Thursday, October 2, 2008

Africa y la crisis del SIDA

Africa and the A.I.D.S. Crisis

It was rather apt that the 13th International A.I.D.S. conference held in July 2000 should have been hosted by the South African city of Durban. With 24.5 million of the 34.3 million people worldwide infected with H.I.V., Southern Africa is now the epicentre of a global A.I.D.S. pandemic, with South Africa itself being the worst affected country in the region. The sheer enormity of what is happening here is something this event did much to highlight.

However, it was an event overshadowed by controversy: South African President, Thabo Mbeki's, support for the dissident (and, according to most medical experts, wholly discredited) ideas of the American researcher, Professor Peter Duesberg. Duesberg has claimed that there is no link between H.I.V. and A.I.D.S., that the latter is simply a new label for a collection of old African diseases. Thus, Tuberculosis (TB) is said to account for "60% of the Aids-projection figures" in South Africa. Even the very existence of H.I.V. itself has been called into question. Prof Luc Montagnier, the accredited discoverer of H.I.V., has acknowledged that his team has still not been able to isolate this virus, its existence being inferred from the presence of antibodies (New African, Sept 2000)

While Mbeki himself has tended—at least in public—to be agnostic about the connection between H.I.V. and A.I.D.S., he has fiercely defended Duesberg and others who he said were being treated like "religious heretics" by the scientific establishment. Furthermore, to the chagrin of many of the delegates present, he has suggested that poverty, rather than the sexual transmission of H.I.V., is basically responsible for the A.I.D.S. crisis affecting the region. This, say his critics, can only detract from efforts to promote safe sex. In short, Mbeki is, in their view, inadvertently helping to make an already bad situation, even worse.

Assuming they are right about what causes A.I.D.S., there is much to be said for such criticism. A vigorous programme of public health education, stressing the dangers of H.I.V. infection through unsafe sex can, it seems, make quite a difference. What is more, it is relatively affordable—even by African standards. In some African countries—notably Uganda (which, in 1987 initiated the first such programme)—this approach is apparently yielding good results. According to President Museveni, H.I.V. prevalence among Ugandan adults has fallen from 30 per cent in 1992 to under 10 per cent today (The Observer, U.K. 09 July 2000). By contrast, H.I.V. infection rates in Southern Africa—assuming such data is reliable—have been steadily rising, having overtaken those in Central Africa where A.I.D.S. made its first appearance.

On the other hand, there is equally something to be said for Mbeki's standpoint. It is surely no coincidence that Africa, the poorest continent on the planet, should contain 70 per cent of all H.I.V. cases worldwide. There is clearly a significant correlation between the economic circumstances created by global capitalism and the spread of A.I.D.S. itself. In short, economic considerations pervade every facet of this phenomenon.
Origins of an Epidemic

How A.I.D.S. began is still the subject of much controversy—at least among the majority of scientists who accept it is linked to H.I.V.. It is now generally believed by these scientists that the ancestor of H.I.V.-1 is the simium immunodeficiency virus (S.I.V.) found in chimpanzees which is remarkably similar to the A.I.D.S. virus itself. But how did S.I.V. come to jump the species barrier and acquire a foothold in the human population as H.I.V.?

The conventional hypothesis is that this probably happened when a hunter cut his hand while preparing the carcass of a butchered chimp, thus allowing S.I.V. to come into contact with human blood and eventually mutate into H.I.V.. However, chimps have been hunted for bushmeat for aeons whereas the earliest documented cases of A.I.D.S. are relatively recent—the first being in Kinshasa in 1959. So some other factor had to be involved as well. According to proponents of the "cut-hunter theory" that had to do with the conditions created by de-colonisation leading, as Edward Hooper puts it, to "urbanisation and new sexual interactions that allowed the newly acquired chimp virus to break free from its rural hearth, to proliferate in an urban environment and then to spread across Africa" (The Observer, U.K. 09 July 2000).

However, Hooper himself favours an alternative explanation, pioneered by the late Bill Hamilton, which appears to be gaining ground. In his book, The River, he claims that the Aids epidemic was unwittingly unleashed by the medical authorities in the then Belgian colonies of Congo, Rwanda and Burundi in the late fifties when they embarked on a mass anti-polio vaccination campaign, using an experimental oral vaccine called C.H.A.T. According to Hooper, some of this vaccine may have been cultured in the kidney cells of chimps and so became contaminated with S.I.V.. To support of this claim, he points to the strong spatial correlation between these C.H.A.T. vaccination sites and the earliest distribution of A.I.D.S. cases.

But the C.H.A.T. theory has yet to be conclusively proven. Hilary Koprowski who led the team that developed C.H.A.T. has vehemently denied that chimpanzees were ever used in this way—despite the testimony of witnesses suggesting otherwise. Furthermore, the few remaining samples of the vaccine held by the Wistair Institute in Philadelphia have recently been shown to be free of S.I.V. contamination (although this could be because they came from batches developed from cultures other than chimp cells). Whatever the truth of the matter, the C.H.A.T. theory does, nevertheless, raise an important question: why was an experimental live vaccine administered to a million Africans in Central Africa when it was known that the vast majority of them were naturally immune to the polio virus in the first place?

In the West where, by contrast, immunity was low, paralytic poliomyelitis was, at the time, greatly feared. Before the arrival of a vaccine, some 22,000 Americans succumbed to this disease each year. Hooper is in no doubt that the African recipients of C.H.A.T. were being used as guinea-pigs to "safety test a western vaccine". But they were not alone. In 1951 in what was the very first experiment with a polio vaccine, 20 "mentally deficient" children under the care of the New York State Department of Mental Health were used as subjects (The Western Australian, 26 June 1992). Later on, prisoners were likewise used.

What all of these cases have in common is that they involve groups that, as Hooper points out, "did not control their own destinies." In other words, some of the most economically vulnerable people were selected to carry the burden of risk. Thus, were things to go horribly wrong, the likely costs in terms of reparations and adverse publicity would be minimised. Such is the kind of society that judges the worth of a human being in terms of his or her economic significance.
Research and Development Bias

However, it is not just a question of minimising costs but, also, of maximising revenue. That means closely aligning "research and development" of new medical products to the contours of market demand. Thus, while Uganda was recently chosen as the site of the first A.I.D.S. vaccines trials since "Africa affords a more logical setting for trials than the U.S.A. or Europe", being an area of high H.I.V. prevalence, the vaccine being tested is against H.I.V.-1 subtype B—"the so-called Euro-American strain which is hardly, if at all, found in Africa"—and, moreover, is unlikely to provide protection against other strains. (The Observer, U.K., 9 July 2000)

True, some expertise and funding to help places like Africa have been forthcoming from the International Aids Vaccine Initiative (I.A.V.I.), set up in 1996 "in the knowledge that the multinational pharmaceutical companies were funding only research into vaccines for the West where they stand to make large profits" (The Guardian, U.K. 12 July 2000). But the I.A.V.I. is a Non-Governmental Organisation (N.G.O.) reliant on donations; for conventional businesses, helping the poor often just doesn't pay. As one U.S.A.-based biotech company, Genetic, discovered, this caused its share price to "drop dramatically on the stock market" (New African, Sept 2000)

Indeed it is the drive for profit which perhaps explains some of the adverse reaction from many in the scientific establishment to the C.H.A.T. theory. For if this theory were to prove well founded, the implications could be enormous—for the future of biotechnology generally and xenotransplantation (putting animal organs in humans) in particular. As Hooper explains:

"If we continue to be overhasty in our pursuit of biotechnology advances we may as a species spark a chain reaction that leads to a terminal disaster. There are massive commercial pressures for xenotransplantation to go ahead despite ever-present risks that undiscovered viruses may be passed from animals to humans during the transplantation process" (The Guardian, U.K. 12 Sep 2000)

In an ideal world, the application of medical interventions would be guided by the criterion of scientific objectivity and driven solely by the concern to meet human needs. But we live in a world in which needs are subordinated to profit, where objectivity may sometimes be compromised as a result. As Thomas Kuhn's seminal book on The Structure of Scientific Revolutions (1962) ably demonstrated, the logical empiricist view of science as an "objective progression towards the truth" belies the influence of various non-rational factors. We may include among these the influence of vested interests.

When research grants are dependent on toeing the right line and pharmaceutical firms stand to lose millions should their drugs be shown to be ineffective—or worse—this influence can be considerable. Admittedly, such potential losses may appear to give firms every reason to want to avoid making mistakes at the outset. But with the best will in the world mistakes can and do happen. Drug trials can be costly and protracted, so there will be a tendency to take risks and cut corners to reduce costs. But even the most rigorous trials cannot always anticipate the adverse side-effects of new products in the long term. Added to that, the pressure of competition means that firms are driven to establish their own brand as the market leader before their rivals can get in on the act. And that is when the problem really begins—once a firm has financially committed itself and put its reputation on the line. That is when commitment to scientific objectivity is subject to greatest strain.

Some would argue this is now the case with the A.I.D.S. industry. According to Pusch Commey, Mbeki was lambasted at Durban because, he "dared to threaten the very foundation upon which is built a huge A.I.D.S. edifice that feeds on the virus… and which replicates as fast as the virus itself as sufficient panic is created to force governments and institutions to fork out more and more cash" (New African Sept 2000).
The Politics of A.I.D.S.

However, Mbeki's stance on A.I.D.S. has not gone down well with the general public. Polls indicate a sharp decline in his personal ratings—from 71% in May to 52% in October 2000—with 62% lacking confidence in the government's efforts to halt the spread of A.I.D.S. . This has now prompted it to finally abandon its non-committal approach on the link between H.I.V. and A.I.D.S. and to unequivocally acknowledge that such a link exists.

Yet, despite this change of heart, Mbeki's own position has, if anything, hardened. According to a leaked account of a recent A.N.C. caucus meeting he asserted that "the truth" - that there is no proof of a causal link between H.I.V. and A.I.D.S.—was "being covered up by a conspiracy among the drug companies, backed by the C.I.A." and that "this international conspiracy to undermine him and South Africa had been mounted because the country was seen as an emerging leader of the developing nations in its challenge to the world economic order" (The Guardian, U.K. 25 Oct 2000)

In similar vein, he has castigated internal critics for being racist in looking for a solution to the A.I.D.S. crisis in Africa outside Africa itself—in effect, lining up behind the very international drug companies that have, in his view, sought to discredit him to further their own commercial objectives. In an oblique reference to Tony Leon, leader of the opposition Democratic Alliance, who accused Mbeki of resorting to "snake oil-cures and quackery" to stem the epidemic, he declared:

"The white politician makes bold to speak openly of his disdain and contempt for African solutions to the challenges that face the peoples of our continent. According to him, these solutions, because they are African, could not but consist of pagan, savage, superstitious and unscientific responses typical of the African people". (The Times, U.K., 14 Aug 2000)

For their part, critics of Mbeki maintain that the position he has taken on A.I.D.S. is fundamentally opportunistic. It is, they say, a crude attempt to shore up political support by playing the race card while deflecting attention from the government's own woefully inadequate response to the epidemic.

Even within the A.N.C. there are many who are unhappy with Mbeki's views. Judging by his government's recent volte face on A.I.D.S., it would seem that this faction, (represented by the likes of Cyril Ramaphosa, once Mbeki's chief rival in the A.N.C. leadership contest), has become increasingly influential within the Party, to the point of now over-ruling their leader on this matter. This may well be linked to a growing sense of unease—in and outside the party—with the general drift of government policy towards non-interventionism and the free market. In other words, the A.I.D.S. crisis may have conveniently provided these interventionists with just the kind of cause celebre by which they might hope to reverse this policy drift, using public opinion on this issue as a lever to bring about that end.

However, with 4.2 million in South Africa already H.I.V. positive—more than anywhere else in the world and growing rapidly—there is little that its government can do in the short term anyway. Given the sheer scale of the problem, the costs of mounting an effective programme of prevention and treatment would be just too prohibitive. Though wealthy by African standards, South Africa falls well short of being a "First World" nation. Not only that, its recent economic difficulties means that any large increase in the nation's health budget now would substantially add to the tax burden on the local capitalist class and so further impair its ability to compete on the global market—something that Mbeki and his friends in the business community would want to avoid at all cost.

That may be one reason why the government has hitherto been so reluctant to openly acknowledge a link between H.I.V. and A.I.D.S.. Because to do so would make it more difficult to resist popular demand for access to affordable (that is, subsidised) drug therapies, were it widely accepted that this was the only hope for the millions who are now H.I.V. positive.

Recently, the government refused to sanction the use of Nevirapine, believed by experts to be the most effective drug to prevent the transmission of H.I.V. from mother to child. As a result, it is reckoned that in South Africa 5000 babies are born each month with H.I.V. (Sunday Mirror, U.K. 06 Aug 2000). Similarly, it has refused to provide rape victims, who have contracted the virus, with anti-retroviral drugs. On the face of it, this would seem to be either incredibly callous or else based on an almost wilful misapprehension that such drugs could be of no benefit whatsoever when evidence from the West suggests they have helped to slash mortality rates among H.I.V.-infected individuals by 80% (The Guardian, U.K. 30 Jun 2000).

To save face the government initially justified its decision not to supply public hospitals with anti-A.I.D.S. drugs on grounds that they were "unproven and toxic" but then, after a "barrage of criticism", claimed that it could not afford them anyway (The Guardian, U.K. 20 Oct 2000). Yet, when five pharmaceutical companies decided earlier this year to make massive discounts on the price of Nevirapine, if its use was sanctioned, Mbeki still decided to decline their offer (Sunday Mirror 06 Aug 2000). Presumably, he must have recognised that, were he to take up the offer in question, this would dramatically signal his acceptance of the conventional scientific model of A.I.D.S. with all that that entailed. Meanwhile, the Democratic Alliance has cynically exploited this impasse by claiming that it would distribute some anti-A.I.D.S. drugs free of charge but only in those municipalities that came under its control after the next local elections (The Guardian, U.K. 25 Oct 2000)
Beyond Science

We are not suggesting Mbeki is not sincere in entertaining doubts about the claims of the scientific establishment regarding the A.I.D.S. epidemic. After all, there is not much point in putting up a pretence; unless some effective way is found of curbing this epidemic, its eventual impact will be utterly devastating—for society as a whole and the economy in particular.

Already, comparisons are being made with the 1918 influenza epidemic which caused over 30 million deaths worldwide. The number of people likely to die of A.I.D.S. over the next 10 or 15 years is, according to Roy Anderson of U.N.A.I.D.S., "going to be many factors bigger than that" (The Guardian, U.K. 12 Jul 2000). So far, 18m have died of the disease—2.6m of them in 1999—but with every passing year the annual death toll is steadily rising . In the main, its victims are young, economically-productive, people under 35. The repercussions of this for future labour markets is now becoming a matter of grave concern for bourgeois economists. In South Africa's case, it will mean more than a quarter of the workforce being infected with H.I.V. by 2006, leading to a shortfall of 10 million workers by 2015 (The Times, U.K. 10 Jul 2000).

Thus, even from a strictly economic standpoint , it has become desperately urgent that an effective remedy should soon be found. But for such a remedy to be effective presupposes a correct understanding of the nature of the disease itself. Hence the intensity of the debate between mainstream scientists and dissidents like Duesberg and the Australian, Eleni Papadopulos- Eleopulos. With so much at stake it could hardly be otherwise.

However, vital though it may be to scientifically understand the nature of the disease, the solution cannot come from science alone. Indeed, if the C.H.A.T. theory is correct, there is sense in which science may be held partly responsible for the problem itself. The solution has also to involve a fundamental shift in the priorities of society. But this is unlikely to happen without a fundamental change in the economic basis of society itself.

The fact is that we already have in place all the elements of a comprehensive package, short of an effective vaccine, that, if fully implemented, could drastically curb the spread of this disease and prolong the lives of those affected. As it is, such a package is often only partially, or patchily, implemented—for reasons that lie well beyond the control of scientists themselves.

An obvious example is the cost of anti-retroviral drugs which the poor simply cannot afford. According to the Panos Institute "at least 12 m people with H.I.V. worldwide needed drugs to suppress the virus which would cost $60bn a year at current prices" (The Guardian, U.K. 12 Jul 2000). Some A.I.D.S. activists believe that the only way to force drug companies to drastically cut their prices is through greater competition. Developing countries, they argue, should be allowed to "buy cheap generic copies of Aids drugs rather than negotiating for small discounts from major firms". The trouble is this runs up against a World Trade Organisation (W.T.O.) agreement which specifically protects the intellectual property rights of these self-same firms (The Guardian, U.K. 04 Jul 2000).

However, the cost of drugs is only one aspect of the problem; others include access to adequate medical infrastructure (e.g medical staff and equipment) and reliable drug distribution systems. Drug firms look to governments to provide such facilities but rising debts incurred during the 1970s and 1980s have rendered many Third World countries even less able to do so. Forced to seek assistance from bodies like the I.M.F. and the World Bank, they have been obliged to comply with terms that require them to cut public expenditure in areas like health and education, in order to reduce their budget deficits.

Such "structural adjustment" programmes have not only undermined the treatment of A.I.D.S. but, also, efforts to prevent it from spreading. Condoms, largely provided by international donors, are often done so on the basis of "cost recovery", limiting the extent of their distribution. Usually, the easiest way to acquire a condom is to purchase it in the local market. But these are usually of poor quality or inappropriately packaged, resulting in the rubber tending to perish through exposure to direct sunlight (The Guardian, U.K. 15 Jul 00)

There are others ways, too, in which poverty can assist the spread of A.I.D.S. The expectation among poor people that they are unlikely to live to a ripe old age when most around them are dying young anyway makes them more likely to take risks. Sex workers drawn into prostitution because of poverty may engage in unprotected sex if the client is willing to pay more for the experience. When you don't know when your kids are next going to get a square meal, what happens in the long term may well seem academic.

In some parts of Africa where labour migration is prevalent the risk of H.I.V. infection is high. Among the mines of Southern Africa, for example, vast single-sex barracks to house mine workers are still commonplace—a legacy of the colonial era. This encourages the use of prostitution with with prostitutes being bused on a Friday night to ply their trade among the workers. Once infected with H.I.V., these same workers may pass on the virus to their spouses when they return home.

There are, of course, many different factors involved in the spread of A.I.D.S.. But it is the effect of poverty which looms above all. In this respect Mbeki does have a point. But it is a point about which he can do little or nothing. Neither for that matter can his critics.

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