatient clinic, admits that early hopes that combination therapies would make a significant dent in the disease have since been tempered by the sobering reality of treatment failures and horrific side effects.

"We have 16 or 17 deaths just since January out of an active patient population of 800. If you multiply that, that would put us on track for around 100 deaths this year. Clearly, the drugs play a role in morbidity.

"I'm concerned that just a blind faith that we'll give anti-HIV therapy to everyone who walks in the door isn't going to be the answer for every patient."

Still, many people living with an AIDS diagnosis feel that imperfect drugs are better than none at all. In South Africa, they have unleashed their bewilderment and anger at the government, especially in light of the decision by pharmaceutical giant and AZT-maker Glaxo Wellcome to cut the prices of drugs to benefit poorer countries.

AIDS activists have accused the ANC leader of "passive genocide," calling his decision unconstitutional, "scientifically mistaken" and "morally bankrupt." Mbeki has been threatened with embarrassment at the international AIDS meet in July.

But those who've worked with him say Mbeki has fortified himself with intellectual and scientific arguments, and is not likely to succumb to pressure.

Not only does he surf AIDS dissidents' Web sites, but among the experts he has consulted in recent weeks is David Rasnick, a San Francisco-based scientist who's spent 20 years in the pharmaceutical industry.

Rasnick, president of the Group for the Scientific Reappraisal of the HIV-AIDS Hypothesis, comprising some 600 medical scientists and other professionals, got a fax from the president's office on January 19.

Mbeki was asking for answers to questions about AIDS. A day after Rasnick responded, his phone rang -- it was Pretoria calling.

"Mbeki has a good sense of humour and a quick laugh," Rasnick was surprised to discover during his chat with the leader. "He's read extensively. He asked me if I would personally support his efforts in all this stuff that has to do with AZT and AIDS."

Rasnick says he responded by wholeheartedly committing the resources of the Group as well as those of the International Coalition for Medical Justice, a Virginia-based patients' rights association already lobbying the U.S. Congress to investigate alternate approaches.

According to Rasnick, Mbeki says he is asking other leaders -- U.S. president Bill Clinton, UK prime minister Tony Blair, and German chancellor Gerhard Schroeder -- to join him in an international discourse about these issues.

"South Africa may be the place where this whole craziness comes to an end," Rasnick says. "It's no messier than bringing down apartheid peacefully. I can't think of a better-positioned person, as a head of state, in the entire world."

VIRUSMYTH HOMEPAGE