AIDS IN AFRICA – THE WAY FORWARD
Retrospect from a European point of view
By Christian Fiala
May 2000
In Europe (and the US) in the late 80s and early 90s there was an
unprecedented media campaign on HIV/AIDS. On the basis of steeply rising
statistics (1) AIDS experts explained that the whole population was
facing an AIDS epidemic because the infection had broken out of the
original high-risk groups – part of the male homosexual population and
intravenous drug users. "In a few years AIDS will be killing more people
in the western industrialised countries than all other illnesses and
infectious diseases put together." This was one of the many horror
scenarios of the time. (2) And the American AIDS specialist Robert Gallo
was quoted as saying: "AIDS could mean the end of humanity." (3)
The message was that basically there was no escape. Only a major change
in the sexual behaviour of the heterosexual population could prevent the
worst. Thus campaigns for greater faithfulness were launched, something
the Catholic church has been doing for 2,000 years, and the use of
condoms was promoted for young people in particular. The extent of the
hysteria that prevailed at the time is hard to imagine in retrospect.
Isolated voices arguing that the forecasts were based on false
assumptions and unscientific conclusions were either suppressed "because
they contradicted the consensus of the general population" (4) or they
were accused of recklessly playing with innocent lives.
Most statisticians have added all AIDS cases since the beginning of the
1980s together – that is, they have presented them cumulatively. This
form of presentation is unusual in medicine as it produces useless
results. The figures automatically rise, even if only a few new cases
are still coming in each year. Thus the monthly publication of the
German Medical Board (Deutsches Ärzteblatt) writes as early as 1989,
under the headline "Cumulative Confusion": "Nobody thinks of adding up
the case figures for mumps, tuberculosis or scarlet fever from the day
the law on epidemics was passed" Consequently, the only sense in such a
form of presentation is that "Large figures bring in large amounts of
public money." (5) (Also to be found in the book So lügt man mit
Statistik [How to lie with statistics] (6).) With rare openness this
article puts its finger on the main issue in health politics: whoever
shouts the loudest and whoever most convincingly sets the general public
in a state of fear, gets the most support. In this regard the
institutions engaged in the fight against AIDS over the last 20 years
have been extremely successful.
In the end the actual developments in Europe were less dramatic. (7)
From 1993 to 1994 the number of new cases of AIDS reached a highpoint
at
a low level compared to other illnesses. Thus AIDS is responsible for
less than 0.2 per cent of all deaths in Germany. (8) At the same time
the number of AIDS sufferers had risen partly because the definition of
the AIDS illness has repeatedly been changed. (9-20) This
definition-conditioned increase in numbers even amounted to 100 per cent
in the US in 1993. (21) (Apart from which, since 1993 the definition of
AIDS has differed between the US and Europe on one essential point. (10)
(In the US, HIV-positive people with a particular laboratory count, <200
CD4-cells, are considered as having AIDS even if they display no
symptoms or complaints).
After 1993-94 the number of new cases of AIDS fell significantly. This
regression happened because there was no independent spread of AIDS
outside the original risk groups. In retrospect this is also confirmed
by the Robert Koch Institute in Berlin, which is responsible for the
evaluation of the German figures, (22) and the European Centre for the
Epidemiological Monitoring of AIDS in Paris. (23) In one study the
average ten years‘ incubation time (between HIV infection and full-blown
AIDS) was subtracted from the reported AIDS-cases. This showed that new
HIV infections had reached a highpoint as early as 1984, long before the
first "prevention" campaigns.
These, incidentally, have hardly raised condom use in Germany at all.
The annual usage in 1980 was two condoms per inhabitant; in 1995 it was
2.3 (44, 45)
And in the evaluation of anonymous, unlinked testing of umbilical-cord
blood since 1993 the Robert Koch institute in Berlin has come to the
following conclusion: "The results – HIV prevalence significantly under
one per thousand among women giving birth – confirm the assumption of a
low distribution of HIV in the general heterosexual population so far."
(23)
To sum up, it can be said that:
at no time was an AIDS epidemic to be expected in Europe and the US
the catastrophe prophesied by many AIDS experts has not happened
the forecasts in relation to this were based on false assumptions and
unscientific conclusions
in fact there have been relatively few cases of AIDS
the heterosexual population in particular is not affected by AIDS
an effect of "preventative" measures on these developments cannot be
demonstrated
the sexual behaviour of heterosexual Europeans, in particular of young
people, has not demonstrably changed despite the years of fear-mongering
media reports.
This means that the great financial and personnel investments in AIDS
prevention and the AIDS institutions have had no demonstrable effect on
the number of positive HIV tests and AIDS sufferers. Europe has coped
with this squandering of resources without obvious harm. Nevertheless
the financial and human resources could have been more sensibly employed
elsewhere.
What is the meaning of AIDS in Africa?
The AIDS diagnosis in Africa is essentially made on the basis of the
Bangui definition published by the World Health Organisation. (24, 25)
However, this has been individually adjusted by many countries. It was
created by the WHO uniquely for developing countries and is
fundamentally different from the definitions uses in Europe and the US.
Tab. 1: WHO AIDS Definition (1986) for adults in developing countries:
(24,25)
Major signs:
- weight loss >10%
-
- chronic diarrhoea > 1 month
- fever > 1 month (intermittent or constant) Minor signs:
- cough for > 1 month
- generalised itching
- ecurrent herpes zoster
- oro-pharyngeal candidiasis
- chronic progressive and disseminated herpes simplex infection
- generalised lymphadenopathy
- exclusion criteria:
- cancer
- severe malnutrition
- other recognised causes
AIDS is defined by the existence of:
at least 2 major signs
and
- at least 1 minor sign
and
- in absence of any exclusion criteria
or
- in a patient with generalised Kaposi's sarcoma
or
- in a patient with cryptococcal meningitis
Under this, someone is declared to be suffering from AIDS if they have
had, for example, diarrhoea for more than a month, pronounced weight
loss and coughing or general itching and no other cause can be
ascertained with available means. On this definition an HIV test is not
necessary, and shortage of funds means that a test is still only carried
out occasionally today. And on the Ugandan health ministry‘s
registration form for people with AIDS the possibility of an HIV test is
not even mentioned. Even the exclusion criteria will hardly prevent
someone from beeing misdiagnosed of having AIDS, as this definition was
intended for poor countries. If they do not even have the possibility to
perform an HIV-test it is hard to imagine how they should do any other
diagnostic examination.
(Based on this way of registering AIDS cases Uganda was long considered
the epicentre of the AIDS epidemic.)
This means that AIDS, the illness that in the words of Professor Luc
Montagnier, the man who discovered HIV, "has no typical symptoms", is
being diagnosed in developing countries exclusively on the basis of
unspecific symptoms. (26) The symptoms called for are not exactly rare
in a continent where, because of the many infectious illnesses and poor
hygienic conditions, the average life expectancy is around 50 years. If
a doctor in Europe formed his or her AIDS diagnosis on such a basis they
would probably have to face legal action and presumably be struck off
the register.
On this issue, Dr Chin, the former Chief of the Forecasting and Impact
Assessment unit at the Global Programme on AIDS at the WHO, was writing
as long ago as 1990: "It should be emphasised that surveillance
definitions for AIDS were not intended to be reliable indicators for HIV
infection. Thus, in areas where the prevalence of HIV infection is very
low, the WHO clinical definition primarily identifies patients with
tuberculosis, severe malnutrition or diarrhoea." (27)
And even the US American Centers for Disease Control and the
Pan-American Health Organisation arrived independently of each other at
the conclusion that the WHO definition "may not be adequate for clinical
work" because of "the potential inapplicability of that definition".
They therefore established two further definitions for the diagnosis of
AIDS in developing countries. (28, 29)
It follows that the diagnosis of AIDS in Africa has little to do with
what is understood by this in Europe or the US. Rather, people who are
suffering from well-known infectious diseases are now officially
described as suffering from AIDS. (30,31) This was tragically confirmed
in the case of an AIDS-infected child from Africa who was treated and
re-nourished in Belgium. As a result the child no longer fulfilled the
criteria of the African definition of AIDS. (32)
Who is HIV positive in Africa
Fundamentally, all HIV tests do not identify the virus but particular
antibodies in the blood. As always the controversy is over which
antibodies are supposed to be typical for HIV and what methods can be
used to determine this.
Interestingly, different antibodies are regarded as being typical for
HIV in different countries and institutions. (33) The reliability of the
various tests is also to some extent differently evaluated. Thus, for
example, in England the Western Blot is not accepted in HIV diagnosis.
Regardless of this, however, some antibodies are very similar, so there
is occasionally confusion. This means an HIV test wrongly gives a
positive result when antibodies against a completely different pathogen
are present. (This is essentially true for all such tests.) At the
moment more than 70 illnesses or situations are recognised in which such
positive results can occur, among others malaria, following blood
transfusions, and leprosy. (34)
One study of the reliability of tests thus recommended that "the usual
HIV tests (Elisa or Western Blot) are possibly not sufficient to
diagnose infection with HIV in Central Africa." (35)
The current WHO estimates however, in particular for Africa, are based
precisely on the results of these HIV tests on a small group of people.
The spread of HIV in the rest of the population is then estimated on the
basis of this data. The funds that the African countries should provide
for preventative measures – such as, for example, one billion US dollars
as deemed necessary by UNAIDS– are derived from just such an estimate of
23.3m people with HIV/AIDS in Africa. (36, 37)
How are the figures interpreted?
All registered figures for AIDS cases are collected at the WHO. These
figures are added together even though they are based on totally
different definitions. As the WHO writes in it's Bulletin: "Reports of
AIDS cases from most of the industrialized countries of Europe, North
America and Oceania are based primarily on the CDC/WHO definition; those
from Africa are, in general, based on nationally adapted versions of the
WHO clinical (Bangui) definition; and those from other countries involve
a combination of these definitions." (27)
Finally, another figure is added on top of the registered cases in order
to take account of the non-registered cases. Interestingly the number of
registered cases in Africa has been relatively low in recent years. In
contrast to this the estimate of non-registered cases has assumed
unbelievable proportions. Thus the total number of AIDS cases in Africa
consists almost entirely not of registered cases but of cases estimated
by he WHO.
|
Number of AIDS-cases in Africa following the WHO
cases in Africa (cumulative since 1980) reported
in millions |
estimated underreporting in millions |
estimated total in millions |
estimated cases in % of the total |
| WHO report July 1994 |
0.33 |
2.35 |
2.68 |
88% |
| WHO report January 1995 |
0.35 |
2.8 |
3.15 |
89% |
| WHO report July 1996 |
0.5 |
5.43 |
5.93 |
91,6% |
| WHO report November 1997 |
0.62 |
9.78 |
10.4 |
94% |
| cases between July 96 and November 97 |
0.12 |
4.4 |
4.5 |
97,3% |
Why should HIV be transmitted heterosexually in Africa?
As has already been mentioned, studies show that there is no independent
spread of HIV/AIDS in the heterosexual population in the US and Europe.
The assumption that this should therefore happen in Africa and Thailand,
for example, is not comprehensible. Further, it is without precedent in
medicine that the transmission of a pathogen should be so different in
different countries and continents.
The theory of the supposed heterosexual transmission of HIV in Africa
and Thailand because of widespread promiscuity is based solely on the
HIV tests described, which, as has been shown, often cannot be
interpreted under tropical conditions. This belief among other things is
contradicted by an international comparison of the number of sexual
partners and sexual activity. Here the US leads, followed by France,
Australia and Germany. In contrast, South Africa and Thailand are below
the world average. (38)
It is logical to suppose that the widespread explanation has been so
readily accepted because it fits in with the deep-rooted prejudices of
the Christian countries concerning the sexuality of Africans (and
Thailanders).
And if one reads the latest UNAIDS report the impression arises that
HIV/AIDS is being used as an apparently scientific proof of an enduring
prejudice:
"Indeed, since not every encounter between an HIV-positive and an
HIV-negative partner will result in a new infection, a sustain
heterosexual epidemic suggests that a substantial proportion of the
population, both male and female, have a number of sex partners over
their lifetimes." (36)
This fixation on heterosexual transmission shows the extent to which the
public discussion is shaped by Western convictions. In contrast, the
dissemination of Western medicine as a possible cause for the spread of
infectious diseases is played down. Yet it is generally well known that
the extent of invasive techniques with injections, blood transfusions
and operations, which characterises this form of medicine, can very
quickly become dangerous if standards of hygiene are not observed.
(39-41) And even the WHO confirms that "at minimum 12 billion injections
are performed every year throughout the world", and "at least one third
are not being carried out in a safe manner and may be spreading
disease". The situation is particularly dramatic in Africa, where more
than 80 per cent of disposable single-use syringes are used more than
once." (42)
In contrast, traditional medicine is less successful, but also less
dangerous when applied under poor hygiene conditions.
In view of the poverty in most African countries – more than half of
the population has no access to clean drinking water (43) – the European
fixation with a supposedly heterosexually transmitted AIDS epidemic in
Africa due to a promiscuous lifestyle can only be regarded as cynical.
What should be done?
1. Any Western country would strictly forbid foreign intervention in the
distribution of its budget. Consequently, lobbying for so-called
preventative measures in other countries should also be stopped.
2. In view of the shortage of resources, it is not medically
comprehensible why such funds should be invested precisely in the
documentation of HIV on the basis of unreliable tests, and of AIDS on
the basis of unsatisfactory definitions. Ultimately, these funds are
then not available in other areas. These activities should thus be
significantly reduced.
3. It is sufficiently recognised that people‘s health is essentially
dependent on their standard of living. Consequently, the available
resources should be invested there, for example in clean drinking water
and sewerage.
4. In the health sector the focus should again be on prevention and using
tried and tested treatment for well-known infectious diseases.
5. Invasive treatment should be avoided if it cannot be carried out under
strict hygienic conditions.
Where is the information coming from?
This consideration is essential for an understanding of developments
over the last 20 years, even if strictly speaking it does not have a
medical aspect.
Most scientific information on HIV/AIDS and advice on what to do about
it comes from the US and to some extent from Europe or from
organisations which operate from there. Developing countries are thereby
particularly dependent on the industrialised countries when it comes to
issues in their own country. Or, looked at from the other side, through
the AIDS discussion the industrialised countries have ensured themselves
of a right to a say in the internal affairs of the developing countries,
such as budget distribution and assessment of health priorities.
The international protest at the President of South Africa‘s initiative
to raise critical questions has impressively demonstrated that
developing countries are accorded no right to change this concept or to
introduce their own considerations.
This monopolisation of information and control of the media facilitates
manipulations that recall memories of colonial times.
People in Africa need our help and support. It is neither helpful nor
effective if wrong data and absurd definitions are employed to mislead
us and to divert attention from a country‘s real problems.
And most often these lie in well-known and treatable infectious diseases
and are essentially caused by low standards of living.
Christian Fiala MD
Mollardg. 12a
1060 Vienna, Austria
e-mail: christian.fiala@aon.at
Fax +43-1-597 31 92
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