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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

        

AIDS in Africa: A Call for Sense, Not Hysteria

19 August 2003

Christian Fiala,

Specialist in OB/GYN
Vienna, Austria


Pat Sidley makes dire predictions indeed. However, the claim of saving
such a high number of lives is based on estimates and certain
assumptions. It seems essential to substantiate these claims before
asking for wide ranging interventions. The case of Uganda provides an
important lesson in this respect. A detailed analysis seems mandatory
before engaging in costly and potentially dangerous interventions in
South Africa.


The absence of the predicted Aids catastrophe in Uganda calls the
basic assumptions about the epidemic into question. It is high time
to reconsider the priorities of health policy.


"Can Africa be saved?" asked Newsweek on it's front page as far back
as 1984, reflecting the old Western belief that Africa is doomed to
starvation, terror, disaster and death. (1) This was repeated two
years later in an article in the same journal in a story about Aids
in Africa. The title set the scene: "Africa in the Plague Years". (2)
It continued: "Nowhere is the disease more rampant than in the Rakai
region of south-west Uganda, where 30 percent of the people are
estimated to be seropositive." The World Health Organisation
(WHO) confirmed "by mid-1991 an estimated 1,5 million Ugandans, or
about 9% of the general population and 20% of the sexually active
population, had HIV infection". (3) Similar reports were repeatedly
published during the last 15 years, declaring as much as 30% of the
population doomed to premature death, with all the consequences on
the families and the society as a whole. The predictions announced
the practically inevitable collapse of the country in which the
worldwide epidemic supposedly originated.


Today, however, one reads little about Aids in Uganda. Because all
prophesies have proved false, as the results of the (ten-year) census
in September 2002 show. (4) Summing up, the Uganda Bureau of
Statistics says, "Uganda's population grew at an average annual rate
of 3.4% between 1991 and 2002. The high rate of population growth is
mainly due to the persistently high fertility levels (about seven
children per woman) that have been observed for the past four
decades. The decline in mortality reflected by a decline in Infant
and Childhood Mortality Rates as revealed by the Uganda Demographic
and Health Surveys (UDHS) of 1995 and 2000-2001, have also
contributed to the high population growth rate." In other words, the
already high population growth in Uganda has further increased over
the past 10 years and is now among the highest in the world. (5)
Similarly economic development has shown a constant growth over the
same period reflecting the energy and determination of Ugandans to
improve their living conditions. (6)

 

    


How can this contradiction be explained, that a land condemned to
death has not only avoided the predicted catastrophe but that
population growth has even dramatically accelerated in this period
and economic development has been positive? And more specifically,
how has it been possible to reduce HIV-prevalence without
antiretroviral therapy, the so-called Aids-drugs.


It is often mentioned that the energetic action of the government and
the aid organisations as well as the numerous campaigns against Aids
could have led to a change in sexual behaviour and thus to a fall in
HIV infections. This belief, however, cannot be sustained on the
basis of the indicators of sexual behaviour in Uganda, as the latest
household survey in 2001 shows. (7)The following indicators have been
stable, some for 30 years: fertility (seven children per woman), the
average age of women at the time of first sexual intercourse (16.7
years), the time of marriage (18 years) and first childbirth(18.5
years). The only indicator that has slightly changed is the
proportion of married women using contraception. This has risen over
the last five years from 15 to 23 percent - still very low by
international comparison. (8) And only 2 percent regularly use a
condom. (But 35% have unmet needs for Family Planning!) There is thus
no reliable evidence showing a change in sexual behaviour of
people in Uganda.


Actually the explanation is to be sought elsewhere. The horror
scenarios were based on the large number of people testing HIV
positive in Uganda in antenatal surveys and numerous other studies.
(9) Most of these HIV positives, according to the underlying
assumption, would contract Aids in eight to ten years and consequently
die relatively fast. Surprisingly however, mortality did not increase
over the last decade - obviously therefore this assumption has been
wrong. The reason is suggested by a 1994 survey of reliability of HIV
tests: "ELISA and Western Blot [the most frequently used tests] are
possibly not sufficient for the diagnosis of HIV infection in central
Africa." (10) Numerous other studies since then have confirmed this
statement and the unreliability of HIV tests. In Africa in particular,
people have a high number of antibodies against infectious diseases
or against foreign proteins after receiving blood or dirty injections.
Some of these antibodies may lead to a false positive HIV test. As
these people do indeed have a positive HIV test but are not infected
with HIV, they also do not die after the allotted time.


Not only are the figures on HIV infections unreliable and misleading,
but so are the official Aids statistics. The diagnosis of Aids in
Africa is based on a special definition for developing countries (the
so called "Bangui definition"), which WHO decided in 1985. (11, 12)
According to this definition, Aids is diagnosed on the basis of non-
specific clinical symptoms and without an HIV test. Even today in
Uganda and other African countries, people with for example
continuous diarrhoea, weight loss and itching are declared to be
suffering from Aids. But also the typical symptoms for tuberculosis -
fever, weight loss and coughing - are officially considered to be
Aids, even without an HIV test. (13)


In order to get a total estimate of Aids cases, WHO at it's
headquarters in Geneva adds the registered Aids sufferers to a high
number of unreported cases, which WHO presumes to have occurred. Thus
in November 1997, the WHO announced that since its previous report in
July 1996, there had been a further 4.5 million Aids cases in Africa.
In this period, however, only 120,000 Aids sufferers were actually
registered. In other words, 97 percent of the supposed new Aids cases
during this period occurred only at the WHO headquarters in Geneva.
The WHO has since been avoiding this absurdity by preparing the
statistics differently. Now, healthy people with a positive HIV test
are included in the WHO statistics together with those suffering from
Aids. Again this procedure is highly unusual in medicine. As for
example in tuberculosis no one has suggested putting together sick
people actually suffering from tuberculosis and those that are
healthy but having antibodies against the bacteria.

 

    


The fight against Aids conducted on this misleading basis has fatal
consequences however. Thus for example, UNAIDS 1999 recommended
finance ministers in the African countries cut their budgets for
social security, education, health, infrastructure and rural
development in order to have more funds available for the fight
against Aids. (14) And if, just in Uganda, 4,000 aid organisations
are active in the struggle against Aids (as of 1994), the
priorities of the health system are clear. Powerlessly, Uganda
authors remark: "Because local decision-makers are so dependent on
donations, they tend to accept aid projects indiscriminately." (15)


Other problems are widely neglected in the fight against Aids. Thus a
large part of Uganda's population has no access to clean drinking
water. In 1990 the figure was 56 percent. Ten years and millions of
dollars of donations later it was 50 percent. (16) The situation in
Kyotera, a town in the Rakai district, is particularly cynical for
example. In this district a particularly large amount of money has
been spent on the fight against Aids, because it is supposed to be
most heavily affected by the epidemic. Despite millions of aid
funds, campaigns for abstinence and the distribution of condoms, the
people of Kyotera still have to get their water during most time of
the year from an unprotected water hole, which they share with
cattle.


Maternal mortality in Uganda is also one of the highest in the world
and has not fallen over recent decades. As before, one in 16 women
die during their years of fertility. (17) One major reason for this
is the consequences of unsafe abortions. (Abortions are illegal in
most parts of Africa based on the medieval laws of the former
colonialist countries.) A second reason is the lack of the most
important medicament in obstetrics: prostaglandins are used world-
wide and there is also a very good and inexpensive preparation. But
even WHO does not include a single prostaglandin in their list of
essential drugs and in Africa this life- saving medication is only
approved in three countries. (18) Uganda has only been among them
since last autumn.


In the meantime, Aids experts drive around the country in four-
wheel-drive air-conditioned vehicles, if they are not saving the
world from Aids in their comfortable offices or presenting their
latest medical experiments on Africans at an overseas conference. The
government has not only bought condoms for millions of dollars on
credit, but borrows even more money from the industrialised countries
in order to buy imprecise HIV tests and toxic Aids medications.
Previously there were only isolated voices against this sometimes
cynically understood imbalance. Thus a reader of the daily New Vision
in Kampala wrote recently: "Most people die from malaria. So give us
free mosquito nets instead of condoms and Aids medicaments."


To draw a balance: the Aids hysteria of the last 20 years was indeed
politically correct, but led to a neglect of other far more important
aspects in health care. Unfortunately, not only did the commitment to
fight Aids cost a lot of money, but it was also to the disadvantage
of people in Africa. Innumerable western companies, NGOs,
international organisations and Aids experts profited from it.
HIV/Aids is indeed a new disease in this world of virtual reality and
Infotainment: The celebrated discoverer of HIV later admits that he
could in fact never purify the virus and the supposedly deadly
disease leads to a real explosion in population growth in the so-
called "epicentre", the country most heavily affected. (19) Now, to
err is human, however, a policy that is obviously based on false
assumptions and has predominantly negative effects for those
concerned has to be discarded or adapted. Adhering to it leads to
questions regarding the responsibility of the decision makers. The
ever more urgent question thus arises of when the current policy will
be rethought and adapted to the priorities of the population. People
in Africa need help and support. But it is neither helpful nor
effective if wrong data and absurd definitions are employed to
mislead and divert attention from the real problems.


Literature: 1. Newsweek 1984, November 19


2. Newsweek 1986, December 1


3. Taso Uganda - The inside story, Taso - WHO, 1995; WHO/GPA/
TCO/HCS/95.1


4. Results from the Population Census from September 2002, Uganda
Bureau of Statistics, Entebbe, Uganda,


5. The State of World Population 2001, Demographic, Social and
Economic Indicators, http://www.unfpa.org/swp/2001/english/
indicators/indicators2.html


6. Gross domestic product (GDP) 1991 to 2000 according to Uganda
Bureau of Statistics


7. Demographic and Health Survey 2000-2001. Uganda Bureau of
Statistics, Entebbe, Uganda


8. Contraceptive use 2001, Population Division of the Department of
Economic and Social Affairs of the United Nations, New York


9. HIV/Aids Surveillance Report, STD/Aids Control Programme, Ministry
of Health, Kampala, Uganda, June 2001


10. Infection with HIV Type 1 and Human T Cell Lymphotropic Viruses
among Leprosy Patients and Contacts: Correlation between HIV-1 cross-
reactivity and antibodies to Lipoarabinomannan, The Journal of
Infectious Diseases, 1994;169:296-304


11. WHO; Workshop on Aids in Central Africa, Bangui22.-25. October
1985, Dokument WHO/CDS/AIDS/85.1, Genf, 1985


12. WHO, Global programme on AIDS; Provisional WHO clinical case
definition for AIDS, Wkly-Epidemiol-Rec, 1986; March 7; no 10: 72-3


13. Reporting form for Aids; Ministry of Health, Kampala, Uganda:
online at: http://aids-kritik.de/aids/SA/meldeformulare.htm


14. Joint Conference of African Ministers of Finance & Ministers of
Economic Development and Planning, 1999 - Addis Ababa, Ethiopia,
UNAIDS,



15. Reproductive Health in Policy and Practice Uganda, Florence
Mirembe, Freddie Ssengooba, Rosalind Lubanga, September 1998,
Population
Reference
Bureau, USA


16. WHO, Global Water Supply and Sanitation Assessment 2000 Report,
http://www.who.int/docstore/water_sanitation_health/
Globassessment/Global6-2.htm


17. Maternal mortality in 1995. Estimates developed by WHO, UNICEF
and UNFPWHO/RHR/01.9, http://www.who.int/reproductive-health
/publications/RHR_01_9_maternal_mortality_estimates/index.en.html


18. WHO Model List of Essential Medicines,
mf/userscripts/p_eml_qrymenu.asp


19. Luc Montagnier in an interview with Djamel Tahi, Continuum 1997,
vol 5, no 2, 30-4, available on the net at: http://
www.virusmyth.net/aids/data/dtinterviewlm.htm


Competing interests: None declared