Under Development & Racial Stereotypes
Reappraising AIDS in Africa
By Charles L. Geshekter, Professor of African History, California State
University, Chico
The problem with the truth is that it is mainly uncomfortable and often dull .
-- H.L. Mencken
Millions of Africans have long suffered from severe weight loss, chronic
diarrhea, fever, and persistent coughs. In 1985 Western researchers suddenly
defined this cluster of symptoms as a distinct syndrome, AIDS, and declared
that it was caused by a single virus, HIV, which they considered to be
sexually contagious.(1)
American health officials universally accept this HIV-AIDS model to explain
what used to be considered the diseases of rampant poverty in Africa. There
are at least three reasons why this view needs careful reconsideration.
First is the fact that many of the Africans who qualify for AIDS diagnoses
-- perhaps as many as 70% -- turn out to be negative when tested for HIV.
Second is the failure of the African HIV-AIDS model to predict the
course of AIDS in the United States. Since AIDS symptoms are widespread
in the general African population,(2) 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, 16 years after it was first described in the medical
literature, in the United States AIDS has remained rigidly confined to
special risk groups. Of the 70,000 annual American AIDS patients, at least
90% are drug users (including nearly all the gay patients), and fewer than
10,000 are designated as heterosexual cases.
Third, sexual transmission can't explain the differences in rates of
HIV positivity between African (about five per 100) and American (about
one per 7,000) heterosexuals. When the HIV-AIDS paradigm made its debut
in 1984, its proponents assumed that HIV was easily transmitted coitally.
Scientists tested this idea only years later, though, when they arrived
at extremely low coital transmission frequencies. The latest study shows
that an HIV-negative woman converts to positive on average only after one
thousand unprotected contacts with a positive man, and a negative
man becomes positive on average only after eight thousand contacts
with a positive woman.(3)
These data suggest two mutually exclusive conclusions. Either HIV isn't
a sexually transmitted microbe after all, and other factors account for
HIV prevalence; or African heterosexuals are wildly more promiscuous than
American heterosexuals, a scenario that surely is not true.
With all of this in mind, why do so many health professionals consider
it useful or necessary to view the diseases of poverty in Africa as sexually
contagious? And why did they ever believe it?
Defining AIDS in Africa
CDC physicians Joseph McCormick and Susan Fisher-Hoch convened 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 the diseases of American drug injectors, a cohort of promiscuous
urban gays in the party drug scene, and transfusion recipients. HIV turned
out to be one of the many viruses that tended to react with blood from
these patients. The same was true of blood from Africans afflicted with
the diseases of poverty. The HIV-AIDS model assumed that AIDS would "spread"
via HIV to a much larger fraction of Africans than those who currently
suffered from it.
McCormick and Fisher-Hoch accepted this model. They recently explained
their motivation for the 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.(4)
The doctors wanted to refute the ugly moralism of the 1980s that AIDS
was a "gay plague" by convincing the American government that "AIDS was
a plague all right, but that no one was immune."(5)
McCormick and Fisher-Hoch 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.(6)
It was upon these grossly unscientific claims, inaccurate clinical generalizations,
western notions of sexual morality, and 19th-century racist stereotypes
about Africans that AIDS became a "disease by definition." Africa was assigned
a central role in promoting 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 couple. "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."(7)
As proof that these "AIDS symptoms" were sexually transmitted, McCormick
and Fisher-Hoch point to a narrow survey conducted by Kevin DeCock, another
CDC epidemiologist. In 1986, DeCock examined stored blood samples taken
in 1976 (for Ebola virus testing) of 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 [60%] 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 [emphases added]."(8)
DeCock concluded from these interviews that the dead subjects died from
AIDS, and that HIV had caused it. He reached this conclusion without properly
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 as well. Had he done this, perhaps he would have discovered
that even HIV-negative Africans 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 has he was concerned, this meant that HIV
-- and thus AIDS -- really did originate in Africa. HIV (AIDS) existed
for years in small numbers of rural inhabitants (who had contracted the
HIV from primates, he imagined). He speculated that once some of those
people in the late '70s migrated to what DeCock falsely assumed were sex-crazed
cities, 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 sort of 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."(9)
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%
(10)
These findings prompted The Lancet to acknowledge editorially that
"current strategies to improve the world's health may need to be reassessed"
and to ponder "how much more money is spent on research into HIV infection
[the 30th cause of death] than into the causes of suicide [#12] or the
prevention of road-traffic accidents [#9] and why should this be."(11)
Racism and African Sexuality
Whereas AIDS in the industrialized countries almost exclusively confines
itself to a tiny percentage of homosexuals, drug injectors, and transfusion
patients, AIDS afflicts the same general African population that faces
such ancient scourges as malaria, schistosomiasis, and sleeping sickness
(trypanosomiasis).
This is known as the "heterosexual paradox" of AIDS. Champions of the
HIV model attempt to explain it in two contradictory ways. Some simply
declare that the paradox is temporary. They speculate that HIV arrived
first in Africa and, in time, AIDS will be just as rampant in the West.
However, they've been saying this now for over ten years.
Others recognize the permanence of the paradox. They account for it
by declaring that Africans are just different from Westerners. They are
substantially more promiscuous and more likely to have genital ulcers.
How else to explain the widespread distribution of a virus that requires,
for non-ulcerated genitals, a thousand heterosexual acts?
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 Universite 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."(12)
Such racist 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 East African truck drivers who get AIDS from
prostitutes and then go home to infect their wives.(13)
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.(14)
No one has ever shown that people in Rwanda, Uganda, Zaire, and Kenya --
the so-called "AIDS belt" -- are more active sexually than people in Nigeria,
which has reported only 3,002 cumulative AIDS cases out of a population
of 100 million, or Cameroon, which reported only 8,141 cases in 10 million.
(15)
No continent-wide sex surveys have ever been carried out in Africa. Nevertheless,
conventional researchers perpetuate racist 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 over-use
of antibiotics -- the early epidemic of immunological dysfunction among
a small sub-culture of gay men in the West.(16)
The research from Africa suggests nothing of the sort. In 1991 researchers
from Medicins Sans Frontieres and the Harvard School of Public Health did
a survey of sexual behavior in the Moyo district of northwest Uganda. Their
findings revealed behavior that was generally 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 did so in the preceding year.
(17)
The media misrepresentations that link sexuality to AIDS have spawned inordinate
anxieties and moral panics 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 them 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."(18)
Public health seems to require salesmanship, not skepticism. The media's
appetite for scary scenarios and its disdain for alternative perspectives
enables it to treat Africa in apocalyptic terms. This marketing of anxiety
helps to promote behavior modification programs to "save Africa." 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."(19)
The serious consequences of claiming that millions of Africans are threatened
by infectious AIDS makes it politically acceptable to use the continent
as a laboratory for vaccine trials and the distribution of toxic drugs
of disputed effectiveness like ddI and AZT. On the other hand, campaigns
that advocate monogamy or abstinence and ubiquitous media claims that "safe
sex" is the only way to avoid AIDS inadvertently scare Africans from visiting
a public health clinic for fear of receiving a "fatal" 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."(20)
Some Western scientists, including Dr. Luc Montagnier, the French virologist
who discovered HIV, claim that the practice of female circumcision facilitates
the spread of AIDS.(21)
Yet Djibouti, Somalia, Egypt, and Sudan, where female genital mutilation
is the most widespread, are among the countries with the lowest incidence
of AIDS.
Does the "AIDS epidemic" in Africa portend the future of the developed
world? The scientific establishment certainly thinks so. Biomedical funds
that had been earmarked to fight African malaria, tuberculosis, and leprosy
are now diverted into sex counseling and condom distribution, while social
scientists have shifted their attention to behavior modification programs
and AIDS awareness surveys.
Good Intentions, Bad Science: HIV Tests and Disease
A reappraisal of AIDS in Africa must recognize that HIV tests are notoriously
unreliable among African populations where antibodies against endemic conventional
viruses and microbes cross-react to produce ludicrously high false-positive
results. For instance, a 1994 study on central Africa reported that the
microbes responsible for tuberculosis and leprosy were so prevalent that
over 70% of the HIV-positive test results there are false.(22)
The study also showed that HIV antibody tests register positive in HIV-free
people whose immune systems are compromised for a wide variety of reasons,
including chronic parasitic infections and anemia brought on by malaria.
The very low frequency of vaginal transmission of HIV makes it hard
to imagine that heterosexual transmission can be responsible for high rates
of HIV prevalence observed in some regions.(23)
So what is responsible?
Perhaps the tests used to determine HIV infection in Africa overstate
the prevalence. Some HIV tests detect entities believed to be part of HIV
itself, such as certain proteins or genetic sequences. But in Africa HIV
prevalence is determined by testing for antibodies, which are components
of the host immune system, not the virus. The fact that these tests react
with antibodies triggered by ordinary African microbes suggests an explanation
for HIV prevalence in Africa that is more plausible than sexual transmission.
(24)
Even the association of HIV antibody tests with ordinary infections does
not mean that positive results warrant a prognosis of death. Consider an
investigation, reported in The Lancet , of 9,389 Ugandans with unequivocal
HIV antibody test results.(25)
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" had tested
nearly 9400 people in Uganda, the so-called 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.
If it is not sexual transmission of HIV, then what causes the widespread
appearance of AIDS symptoms throughout Africa? The evidence strongly implicates
the ordinary, widespread socio-economic conditions that give rise to AIDS
symptoms even among HIV-negative Africans.(26)
In her meticulous 1997 doctoral dissertation, Michelle Cochrane juxtaposed
the central tenets of AIDS orthodoxy against the material record of San
Francisco AIDS patients' charts. She found that public health officials
persistently over-estimated the risk of contracting HIV/AIDS 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 health care and prevention
services."(27)
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 considered sufficient for
a heterosexual female 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 female AIDS cases [out of 24,371 cumulative cases in San Francisco]
attributed to sexual transmission could, 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 [emphasis added].(28)
The a priori assumptions that directed AIDS surveillance activities in
the United States subsequently allowed predictions about an exponential
spread of the disease to survive as "common knowledge," despite the lack
of empirical data. These are critical points to consider when reviewing
any epidemiological data on "AIDS" cases in Africa.
For the period 1984-95, the WHO compared estimates of HIV seropositivity
with the actual numbers of AIDS cases in its Weekly Epidemiological
Reports. The cumulative result is that 99.95% of all Africans do not
have AIDS -- including 97% of those who test HIV-positive. These facts
strikingly contradict the popular view of an Africa overrun by fatal HIV
infections.(29)
AIDS and the Medicalization of Poverty
Primary health care systems in Africa will remain hampered until public
health planners systematically gather statistics on morbidity and mortality
to accurately show what causes sickness and death in specific African countries.
During the past ten years, as the external financing of HIV-based AIDS
programs in Africa dramatically increased, money for studying other health
problems remained static, even though deaths from malaria, tuberculosis,
neo-natal tetanus, respiratory diseases, and diarrhea grew at alarming
rates.(30)
While Western health leaders fixate on HIV, 52% of sub-Saharan Africans
lack access to safe water, 62% lack proper sanitation, and an estimated
50 million pre-school children suffer from protein-calorie malnutrition.(31)
Poor harvests, rural poverty, migratory labor systems, urban crowding,
ecological degradation, social mayhem, the collapse of state structures,
and the sadistic violence of civil wars constitute the primary threats
to African lives.(32)
When essential services for water, power, and transport break down, public
sanitation deteriorates, and the risks of cholera, tuberculosis, dysentery,
and respiratory infection increase.
WHO Director General Hiroshi Nakajima warns emphatically that "poverty
is the world's deadliest disease."(33)
Indeed, the leading causes of immunodeficiency and the best predictors
for clinical AIDS symptoms in Africa are impoverished living conditions,
economic deprivation, and protein malnutrition, not extraordinary sexual
behavior or antibodies against HIV, a virus that has proved difficult or
impossible to isolate directly, even from AIDS patients.
The so-called "AIDS epidemic" in Africa has been used to justify the
medicalization of sub-Saharan poverty. Thus, Western medical intervention
takes the form of vaccine trials, drug testing, and almost evangelistic
demands for behavior modification.
AIDS scientists and public health planners should recognize the role
of malnutrition, poor sanitation, anemia, and ordinary infections in producing
clinical AIDS symptoms in the absence of HIV.(34)
The data strongly suggest that socio-economic development, not sexual restraint,
is the key to improving the health of Africans.
Medically trained charity workers Phillipe and Evelyn Krynen, employed
by the French group Partage, in Kagera Province of 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."(35)
A similar observation comes from Father Angelo D'Agostino, a former surgeon
who founded Nyumbani, a hospice for abandoned and orphaned HIV-positive
children in Kenya:
"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."(36)
Conclusion
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. Multilateral institutions and African
AIDS educators should familiarize themselves with the scientific literature
that demonstrates the contradictions, anomalies, and inconsistencies in
the HIV/AIDS orthodoxy.(37)
They have a major responsibility to consider the non-contagious explanations
for "AIDS" cases in Africa and to stop the proliferation of terrifying
misinformation that equates sexuality with death.
References
(1) Gilks CF "What use is a clinical case definition for AIDS in Africa?"
BMJ 303:1189-90, (Nov. 9, 1991).
(2) Bentwich Z, "Immune activation is a dominant factor in the pathogenesis
of African AIDS", Immunology Today 16(4):187-91 (1995).
(3) Padian N "Heterosexual transmission of HIV" Am J Epidem 146[4]:350-7
(Aug. 15, 1997).
(4) McCormick JB, Level 4: Virus Hunters of the CDC (Atlanta: Turner
Publishing, 1996) pp. 188-90.
(5) Ibid ., 176.
(6) Ibid ., 173-74.
(7) Ibid ., 179-80.
(8) Ibid ., 193.
(9) Kitange HM, BMJ 312:216-17(Jan. 27, 1997).
(10) Murray C, The Lancet 349:1269-76 (May 3, 1997).
(11) Editorial, The Lancet 349 (May 3, 1997) 1263.
(12) Jau JY Le Monde section of Manchester Guardian Weekly (Dec.
14, 1993).
(13) Conover T, "Trucking through the AIDS belt, " The New Yorker (Aug.
16, 1993).
(14) Sebastian R, "Did AIDS start in the jungle?", The Lancet 348:1392
(Nov. 16, 1996).
(15) WHO, Weekly Epidemiological Record 71(26):215 (July 1, 1996).
(16) Review of: Rotello G, Sexual Ecology: AIDS and the Destiny of Gay
Men , (New York: Dutton, 1997); Signorile M Life Outside: The Signorile
Report on Gay Men , (New York: Harper Collins, 1997); Kevles D "A Culture
of Risk", New York Times Book Review (May 25, 1997), p8; Sonnabend
J, "Fact and Speculation about the cause of AIDS," AIDS Forum 2(1):2-12;
Lauritsen J, The AIDS War (New York: Asklepios Press, 1993).
(17) Schopper D, Social Science and Medicine 37(3):401-12, (Aug. 1993).
(18) Deane J, SIDAfrique 8/9:29 (1996).
(19) Commentary, The Economist , p38 (Sep. 7, 1996).
(20) Chintu C, The Lancet 349:649 (March 1, 1997).
(21) Bass T, Reinventing the Future (Reading, Massachusetts: Addison-Wesley,
1994).
(22) Kashala O, J Inf Diseases 169:296-304 (Feb. 1994).
(23) de Vicenza NEJM 331:341-46 (1994); and Mandelbrot L, The Lancet
349:885-89 (March 22, 1997).
(24) Papadopulos-Eleopulos E, Bio/Technology 11:696-707 (June, 1997).
(25) Mulder DW, The Lancet 343:1021-23 (April 23, 1994).
(26) Papadopulos-Eleopulos E, W J Microbiology and Biotechnology 11:141-42
(March 1995).
(27) Cochrane M, "The social construction of knowledge on HIV and AIDS," PhD
dissertation, Department of Geography, UC-Berkeley (April 1997), p. 7.
(28) Ibid . , pp. 259-60.
(29) WHO, World Health Report 1996 , p130.
(30) WHO, Bridging the Gaps (Geneva: WHO, 1995), Table 5 and Table
A3; WHO, World Health Report 1996, Table 4 and Table A3.
(31) The Lancet , p69 (Jan. 11, 1997).
(32) Murray C, The Global Burden of Disease (Cambridge: Harvard
Univ. Press, 1996).
(33) WHO, The World Health Report 1995 .
(34) Geshekter C, Transition 67:4-14 (Fall 1995); Patton C, Inventing
AIDS (New York: Routledge 1990).
(35) Hodgkinson N in Duesberg P, AIDS: Virus or Drug Induced? (Dordrecht:
Kluwer, 1996), p. 353.
(36) Ibid ., pp. 350-51.
(37) Chirimuuta R, AIDS, Africa, and Racism (London: Free Association
Press 1989); Root-Bernstein R, Rethinking AIDS (New York: Free Press
1993); Duesberg P, Infectious AIDS: Have We Been Misled? (Berkeley:
North Atlantic Books 1996); Brody S, Sex at Risk; Lifetime Number of
Partners, Frequency of Intercourse and the Low AIDS Risk of Vaginal Intercourse
, (New Brunswick: Transaction Pubs., 1997)