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.
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, www.ubos.org
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, http://www.unaids.org/publications/graphics/ addis/sld025.htm
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, http://mednet3.who.int/ 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
Dire predictions about the imminent deaths of thousands and even millions of innocent people seem to be part of the HIV/Aids era. Numerous predictions of this kind have been published since the first days of the media coverage of HIV, first for the US, then for Europe, Uganda and Thailand. All those predictions had one thing in common: they were completely wrong. But usually it took several years before reliable data could be produced to prove them wrong. By that time, the media attention had already turned to more „sexy„ subjects and coverage of the correction has usually been minor.
South Africa may be in the comfortable situation to learn from past experience. The recent article by Pat Sidley (BMJ 26 July 2003) predicted the imminent deaths of 1,7 million people due to HIV/ Aids in case so-called HIV drugs would not be made available. (1) However, earlier this year Statistics South Africa announced the results of the latest population census in 2001: the total population was found to be at 44,8 million, an increase of 4,3 million during the 5 years since the census in 1996. (2) This is equivalent to an annually population growth rate of about 2%.
We are used to learning new things in medicine. Nevertheless, there seems to be a contradiction between the dire predictions of more than a million deaths due to a deadly epidemic said to have been ravaging South Africa for more than 10 years and the finding of a growing population. At least there is no historical precedent where a deadly epidemic had a similar effect.
Furthermore one may ask, why the article by Pat Sidle contained only speculations and rumours about unpublished estimates, while existing data on the continuous population growth were not mentioned.
1, Pat Sidley , Free retroviral drugs could save up to 1.7 million South Africans, BMJ 2003;327:184 (26 July)
2. Results from the Census 2001, Statistics South Africa, "Census 2001" www.statssa.gov.za