Tempus
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Tidskriften
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Jun 5th 2008
TO EVERY action, there is an equal and opposite reaction. Newton's third law describes life as well as physics. Once it was only AIDS activists—those with the disease, or at high risk of getting it—who criticised the mandarins of the AIDS establishment. Even then, the criticisms mostly boiled down to two things: “you're not acting fast enough,” and “you're not spending enough money.”
Now, insiders, too, are queuing up to put the boot in, accusing the World Health Organisation (WHO) and UNAIDS, in particular, of sloppy methodology, of the selective presentation of data, and of kowtowing to political correctness in a way that has distorted priorities for the treatment and prevention of the disease.
Ironically, this is happening at a time when the desire of the activists—treatment for all—no longer looks like a pious hope. It may take longer than those activists would wish. And the definition of “all” may not quite be the one in the dictionary. But the treatment of AIDS is steadily improving.
The latest news on treatment is contained in a report published by the WHO, UNAIDS and UNICEF, the United Nations children's fund, on June 2nd. It says that, by the end of 2007, about 3m people were receiving anti-AIDS drugs. That is a rise of 1m in a year, and is part of an accelerating trend (see chart).
This number may look woefully small in the face of an epidemic reckoned to infect 33m people, but most doctors agree that the drugs are best reserved for those whose immune systems are most in danger. That is about 10m people around the world. In other words almost a third of those who could benefit are doing so. Moreover, scepticism that the poor would not comply with the strictures of such drug programmes (in particular, the need to take the drugs regularly to prevent the evolution of resistant strains) has proved unfounded. People in poor countries comply as well as those in the rich world do.
- or, rather, its financial consequence—is one of the objects of the revisionists' criticism. Writing earlier this year in the British Medical Journal, Roger England of Health Systems Workshop, a health-policy charity, suggested that spending on AIDS is diverting resources from more cost-effective health interventions, and called for the abolition of UNAIDS. Dr England and those who think like him argue that because of the single-issue activism that AIDS inspires, it receives a quarter of global health aid even though it causes only 5% of the burden of disease in poor and middle-income countries. They also claim that earmarking money in this way makes it harder to strengthen the health systems of those countries. Dr England summed up his criticism thus: “The global HIV industry is too big and out of control. We have created a monster with too many vested interests and reputations at stake.”
The industry's response is that a lot of the money does indeed go into medical infrastructure. A rising tide, as the saying goes, lifts all boats. That is particularly true of money directed through the Global Fund, which deals not only with AIDS, but also with tuberculosis (which kills many of those whose immune systems have been destroyed by AIDS) and malaria (which may kill more people than AIDS does). The World Bank, too, recognises the need to build medical infrastructure. Its latest policy document on the subject, published in May, also emphasises the link between treating AIDS and tuberculosis.
However, there is no plausible rejoinder to another part of the critics' observation, which is that the treatment programme is an open-ended financial commitment. Since the drugs only control AIDS, but do not cure it, they have to be taken indefinitely. Indeed, the WHO report acknowledges that 2.5m people became infected last year. At the moment, those new infections are almost balanced by 2.1m deaths. But as more people are treated, the death rate will fall. Bearing all this in mind Mead Over, of the Centre for Global Development, a think-tank in Washington, DC, calculates that American-financed spending on HIV treatment could soar to $12 billion a year by 2016, up from about $2 billion today. That amount would represent over half of America's total foreign-aid budget for all causes.
Dr England is not the only critic of the acronym-ridden world of AIDS to make his opinions known recently. Elizabeth Pisani, a journalist turned epidemiologist who worked for UNAIDS, spilled her account of spin, waste and denial in “The Wisdom of Whores”, published last month (and reviewed by The Economist on May 3rd). Meanwhile Jim Chin, formerly an epidemiologist at the WHO, has given a more scientific account of the story in a monograph published by the International Policy Network, in London.
Both level two main accusations. First, that the agencies spent many years overcounting the number of cases. Second, that for political reasons they have failed to match their prevention policies to the epidemiological data, and have thus wasted money preaching to the wrong people.
Dr Pisani cheerfully admits to being a doctor of the spin variety herself—she refers to the process as “beating up the news”. She absolves UNAIDS's researchers of any blame. They did their best to collect true numbers in difficult circumstances and with little money. But so as to rack the world's conscience, she wrote reports that put the worst possible complexion on those numbers. When new methods came in a few years ago, the stated size of the epidemic shrank sharply and it became apparent that the annual rate of new infections had peaked in the late 1990s.
Every war has its propagandists and the money was for a decent cause. So a little forgiveness may be in order. But the second charge, concerning prevention, is harder to excuse. It has been known for years that HIV is hard to pass on during normal heterosexual intercourse. Only one copulation in 500-1,000 with an infected individual will do so. The risk comes with certain behaviour (anal intercourse, which risks tearing the lining of the gut; and injecting drugs using dirty needles), certain professions (prostitutes of both sexes) and certain ways of life (multiple, simultaneous lovers, rather than serial polygamy). Aiming propaganda at heterosexual teenagers is (outside the special case of Africa) a waste of money. It is, however, often an easier course than tackling drugs, whores and buggery, which many politicians would prefer to pretend have no place in their countries.
Both Dr Chin and Dr Pisani are hard on what they think was a refusal to see Africa as a special case. For years, the continent was, instead, taken as an awful warning of what might happen elsewhere. Both suggest that the disease is severe in Africa not just because this is where it started, but also because many Africans (of both sexes) have multiple, simultaneous lovers. There are married sugar-daddies with teenage girlfriends; lorry drivers and mine workers, who spend weeks or months away from home; wives whose husbands spend weeks or months away from home in lorries and mines. Africans do not have more lovers than other people in the course of their lives, but they do tend to have more at the same time. That creates networks, rather than chains, of transmission, making it easier for HIV to spread. A politically correct refusal to offend by stating that this makes a difference meant, once again, that efforts elsewhere were aimed at preventing a heterosexual epidemic that was never going to happen.
That is not, of course, quite how the WHO sees things. As Kevin De Cock, its head of AIDS, points out, if donors had been more willing to put money into the unglamorous business of counting the infected, rather than the headline-grabbing activities of treatment and prevention, then the true numbers may have emerged sooner. He also says that the uniqueness of the African epidemic has been recognised for quite a long time. Transgenerational transmission of the sugar-daddy variety, for example, was a big topic of discussion at the Durban AIDS conference eight years ago. Moreover, prevention efforts in Asia have concentrated on commercial sex almost from the beginning, even if the squeamish issue of homosexuality has taken longer to confront.
There is, nevertheless, likely to be a lot of flying mud at
the next AIDS conference, in Mexico in August. Dr England's point
will no doubt lead to demands for yet more money, so that all
diseases may benefit as much as AIDS has. Dr Over's will raise
an old spectre, one that also goes back to Durban, of the division
of the spoils between treatment and prevention. At the moment,
treatment has the upper hand, but prevention is becoming fashionable
again—it was, for example, emphasised in the World Bank policy
document. Dr Chin's and Dr Pisani's criticisms will be dismissed
with an embarrassed shrug as old news from people who have books
to sell, even as any changes in prevention policy resulting from
such criticism are scrutinised for political incorrectness. For
you may be sure that throughout it all, the thought-police will
be watching for any deviation from the activists' agenda
