www.sfgate.com Return to regular viewMegadeath and Megahype
The numbers for AIDS in Africa don't add up
Rian Malan
Sunday, January 6, 2002
©2002 San Francisco Chronicle.URL: http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2002/01/06/IN159089.DTL
Johannesburg -- Africa's era of megadeath dawned in the fall of 1983, when the chief of internal medicine of a hospital in what was then Zaire sent a communique to American health officials, informing them that a mysterious disease seemed to have broken out among his patients.
At the time, the United States was being convulsed by its own weird health crisis. Large numbers of gay men were coming down with an unknown disease of extraordinary virulence, something never seen in the West before. Scientists called it GRID, an acronym for Gay-Related Immune Deficiency. Political conservatives and holy men called it God's vengeance on sinners.
American researchers were thus intrigued that a similar syndrome had been observed among heterosexuals in Africa. A posse of seasoned disease cowboys was convened and sent forth to investigate.
On Oct. 18, 1983, they walked into Kinshasa's Mama Yemo Hospital, led by Belgian microbiologist Peter Piot.
Tests confirmed his worst apprehensions: The mysterious new disease was present in Africa, and its victims were heterosexual.
When researchers started looking for the newly identified human immunodeficiency virus, it turned up almost everywhere -- in 80 percent of Nairobi prostitutes, 32 percent of Ugandan truck drivers, 45 percent of hospitalized Rwandan children. Worse, it seemed to be spreading very rapidly. Scores of millions -- maybe more -- would die unless something was done.
These prophecies transformed the destiny of AIDS. In 1983, it was a fairly rare disease, confined largely to the gay and heroin-using subcultures of the West. A few years later, it was a threat to all of humanity.
By 2000, global spending on AIDS had risen to many billions of dollars a year. Activists urged the commitment of many billions more, largely to counter the apocalypse in Africa, where 22 million were said to carry the virus and 14 million to have died of it.
This is about where I entered the picture -- July 2000, three months after South African President Thabo Mbeki announced that he intended to convene a panel of scientists and professors to re-examine the relationship between the human immunodeficiency virus and AIDS.
Mbeki never exactly said AIDS doesn't exist. But his action begged the question. The implications were mind-bending.
South Africa was said to have more HIV infections (4.2 million) than any other country on the planet. One in five adults was already infected, and the toll was rising daily.
As his words sank in, disbelief turned to derision. "Ludicrous," said the Washington Post. "Off his rocker," said the Spectator.
Mbeki had gleaned much of what he knew from the Web, so I revved up the laptop and followed him into the virtual underworld of AIDS heresy. It's where renegade scientists maintain Web sites dedicated to the notion that AIDS is a hoax dreamed up by a diabolical alliance of pharmaceutical companies and "fascist" academics whose only interest is enriching themselves. I then turned to universities and governments, whose Web sites offered crushing rebuttals.
AIDS is caused by a tiny virus that lurks unseen in the blood for many years, only to emerge in deep disguise: a disease whose symptoms are other diseases, like TB. Or pneumonia. Running stomach, say, or bloody diarrhea in babies.
These diseases are not new, which is why some Africans have always been skeptical, maintaining that AIDS actually stands for American Idea for Discouraging Sex.
Orthodox scientists say HIV destroys the immune system, allowing the tuberculosis (or whatever) to run riot. The dissidents say the virus is a harmless creature that just happens to accompany immune-system breakdown caused by other factors, in this case a lifetime of hunger and exposure to tropical pathogens.
Incensed, the orthodoxy whistles up a truckload of studies from all over Africa showing that HIV-positive hospital patients die at astronomical rates relative to their HIV-negative counterparts. Dissidents claim this proves nothing, except that dying hospital patients carry the virus. The orthodoxy grits its teeth. There's only one way to crush these rebels, and that's to show that AIDS is a new disease that has caused a massive increase in African mortality, which is, of course, the truth as we know it: 22 million Africans infected, with 14 million more already dead.
Cancer fighters tell you that their crisis is deepening, and more research money is urgently needed. Those doing battle with malaria make similar pronouncements, as do those working on TB. If all the claims are added, you wind up with a theoretical global death toll that "exceeds the number of humans who die annually by two- to threefold," said World Health Organization director Christopher Murray.
Malaria kills around 2 million humans a year, roughly the same number as AIDS, but malaria research currently gets only a fraction of the resources devoted to AIDS. Tuberculosis (1.7 million victims a year) is similarly sidelined, to the extent that there were no new TB drugs in development at all as of 1998.
AIDS, on the other hand, is replete with funds, employing an estimated 100, 000 scientists, sociologists, epidemiologists, caregivers, counselors, peer educators and stagers of condom jamborees.
Until the attacks of Sept. 11 diverted the world's anxieties (and charity dollars), the level of funding for AIDS grew daily. Foundations, governments and philanthropists like Bill Gates entered the field, unnerved by the bad news, which usually arrived in the form of articles describing AIDS as a "merciless plague" of "biblical virulence," causing "terrible depredation" among the world's poorest people.
These stories all originate in Africa, but the statistics are from World Health Organization headquarters in Geneva. WHO officials are the world's disease police. In conjunction with UNAIDS (the Joint United Nations Programme on HIV/AIDS), WHO also collects and disseminates information about the AIDS pandemic.
In the West, almost every new AIDS case is scientifically verified and reported to health authorities. But AIDS mostly occurs in Africa, where hospitals are thinly spread, understaffed and often bereft of the laboratory equipment necessary to confirm HIV infections.
How do you track an epidemic under these conditions?
In 1985, the WHO people asked experts to hammer out a simple description of AIDS that would enable bush doctors to recognize the symptoms and start counting cases. It was a fiasco -- mostly because African governments were too disorganized to collect the numbers and send them in. Hence, when it's announced that 14 million Africans have succumbed to AIDS, it does not mean that 14 million infected bodies have been counted. It means that 14 million people have theoretically died, some of them unseen in Africa's swamps, shantytowns and vast swaths of terra incognita.
Checking the number of registered deaths in South Africa was the surest way of assessing the statistics from Geneva, so I dug out the figures. Geneva's computer models suggested that AIDS deaths here had tripled in three years, surging from 80,000-odd in 1996 to 250,000 in 1999. But no such rise was discernible in total registered deaths, which went from 294,703 to 343,535 within roughly the same period.
Geneva's figures reflected catastrophe.
Pretoria's did not.
Between these extremes lay a gray area populated by local experts such as Stephen Kramer, manager of insurance giant Metropolitan's AIDS Research Unit. Its computer model shows AIDS deaths at about one-third Geneva's estimates.
I believe that AIDS exists and it's killing Africans. But as many as all the experts tell us? Hard to say. We automatically assume almost everyone who falls seriously ill or dies has AIDS, especially if they're poor and black. But we don't really know for sure, nor do the sufferers themselves, because hardly anyone has been tested.
I was living in Los Angeles in 1981, when the very first cases of GRID were detected. I knew men who were stricken, and I sympathized with their desperation. They wanted government action and knew there would be little as long as the disease was seen as a scourge of queers, junkies and Haitians.
So they forged an alliance with powerful figures in science and the media and set forth to change perceptions, armed with potent slogans such as "AIDS is an equal-opportunity killer" and "AIDS threatens everyone."
Madonna, Liz Taylor and other stars were recruited to drive home the message to the straight masses: AIDS is coming after you, too. These warnings were backed up by estimates such as the one issued by the Centers for Disease Control and Prevention in 1985, stating that 1.5 million Americans were already HIV-infected, and the disease was spreading rapidly.
Dr. Anthony Fauci, now head of the National Institute of Allergic and Infectious Diseases, prophesied that "2 to 3 million Americans" would be HIV- positive within a decade. Newsweek's figures in 1986 were at least twice as high. That same year, Oprah Winfrey told the nation that "by 1990, one in five" heterosexuals would be dead of AIDS.
As hysteria intensified, challenging such certainties came to be dangerous. In 1988, New York City Health Commissioner Stephen C. Joseph reviewed the city's estimate of HIV infections, concluded that the number was inaccurate and halved it, from 400,000 to 200,000. His office was invaded by protesters, his life threatened. Demonstrators tailed him to meetings, chanting, "Resign, resign!"
In hindsight, Dr. Joseph's reduced figure of 200,000 infections might itself have been an exaggeration, given that New York City has recorded a total of around 120,000 AIDS cases since the start of the epidemic two decades ago.
In 1997, a federal health official told the Washington Post that by his calculation, the true number of HIV infections in the United States back in the mid '80s must have been around 450,000 -- less than one-third of the figure put forth at the time by the CDC.
If the numbers could be so wrong in America, what are we to make of the infinitely more dire death spells cast upon the developing world?
In 1993, Laurie Garrett wrote in "The Coming Plague" that Thailand's AIDS epidemic was "moving at supersonic speed." It has stalled, however, at just below 2 percent, according to UNAIDS.
In 1991, All India Institute of Medical Sciences official Vulmiri Ramalingaswami said AIDS in India "was sitting on top of a volcano," but infection levels there have yet to crest above 1 percent.
The only place where the AIDS apocalypse has materialized in its full and ghastly glory is in Geneva's computer models of the African pandemic, which show millions dead and far more dying. Why Africa, and Africa only?
Lots of people thought it was wrong even to pose questions such as these, especially at a moment when rich countries, rich corporations and rich men were considering billion-dollar contributions to a Global AIDS Superfund. They were brought to this point by a ceaseless barrage of stories and images of unbearable suffering in Africa, all buttressed by Geneva's death projections. Casting doubt on those estimates was tantamount to murder.
But what are the facts?
Deaths registered in South Africa in 1996 were 363,238. Deaths registered in 2000 -- 457,335.
Registered deaths have indeed risen -- not to the extent prophesied by the United Nations, perhaps, but there is definite movement in an ominous direction.
Deaths are up across the board but concentrated in certain critical age groups: females in their 20s and males aged 30 to 39. A team of experts commissioned by the Medical Research Council has studied this changing death pattern and found it to be largely consistent with the pattern predicted by the council's computer model. The conclusion: AIDS has become the "single biggest cause" of mortality in South Africa, responsible for 40 percent of adult deaths.
Another governmental body, Stats SA, has challenged these findings. The Washington Post reported that the South African census bureau called the Medical Research Council study "badly flawed," saying "the samples were not representative, and assumptions about the probability of the transmission of the virus that causes AIDS were not necessarily accurate."
Enigma upon enigma, riddle leading to riddle, and no reprieve from doubt.
Local actuarial models say 352,000 South Africans have died from AIDS since the epidemic began. The Medical Research Council says 517,000. The figure from the United Nations Population Division is double that -- 1.06 million -- and the unofficial WHO/UNAIDS projections are even higher.
Dr. Joseph Sonnabend is a South Africa-born physician who ran a venereal- disease clinic in New York back in the early '80s, when GRID first appeared. He became known as a pioneer in AIDS treatment.
When President Mbeki launched his controversial inquiry last year, Sonnabend came home to participate, an experience he likens to "entering hell. " As founder of the AIDS Medical Foundation, which became the American AIDS Research Foundation, or AmFAR, Sonnabend has no patience with dissidents who dispute the syndrome's existence or HIV's power to cause it. But he also believes there are "opportunists" and "phonies" whose chief skill is "manipulation of fear for advancement in terms of money and power."
In fact, he quit AmFAR, his own group, because he felt it was exaggerating the threat of a heterosexual epidemic. A decade later, he's still fighting for wise AIDS policies, especially in Africa.
In Pretoria, he says, one faction argued for the bulk of available funds to be committed to the purchase of AIDS drugs. But merely dumping AIDS drugs into resource-poor countries is pointless, he argued, although he does believe there are situations where they could be safely and effectively used.
Sonnabend is trying to organize an international conference to discuss the disposition of the money lodged in the Global AIDS Superfund. The way he sees it, $1 billion a year would be enough to transform the lives of ordinary Africans and curb the AIDS epidemic, but only if it's not squandered on unsustainable "drugs into people" programs.
"There's a place for AIDS drugs and prevention campaigns" he says, "but it's not the only answer. We need to roll out clean water and proper sanitation. Do something about nutrition. Put in some basic health infrastructure. Develop effective drugs for malaria and TB, and get them to everyone who needs them."
I attempted to bring my unanswered questions to the man who was there when the epidemic first hit this continent, Dr. Peter Piot, who has today risen to the role of chief of UNAIDS. But my call was directed instead to his chief epidemiologist, Dr. Bernhard Schwartlander.
The UNAIDS computer model of Africa's epidemic is in fact completely dependable, Dr. Schwartlander says, because it relies on what he calls a very simple formula.
"Take the pregnancy clinic numbers," he says. "Take the median survival time -- around nine years in Africa. This is roughly the distribution curve. Calculation of deaths is completely plausible if you have a good idea of the prevalence of HIV and how it spreads over time."
Why, then, I asked, do we have so many different estimates of AIDS deaths in South Africa?
"The models may completely disagree at a particular point in time, but in the end the curves look incredibly similar. They're goddamn consistent," he said.
If that's true, I said, then why would we have 457,000 registered deaths here last year when the U.N. says 400,000 of them died of AIDS? One of those numbers must be wrong.
"You say there are 457,000 registered deaths in South Africa?" Schwartlander said, momentarily nonplussed. "This is an estimate based on projections."
"No," said I, "it's the actual number of registered deaths last year."
"We don't really know," he replied. "Things are moving very fast. What is the total number of people who actually die? For all we know, it could be much higher. HIV has never existed in mankind before.
"The UNAIDS numbers are, after all, only estimates. We are not saying this is the number. We are saying this is our best estimate. Ten years from now, we won't have these problems. Ten years from now, we'll know everything."
Ten years! Had I known, I could have saved myself a lot of grief. Even as I tried to track down the old numbers, bigger new ones were supplanting them -- 17 million Africans dead of AIDS and 25 million more with HIV, UNAIDS now estimates; not one in five South African adults infected but one in four. Are these numbers right? Who knows?
South Africa-based writer Rian Malan is author of "My Traitor's Heart." A version of this article appeared in Rolling Stone.
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