How public health failed

The strategies needed to prevent the spread of HIV/AIDS never came close to being effective
Larry Krotz
How public health failed
With an almost eight per cent infection rate, 60 per cent of government health spending in Kenya goes toward AIDS; John only recently began to practice safe sex | Marco Negri/Zuma/Keystone Press; Larry Krotz

John is something unusual in Kenya, a gay man who openly admits to both that and to being a sex worker. Homosexuality there has long been anathema, labelled by former president Moi as “foreign, not done by Kenyans.” Putting the lie to this, John every morning dabs on some Hugo Boss cologne, stops into an Internet café to check out a gay website for arriving tourists, then cruises the streets looking for business. But when we sat down and talked in Nairobi, John, who is 32 years old and asked not to be identified by his full name, admitted something astonishing: despite his high-risk occupation and the fact that AIDS has been around almost his entire life, he claimed not to know until last year that he could get HIV through sex with men. In Kenya, the HIV epidemic is overwhelmingly a heterosexual calamity. Eventually tested, he knows he is positive and, though he now uses condoms, for a long time he very likely spread the virus.

Astoundingly, a full generation after the arrival of AIDS, especially in that most hard-hit of regions, southern Africa, disinformation remains rife. As the 23rd World AIDS Day approaches on Dec. 1, what is similarly disturbing is that strategies needed to prevent the spread of this awful epidemic never came close to being effective. Statistics alone tell the tale. True, more and more people are on life-prolonging antiretroviral therapies (ART), something that mushroomed when costs dropped to $100 per year per patient with the arrival of generic drugs. Yet for every 100 people put on ART, southern Africa registers 250 new HIV infections.

It would be overstating matters to say that AIDS could have been prevented totally but, according to Canadian Frank Plummer, it “should have been easily stopped before the epidemic became what it did.” Plummer, now head of Health Canada’s National Microbiology Laboratory in Winnipeg, spent 17 years in Nairobi where, among other things, his research identified sex workers who remain immune to HIV. He stresses that had high-risk groups—including sex workers like John—been aggressively targeted, preventative strategies would have worked. As early as the late 1980s, those on the front lines knew that HIV is transmitted most easily through sores, lesions or a foreskin. Solutions: screen for and treat sexually transmitted infections; create incentives to use condoms when sex is bought or sold; where there is lots of HIV, encourage men to get circumcised. “That we were not able to do those things,” says Plummer, “was a colossal failure of public health.”

The purpose of epidemiology is to contain and, at the very best, prevent epidemics. Much was made, however, of the idea that HIV/AIDS differed from any other epidemic. HIV, for one thing, is a virus that mutates rapidly, making it almost impossible to nail with a vaccine. The epidemic also occurred within a complicated social-cultural context, primarily striking North American gays, drug addicts who shared needles, and heterosexuals in Africa. Sex and drugs, almost everywhere, are hot-potato topics, so people—and governments—became careful to the point of reticence. Public health authorities, starting in North America, bent over backwards to assure people that their lifestyles were not the business of the authorities, but then seemed confused about whether to fight the epidemic or to avoid offending people.

“Public health is inherently a somewhat fascist discipline,” declares Elizabeth Pisani, who has a Ph.D. in epidemiology and wrote the book, The Wisdom of Whores; Bureaucrats, Brothels, and the Business of AIDS. She uses SARS, the virus that landed squarely in Canada in 2003, as an example. When SARS emerged, there was no hesitation restricting people’s movements, forcing people to be tested, and registering or hospitalizing them if they were infected. Those practices adhered to a pattern going back to the 19th century, when many countries registered people with syphilis and did not hesitate to ask about their sex partners. But HIV/AIDS somehow got cast differently. “AIDS,” she writes, “focused people’s attention on the rights of people living with an infectious disease, [and] the fear of violating people’s perceived rights overrode many otherwise routine principles of public health.”

It was possible to contain HIV/AIDS, and some places did just that. Uganda, a country of 32 million, had one of the worst infection rates in all the world, an alarming 22 per cent. But early on, it rolled out a campaign with directives coming straight from President Yoweri Museveni. An intense program of public education, information and skills-building reached into every corner of the country. Within a couple of years it paid off, and infection rates dropped by 80 per cent. The public saw AIDS right away as a disease that, alarmingly, killed otherwise healthy people, and responded by altering their sexual habits to something colourfully termed “zero grazing.”

For a long time, slow progress in the battle against AIDS got framed as a question of money. The West was too stingy toward Africa’s plight. But AIDS, in fact, receives the lion’s share of health monies in many developing countries. According to Peter Piot, for 13 years head of the international response organization UNAIDS, global expenditure rose dramatically since 2001, reaching, by 2010, $15 billion a year. “This is serious money,” he notes. It is nothing, though, compared to estimated future costs for controlling the epidemic. The Washington-based Results for Development Institute’s aids2031 financing group recently suggested that over the next 20 years, up to US$733 billion will be required. Twenty years ago, curtailing AIDS would have cost a great deal less. In 1990, University of Manitoba researchers in Nairobi constructed a mathematical model predicated on 80 per cent condom use by commercial sex workers and their clients. The conclusion was that such a strategy, if broadly implemented, would cost about $10 per HIV infection prevented.

But it wasn’t implemented and the moment was lost. Piot conceded to the New York Times last spring that “in 2003 we were at a tipping point in the right direction, now I’m afraid we’re at a tipping point in the wrong direction.” What he worried about was a combination of increasing infections and donor fatigue. Those donors, including individuals like Bill Gates, are financing what few control measures are succeeding, but they are reputedly becoming increasingly frustrated. Piot might also worry about the sustainability of government programs. In Kenya, a country with an almost eight per cent infection rate, 60 per cent of government health spending goes toward AIDS. Meanwhile, 98 per cent of HIV/AIDS work in Kenya is financed by foreign donors. “How,” asks Dr. Omu Anzala, chair of microbiology at his country’s medical school, “is this sustainable?”

One of the hallmarks of the success in Uganda was that individuals embraced responsibility for their own health. This is no small point. People must know the facts, and know how serious is the threat they are facing. But then they, too, not just the government, have to take responsibility. Along with thousands of fellow sex workers and others, John was not wilfully ignorant, but proof of the failure of prevention.