The Coming Plague (84 page)
Authors: Laurie Garrett
As HIV emerged in new areas of the world, Mann hoped to find a way to break this chain of social epidemics; to push governments out of denial before they had an epidemic on their hands; or failing that, to move a society out of fear to effective action, rather than panic-driven repression. The GPA group knew that they were breaking new ground, that few societies had ever in history responded wisely or rationally to major epidemics, and that lessons learned with AIDS could be applied to combating future emergences of all sorts of microbes. They searched for answers.
In Nigeria, Dr. F. Soyinka studied his society's response to AIDS in 1987. Nigeria had very few cases of the disease, as it was located far from Africa's AIDS epicenter. Nevertheless, Soyinka and other physicians knew it was only a matter of time before HIV took its toll in Nigeria, so they waged a massive monthlong television, radio, and newspaper campaign to warn the public. At the campaign's end, Soyinka surveyed residents of Lagos.
He was sadly surprised to discover that “85 percent believe AIDS is a disease of the white man. They believe it can only be gotten if you have sex with a white man.”
A 1987 Gallup poll conducted in thirty-five nations showed that 96.5 percent of the people questioned had heard of AIDS, but most respondents were deeply confused about how dangerous the virus might be, how one got infected, and which activities put a person at risk. Similarly, U.S. CDC surveys year after year revealed that nearly every adult American had heard of AIDS and knew that it was caused by a virus. But about half thought one could become infected by donating blood, by being bitten by an insect, and/or by sitting on a public toilet.
Throughout the world there was an alarming confusion between the myths and the realities of AIDS, producing either continued denial or highly exaggerated fear.
A complicating factor unique to AIDS and other sexually transmitted diseases was the nearly universal dislike of condoms. All over the world,
men felt that condoms diminished their pleasure and women had little or no control over their use. Nobody enjoyed talking about condoms during lovemaking, and it could be dangerous for a woman to request that her lover or husband use one: there were widespread reports of men beating their wives or partners in response to such requests.
men felt that condoms diminished their pleasure and women had little or no control over their use. Nobody enjoyed talking about condoms during lovemaking, and it could be dangerous for a woman to request that her lover or husband use one: there were widespread reports of men beating their wives or partners in response to such requests.
Studies of gay male behavior in San Francisco showed that crucial to individual protective action, such as consistent use of condoms, was a high level of fear, brought about by witnessing the deterioration and AIDS death of a close friend, relative, or lover. Similarly, on a societal scale it was apparent that few cultures were able to confront AIDS until the death toll had become sufficiently high to have given more than 10 percent of all adults a firsthand view of the horrendous disease.
But that was unacceptable. How could Jonathan Mann, the GPA staff, the World Health Organization, or the planet's citizenry sit back and wait for a massive death toll before taking effective action? How could they allow the microbes to emerge in one geographic or cultural place after another, infect tens of thousands of people, slowlyâover a period of yearsâcause visible disease and deaths, and be utterly
endemic
to the societies before action was then taken to stave off an
epidemic?
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endemic
to the societies before action was then taken to stave off an
epidemic?
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Studies all over the world were revealing the scale of the problem. For example, by 1987 more than 5 percent of the adult population of Brazzaville, Congo, were infected with HIV, and the visible AIDS death toll was already obvious to even the casual observer. Yet researcher Marc Lallemont found that pregnant women in the city were in “an almost complete state of denial, perhaps the most complete I've ever seen.” Lallemont surveyed hundreds of women who were making prenatal visits to local clinics and discovered that more than half of them insisted AIDS was caused by mosquito bites, despite numerous government educational campaigns stating just the opposite and warning about sexual transmission of the disease.
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In 1986 the U.K. government launched one of the highest-profile AIDS education campaigns seen anywhere in the world. It was a case where most of the elements for success appeared to be in place: top-level political will, resources, national television accessibility, and a heightened media interest. Yet the campaign was eventually judged a failure, as it succeeded in raising AIDS awareness and fear but failed to put a dent in public misperceptions about how the virus was transmitted or general disdain for those who carried HIV.
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In no country, it seemed, had a government found the secret to preventing further spread of HIV once the epidemic became endemic.
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At the Global Programme on AIDS, Manuel Carballo said that the epidemic was forcing researchers all over the world to evaluateâand reevaluateâthe effectiveness of a whole battery of standard public health weapons, in hopes that something besides a chilling death toll could motivate individuals and governments to take rational steps to protect themselves from the virus.
“What makes the AIDS effort especially difficult,” Carballo said one afternoon shortly before the London Summit, “is that those who are at greatest risk are those who are divorced from traditional values and culture. They have had to innovate new cultures. They find friends in bars and clubs. And nothing in the relationships is stable.”
Without social stability, people were hard to reach, whether they were gay men frequenting bars in San Francisco, migrant workers in Mexico, newly urbanized young women in Kinshasa, Burmese prostitutes in Bangkok, or injecting drug users in the Bronx. Such people were deeply separated from the traditional mores of their respective societies, often cut off from their families and mainstream workplaces.
In the 1960s, René Dubos wrote extensively about the special vulnerability to the microbes among people who lived lives of poverty. History demonstrated repeatedly that, with rare exceptions, the microbes exploited the weak points of economically bereft lives: chronic malnutrition, prostitution, alcoholism, dense housing, poor hygiene, and egregious working conditions.
Carballo and his colleagues recognized that there was more to microbial vulnerability than the social-class arguments put forward by Dubos. When information was the key to self-protection, there were gradations of
Homo sapiens
vulnerability that, yes, could be rooted in economic class, but could also stem from social alienation. People who were treated as outcasts from the dominant culture in which they lived could be denied vital lifeprotecting information or public health tools. If the larger society reviled a particular subgroup, its marginalization could be a risk factor, Carballo argued, every bit as crucial as a contaminated syringe.
Homo sapiens
vulnerability that, yes, could be rooted in economic class, but could also stem from social alienation. People who were treated as outcasts from the dominant culture in which they lived could be denied vital lifeprotecting information or public health tools. If the larger society reviled a particular subgroup, its marginalization could be a risk factor, Carballo argued, every bit as crucial as a contaminated syringe.
Carballo saw a confluence of social factors at play in the emergence of HIV in societies: marginalization, social alienation, poverty, and discrimination. In his mind, they united to form a social bridge across which HIV traveled into one society after another.
As Panos Institute AIDS researcher Renée Sabatier put it: “I think there is a very real danger that we're going to end up as a [world] society divided between those who were able to inform themselves first and those who were informed late. Those who have access to information and health care, and those who don't. Those who are able to change, and those who aren't. I think there is a real danger of half of us turning into AIDS voyeurs, standing around watching others die.”
On January 28, 1988, the London Summit endorsed the GPA's fifteen-point declaration that called for openness and candor between governments and scientists, opposed AIDS-related discrimination, gave primacy to national education programs as means to limit the spread of AIDS, and reaffirmed the GPA's role in international leadership. Mann and Mahler viewed it as a triumph.
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But even as they smiled for the cameras and signed the declaration, seeds of failure were being sown. The declaration said nothing directly
about quarantines, immigration policies, or forced deportations, delegates to the Summit having concluded that no agreement on those pivotal issues could be reached between the 149 nations. Worse yet, representatives of critically important countriesâlike China and the U.S.S.R.âopenly scoffed at the GPA's attempts to promote educative efforts over restrictive measures. China's delegate denied the existence of homosexuals, drug users, and prostitutes in his country, thus insisting AIDS couldn't threaten the People's Republic. And Soviet Minister of Health Yevgeny Chazov insisted that Slavic genetic superiority had rendered the populace immune to the virus.
about quarantines, immigration policies, or forced deportations, delegates to the Summit having concluded that no agreement on those pivotal issues could be reached between the 149 nations. Worse yet, representatives of critically important countriesâlike China and the U.S.S.R.âopenly scoffed at the GPA's attempts to promote educative efforts over restrictive measures. China's delegate denied the existence of homosexuals, drug users, and prostitutes in his country, thus insisting AIDS couldn't threaten the People's Republic. And Soviet Minister of Health Yevgeny Chazov insisted that Slavic genetic superiority had rendered the populace immune to the virus.
Despite the efforts of the GPA, the pandemic spread relentlessly, always emerging first in communities that were on the outer periphery of societies' margins. Mann, Tarantola, Carballo, and the rest of the GPA staff zigzagged madly about the planet, living in a perpetual state of jet lag, as they frantically tried to squelch the tandem fears of HIV emergence and social denial, fear, or repression.
With each passing day in 1988, Mann became more strongly convinced that disease emergence was a human rights issue, in the strictest legal sense of the phrase. Though the physician/scientist had never before been exposed to international human rights law, some of those working around him hadâparticularly Katarina Tomasevski, an attorney and public health expert who served as a consultant to the GPA. Tomasevski introduced Mann to the body of international human rights law. And Mann, in turn, increasingly framed GPA policy pronouncements on such issues as international freedom to travel, HIV screening of refugees, access to health care for prostitutes, and discrimination against homosexuals in the context of the major instruments of human rights law.
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Tomasevski demonstrated that most of the government actions the GPA found repugnant, such as deportation of HIV-positive Africans from Asian countries following enforced testing and detention, were violations of international legal pacts to which the offending nations had previously agreed.
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Tomasevski demonstrated that most of the government actions the GPA found repugnant, such as deportation of HIV-positive Africans from Asian countries following enforced testing and detention, were violations of international legal pacts to which the offending nations had previously agreed.
In the United States, attorney Larry Gostin, of the Boston-based American Society of Law and Medicine, was carefully documenting the astonishing growth in AIDS-related legislation and precedent-setting legal decisions. He, too, felt that basic tenets of international human rights and national civil rights law were being violated or eroded.
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While the staff of the Global Programme on AIDS became more outspoken about the connection they perceived between human rights and the spread of HIV, anger and jealousy were building all around them. Some critics began dropping hints to the international press corps about “left-wingers in Geneva.” Among Mahler's top aides were men who made no bones about their feelings that the GPA was reflecting “homosexual politics.” Human rights, though a topic of serious discussion within most other UN agencies, had never received much attention at the World Health Organization.
“WHO human rights policies were characterized as incoherent, fragmented,
inconsistent. We really didn't get moving on human rights until it was thrust upon us,” WHO rights expert Sev Fluss said. What thrust human rights up to WHO's front burner was AIDS, and specifically references in the London declaration to abolishing discrimination and inequity.
inconsistent. We really didn't get moving on human rights until it was thrust upon us,” WHO rights expert Sev Fluss said. What thrust human rights up to WHO's front burner was AIDS, and specifically references in the London declaration to abolishing discrimination and inequity.
“Medical people think of human rights as torture and so on. They don't think of it as what they do. And they certainly don't think of a constitutional right to health care,” Fluss explained.
“When AIDS first emerged, our response was disastrous,” Fluss conceded. “People thought it was like Ebola and Marburg, which went away without creating a global epidemic. A flash in the pan, that's what they thought.”
But as early as 1983 ten countries passed legislation specifically targeting AIDS, and Fluss thought it rather intriguing that a new disease was prompting so many laws. By the time the GPA was established, twenty-one more countries had passed major AIDS legislation, and Fluss had an office designated as the WHO Health Legislation Unit. But the HIV pandemic kept spreading, right past all those laws, national border patrols, HIV-testing centers, and alleged human genetic superiority. Within nations it spread to new population groups, made its way from urban centers to rural areas, crossed class boundaries. Between nations it surmounted virtually every obstacle, save condoms, that humans placed in its wayâand certainly each legislative barrier.
By 1988 Western economists and African leaders were asking out loud, “Will this epidemic slow, or even destroy, African development? Is it possible that AIDS will destroy all the development programs we have spent the last three decades building?”
The disease, which so recently had been added to the agenda of international human rights, was also becoming a bona fide macroeconomics issue, threatening both fiscal and social development in the world's poorest nations. It seemed too horrible to contemplate, yet inescapably apparent, that the global AIDS pandemic might well make the world's poorest nations much, much poorer. After years of struggling to rise above Third World status, these nations might be slipping backward on a wave of Thirdworldization.
The World Bank's Mead Over pioneered much of the research on the economic impact of AIDS in Africa, which between 1988 and 1993 was supplemented greatly by the research of economists, mathematical modelers, and epidemiologists in the United States, U.K., France, and at WHO.
They began their calculations with several key assumptions: first, that African nations entered the AIDS era already severely impoverished. For
example, the 1987 GNP per capita in the United States was $16,690. In Tanzania it was $290, in Zaire a mere $170.
example, the 1987 GNP per capita in the United States was $16,690. In Tanzania it was $290, in Zaire a mere $170.
Second, no African nation faced a single epidemic crisis. Since the 1970s a host of new microbes had successfully emerged and swept across the continent: drug-resistant malaria, drug-resistant tuberculosis, urbanized yellow fever, Rift Valley fever, and waves of measles epidemics, to name a few. That meant that the health care systems of African nations were already stretched to their limits. Given scarce resources for health careâaveraging $1.00 to $10 per capita annuallyâany additional burden seriously endangered the viability of entire national medical systems.
Compounding the problem was the seeming synergy between microbial epidemics. Wherever AIDS became endemic, tuberculosis followed closely. One epidemic sparked another: malaria and HIV fed upon one another, as did cytomegalovirus, Epstein-Barr virus, syphilis, gonorrhea, chancroid, and a host of others. Though no one had a detailed empirical grasp of the relationship, it was clear throughout Africa that wave upon wave of infectious diseases influenced one another, and further taxed the health care systems and economies of afflicted nations.
A third assumption was that AIDS would have a uniquely harsh impact because of who in Africa were the microbe's primary targets. Studies all over the continent showed that among the hardest-hit social groups was the well-educated urban elite. These were the young adults who had attended universities in Boston, Oxford, Moscow, and Paris, acquiring skills that could be used to navigate their countries out of postcolonial stagnation into prosperity and infrastructural order. But they were also among the few Africans who possessed disposable incomes and could afford to indulge in the carefree nightlife of cities like Kinshasa, Nairobi, Harare, and Yaoundé. Long before anyone had heard of AIDS, the continent's educated elite was unknowingly becoming infected in the discos, brothels, and nightclubs of Africa's glittering nocturnal ambience. To economists, who placed productivity values on human lives, that meant that AIDS was taking a particularly sharp toll on Africa's future.
A fourth consideration was the familial nature of the epidemic. In Africa, whole families seemed to die off, each survivor's burden increased by the need to care for the sick and compensate for the decline in family income brought about by the deaths of adult providers. In some devastated areas, such as the Lake Victoria region, familial destruction led to the economic collapse of whole villages. And, with time, that could have a ripple effect through all tiers of the regional economy.
All economic forecasts had to begin with estimates of the size and forecasted scope of a country's current epidemic. Nobody, however, including those who reported countries' AIDS statistics, believed that the officially reported numbers came close to reflecting the true scope of the HIV/AIDS epidemics in developing countries. But what was the reality?
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Some African countries were still holding back accurate information
about the scope of their epidemics as late as 1990, particularly when sensitive groupsâsuch as the militaryâevidenced high infection rates. Still other countries were overwhelmed by famines, civil wars, and political instabilities that rendered the business of disease record keeping all but impossible. And all African countries were hampered by severe infrastructural problems that hindered diagnosis, treatment, and reporting of AIDS.
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about the scope of their epidemics as late as 1990, particularly when sensitive groupsâsuch as the militaryâevidenced high infection rates. Still other countries were overwhelmed by famines, civil wars, and political instabilities that rendered the business of disease record keeping all but impossible. And all African countries were hampered by severe infrastructural problems that hindered diagnosis, treatment, and reporting of AIDS.
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HIV infection rates in some groups were already staggering by 1988, and would reach positively horrendous proportions by 1993, when some studies would find, for example, that upward of 40 percent of women of reproductive age in key African cities carried the virus.
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Even without solid epidemic estimates economists who were paying attention to Africa's pandemic were, as early as January 1988, predicting financial hard times for the continent: patchworks of small-scale famines;
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“an economic disaster” based on the direct costs of AIDS care, HIV-testing costs,
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a year's supply of condoms,
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AZT and other drugs for opportunistic infections (where such pharmaceuticals were at all available); and loss of net industrial and agricultural productivity due to deceased workforce. They warned that AIDS was creating “a global underclass,” over and above the previously existent world community of impoverished individuals.
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“an economic disaster” based on the direct costs of AIDS care, HIV-testing costs,
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a year's supply of condoms,
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AZT and other drugs for opportunistic infections (where such pharmaceuticals were at all available); and loss of net industrial and agricultural productivity due to deceased workforce. They warned that AIDS was creating “a global underclass,” over and above the previously existent world community of impoverished individuals.
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Direct AIDS costsâdrugs, hospitalization, health care personnelâwere very low in the African countries when compared with the United States, simply because of the differences in availability of such resources and lower labor costs, according to studies by the World Bank's Over and collaborators in Tanzania and Zaire. They estimated that direct HIV-positive lifetime costs for the United Kingdom topped $20,000; under the U.S. health care system it averaged more than $50,000.
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In contrast, Zaire spent less than $600 in direct AIDS costs per average patient, Tanzania about $800.
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In contrast, Zaire spent less than $600 in direct AIDS costs per average patient, Tanzania about $800.
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But when the researchers compared various African diseases in terms of years of productive life lostâeconomically significant life for society as a wholeâHIV infection ranked roughly equal to the other top scourges, sickle-cell anemia, birth injury, and neonatal tetanus. And what were the monetary values of those lost productive lives? In 1985 dollars, the group estimated the average Zairian life lost to AIDS had a top value of $3,230; the equivalent Tanzanian loss was valued at $5,316.
When those values were compared with national GNPs per capita, that meant that a typical Zairian AIDS death equaled about 19 years of per capita GNP, a Tanzanian about 18.3 years. If such numbers were multiplied by thousands or tens of thousands of losses in the two nations' epidemic futures, it was clear that the result could be financial ruin for the already desperately poor countries.
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But such an analysis had its limits because it assumed that costs and values would be stagnant over time. In an expanding epidemic, however, costs were compounded over time as family and workplace burdens increased
due to multiple deaths: their combined impact was more than additive. For example, a farming family might be able to compensate for the loss of productivity due to the death of one adult, but after two or three deaths it would no longer be possible to till the soil or harvest a crop, particularly in areas lacking all forms of agricultural machinery.
due to multiple deaths: their combined impact was more than additive. For example, a farming family might be able to compensate for the loss of productivity due to the death of one adult, but after two or three deaths it would no longer be possible to till the soil or harvest a crop, particularly in areas lacking all forms of agricultural machinery.
From Mead Over's point of view, the real compounding crisis was loss of skilled and professional labor. A national bank in a country like Zaire would typically be operated by a handful of well-educated men, with no surplus labor pool upon which to draw for replacements. For many professions Africa's generation of twenty-five- to forty-year-olds was the first in the continent's history to achieve expertise. With colonialism so recently defeated, this was not surprising, but it did place most sub-Saharan economies in extraordinarily vulnerable positions in the face of an expanding epidemic.
“Indirect costs are twenty times as important as direct costs, because AIDS is striking people in their productive years. That is the real problem. I think the impact of the indirect costs on a typical East African country over the next twenty years could be to reduce the growth rates of the national economies from two or three percent, where they are now, to close to zero percent,” Over said. “That means a zero GNP growth. That's a worst-case scenario. So what we've got is a menace on the horizon.”
The real question was whether the AIDS epidemic might destroy the Third World's arduous efforts to pull itself out of perpetual poverty and disease into political stability and economic growth. After the expenditures of billions of dollars of foreign aid and loans from wealthy nationsâand after accruing massive debtsâsome of the world's poorest nations were just beginning to turn the tide.
Jonathan Mann felt it essential to get a handle on the development issue, not only because it was intrinsically important but also because solid empirical answers to the economic question would most likely affect investments in AIDS prevention programs at the international, national, and local levels.
The task fell to the GPA's Jim Chin. A year earlier Chin had been running infectious disease programs for the state of California, living a comfortable, albeit generally routine, life in Berkeley. There, he had commanded a staff of about 400 people and oversaw an annual $65 million budget. In 1989, however, the cautious American found himself facing the formidable task of forecasting the fate of a continent. With a total staff of five people and a tiny piece of the GPA's $90 million budget, Chin toiled in a cramped Geneva office. Though by nature an affable social animal, Chin approached his new job with introspection and conservatism, consciously lowballing his estimates lest he later be accused of playing Chicken Little.
Chin collaborated with Tanzanian scientist S. K. Lwangwa to develop models that, first, could determine how many unreported AIDS cases were
currently occurring in Africa; second, how large the current pre-AIDS HIV epidemic might be; and, finally, what might be the epidemic's growth rate and future toll.
currently occurring in Africa; second, how large the current pre-AIDS HIV epidemic might be; and, finally, what might be the epidemic's growth rate and future toll.
In 1989 the pair published a study that predicted that a typical East or Central African country already in the grips of a severe AIDS epidemic could expect by 1991 to have HIV infection in one out every five of its citizens.
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“That's lowball,” Chin said. “It's the high-end estimate based on an overall conservative set of assumptions. It could be a lot worse. Our most conservative estimate is that there will be 575,000 new AIDS cases in Africa in 1991, for a cumulative total of more than 800,000.”
Sitting at Chin's side, Mann listened attentively, then said with a heavy voice that the 1990s would be far worse.
“I would like to be optimistic,” Mann said, “but I think we must be realistic. Not until 1985 did the message really come home that AIDS was a global problem. In retrospect, probably historians will say it took too long. We are consistently faced with situations where the reality far exceeds our grasp. It's legitimate to ask, âAre we able to see clearly enough? Or, when we look into the future, is the horror of it all simply too much even for us to confront?'”
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But by 1990 Chin's estimates were even grimmer. He was saying that 8 to 10 million were infected, perhaps 5 million of them in Africa. It would prove the first of many upward revisions.
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By the time WHO's July 1990 revised forecast was released, Jonathan Mann and much of his GPA staff were gone. They had lost a power struggle within the Geneva-based organization, and Mann had developed a contentious relationship with the new WHO director-general, Hiroshi Nakajima. Mann's enemies within WHO were legion: all those months of greening with envy over the upstart American's meteoric rise finally paid off.
Japanese physician Nakajima, who had headed WHO's Asian regional office during the period when multidrug-resistant malaria spread across the southern region, was clearly uncomfortable with Mann's very public persona and high-profile AIDS program. He shared the views of those who had long whispered derisive comments about the GPA in the WHO hallways. Nakajima felt that disease programs should be managed in accordance with established WHO protocol. It was a reasonable expectation, except for one key point: established protocol did not provide for the contingencies presented by a rapidly expanding worldwide epidemic.
In Mann's stead Nakajima placed another American physician, Michael Merson. For most of his professional life Merson had worked for WHO in Geneva, managing programs for respiratory and diarrheal diseases. Merson understood WHO protocol.
An unfortunate political battle ensued, with leaders in the world's AIDS control effort taking sides for or against Mann, Merson, Nakajima, and the professional positions each took on approaches to the pandemic.
In Merson's first six months heading GPA, the program upwardly revised its estimates of the size of the global pandemic three times. By September 1990 the official WHO estimate of the cumulative number of AIDS cases was 1.2 million, 400,000 of which were infants and small childrenâ90 percent of whom were in sub-Saharan Africa. And the new WHO year 2000 projection was for 25 to 30 million HIV infections worldwide.
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