Three international scholars from different continents review the subject, in an essay entitled "AIDS, Medicine and Public Health: The Scientific Value of Thabo Mbeki's Critique of AIDS Orthodoxy." While they supplied all notes and references, I have not included them with this essay, but will be glad to do so on request. The three authors want comments.
Charles L. Geshekter
Department of History
California State University, Chico
Chico, California 95929-0735
Sam Mhlongo, M.D.
Department of Family Medicine
Medical University of South Africa
P.O. Box 222
Medunsa, South Africa
Claus Köhnlein, M.D.
24103 Kiel Königsweg 14
In his installation address at the University of Witwatersand in 1998, Vice Chancellor Colin Bundy reminded the audience that a university "must encourage its academics and students never to take knowledge as given, as fixed: they must recognize that knowledge is 'socially sustained and invested with interests and backed by power'."
This advice was forgotten when scientists and activists gathered in Durban for the 13th International AIDS Conference in July 2000 - then again in Barcelona/2002 and in Bangkok/2004. They ignored the many paradoxes and contradictions that arouse serious concern about the reliability of African AIDS research. In the United States, where AIDS was first identified, an imprecision about the definition of the syndrome and its causation (abetted by a lack of journalistic and social science scrutiny) still clouds the public's understanding of HIV and AIDS.
This paper evaluates how the assumptions and claims that turned "AIDS is everywhere" into an American cliché are being perpetuated in Africa. It scrutinizes the predictions of increased numbers of AIDS cases in Africa to show how conceptual flaws and questionable statistics mar conventional studies. It suggests that western stereotypes, poorly designed research and racist claims about African sexuality have created the untenable conclusions about AIDS now proliferating in Africa.
In a critique of armchair empiricism that applies to much AIDS research, Margo Russell and Mary Mugyenyi showed how analysts often squeeze "African data into inappropriate Western categories" and "international agencies, with their passion for international comparison...exert a strong pressure for just the kind of standardization that sociologists should be well-placed to reject."
In many ways, AIDS has become a great diversion. The belief that behavior modification will cure poverty disguises the endemic conditions that cause the appearance of the "symptoms" in the first place. Many AIDS activists and researchers ignore the complexity of historical forces that propelled parts of Africa into a downward economic spiral beginning in the late 1970s that set the stage for the appearance of "AIDS."
In the Reagan Era, a "Washington Consensus" dominated official thinking about economic development in the U.S. government, the IMF, the World Bank and private banks and foundations. It called for sharp cutbacks in government spending, financial liberalization, privatization of state-owned enterprises, deregulation and the supremacy of the market over all other values, policies that contributed mightily to the demise of Africa. According to Joseph Stiglitz, an economist formerly with the World Bank, during the 1990s, the number of people living in extreme poverty (less than $2 per day) increased by nearly 100 million, world-wide, with the disproportionate amount being found in Africa.
Countries in east and southern Africa became so indebted to and dependent on international financial institutions that they were no longer free to make basic decisions about which goods and services could be allocated. Beginning in the late 1970s, corruption and decay in the public health field, sharp decreases in the prices of exported commodities, severe restrictions on social services due to the IMF and World Bank strictures of "structural adjustment," savage civil wars, declining rates of immunization, and crowded refugee camps were among the major forces afflicting Africa as the 20th century ended. None of these forces were related to sexual promiscuity.
It is crucial to distinguish between a virus (HIV) and a syndrome (AIDS) to recognize how ambiguous definitions help to spawn misinformation about AIDS. A major part of this problem derives from alphabetic shorthands that are often used interchangeably, such as HIV, HIV disease, HIV infection, HIV/AIDS, AIDS, STD/AIDS, TB/AIDS, STD/TB/AIDS. In July 1997, the Gauteng Health Department [South Africa] concluded that it was "outdated and inaccurate" to say that someone "has AIDS." Rather than distinguish between an HIV antibody test result and a case of AIDS, the Department decided it would henceforth use the term "HIV infection" to include every stage of infection and disease.
This shift in terminology is often overlooked in those media accounts that predict African life expectancy or death rates based on projections of HIV infections. Discrepancies are further evident when comparing HIV and AIDS figures in the annual World Health Reports issued by the World Health Organization and its Weekly Epidemiological Record (WER) with statistics from the frequently cited Report on the Global HIV/AIDS Epidemic that was widely distributed by UNAIDS at the XIII International AIDS Conference in Durban (July 2000).
In November 2000, the WER provided the cumulative totals of AIDS cases for the past 18 years in the following countries: Zimbabwe (74,782); South Africa (12,825); Uganda (54,712); and Swaziland (3,528). The World Health Report 1998, which "uses the latest data gathered and validated by WHO", gave the following numbers of AIDS cases in those four countries for 1996: Zimbabwe - 9,129; South Africa - 729; Uganda -3,021; and Swaziland - 249.
When the Report on the HIV/AIDS Epidemic conflated the number of reported AIDS cases with the estimated number of Africans said to be HIV antibody-positive, these were the results:
Zimbabwe South Africa Uganda Swaziland
Estimated number living with HIV/AIDS 1.5 million 4.2 million 820,000 130,000
Conventional claims about the viral cause of AIDS rarely rely on empirical standards of verification. For instance, a survey of adult mortality in Lusaka, Zambia cited the most frequently reported causes of death to be "diarrhoea (20%), malaria or fever (9%), witchcraft (7%), tuberculosis (7%), and cough (6%). AIDS was given as the cause in 3% of deaths." The researchers breezily concluded that since "HIV seroprevalence in Lusaka is currently 25-30%, and given the unusual prominence of diarrhoeal disease as a cause of death, we believe that HIV infection is largely responsible for the high death rate [emphasis added]".
Before international donors conduct yet another knowledge-attitude-practice survey or insist that people modify their sexual behavior, they should subject the basic suppositions about AIDS cases in Africa to the standards of consistency, testability and parsimony. Unless researchers concur on the surveillance methodology used to define a case of AIDS, they will disagree on substantive policy recommendations regarding its prevention and treatment. It is important for scientists to gather data, weigh and interpret evidence and verify the accuracy of the claims made by AIDS experts.
AIDS in Africa has become one of the great medical fallacies of our times. After twenty-four years, AIDS in Africa has devolved into a series of rhetorical gimmicks, underneath which remains a vacuum that, at its core, is devoid of historical context. The "war on AIDS" is a political slogan, not a coherent strategy for public health improvements, and it succeeds brilliantly as political theater. Why have African Studies academics submitted so willingly to this set of claims organized around sexual fears? Why do AIDS researchers and activists become unhinged at the prospect of new thinking? Even posing questions is often considered impermissible and anyone who raises them usually evokes dismissive name-calling, deligitimizing, or much worse. Why do mundane facts, the scientific method, and second thoughts seem to matter so little to social crusaders on the hunt for improper sexual behavior?
By dogmatic repetition, the notion has been pounded into the public's mind that HIV tests are reliable. Those who start with the concept of HIV as a retrovirus that causes AIDS, quickly seize on any decline in HIV rates as proof or evidence that AIDS cases are receding.
The confusion that deters us from thinking carefully about AIDS in Africa is borne of several factors: 1) racist claims about African sexuality and assumptions about truck drivers and prostitutes that have achieved the status of "urban legends;" 2) conjured up statistics that evaporate whenever one tries to pin them down specifically to a metropolitan area or the province of any country; 3) an inability to distinguish the unreliability of HIV antibody tests from the clinical symptoms of an "AIDS" case; and 4) an unfamiliarity with the nature of political economies of African states since the late 1970s. Nowhere are these factors more pronounced than in contemporary South Africa.
And it is South Africans who have begun to demand more reliable data concerning HIV infection rates and actual AIDS cases. The editor of the South African Medical Journal, Daniel Ncayiyana, questioned the uncritical way that HIV and AIDS statistics are selectively gathered from women at antenatal clinics, then extrapolated as somehow representative of the entire country. He pointed out that a "gaping discrepancy in prevalence between KwaZulu-Natal and the eastern Cape remains unelucidated" and wondered why the "actual trail of infection from the city to rural areas has not been properly traced."
In late 1999, President Thabo Mbeki directed his Minister of Health, Dr. Manto Tsabalala-Msimang, to investigate the safety and health benefits of AZT, a toxic and expensive drug that produces metabolic abnormalities in laboratory animals and whose life-extending benefits remain unproven.
Dr. Tshabalala-Msimang told South African television audiences in December 1999 that she would never recommend AZT, advice echoed on the same program by Dr. Sam Mhlongo, the Head of the Family Medicine Department at MEDUNSA. These controversial opinions suggested that a re-appraisal of HIV/AIDS research in Africa was underway.
In early 2000, President Mbeki appointed an AIDS Advisory Panel that consisted of 52 researchers, scholars and activists (including the three co-authors of this paper) who held widely discordant views on the definition, causation, prevention and treatment of AIDS cases. Mbeki sought evidence-based answers to three basic questions: 1) what causes the immune deficiency that leads to death from AIDS; 2) what is the most efficacious response to this cause or causes; and 3) why is HIV/AIDS in sub-Saharan Africa heterosexually transmitted while in the western world it is said to be largely homosexually transmitted?
Mbeki applied the principle of "Occam's razor" to AIDS, the scientific rule that the simplest of competing theories is preferred to the more complex, that explanations of unknown phenomena are to be sought first in terms of known quantities. The essence of the scientific method is to frame and operationalize a hypothesis "whose predictions comport with observable results in a consistent manner. If the hypothesis is valid and testable, its result should be generally reproducible, rather than unique to a particular experiment."
As an economist, Mbeki questioned the authority of the international AIDS establishment because he was not convinced that sexual behavior, rather than poverty and malnutrition, were "at the root of his country's medical woes." As a political leader concerned about his nation's well being, he sought credible explanations for how an alleged "disease" could be defined with such decisive differences from one continent to another. Mbeki felt that light could be shed on these issues in a public dialogue about public health, politics, and scientific accuracy.
Interested in academic risk-taking, Mbeki unwittingly stirred up a hornet's nest and furious international swarming began immediately. It become apparent that those intent on "fighting AIDS" had adopted a missionary-style crusade, evidently similar to "fighting apartheid" in the minds of many "activists" whose lives seemed to be on a "permanent campaign" of some sort. Their reliance on military metaphors, apocalyptic visions, and the withering scorn shown toward any disagreement reflected a zealotry that brooked no opposition or dissent. Outside the Durban Conference Center at the 2000 AIDS Conference, demonstrators held signs that advocated, "one dissident, one bullet," neatly capturing the anti-science militancy of AIDS activists.
The AIDS orthodoxy has long rejected unconventional views and stifled what ought to have been a lively, inclusive debate on issues ranging from statistics and epidemiology to science, economic history, and notions about African sexuality. They believe that if anyone dares to question their core beliefs, he commits a great evil. This is not something they can prove logically or explain rationally -- it is, for them, simply an article of faith.
Thabo Mbeki challenged their faith and ignited an overdue debate in crucial ways. He created a forum and an opportunity to consider all manner of questions. From his readings, he detected ambiguities and tautologies in the mainline AIDS literature. Mbeki resisted pat answers and challenged many assertions. He insisted that we consider a different causal reality in terms of what was making South Africans ill. Mbeki did something that AIDS experts and other African leaders rarely did: he defied the professional consensus about HIV/AIDS and opened his mind to new ideas.
After several acrimonious meetings in South Africa (May and July 2000) followed by a robust set of internet exchanges among its members, the Presidential AIDS Advisory Panel issued a synthesis of its findings; its March 2001 report failed to reach a consensus but carefully articulated several opposing viewpoints.
Millions of Africans have long suffered from severe weight loss, chronic diarrhea, fever and persistent coughs. In 1985, western researchers suddenly reconfigured this cluster of symptoms into a new syndrome (AIDS), which they declared was caused by a single virus - HIV - that could be transmitted through sexual contact. American health officials accept this HIV/AIDS model to explain the clinical manifestations of impoverished living conditions in Africa. There are several reasons why Mbeki realized the need for careful reconsideration.
First, many Africans who qualify for an AIDS diagnosis - perhaps as many as 70% - turn out to be negative when tested for HIV according to the Western Blot.
Second, this African HIV/AIDS model failed to predict the course of AIDS in the United States. Since the clinical symptoms that define an AIDS case are widespread in the general African population, if it transmits heterosexually it should also become widespread in other general populations, such as Americans, in which hundreds of thousands of heterosexuals annually contract venereal diseases. Instead, 23 years after it was first described in the medical literature in the United States, AIDS remains confined to special risk groups. Of the 40,000 annual American AIDS patients, nearly 90% are either drug users or homosexuals and fewer than 10,000 are identified as heterosexual cases.
Third, sexual transmission cannot explain the differences in alleged rates of HIV positivity between African (about five per 100) and American (about one per 7000) heterosexuals. When the HIV/AIDS paradigm debuted in 1984, its proponents assumed that HIV was easily transmitted coitally. When scientists actually tested this idea ten years later, they arrived at extremely low coital transmission frequencies. Researchers routinely classify HIV infection as a sexually transmitted disease (STD) without acknowledging the extraordinary difficulty of the sexual transmission of HIV.
Studies by Nancy Padian and her associates demonstrate that the infectivity rate for male-to-female transmission is extremely low, "approximately 0.0009 per contact," while female-to-male transmission is eight times less efficient. In other words, an HIV-negative woman may convert to positive on average only after one thousand unprotected contacts with an HIV-positive man. An HIV-negative man may become positive on average only after eight thousand contacts with an HIV-positive woman. These data suggest two mutually exclusive conclusions. Either HIV is not a sexually transmitted microbe at all and other factors must account for HIV seroprevalence, or else African heterosexuals are more promiscuous than American heterosexuals, an unproven assumption rooted in hoary racist stereotypes.
With this in mind, why did so many public health professionals and officials come to view the diseases of poverty in Africa as sexually contagious? How can one virus cause twenty-nine heterogeneous AIDS indicator diseases almost entirely among males in Europe and America but afflict African men and women in nearly equal numbers? The answer is that the World Health Organization uses a definition of AIDS in Africa that differs decisively from the one used in the West. The origins of this definition of African AIDS are quite illuminating.
3. Defining AIDS in Africa
Joseph McCormick and Susan Fisher-Hoch were physicians from the U.S. Centers for Disease Control (CDC) who were instrumental in convening the WHO conference in the Central African Republic in 1985 that produced the "Bangui Definition" of AIDS in Africa. The CDC had just adopted the HIV/AIDS model to explain immune disorders found among American drug injectors, transfusion recipients, and a small cohort of promiscuous urban gay men. There was a tendency for HIV antibodies to react with plasma from some of these patients. The same was apparently true of blood from Africans afflicted with the diseases of poverty. The infectious viral model of AIDS assumed that immune deficiency would spread via HIV to a much larger faction of Africans than those who tested positive for the antibodies.
McCormick and Fisher-Hoch accepted this model. Here is how they explained their motivation for the Bangui Conference and the rationale behind the AIDS definition that resulted from it:
"We still had an urgent need to begin to estimate the size of the AIDS problem in Africa....But we had a peculiar problem with AIDS. Few AIDS cases in Africa receive any medical care at all. No diagnostic tests, suited to widespread use, yet existed....In the absence of any of these markers [e.g., diagnostic T4/T8 white cell tests], we needed a clinical case definition....a set of guidelines a clinician could follow in order to decide whether a certain person had AIDS or not. [If we] could get everyone at the WHO meeting in Bangui to agree on a single, simple definition of what an AIDS case was in Africa, then, imperfect as the definition might be, we could actually start to count the cases, and we would all be counting roughly the same thing. [emphasis added]
The definition was reached by consensus, based mostly on the delegates' experience in treating AIDS patients. It has proven a useful tool in determining the extent of the AIDS epidemic in Africa, especially in areas where no testing is available. Its major components were prolonged fevers (for a month or more), weight loss of 10 percent or greater, and prolonged diarrhea..."
The doctors recalled that:
"experts in STDs continued to regale us with tales of the excessive and often bizarre sexual practices associated with HIV in the West...we were also beginning to see a direct correlation between the number of sexual partners and the rate of infection...Compared to the West, heterosexual contacts in Africa are frequent, and relatively free of social constraints - at least for the men....There was every reason to believe that, having found heterosexually transmitted AIDS in Kinshasa, we were likely to find it everywhere else in the world."
It was upon these unsubstantiated claims, clinical generalizations, western notions of sexual morality and stereotypes about Africans that AIDS became a disease by definition. Africa was assigned a central role in the premise that AIDS was everywhere and everyone was at risk. By 1986, "people were falling over one another to get involved in AIDS research," recalled the physicians. "They realized that AIDS represented an opportunity for grant money, training, and the possibility of professional advancement....A certain bandwagon mentality took hold. Careers and reputations were riding on the outcome."
As proof that these AIDS symptoms were sexually transmitted, McCormick and Fisher-Hoch relied on a narrow survey conducted by Kevin DeCock, another CDC epidemiologist. DeCock examined stored blood samples taken in 1976 (for Ebola virus testing) from 600 residents of the small town of Yambuku, in northern Zaire. Samples from five patients (0.8%) tested positive for HIV antibodies.
DeCock wanted to know what happened to those five people during the intervening ten years. According to McCormick and Fisher-Hoch:
"three of the five were dead. To determine if their deaths were attributable to AIDS, Kevin interviewed people who had known them. The friends and relatives of the deceased described an illness marked by severe weight loss and other ailments that left little doubt in Kevin's mind that they had succumbed to AIDS [emphasis added]."
DeCock concluded from these interviews that the subjects had died from AIDS, and that HIV had caused their death. He reached this conclusion without matching the five HIV-positive patients with peers from among the 595 HIV-negative subjects and without collecting mortality data and morbidity information about them. Had he done this, perhaps he would have discovered that numerous HIV-negative Africans also die of severe weight loss and other so-called AIDS conditions.
DeCock further noted that antibody tests conducted in 1986 showed that the HIV prevalence in Yambuku had remained constant at 0.8% during the ten years since 1976. As far as he was concerned, this meant that HIV - and thus AIDS - really originated in Africa where it had existed for years in small numbers of rural inhabitants whom he imagined had contracted it from primates. He speculated that once some of those people in the late 1970s migrated to what he assumed were sexually promiscuous urban areas, an epidemic of HIV and AIDS exploded. DeCock did not consider that these same data could have been interpreted as indicating that HIV is a mild virus and difficult to transmit. Neither did McCormick and Fisher-Hoch.
The presumptive diagnosis employed by DeCock is known as a "verbal autopsy." It is widely accepted in Africa, where "no country has a vital registration system that captures a sufficient number of deaths to provide meaningful death rates." While medically certified information is available for less than 30% of the estimated 51 million deaths that occur each year worldwide, the Global Burden of Disease Study (GBD) found that sub-Saharan Africa had the greatest uncertainty for the causes of mortality and morbidity since its vital registration figures were the lowest of any region in the world - a microscopic 1.1%.
When the mainstream media use the term "AIDS-related illness," they accept the sweepingly wide set of clinical symptoms that suddenly came to "define" an AIDS case anywhere in Africa in October 1985 and has remained in place ever since.
4. AIDS and Historiography: A Case Study from East Africa
As a case study in how scholarship about recent African history may be marred by an over-emphasis on HIV/AIDS, we examine an otherwise fine book by John Illiffe, East African Doctors: A History of the Modern Profession.
Based on extensive archival research and a meticulous review of the vernacular press, this study by a leading historian of Africa explains how Africans became physicians in 20th century Uganda, Kenya and Tanzania. The writing is lucid and compelling, the arguments rich with personal anecdotes and insights.
At the outset, Iliffe states, "Not since the origins of mankind has East Africa been so important to the world as it is today. The special importance comes from the AIDS epidemic" Claiming that East African doctors have charted the "epidemiology of heterosexually transmitted AIDS" and devised control strategies, Iliffe eventually ends his book "as it began, with AIDS" His historical analysis is framed by assumptions about AIDS that warrant careful scrutiny.
Chapters two through nine of East African Doctors epitomize Iliffe's cogent style of historical reconstruction. The chapters on post-colonial public health document how deteriorating political economies (not some rainforest virus) produced the classic symptoms of sickness - fever, persistent cough, diarrhea and weight loss - that American researchers re-defined as a new and distinct illness (AIDS) in the early 1980s, declaring it was caused by a single virus (HIV) which could be transmitted through sexual contact.
Under colonial education systems, an elite corps of African trainees dissected cadavers, learned precision in dosages and relied on microscopes "to embody rationality and enlightenment" In the 1940s, Ugandan physician Sebastiano Kyewalyanga promoted hospitals and doctors for babies so Africans would achieve "better health, stressing regular breastfeeding, hygiene, nutrition, better housing, [and] the advantages of modern medical aid" Bernard Omondi, a Kenyan doctor in the 1950s, diagnosed the causes of death at Kerugoya district hospital - pneumonia, gastroenteritis, tuberculosis and kwashiorkor - as a "syndrome with malnutrition at its root," due primarily to socio-economic changes. The writings of these men impressed Iliffe "by how optimistic they were at this time of their ability to improve their societies."
Chapters 7-9 provide the plausible context for the public health debacles that set the stage for AIDS: the violence and social chaos in Uganda, corruption and financial stringency that attended capitalist development in Kenya, and flawed attempts to transform the medical system in a socialist direction in Tanzania. After independence, public health was weakened throughout East Africa by fiscal constraints, population growth, the spread of tuberculosis, and such endemic environmental diseases as "malaria in the lowlands and respiratory infections in the highlands."
During Idi Amin's destructive regime (1971-79), per capita income in Uganda declined by 6.2% per year and the Ministry of Health's real expenditure per person fell 85% while the country endured cholera and typhus epidemics, a major expansion of sleeping sickness and the worst measles epidemic in its history. At Mulago Hospital and Medical School, the water supply broke down for a decade, the mortuary's refrigeration system collapsed, sewerage ceased to function, no X-ray units worked, and the food store was "full of rats and vermin."
Insecurity persisted after Amin's ouster. Immunization rates among Ugandan infants in 1985 were only 13% for polio, 17% for measles, and 37% for tuberculosis. The illicit sale of pharmaceuticals grew rampant as self-medication with illegal drugs was the "surrogate for a collapsing medical system" in a country whose GDP per capita in 1985 remained 43 per cent lower than in 1970. "The accumulated deterioration made the late 1980s the nadir of health services," writes Iliffe, when "the pain and squalor of dilapidated hospitals" left them with little water, electricity, sewerage, equipment, transport or drugs.
A similar degeneration affected Kenya. The open selling of drugs, "apart from ...the possibility of poisoning," alarmed doctors because "it bred drug resistance." By 1992, "the dose of penicillin needed to cure gonococcal infection had increased over a hundredfold"
Tanzania shifted expenditures and doctors from urban hospitals to village health centers to cultivate ujamaa egalitarianism. Despite successful mass immunizations against measles, polio, and tetanus, public health worsened by the 1980s. Health facilities "were often dilapidated and the staff demoralized, chiefly for lack of money in a country whose real Gross National product per capita had fallen by an average of 0.5 per cent a year between 1965 and 1988." According to Iliffe, "[P]overty-related conditions like malnutrition, malaria and diarrhoea were ... treated least effectively. Poverty explained why the main complaint against health facilities was lack of drugs, for poverty not only prevented their procurement and distribution but corrupted the medical staff who sold them for their own profit."
In his concluding chapters, Iliffe appears undisturbed by the major role of pharmaceutical corporations in funding AIDS research, has no qualms about the zealotry of sexual behavior modification programs imported from the West, is not skeptical about the infectious viral theory of immuno-deficiency, and never questions whether "AIDS" really exists as a "new" disease.
Iliffe simply calls AIDS a "plague," a "death sentence," and a "general malaise" marked by sporadic fever, weight loss, persistent cough and periodic diarrhea. These are also the clinical symptoms of malaria, tuberculosis or malnutrition. He seems not to know that HIV tests do not detect a virus itself, only viral antibodies that are analyzed with an assortment of proteins not unique to HIV.
In contrast to the media's doomsday scenarios, Iliffe quotes Dr. Anthony Lwegaba who wisely concedes that AIDS "might not be one disease, but a collection of diseases" and Dr. Elly Katabira who sensibly observes that "many treatable conditions requiring hospitalization occur in AIDS patients." Iliffe even allows that "if properly treated, most AIDS patients improved before leaving hospital," and that "although AIDS was incurable, chronic, infectious and widespread...it was also treatable, long-survived, [and] hard to transmit."
As our paper attempts to show, the clinical symptoms that define AIDS in Africa seem to appear in roughly equal numbers among men and women, not because of heterosexual transmission, but because the socio-economic conditions that produce those symptoms are caused by environmental insults to which many impoverished Africans - male and female - are regularly exposed.
Malnourished individuals or those who suffer from malaria, tuberculosis or repeated attacks of dysentery have many cross-reacting antibodies in their systems making it impossible to prove that any one particular microbe was the cause of the symptoms. The best predictors for an AIDS diagnosis in Africa are economic deprivation, protein malnutrition, poor sanitation and parasitic infections, not extraordinary sexual behavior or antibodies for a virus that has proven difficult to isolate directly.
John Illiffe has written a superb historical analysis of the East African medical profession. Although it probably wasn't his intention, his seminal book provides abundant data for scholars to begin a thorough reappraisal of the real origins of "AIDS" in Africa.
5. Racism and African Sexuality
Whereas acquired immune deficiency in the industrialized countries is almost exclusively a disease of a tiny percentage of homosexuals, intravenous drug users and recipients of tainted blood transfusions, AIDS cases in Africa are said to be as general and indiscriminate as such long-time African scourges as malaria, tuberculosis, schistosomiasis, and sleeping sickness (trypanosomiasis).
This is the "heterosexual paradox" of AIDS in Africa when compared to the United States and western Europe. Some researchers consider the paradox is temporary. They speculate that HIV evolved or emerged first in Africa and that, in time, AIDS will be just as rampant in the West. However, they have said this for twenty-four years and nothing of the sort has occurred.
Other researchers account for a "permanent paradox" by suggesting that Africans are somehow different from Westerners, are substantially more promiscuous, and hence more likely to have genital ulcers. How else can they explain the widespread distribution of a virus whose transmission requires, for non-ulcerated genitals, a thousand heterosexual acts? Such insinuations warrant the closest scrutiny since generalizations about African sexual practices are analytically useless on an internally diversified continent of 650 million people.
At the 10th International AIDS Conference in Yokohama (August 1994), Dr. Yuichi Shiokawa claimed that AIDS would be brought under control only if Africans restrained their sexual cravings. Professor Nathan Clumeck of the Université Libre in Brussels was skeptical that Africans will ever do so. In an interview with Le Monde, Clumeck claimed that "sex, love, and disease do not mean the same thing to Africans as they do to West Europeans [because] the notion of guilt doesn't exist in the same way as it does in the Judeo-Christian culture of the West." AIDS educators try to counter this purported lack of guilt in African sexuality through conservative appeals to restraint, negotiating safe sex and a nearly evangelical insistence on condom use.
Many orthodox AIDS researchers glibly perpetuate racist stereotypes of libidinous black men and women. The myths about the sexual excesses of Africans are old indeed. Early European travelers returned from the continent with tales of black men performing carnal feats with unbridled athleticism, with black women who were themselves sexually insatiable. These affronts to Victorian sensibilities were cited, alongside tribal conflicts and other "uncivilized" behavior, as justification for colonial social control.
AIDS researchers added new twists to an old repertoire: stories of Zairians who rub monkeys' blood into cuts as an aphrodisiac, of ulcerated genitals, and of philandering truck drivers who get AIDS from prostitutes and then go home to infect their wives. A facetious letter in The Lancet even cited a passage from Lili Palmer's memoirs as evidence for how a large male chimpanzee's "anatomically unmistakable signs of its passion for [Johnny] Weismuller" on the Tarzan set in 1946 "may provide an explanation for the inter-species jump" of HIV infection.
Some researchers assert that many African men prefer "dry sex" whereby women, particularly prostitutes, are said to "insert substances, such as household detergents or antiseptics, in their vagina prior to intercourse in order to prevent wetness." According to a study in The Lancet, this practice allegedly produces a "hot, tight, and dry" environment, which their men find more pleasurable but which may "increase the risk of HIV-1 transmission, since the substances could cause the disruption of the membranes lining the vaginal and uterine wall."
Another theory attributed the origin of HIV to the "repeated radiation exposure of chimpanzees and mangabey monkeys in equatorial Africa" to strontium-90 from uranium mining in the former Belgian Congo and to radiation from atmospheric nuclear tests in the equatorial Pacific Ocean in the 1950s and 1960s after "radioactive fallout from them circled the globe around that latitude." The latest speculation traced the origins of AIDS cases to live attenuated oral polio vaccines that were accidentally contaminated in the Congo, allegedly with tissues from a primate version of HIV.
Aside from the lack of verification to corroborate these claims, no one has ever shown that people in Rwanda, Uganda, Zaire, and Kenya - the so-called AIDS belt - are more sexually active than people in Nigeria which has reported a cumulative total of only 26,276 AIDS cases out of a population of 120 million or Cameroon which reported 18,986 cases in 14 million. No continent-wide sex surveys have ever been carried out in Africa. Nevertheless, conventional researchers perpetuate stereotypes about insatiable sexual appetites and carnal exotica. They assume that AIDS cases in Africa are driven by a sexual promiscuity similar to what produced - in combination with recreational drugs, sexual stimulants, venereal disease, and the over-use of antibiotics - the early epidemic of immunological dysfunction among a small sub-culture of urban gay men in the West.
Case studies from Africa suggests nothing of the sort. In 1991 researchers from Médicins Sans Frontières and the Harvard School of Public Health surveyed sexual behavior in Moyo district of northwest Uganda. Their findings revealed behavior that was not very different from that of the West. On average, women had their first sex at age 17, men at 19. Eighteen per cent of women and 50% of men reported premarital sex; 1.6% of the women and 4.1% of the men had casual sex in the month preceding the study, while 2% of women and 15% of men had done so in the preceding year.
The media misrepresentations that link sexuality to AIDS have spawned inordinate anxieties in regions of Africa already afflicted with extreme poverty, ravaged by war, and deprived of primary health care delivery systems. The disaster voyeurism of tabloid journalism enables the media to use AIDS to sell "more newspapers than any other disease in history. It is a sensational disease - with its elements of sex, blood and death it has proved irresistible to editors across the world." In the past ten years, western media have used unrelentlingly melancholy metaphors to portray Africans as helpless wretches, which, according to one study, only homogenize complex situations and ironically contributes to public apathy and "compassion fatigue."
In this age of globalization, public health seems to require more salesmanship than skepticism. The media's appetite for scare tactics and its disdain for alternative perspectives enables them to treat Africa in apocalyptic terms. Doomsday scenarios compare AIDS in Africa to the great epidemics in history like the Black Death of the Middle Ages that killed 20 million people. USA Today warned about "a time bomb ticking south of the Sahara" and UNICEF called AIDS "the modern incarnation of Dante's Inferno." U.S. Senator Diane Feinstein of California said, "I truly believe that the AIDS crisis is worse than the bubonic plague...this crisis can wipe out sub-Saharan Africa as we know it today. It is mega in its impact on the world..." Earlier this year, Professor Richard Feachem, Director of the Global Fund to Fight AIDS, TB, and Malaria, pronounced it "the worst disaster in recorded history."
At the 15th International AIDS Conference in Bangkok (July 2004), these images of HIV/AIDS-ravaged Africa were taken as indisputable. Convinced that a strange mutant retrovirus was unleashed on Africa from the rainforest to cause AIDS, spread by promiscuous truck drivers and prostitutes, activists and researchers have ignored the socio-economic history of modern Africa when waging their war on AIDS. Its preferred weapons are the endless preaching of abstinence, sexual behavior modification schemes and condom use (the ABCs), and the prescribing of drugs of dubious effectiveness and often-demonstrated toxicity.
The marketing of anxiety is supposed to promote the sexual behavior modification that will help "save Africa." Some writers feel that the manufacture of fear is a good way to increase social awareness. For conservatives who want to see "the notion of sexual responsibility [shake] off its puritanical image," the subsequent "public anxiety about AIDS is seen as an important sentiment for popularizing a more restrictive and puritanical sexual ethos."
Oblivious to the morbidity and mortality data from the Global Burden of Disease Study, journalists reflexively maintain that "AIDS is by far the most serious threat to life in Africa." Given the momentum behind this assumption, few scientists question the infectious AIDS hypothesis, leaving little reason for the media to scrutinize the premises or reliability of AIDS research.
The claims that millions of Africans are threatened by AIDS or are already HIV-positive make it politically acceptable to use the continent as a laboratory for vaccine trials and for the distribution of toxic drugs of disputed effectiveness like AZT. For instance, AZT is a toxic chemical whose primary biochemical action is the random termination of DNA synthesis, the central molecule of life. It is frightening to recommend giving such a carcinogenic drug to pregnant women because fetuses cannot develop into babies without DNA synthesis.
Moreover, media claims that safe sex is the only way to avoid AIDS inadvertently scare Africans from visiting public health clinics for fear of receiving an AIDS diagnosis. Even Africans "with treatable medical conditions (such as tuberculosis) who perceive themselves as having HIV infection fail to seek medical attention because they think that they have an untreatable disease." Biomedical funds that used to fight malaria, tuberculosis and leprosy are now diverted into sex counseling and condom distribution, while social scientists shift their attention to behavior modification programs and AIDS awareness surveys.
One such initiative - the Summertown HIV-Prevention Project - lasted three years in an impoverished South African township. It was described as a "mixed bag of disappointments and achievementsŠ[as] many proposed activities [were] yet to be implemented, consistent and widespread condom use remains lowŠand the most damning lack of Project success over the three-year research period is the lack of evidence for any reduction in STI [sexually transmitted infection] levels." The analysis by its Director uses such impenetrable prose that one is not surprised by the Project's admitted lack of effect on either sexual behavior, HIV rates, or AIDS cases. As she states in her conclusion:
"In the interests of contributing to the development of a critical social psychology of sexuality, the research has illustrated the way in which sexual behaviour, and the possibility of sexual behaviour change, are determined by an interlocking series of multi-level processes, which are often not under the control of an individual person's rational conscious choice. Sexualities are constructed and reconstructed at the intersection of a kaleidoscopic array of interlocking multi-level processes, ranging from the intra-psychological to the macro-social."
The researchers of the Summertown project accepted the theory that sexual behavior changes would make people unsick and enable them to stay well. They never imagined that their project failed because its core construct was flawed, erroneous and incapable of correction. Did they ever consider that the production of HIV antibodies was environmentally induced, having little or nothing to do with sexuality?
In Africa, where women contract so-called "Slim Disease" in numbers roughly equal to males, there is no evidence to link the onset of immune deficiency with engagement in promiscuous homosexual intercourse. Intravenous drug use seems uncommon among villagers and city dwellers. Does this mean, deductively, that in Africa heterosexual intercourse itself puts everyone at risk for AIDS? Does the "AIDS epidemic" in Africa portend the future of the developed world? Many scientists, bio-medical researchers and AIDS experts still believe this is the case.
As anyone who attended the International AIDS Conference can attest, there were far
more signs of an openly assertive "sexual culture" of surfers, casual drug users,
semi-nudity, porn shops, sex shops and beautiful prostitutes within one square mile of any
hotel at South Beach in Durban than, say, one ever sees in 1000 square miles of
Zululand and Maputaland. If AIDS in South Africa is linked to heterosexual behavior
or condomless sex, then its epicenter should be found amidst the white oceanfront
culture of Durban, or the leafy suburbs of north Johannesburg, or the international swingers'
scene around Camps Bay and Sea Point in Cape Town. But those areas are, of course, the last
places one finds AIDS cases in South Africa.
This takes us back to Thabo Mbeki. After the distinguished Harvard physician Paul Farmer
found himself at conferences where professional colleagues went "practically purple with
rage discussing Mbeki," even accusing him of genocide, he decided to look dispassionately
at the controversy. Farmer concluded, quite sensibly, that Mbeki's message was that
"poverty and social inequality serve as HIV's most potent co-factors, and any effort to
address this disease in Africa must embrace a broader conception of disease causation."
Farmer acknowledged, "this is precisely the point many of us have tried to makeŠ.and
we haven't been branded as AIDS heretics."
6. Faulty Science: HIV Antibody Tests and Disease
A reappraisal of AIDS in Africa must recognize that HIV tests are notoriously unreliable among African populations where antibodies against conventional microbes cross-react to produce unacceptably high false results. For instance, a 1994 study in central Africa reported that the microbes responsible for tuberculosis and leprosy were so prevalent that over 70% of the HIV-positive test results were false. The study also showed that HIV antibody tests register positive in HIV-free people whose immune systems are compromised for a variety of reasons, including chronic parasitic infections and anemia brought on by malaria that are widespread in populations with the diseases of poverty.
By definition, all viruses that cause a disease infect over 30% of the cells they target, are present in the blood at concentrations in excess of 10,000 per milliliter, and are contagious. HIV is such a weak retrovirus that, when detected at all, it is present in such low concentrations (about one per milliliter) that only its antibodies can be detected. This explains why it is barely transmissible, requiring an average 1000 unprotected vaginal sex contacts with an antibody-positive person for someone to "acquire" HIV.
HIV tests (the ELISA and Western Blot) do not detect any virus itself but rather viral antibodies that are read with an assortment of proteins that are not even unique to HIV. One review of the medical literature identified nearly 70 different medical and disease conditions that were documented as capable of triggering a positive result with the test. The tests detect antiviral immunity which is a prognosis against, not for HIV. The tests fail three basic criteria: they are not specific, there is no standard interpretation of the results, and the results are not reproducible.
In a study that explained why there is no correlation between a positive HIV antibody test result and the isolation of HIV itself, the authors concluded that "the use of HIV antibody tests as predictive, diagnostic and epidemiological tools for HIV infection needs to be carefully reappraised." Another investigation reported that even if HIV-1 is detected in the blood or cervical secretions of an HIV-positive woman, "the amount of HIV-1 excreted in the cervicovaginal fluid is independent of the quantity of virus present in the blood cells or plasma." Richard Strohman, Professor Emeritus of Molecular Biology at University of California (Berkeley), points out:
"HIV science has always been based not on detection of real infectious units (real virus) growing under some reasonable standard condition in living cells in the lab. Rather it is based upon a high tech series of assays constructed so that disappearingly small quantities of the virus, or some part of the virus, or some trace (aura) of viral presence may be measured. We have substituted the measurement for the real thing, like substituting the menu for the meal."
The association of HIV antibody tests with ordinary infections does not mean that a positive result warrants a prognosis of death, an effect that would defy all classical experience with viruses, microbes and antibodies. Antibodies are proteins made by the immune system that react against microbes. The presence of antibodies is a near-perfect predictor of protection against a virus or microbe. It is unprecedented that antibodies would be predictive of a disease to come. Yet with HIV antibodies, the patient has never had one of the diseases which is said to occur after its detection.
According to Dr. Valendar Turner of Royal Perth Hospital (Western Australia), the ELISA and Western Blot tests indicate that "some antibodies in patients react with some proteins in the culture of tissues from the same patients" but with "the total absence of proof of their specificity." In other words, the tests detect proteins that are alleged to form the components of such an antibody but have never been shown to be unique to a virus. The packet insert in an HIV/ELISA test from Abbott Laboratories contains this prudent disclaimer: "At present there is no recognized standard for establishing the presence or absence of antibodies to HIV-1 in human blood." Yet the cornerstone surveillance study for HIV seroprevalence in South Africa rests on administering a single ELISA test to pregnant Africans attending antenatal clinics, never acknowledging that the ELISA is notoriously unreliable in these circumstances since pregnancy is one of 70 conditions known to trigger a "false positive" result.
Consider an investigation, reported in The Lancet, of 9,389 Ugandans with HIV antibody test results. Two years after enrolling in the study, 3% had died, 13% had left the area, and 84% remained. There had been 198 deaths among the seronegative people and 89 deaths in the seropositive ones. Medical assessments made prior to death were available for 64 of the HIV-positive adults. Of these, five (8%) had AIDS as defined by the WHO clinical case symptoms. The self-proclaimed "largest prospective study of its kind in sub-Saharan Africa" tested nearly 9400 people in Uganda, the former epicenter of AIDS in Africa. Yet of the 64 deaths recorded among those who tested positive for HIV antibodies, only five were diagnosed as AIDS-induced.
Dr. Turner explains that, according to the CDC, an African "with an AIDS defining diagnosis is counted as heterosexual AIDS simply by the fact that he or she comes from a country where heterosexual AIDS is claimed to be the 'predominant' mode of transmission. Knowledge of actual sexual contact is not a requirement." In a 1995 report on the Mwanza region of Tanzania, the absence of such knowledge allowed the researchers to claim that "improved STD treatment reduced HIV incidence by about 40%...[in] the first randomized trial to demonstrate an impact of a preventive intervention on HIV incidence in a general population." This occurred even though "no change in reported sexual behavior was observed in either group."
A close review of the data reveals how the 40% reduction was measured. Of the individuals who initially tested HIV antibody-negative, in the intervention group 48 out of 4149 (1.2%) were HIV-positive two years later. In the comparison group, 82 of 4400 (1.9%) tested HIV-positive. The researchers arrived at the 40% reduction figure simply by calculating the difference between 1.2% and 1.9%.
The Africans in this study tested positive or negative for antibodies to HIV but the source of their infection was unknown. While the research suggested that a regimen of antibiotics reduced the prevalence of HIV-antibodies in patients, the investigators maintained, with no evidence whatsoever, that their therapeutic intervention somehow reduced its transmission.
The results of a recent clinical trial in a Ugandan population showed that despite a reduction in sexual transmitted diseases, there was no difference in HIV-antibody incidence between the treated and untreated populations or in pregnant women. Among the 15,127 participants in the study in Rakai District, Uganda, the "incidence rates of HIV-1 did not differ between intervention and control subgroups based on age, sex or marital status, among partners in HIV-1 discordant or HIV-1 concordant relationships, or among individuals reporting single or multiple partners..." Moreover, the findings suggested that while "the mass-treatment strategy [consisting of azithromycin, ciproflaxacin and metronidazole] significantly decreased the rate of maternal cervical and vaginal infections during pregnancy, [there was] no concomitant reduction in incidence of HIV-1 infection either during pregnancy or after delivery."
AIDS researchers in Africa assume there is a correlation between clinical symptoms (weight loss, chronic diarrhea, fever, a persistent dry cough) and sexual activity. Correlation - whether one phenomenon is found in tandem with another - is not causation. Proof of causation requires that we control all variables in order to isolate one variable as a cause, not merely as an associated factor. The clinical symptoms that define an AIDS case in Africa are expressed in roughly equal numbers among men and women, not because of alleged heterosexual transmission, but because the socio-economic conditions that give rise to the gender equity in the distribution of these widespread symptoms are caused by environmental risk factors to which many Africans are regularly exposed.
Moreover, there may be a correlation between having those clinical symptoms, which attest
to an absence of good health, and the likelihood that the patient will generate a positive
antibody test result. This does not prove that it was the antibodies (or "HIV") which
caused those symptoms. Anyone who has those symptoms, which are due to environmental
insults, may cause a positive test result, indicating simply that the patient is likely to be in
To put it another way, the presentation of the clinical AIDS symptoms is likely to predict
a positive HIV-antibody result on a single ELISA test. Thus, these AIDS symptoms could
be said to "cause" a positive test result.
Poverty-stricken, malnourished subsistence farmers with malaria, tuberculosis or repeated attacks of dysentery are likely to have a considerable amount of cross-reacting antibodies in their systems. Dr. F.J.C. Millard, a physician at a small mission hospital in South Africa's North Province (formerly Northern Transvaal), described the local conditions in which the incidence of tuberculosis and AIDS were rising: "the area had suffered from neglect during the apartheid years. There is poverty, malnutrition, violence, unemployment, overpopulation, and, most important of all, a lack of education."
Statistics on AIDS cases in Africa remain marred by the careless use of sources, questionable mathematics and a refusal by those who accept that data to engage in discussions with their critics. Throughout the July 2000 sessions of President Mbeki's AIDS Advisory Panel, purported AIDS cases in South Africa were routinely conflated with the results from a single ELISA HIV-antibody test derived from sentinel surveys performed on 18,000 pregnant (mostly African) women at antenatal clinics. This sleight-of-hand led adherents to the orthodox view on HIV/AIDS to accept "high counters" whose uncritical treatment of sources dismissed any attempt at verification and validation.
For instance, any comparative statistical analysis that is designed to show which illnesses now afflict South Africans and which ones formerly were the causes of death must be acutely sensitive to how the definition of what constituted "South Africa" dramatically changed between 1989 and 1999.
In 1989, South Africa was said, according to the official terminology, to have a total population of about 21 million. But this figure consciously excluded the 6.1 million Africans who lived in the so-called TBVC states (Transkei, Bophuthatswana, Venda and Ciskei), which comprised 100,000 square kilometers. Furthermore, "South Africa" as defined in 1989 excluded another 8.2 million people who lived in the six "self-governing territories" (SGTs) that comprised a further 67,000 square kilometers.
The overwhelming majority of these 14.3 million Africans living in those fragmented territories were the most obvious victims of the white supremacist policy of apartheid. The huge rural slums of the TBVC countries were "urban" with respect to population density but were "rural" with regard to the absence of proper infrastructure or services, especially in terms of public health.
The 1989 study by Francis Wilson and Mamphela Ramphele, Uprooting Poverty: The South African Challenge analyzed the depths of poverty which they showed were caused by "insufficient labour, insufficient capital and the high risk of much toil yielding little fruit." In many cases, they explained that "people are too poor to farm; they cannot afford protective fencing or even to buy seed and fertilizer. Tractors may be too expensive to hire and oxen to weak to plough."
The statistical reporting for any aspect of health, employment and living conditions among those 14.3 million Africans may have been fragmented and systematically evasive. But no one disputed that mortality and morbidity rates were significantly higher in the TBVC countries and the SGTs than in the rest of "South Africa." People in those areas suffered from far higher rates of protein anemia, malaria, tuberculosis, cholera and dysentery and that life expectancy was significantly lower there than in the rest of "South Africa," as defined in 1989.
Imagine what happened when vital statistics on those 14.3 million people (who probably now number at least 17 million) were added for inclusion in post-apartheid, unitary South Africa? Today, the impoverished inhabitants of those former rural slums are citizens of a single South Africa. Their addition to public health statistics reveals a great deal about the unhealthy living conditions that had long prevailed in the TBVC and SGT areas under the apartheid regime, not the transmissibility of a mutant retrovirus from the Congolese rainforest.
Many places in KwaZulu-Natal that corresponded to the former Bantustans or the
Self-Governing Territory of KwaZulu were rural slums and cesspools of poverty,
ignorance and disease in the pre-1991 period. Researchers who claim otherwise should
provide mortality and morbidity statistics for KwaZulu, Transkei, Ciskei, and Venda
for 1980 and 1985 to assure independent verification.
Even after the dismantling of the apartheid system, AIDS cases continued to afflict
black South Africans. As a 1998 report for the American Association for the
Advancement of Science and Physicians for Human Rights explained, "the
epidemiology of the HIV/AIDS epidemicŠ.. demonstrates the link between
poverty, low status, and vulnerability to infection." It also concluded that the
"rigid segregation of health facilities; grossly disproportionate spending on
the health of whites as compared to blacks, resulting in world-class medical
care for whites, while blacks were usually relegated to overcrowded and filthy
facilities; public health policies that ignored disease primarily afflicting black
people; and the denial of basic sanitation, clean water supply, and other
components of public health to homelands and townships."
At one session of Mbeki's AIDS Advisory Panel, held just days before the 2000 International AIDS Conference in Durban, Dr. William Malegaporu Makgoba of the South African Medical Research Council showed a slide that compared a large spike in registered deaths in South Africa in 1999 with those of 1990. Designed to "show" the devastating effect of the AIDS epidemic on the country's mortality rate and based on statistics from the Department of Home Affairs, it made no mention of the statistical discrepancy cited above.
Even more astonishing, nonetheless, was the fact that the graph indicated the grand total of deaths by age and gender in South Africa for 1999 was 337,000. In a country of 42 million, that meant that the death rate for post-apartheid South Africa was 8/10 of 1%, exactly the death rate for the United States! When we queried Makgoba about this startling "good" news, he stared at us blankly, then walked away in silence.
If it is not the sexual transmission of HIV, then what causes the widespread appearance of AIDS symptoms throughout Africa? The evidence strongly implicates that ordinary, widespread socio-economic conditions give rise to AIDS symptoms even among HIV-negative Africans. A literature review in the World Journal of Microbiology and Biotechnology pinpointed the methodological flaw in the belief that AIDS is sexually transmissible:
"Since AIDS is a panoply of diseases or symptoms and signs, the minimum requirement to prove that AIDS is spread by sexual activity is to take an index case, isolate the putative agent, trace the sexual contacts of that case, and then isolate the same agent. To date, no data anywhere of this type has ever been presented either in Africa, or anywhere else.
In the whole history of medicine there has never been an example of a sexually transmitted disease, which is spread unidirectionally, and certainly not one that is spread unidirectionally in one country and bidirectionally in another.
Indeed, given this and the other differences between AIDS in the West and Africa, it is necessary to postulate that HIV must possess unique features...[and] be able to distinguish the gender and country of residence of its host. The only other alternative is to agree with African physicians that positive HIV antibody tests in Africa do not mean infection with HIV and that immunosuppression and certain symptoms and diseases which constitute African AIDS have existed in Africa since time immemorial."
Nor is there any evidence of widespread secondary or tertiary transmission of HIV or AIDS among heterosexuals in the West. "This is an important point to consider," warns AIDS researcher Michelle Cochrane, "because the foundation of orthodox AIDS science and epidemiology rests upon the premise that HIV/AIDS is relatively frequently transmitted from an index AIDS case (the primary individual) to a secondary AIDS case either through an exchange of semen or blood. In turn, this secondarily 'infected' individual must be capable of transmitting HIV/AIDS to a third individual (tertiary transmission) by the same means, or an infectious disease epidemic cannot be sustained."
Cochrane juxtaposed the central tenets of orthodox AIDS research against San Francisco AIDS patients' charts. She found that health officials over-estimated the risk of contracting HIV through sexual activity, "while simultaneously under-estimating the proportion of the HIV/AIDS caseload that were attributable to intravenous drug use and/or socio-economic factors which condition access to healthcare and prevention services."
Cochrane explains how the bureaucracy for AIDS surveillance in San Francisco plays a key role in constructing a global consensus on AIDS historiography and science. This knowledge displays a remarkable coherence and internal consistency that is used to refute any criticism of its assumptions about the etiology, epidemiology and history of AIDS.
The AIDS Seroepidemiology and Surveillance Branch in San Francisco constitutes the world's greatest repository for primary documentation on AIDS. It includes the medical charts and case files for every one of the 26,171 AIDS patients cumulatively reported since 1981 in the city. Cochrane demonstrates how the vested interests of research institutions, AIDS organizations and activist groups perpetuated the conventional consensus that HIV causes AIDS, "a conclusion which persists despite the presence of multiple lacunae or anomalies that the theory has not resolved."
Cochrane showed that health officials conspicuously failed to investigate all risk factors for immunological dysfunction among heterosexual adult females. In their surveillance studies, it was sufficient for such a woman
"merely to claim that the source of her infection was sex with an IV drug user or another man at risk for HIV/AIDS...A percentage of the 187 [heterosexual] female AIDS cases [out of 25,221 cumulative cases in San Francisco] attributed to sexual transmission would, with proper investigation, be attributable to IV drug use. Epidemiological research in the United States and Europe has never proven that a female has sexually transmitted HIV to a man. [Because] heterosexual transmission of HIV from a male to a female happens with difficulty and very infrequently...all AIDS surveillance statistics on female AIDS cases have been gathered without rigorous scrutiny of the woman's risk for disease and with a bias towards including as many women as possible."
The a priori assumptions that directed AIDS surveillance activities in the United States sustained predictions about an exponential spread of the disease despite the lack of empirical data. This may have reflected an unholy alliance between epidemiology, professional journals and the media. Harvard epidemiologist Alex Walker acknowledges that it only takes a handful of papers before a suspected association "springs into the general public consciousness in a way that does not happen in any other field of scientific endeavor." According to a researcher from the National Institute of Environmental Health Sciences, "investigators who find an effect get support, and investigators who don't find an effect don't get support. When times are tough it becomes extremely difficult for researchers to be objective."
These are points to consider when reviewing the epidemiological data on AIDS cases or HIV seroprevalence anywhere in Africa. A study on Uganda alleged that "a reduction in births to HIV-infected mothers will affect demographic projections of the future numbers of AIDS orphans, as well as projections of the impact of HIV-1 on population growth." In 1987, the WHO estimated that 1 million Ugandans were HIV antibody-positive. Twelve years later, that number was unchanged yet the cumulative total of AIDS cases reported in Uganda since 1982 was 54,712. Researchers did not know the health status of the other 945,000 HIV-positive Ugandans who were not AIDS cases nor noticed the erroneous projections and discrepancies among articles published in the same journal.
7. AIDS and the Medicalization of Poverty
During the past twenty-two years, as the external financing of HIV-based AIDS programs in Africa dramatically increased, money for studying other health sectors remained static, even though deaths from malaria, tuberculosis, neo-natal tetanus, respiratory diseases and diarrhea grew at alarming rates.
While western health leaders fixate on HIV, approximately 52% of sub-Saharan Africans lack access to safe water, 62% have no proper sanitation, almost half live on less than one dollar a day, and an estimated 50 million pre-school children suffer from protein malnutrition. Poor harvests, rural poverty, migratory labor systems, urban crowding, ecological degradation, the collapse of state structures, and the sadistic violence of civil wars are the primary threats to African lives. When essential services for water, power, and transport break down, public sanitation deteriorates and the risks of cholera, tuberculosis, dysentery, and respiratory infection increase.
Historian Randall Packard documented attempts made by the South African government to control the spread of tuberculosis and to lower its morbidity and mortality rates. Even though tuberculosis is curable and the available control measures are sufficient to combat it effectively with antitubercular drugs, the apartheid government made little impact on the overall prevalence of the disease. Packard showed that the South African government refused "to address the foundations of black poverty, malnutrition, and disease upon which the current [1980s] epidemic of tuberculosis is based...[and] placed their faith in the ability of medical science to solve health problems in the face of adverse social and economic conditions."
AIDS researchers and policy makers confuse correlation with causation as they conflate tuberculosis incidence and the reactivation of dormant TB with a person's HIV-antibody status. This co-mingling enables conventional AIDS programs to link efforts to reduce the infectiousness and severity of tuberculosis with family planning, safe sex messages and behavior modification proposals.
In August 1998, the New York Times reported that Zimbabwe had become the center of the world's AIDS epidemic. It claimed that as many as 25 percent of all adult Zimbabweans were infected with HIV, the highest infection rate on earth. Although it provided no figures for previous years, the article acknowledged that the presumed increase in HIV incidence had occurred when increasing poverty, food shortages and instability had "begun to overcome the country. Tuberculosis, hepatitis, malaria, measles and cholera...have surged mercilessly. So have infant mortality, stillbirths and sexually transmitted diseases." Malarial deaths had risen from 100 in 1989 to 2,800 in 1997 and tuberculosis cases jumped from 5,000 in 1986 to 35,000 in 1997. The reporter admitted that all of these diseases indicated deepening social deprivation, with tuberculosis as "the sentinel illness of poverty and social decline."
Subsequent reports showed that rural suffering in Zimbabwe was caused by government corruption, a savage drought and the breakdown of civil society under the harsh regime of Robert Mugabe. Zimbabwean misery over the past fifteen years was also the result of local mismanagement and gross inequities in the region that were accelerated by strictures imposed by the World Bank's structural adjustment programs. In such dire straits, people were hurting because of food shortages and untreated illnesses, not because of sexual promiscuity. Once again, it was surely no accident that the clinical symptoms that would define a case of AIDS in Zimbabwe (fever, diarrhea, weight loss, and persistent cough) were actually manifestations of protein anemia, unsanitary drinking water and parasitic infections in a country "with one of the fastest-shrinking economies on earth."
Other articles in the macabre series, entitled "Dead Zones," illustrated fundamental flaws in the HIV/AIDS model. Among sick or dying Africans, clinicians cannot distinguish which patients would test antibody-positive even if test kits were available. People were presumptively diagnosed as "having AIDS" simply by having the clinical conditions that HIV is said to cause, such as tuberculosis or the symptoms of malaria (persistent night sweats, fever, wasting) or that of cholera (diarrhea, fever, wasting).
Former WHO Director General Hiroshi Nakajima warned emphatically that "poverty is the world's deadliest disease." Indeed, the leading causes of immunodeficiency and the best predictors for clinical AIDS symptoms in Africa are impoverished living conditions, economic deprivation and protein anemia, not extraordinary sexual behavior or the trace measurements of antibodies for a retrovirus that has proved difficult to isolate directly.
The AIDS epidemic in Africa has been used to justify the medicalization of sub-Saharan poverty. Rather than treat the clinical symptoms of AIDS as the manifestations of impoverished living conditions, researchers like Dr. David Alnwick, UNICEF's health chief, invert this cause-and-effect relationship to allege that "all our efforts at providing safe water and other protections for children have been undermined, undone, by the AIDS epidemic."
Western medical intervention has taken the form of vaccine trials, drug testing and demands for behavior modification. In 1997, the Division of AIDS at the National Institute of Allergy and Infectious Diseases concluded that there was "not enough evidence that a live attenuated HIV-1 vaccine [was] safe - or effective." Nonetheless, the International Association of Physicians in AIDS Care (IAPAC) insisted that a vaccine should not be required to meet U.S. safety and efficacy standards because the alleged number of AIDS cases rendered "further delay unethical."
AIDS scientists and public health planners should recognize the roles of malnutrition, poor sanitation, and parasitic and endemic infections in producing the clinical AIDS symptoms that are manifestations of non-HIV insults. The data strongly suggest that socio-economic development, not sexual restraint, is the key to improving the health of Africans. Wherever one projects high rates of HIV-antibodies in Africans, one also finds high rates for all germs indicative of sanitation problems which generally indicate abject poverty, destitution and a high disease burden.
Phillipe and Evelyn Krynen, medically trained charity workers employed by the French group Partage in Kagera Province (Tanzania), report that when "appropriate treatment was given to villagers who became ill with complaints such as pneumonia and fungal infections that might have contributed to an AIDS diagnosis, they usually recovered." Father Angelo D'Agostino, a former surgeon who founded Nyumbani, a hospice for abandoned and orphaned HIV-positive children in Kenya came to a similar conclusion:
"People think a positive test means no hope, so the children are relegated to the back wards of hospitals which have no resources and they die. They are very sick when they come to us. Usually they are depressed, withdrawn, and silent....But as a result of their care here, they put on weight, recover from their infections, and thrive. Hygiene is excellent [and] nutrition is very good; they get vitamin supplements, cod liver oil, greens every day, plenty of protein. They are really flourishing."
Finally, a 1998 study of pregnant, HIV antibody-positive women in Tanzania showed that simply providing them with inexpensive micronutrient supplements produced beneficial effects and decreased adverse pregnancy outcomes. 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." Their commitment to the belief that AIDS was caused by a viral infection obliged the researchers to conclude that "how the individual vitamins produce these effects is not fully understood."
Once scholars 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.
Inadequate libraries, poorly paved roads, a dearth of teachers, insufficient childhood immunizations, poor harvests, an excess of rinderpest or locusts, domestic abuse, awful public transportation systems, disruptive regime transitions, unwanted sexual advances......... you name it and HIV/AIDS is somehow, ultimately behind it.
Given the erratic and unreliable keeping of vital statistics across Africa (amply
documented in the Global Burden of Disease Study), and the vague symptomology that
constitutes an "AIDS" case to begin with, it sometimes seems that unless an African was
killed by gunshot wounds or had died from injuries sustained in a traffic accident, then
almost any decedent can safely be alleged, without any death certificate or an autopsy, to
have died from "AIDS" or an "AIDS-related illness."
A recent report, Downward Spiral: HIV/AIDS, State Capacity, and Political Conflict in Zimbabwe exemplifies the all-inclusive nature of the HIV/AIDS hypothesis. One is astonished to learn about the diversity of economic maladies in Zimbabwe that the authors claim are either directly caused or indirectly induced by the HIV/AIDS epidemic and HIV disease, which they call "debilitation and mortality as the virus increasingly colonizes the work force." These include:
1) reduction of the labor supply
2) declining productivity of workers
3) decline in remittance income
4) current food shortage
5) decline in life expectancy
6) increased infant mortality
7) decline in personal savings
8) increased national debt
9) increased orphans
10) criminal behavior and general disenchantment
11) opportunities for terrorists
12) accentuated social class differences
13) reduction in the accumulation of knowledge and skills
14) increased violence against women
15) government collapse
People can be encouraged to behave thoughtfully in their sexual lives if they are provided with reliable information about condom use, contraception, family planning and venereal diseases. Rather than spend billions of dollars on behavior modification schemes or in pursuit of an illusory AIDS vaccine, multilateral aid should be earmarked to subsidize inexpensive but effective medicines to treat the specific symptoms of common illnesses that are a byproduct of impoverished living conditions.
That money can purchase antibiotics to treat syphilis or gonorrhea, rehydration tablets for diarrhea, directly observed therapy (DOTS) with anti-microbial medicine for tuberculosis sufferers, and micronutrients and vitamin supplements for pregnant women and breastfeeding mothers, regardless of their alleged HIV status. These measures may not be sexy, but they will save lives.
Over the past century, infectious diseases have been controlled through such strikingly
successful measures as improved sanitation, cleaner drinking water, eradication of mosquitoes, isolation of genuinely contagious individuals, vaccinations, and the prudent use of antibiotics. Nowadays throughout the AIDS community, the enemies of public health are said to come
from within individuals themselves, especially those with manifestly inappropriate sexual
Multilateral institutions and African scientists should familiarize themselves with the thoughtful body of literature that demonstrates the contradictions, anomalies and inconsistencies in the orthodox view that the symptoms of AIDS are caused by a single viral infection. Once they consider the non-contagious explanations for AIDS cases in Africa, they can help stop the proliferation of terrifying misinformation that associates sexuality with death.