Aids: Rhetoric and reality

Aids: Rhetoric and reality

Ankomah, Baffour

Baffour Ankomah was in Senegal in early February, on a one-week trip organised by the UNDP for 30 journalists across the world to see how Senegal is winning the war against HIV-Aids. Not entirely surprising to him, he found practical examples of how the rhetoric and reality of Aids are still poles apart.

First a disclaimer! For those who already know my personal views on Aids, the following are not my figures. They come from the Joint United Nations Programme on HIV-Aids (UNAIDS), the umbrella body for the seven UN and other organisations (UNICEF, UNDP, UNFPA, UNDCP, UNESCO, WHO and World Bank) that are now at the forefront of the global fight against HIV-Aids.

According to the figures, released in December 2000 by UNAIDS and WHO, Senegal is not (repeat, not) the country in Africa with the lowest HIV prevalence rate. This is contrary to what UNAIDS and WHO have been telling the world for the past three or so years. Nor does Uganda, the other “island of hope”, come anywhere near the top of the league table for the lowest rates in Africa. With an 8.30% rate, Uganda lies a poor 22nd.

Yet for the past three years, UNAIDS and WHO have held up Senegal, Uganda and Thailand as the “islands of hope” in the sea of Aids, to be emulated by others. But UNAIDS and WHO’s own figures show that by the end of 1999 there were five (repeat, five) African countries with even lower rates than Senegal.

But the five countries – Madagascar, Equatorial Guinea, Mauritania, Niger and Guinea – get no credit for their efforts. As a result, how and why they managed to have such low rates is not studied by the UN system, and their successes are lost to the world. The big question is: Why?

By the end of 1999, according to UNAIDS and WHO, Senegal had a prevalence rate of 1.77%, Madagascar had 0.15%; Equatorial Guinea 0.51%; Mauritania 0.52%; Niger 1.35% and Guinea 1.54%. So Senegal (1.77%) was, and still is, sixth on the league table.

Living in denial?

The question that troubled me in Senegal, therefore, was: Why Senegal? Why not Madagascar, or Equatorial Guinea, or Mauritania or Niger? Why make an icon our of the sixth brilliant student in the class when there are five even more brilliant chaps ahead of him?

But there were no UNAIDS and WHO officials on the trip to answer these questions. In their absence, Djibril Diallo, the UNDP director of communications (who is Senegalese himself) tried to help, but he was not the right person to answer those questions as when UNAIDS and WHO are putting their figures together, African voices are hardly heard.

Djibril had not even looked at the “end 1999” figures on the world Aids map published last year by UNAIDS and WHO which had been supplied to us in our press packs by the UNDP.

A very articulate and well-travelled man, Djibril had just finished telling us that Senegal had the lowest HIV-Aids rate in Africa, and that “Africa is living in denial” of Aids (the second time he had said it in three days) when I showed him the “world Aids map” and asked whether the figures on it were still relevant.

Yes, he said. In that case, I said, “you are wrong because the figures show Senegal to be the sixth lowest, not the first.” I then asked him why the first five countries ahead of Senegal were not given any credit for their efforts by the UN system?

It was in fact a twin question, because I also asked him to expatiate on his other substantive remark that “Africa is living in denial of Aids” when the world Aids map says categorically that UNAIDS and WHO have no figures on the “North Africa and Middle East Region” made up of 20 odd countries. And how is that possible?!

Of the 20 countries in the region, only two: Israel (0.08%) and Cyprus (0.10%) have up-to-date figures. The rest have asterisks in front of their names.

If you check the small print, the asterik says: “For countries marked with an asterik, insufficient data were available to calculate an estimated HIV prevalence rate for end 1999. In these cases, the figure used is the 1994 prevalence rate for the country concerned published by WHO.”

UNAIDS and WHO further explain in their latest “Aids Epidemic Update: December 2000” their most current “global summary” of HIV-Aids prevalence, thus:

“North Africa and the Middle East: Because of insufficient data, few new country estimates of HIV infection were produced for this region between 1994 and 1999. Recent evidence, however, suggests that new infections are on the rise. For example, localised studies in southern Algeria show rates of around 1% in pregnant women attending antenatal clinics…”

Ofeibea Quist-Arcton, the correspondent of Allafrica.com, then asked Djibril where the UN system gets its Aids figures. From governments, he said.

Then why do UN officials and Western journalists accuse Africa of “living in denial of Aids” when the “North Africa and Middle East Region” gives them no figures at all?

At least, UNAIDS and WHO have up-to-date estimates on 48 of Africa’s 53 countries (except Eritrea, Comoros, Mauritius, Reunion and Somalia). Yet, they still accuse Africa of “living in denial” while the North Africa and Middle East Region is not similarly accused.

In effect, the world Aids map which has been fed to the world for all these years by UNAIDS and WHO, and which shows Africa to be the only place drowning in Aids, does not tell the whole story.

The illogicalities

Also included in our press packs was this particular fact sheet that caught my eye, published by UNAIDS/WHO about the “main mode(s)” of HIV-Aids transmission in the world.

In “Sub-Saharan Africa”, the fact sheet says the main mode of transmission is “heterosexual” sex.

In North Africa & Middle East, and South & South-East Asia, it is “heterosexual and injecting drug use” (in that order).

In East Asia & Pacific, it is “injecting drugs, homosexual, and heterosexual”.

In Latin America, it is “homosexual, injecting drugs and heterosexual”.

In the Caribbean, it is “heterosexual and homosexual”.

In Eastern Europe & Central Asia, it is “injecting drugs”.

In Western Europe, it is “homosexual and injecting drugs”.

In North America, it is “homosexual, injecting drugs and heterosexual”.

And in Australia & New Zealand, it is “homosexual” sex.

Interesting, isn’t it? One virus, one “disease”, deciding on different modes of transport (concorde, fokker, canoe, bicycle, etc) as it travels round the world. But that is Aids for you!

There was another interesting document in our press packs which, though had the UNAIDS “official” logo embossed all over it, and is included in the “UNAIDS Best Practice (Key Material) Collection”, yet is disowned by UNAIDS as not being a “formal” document of the organisation.

Published in English in June 1999, titled “Acting Early to Prevent Aids – The case of Senegal’, the document says on the “acknowledgement page” that its copyright is owned by UNAIDS. “All rights reserved”, it says, yet in the very next line, UNAIDS says:

“This document, which is not a formal publication of UNAIDS, may be freely reviewed, quoted, reproduced or translated, in part or in full, provided that the source is acknowledged. The document may not be sold or used in conjunction with commercial purposes without prior approval from UNAIDS.”

So, if the document is “not a formal” UNAIDS publication, why does it have its logo on it, and why must “approval” be sought from UNAIDS before it is “used in conjunction with commercial purposes”?

The problem UNAIDS seems to have here is that, apart from the good news in the document about Aids in Senegal and Africa, it also contradicts in many places the “official” UNAIDS and WHO nomenclature of Aids in Africa.

The document was written by Elisabeth Pisani and coordinated by Michael Carael, with contributions from Dr Ibrahim Ndoye (one of the two most respected establishment Aids experts in Senegal), Nicholas Meda, Prof Souleymane M’Boup (a colonel in the Senegalese army, who with Dr Ndoye are the two most respected Aids experts in Senegal and beyond, M’Boup is also credited with discovering HIV-2 in 1986), Alpha Wade, Salif Ndiaye, Cheikh Niang, Fatou Sarr and Idrissa Diop.

Information in the document was drawn from several sources, including two rounds of targeted behavioural surveys conducted in 1997 and 1998 among “school children, students, sex workers and salaried employees”. It is the best source of information about why Senegal has been “successful” at combating Aids. (Incidentally, the same reasons were repeated ad infinitum by officials and local people as we travelled round Dakar and the regions).

The reasons for success

According to the document, “Senegal is a religiously cohesive country [where] 93% of the population is Moslem and 5% is Christian..Both Moslem and Christian leaders actively promote family and sexual norms that would tend to reduce the transmission of HIV…

“Firstly, circumcision is universal and circumcised men appear less likely than the uncircumcised to contract or pass on sexually transmitted infections, including HIV.”

Here lies a fundamental contradiction: If circumcision protects against HIV-Aids (as it does in Senegal, and as other studies elsewhere in Africa have shown), why does Africa which has more circumcised men than any continent, said to have more HIV-Aids infected people?

In Senegal, marriage and virginity are two other important factors. Polygamy is big in Senegal (as Moslems, they can have four wives), so “half of all women are married by the age of 20, but half of men remain unmarried by age 31”.

For both men and women, the document says, Western education makes a difference to marriage patterns. The more Western education a man has, the less likely he is to have several wives. But such a man is more likely to have more sexual partners than a less educated man.

That actually is what happens in the West. Though monogamy is decreed by law, Western men (and women) have multiple sexual partners. What is news here is that, if having multiple sexual partners in the West does not lead to a high HIV– Aids rate, why does it do so in Africa?

In Senegal, there is even something extra: “Married women rarely have partners beside their husbands”, the document says. “In the 1997 Dakar study, 99% of married women said they had not had sex with anyone except their husbands in the preceding 12 months… [while] some 12% of married men said they had sexual partners other than their wives in the preceding year.

On premarital sex, the document says: “For [Senegalese] women, sex before marriage was traditionally uncommon… This means that, while they remain virgins for longer, Senegalese women are more likely to have premarital sex now than in the past.

Again, Western education is a factor. “The more [Western] educated a girl is, the longer she is likely to wait before having sex. In a study of female students in 1998, 95% reported that they had never had sex. Women with at least secondary school education are virgins for six years longer, on average, than women with no education… Male students were far more sexually active than female students, but they still reported only sporadic sex, and a limited number of partners.

“Since younger women are less susceptible to HIV infection than more mature women,” the document says, “it is likely that this increasing age at first sex provides added protection against HIV infection.”

On average, Senegalese girls stay virgin up to age 19. This compares with 17.5 in Tanzania, 17.2 in Benin, 16.7 in Zambia and 16 in Mali. Why then do these countries have higher HIV-Aids rates than, say, Britain which has the highest teenage pregnancy rate in Europe, and where virginity stops much earlier? Condom use among British teenagers, and even the adult population, is not something to write home about.

In Senegal, for example, condom sales rose from just 800,000 in 1988 to seven million in 1997 for the four million people aged between 15– 49. That compares with two million condoms for five million people in the same age bracket in Burkina Faso, and 19 million condoms for 15.5 million people in Tanzania aged 15-49.

illogicalities continued

Another bizarre factor in the Senegalese equation is prostitution, a highly visible “profession” which is not dying away in Senegal. Prostitution was legalised in Senegal in 1969 and prostitutes have since been required to have regular health checks and registration cards. But there are as many, if not more, “illegal” prostitutes as legal. So, how does this affect the HIV-Aids rate? Judging by the country’s “success” story, prostitution appears not to have any adverse effect on the spread of HIV-Aids in Senegal.

Prostitutes get free condoms (50 a week) supplied by some NGOs who in turn get their free supplies from USAID. But contrary to the hype that “condom is safe sex”, some prostitutes told us that the condoms routinely break.

Another “risk group”, we were told, were Senegalese travellers both within the country and abroad, yet tourists (who are glorified travellers and mainly Western in Senegal, a major tourist destination) are not similarly considered as a risk group.

But all over Dakar and beyond – in the hotels, bars and inns – you see these middle-aged Western male tourists having their fill with the young and beautiful Senegalese women (some mere teenagers, and prostitutes).

Senegalese and other African truck drivers are also said to be another “risk group”, but European truck drivers, for example, who criss-cross more countries than African truck drivers, are not considered a risk group.

More illogicalities

Prof Souleymane M’Boup, the “discoverer” of HIV-2, says Africa is basically split in two by the HN virus. HIV-2 “which is less transmissible than HIV-1″, is mainly found in West Africa, Mozambique, Angola and India. There is a link with Portuguese colonialism with HIV-2”, M’Boup said, adding: “A victim of HIV-1 is eight times more at risk of developing Aids than HIV-2 which has a long incubation period.”

He said the West African variant is a “Recombitant Subtype CLV02, between the A and G virus. HRV-1, on the other hand, is found mainly in Southern and East Africa, and Europe and North America.”

The question that arises is: Why did HIV-1 jump West Africa and affect Southern and East Africa, when West Africa is nearer Europe and North America than Southern and East Africa? By the law of averages, you would think that West Africa, Europe and North America would have the same virus, wouldn’t you? But that is Aids, again, for you.

The other Senegalese Aids expert, Dr Ibrahim Ndoye, who has been working on public health since 1978, and on Aids since 1986, is dead sure that Aids and poverty are linked in Africa. His view is shared by Zephrin Diabre, the UNDP’s No.2 in New York (a Burkinabe, who spoke to us via a video linkup). Diabre agrees that “today, Aids is a poor man’s disease”.

Dr Ndoye explained that poverty created the environment for HIV-Aids to thrive in Africa. For example, prostitution and migration in Africa, are due to the poor economic situation. “I have 30 years experience in this area,” he said, “and I can say that prostitution in Africa is due to the poor economic situation.”

Yet, when I put it to him that President Thabo Mbeki is being shot at by the Aids establishment for saying the same thing in South Africa, Ndoye started backpedaling. “No, I am not saying what Mbeki is saying,” he said and went into a long explanation that still amounted to what Mbeki is saying about poverty and Aids. When I reminded him that he was still saying what Mbeki has been saying, Ndoye still insisted that he wasn’t.

Aids v malaria

Mark Malloch Brown, the British boss of UNDP who made Aids advocacy a central plank of the UNDP when he took over a year and a half ago, has effectively consigned malaria (which is proven to kill over one million Africans a year) to the back-burner.

He says in a fact sheet, titled “UNDP’s Role in the fight against HIV-Aids”, that: “HIV-Aids has a qualitatively different impact than [the] traditional health killer such as malaria. It rips across social structures, targeting people, particularly girls. By cutting deep into all sectors of society, it undermines vital economic growth – perhaps reducing future national GDP size in Africa by a third over the next 20 years.”

But you don’t need to be a rocket scientist to know that malaria does exactly the same – “it rips across social structures…cutting deep into all sectors of society.. and undermining economic growth”. But even in Senegal, there is no official programme to fight malaria. There is no NGO distributing free mosquito nets supplied free by USAID.

Rather, three months ago, the UN system in collaboration with the pharmaceutical companies slashed the price of Aids drugs by 90% for Senegal under a deal in which 130 of the estimated 80,000 HIV sufferers in the country are now being treated with the new Aids drugs.

To qualify for the deal, a country must satisfy four conditions: (A) the government must allocate funds for the programme, (B) there must be a training component attached, (C) there must be a means of following up patients, and (D) there must be a system of management of drug purchases.

We did not see (or were not shown) any Aids patient in Senegal throughout the trip. We saw three healthy people “living with HIV” who were not on the new anti-Aids drugs but were doing fine.

From what Mark Malloch Brown has been saying, the UNDP’s new mission includes a social engineering component. He told the African Development Forum’s last conference in Addis Ababa (Ethiopia) last December: “First and most important, we need to break the silence once and for all: to alter permanently the norms, values and traditions that are fuelling the epidemic, especially those that perpetuate gender inequalities and discrimination against those living with HIV-Aids.”‘

As a result, even in countries like Senegal with a very low HIV rate, age-old norms and traditions such as polygamy and wife inheritance are under intense assault. Monogamy is “cool”, yet nobody is talking about what will happen to the Senegalese female population that outnumbers the male 3 to 1. How do they satisfy the basic human need for sex? Perhaps they will become lesbians!

The reality

Judging by all the contradictions enumerated above, there is one plausible explanation for the high HIV-Aids rates (as published by UNAIDS) in Southern and East Africa which nobody wants to confront.

For a start, the sexual behaviour of the Africans in that region is no different from West Africans to warrant HIV rates as high as 35.80% in Botswana, 25.25% in Swaziland, 23.57% in Lesotho, 19.95% in Zambia, 19.94% in South Africa, 19.54% in Namibia, 15.96% in Malawi and 13.22% in Mozambique.

Even going by the UNAIDS and WHO’s usually inflated estimates, West Africa is not in the grip of a serious HIV-Aids epidemic. Out of the 15 countries in Africa with the lowest rates (from 0.15% to 5%,) 13 are in West Africa.

If West Africans, therefore, have the same sexual behaviour as Southern and East Africans, then it makes no sense that sex alone is accountable for the extremely high rates of infection in Southern and East Africa as reported by UNAIDS. There must be something more to it than meets the eye.

In late 1997, Ben Geer, a white South African who fought for the Rhodesians against the African guerrillas during the liberation wars, published the book, Something More Sinister, a “faction” (fact and fiction) thriller about how the white regimes in both Rhodesia and South Africa (via their intelligence agencies) unleashed biological weapons on the black guerrillas then based in the “Frontline States” bordering Rhodesia and South Africa.

Today, interestingly, the “Frontline States” happen to be the worst affected by HIV and Aids.

Geer writes in the epilogue of his book, which is part of the factual bit, that: “Late in December 1979, in the US, a chance remark to the author from an ex-serviceman prompted the writing of this novel. The soldier stated that he had been one of a contingent of US troops en route from Vietnam who had been actively deployed in the Rhodesian Bush war.

“They were given no reasons for being in Africa. Engaging the local militia and having killed a number of persons on their march over a number of days to the coast, they were picked up by the US navy and shipped home. The soldier was not aware of any further involvement in Rhodesia by the US…

“In September 1976, the US secretary of state, Henry Kissinger, makes an impromptu visit to South Africa; the Rhodesian prime minister Ian Smith flies twice to South Africa in one week and [on 18 Septermber 1976] agrees to the terms set out by [Kissinger] without protest!.”

Geer then asks: “What transpired so that, in a space of hours, the Rhodesian prime minister [who had vowed that black rule in Rhodesia would not happen in his life time] did a complete volte-face on his stance against black majority rule?

Geer says: “Kissinger made one serious gaffe during negotiations with [Ian] Smith: he kept on making references to `our own intelligence’ services in Rhodesia. Officially all ties with the US had ceased in 1969. By the continual mention of their presence, [Kissinger] embarrassed the CIA who had told the President and State Department that they had been withdrawn.”

Geer reveals that “the Rhodesian security forces operated a Biological Warfare Unit during the Bush War [that lasted 13 years] … [And] the South African medical research into the immune system was extremely advanced as a result of the work of the pioneering heart transplant unit at Groote Schuur Hospital in Cape Town.”

He continues: “The continued annihilation of villages and refugee centres in Mozambique by the Rhodesian security forces – with no consideration given to innocent civilians, the elderly, women and children – seems incongruous with their Christian ideals. Why was the war protracted (it claimed 30,000 lives) and these atrocities committed after agreement had been reached on Kissinger’s proposal?”

Alan Rake, former editor of New African, reviewing Geer’s book (NA, Feb 1998), pointedly stated: [The book] gives food for thought and tackles the HIV problem… Geer gives another theory about these strange viral diseases that still continue to plague our continent.”

Ongoing court drama

Since October 1999, what Geer wrote is his book has been replayed in real life in a South African courtroom. Dr Wouter Basson, a “decorated former army brigadier” who in civilian life is an eminent cardiologist and founder/leader of Project Coast, a top-secret biological warfare programme set up under the apartheid regime, has been standing trial for his role in the project. What has been revealed at Basson’s trial in the last 17 months really astounds!

Project Coast, it has been said in court, included research into a race-specific bioweapon that would target only blacks, a programme to sterilise South Africa’s black population, the deliberate spreading of cholera, the fatal poisoning of ANC leaders and guerrillas, and large scale production of dangerous drugs.

In a major article on the trial published by The New Yorker on 15 January 2001, William Finnegan wrote: “Many foreign governments are also nervously watching, for the trial threatens to expose not only the frightening permeability of the world of doomsday science and outlawed weaponry, but a maze of deeply embarrassing connections between the apartheid regime’s chemical and biological warfare programme and the intelligence setvices [of many countries, including] the United States, Britain, France, Germany, Israel and Switzerland… Some multinational chemical and pharmaceutical companies are also said to be sleeping poorly.” Basson denies any wrongdoing.

According to Finnegan, Project Coast “relied on a global network of spies, ex-soldiers, sanctions busters, smugglers and bio-warriors to obtain the chemicals, toxins, viral cultures, specialised equipment and expertise necessary to develop the programme.

In 1993, Dr Basson was forcibly retired from the army by President De Klerk but he was re-hired in 1995 by President Mandela because “British and American intelligence agents talked (and frightened) him into it,” says Finnegan. Basson was made the chief cardiologist and head of the heart transplant unit of the main military hospital in Pretoria, a post he still holds even while on trial.

Finnegan reveals that “the American embassy in Pretoria admits privately that the United States government is `terribly concerned’ that Basson may start talking about his sources of information and technology. The embassy hopes that an impression of `unwitting cooperation’ is all that emerges in the way of an American connection.”

If HIV-Aids is to be conquered in Southern and East Africa, the authorities will have to look into some of these things. Sex alone is not enough to explain the “high” incidence of HIV-Aids in that region. NA

Copyright International Communications Mar 2001

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