Unfortunately, it was also a conference afflicted by great distraction, mostly from the U.S. and European HIV/AIDS denialist movement. The denialists believe that AIDS doesn't exist, even in Africa, or that even if it does, it has nothing to do with HIV. For the first time, such views became a major part of the media coverage of the conference. There could not be a worse moment for such intellectual dishonesty, pseudo-science and arrogance to rear its head. Yet there is still hope that the sheer presence of the conference itself and the attending media attention, whatever its focus, was enough to put the issue of AIDS in developing nations in the spotlight where it belongs. By the end of the conference, attention was shifting back to the issues that really matter, such as prevention, unfair pharmaceutical pricing and the lack of medical infrastructure needed to deliver basic healthcare and treatment for HIV.
But the outlook for the conference was confounded when South African President Thabo Mbeki stumbled into the camp of the AIDS denialists while out cruising the Internet. President Mbeki's intrigue with denialist theories caused many scientists in Africa and throughout the world to wring their hands in despair and even cancel plans to attend the meeting. Though it is clear that Mbeki made a big mistake in giving a platform to the denialists on a pre-conference panel he created, it is equally clear that he raised some critically important questions that must be addressed if Africa is ever going to be able to cope with AIDS. Unfortunately, too much attention has been focused on his involvement with discredited fringe theories. Lost in the debate are the true challenges he has raised about how to bring solutions to his country.
Efforts to stop the spread of mother-to-child transmission have been hampered by a mix of high drug prices and confusion about the value of the drugs, stirred up by the AIDS denialists. They raised suspicions about the value of using drugs like AZT by inappropriately applying concerns about toxicity in long-term use to the short-term application of treatment around the time of birth. There is still no government plan in South Africa to intervene in mother-to-child transmission. Instead, the government claims it is awaiting the outcome of additional studies and building the necessary infrastructure. Independent efforts by the Nobel prize-winning group Doctors Without Borders, however, have shown that it is possible to do the job even with the existing infrastructure.
Still, no country in Africa is better poised than South Africa to make a dent against AIDS, even if some other African nations have already initiated more and better programs. Preventive treatment against mother-to-child transmission is financially feasible and the country has already invested in a wide network of clinics that could help administer the therapy in the context of pre-natal care. It is frustrating that obstacles to preventing mother-to-child HIV transmission include politics and misinformation.
More challenging, perhaps, are the problems of prevention and delivery of treatment to people who are already infected. Social conditions and deeply engrained cultural practices regarding sex and the role of women render typical Western-style prevention programs all but impotent. Certainly, condoms can be useful, but only if cultural norms support their use. Rape and other abuses of women by men play a clear role in HIV transmission and must be confronted head on. But it will take time to achieve meaningful change and it will come only as a result of an enduring national debate and strong leadership. It is the lack of movement on these fronts that frustrates many AIDS workers and activists in South Africa and much of the African continent.
It is far too easy to focus on drug treatment as the solution to the problem. And President Mbeki is correct in pointing out that Western treatment programs cannot be simply transplanted to the South African environment. Even with greatly discounted drug costs, treatment for the infected population could easily bankrupt even this, the wealthiest of the sub-Saharan African nations. The raw cost of drugs, moreover, is but a single part of the picture, as today's AIDS therapies cannot be used efficiently without large investments in diagnostic tests and services as well as accompanying medical care. (See the article "Drug Pricing, AIDS and the Developing Nations" in this issue of PI Perspective for more information on this topic.)
Confounding these issues is the fact that AIDS is not the only medical problem demanding attention in South Africa. Many other serious illnesses compete for government attention, along with poverty and malnutrition. All are affected by the high costs of potential solutions.
With this background, no one envies the difficult choices that must be made by the government of South Africa. There are no simple or readily available solutions. The last thing President Mbeki needed was confounding input from discredited Western scientists who themselves have little or no experience in dealing with the AIDS crisis. Yet that is exactly what he asked for and what he got.
Prior to the Durban conference, President Mbeki learned of the denialist views in a sleepless night while searching the Internet for solutions. He thought he had come upon a group of self-described noble "dissidents" who claimed to be unfairly isolated and rejected by the scientific mainstream. Their own writings fail to mention how many times the scientific peer review process has already evaluated, assessed and rejected their arguments that HIV doesn't cause AIDS, that HIV is harmless or doesn't exist, and that there really is no crisis in Africa. To Mbeki, though, "dissident" is an honored political term that he understandably relates to. He had no way of knowing the history of the denialist movement or the characters who populate its web pages, no way of knowing if they were genuine scientific experts, people pursuing a lost cause or just the latest conspiracy theorists.
Unfortunately, Mbeki's personal experience as a political dissident made him an easy target for the denialist yarn. Soon, he was inviting California denialists David Rasnick and Charles Geschectner to South Africa for consultation. Peter Duesberg was asked to send his book and data. Once the word got out, otherwise unknown writers and fringe activists working the denialist circuit were both singing Mbeki's praises and burying him in their papers, documents and opinions. No similar effort was made to seek input from genuine HIV experts, at least at first.
The scientific community in Africa and internationally were aghast, realizing that Mbeki had inadvertently opened the hen house to the foxes. Instead of getting advice from people with genuine expertise in dealing with AIDS, he was soon being told that AIDS didn't exist, that the disease wasn't infectious, that it was just a manifestation of poverty and there was nothing he need do about it. People who didn't want to see their western governments channeling funds and services to Africa at taxpayer expense were now broadcasting their message through the head of an African state. Mbeki wrote a strange and strongly worded letter to U.S. President Clinton suggesting that those who didn't want him to listen to the denialists were somehow similar to the oppressors of South African blacks in the days of Apartheid. It must have come as a great surprise to Mbeki, however, when the main voice supporting his odd turn of direction was in fact the South African Böerstadt party, itself the right wing political remnant of the Apartheid ruling parties.
World-renowned African scientists joined with AIDS researchers internationally in urging him to reconsider.
Reports from people who attended that meeting suggest that within the first hour it became clear that little or no common ground would be found. Shortly after Mbeki himself decried the tragedy of AIDS unfolding in his country, one of the denialist leaders asserted that there was no proof that there was any problem or anything unusual happening in Africa at all. Two days of discussion went downhill from there, with the mainstream scientists and dissidents breaking off into two completely separate groups. After the weekend meeting, the discussions were to continue over a "closed" Internet discussion group, right up until the week before the International AIDS Conference in Durban. At the final meeting, a vague "compromise" was worked out that would arrange for further testing of the accuracy of HIV blood tests. After all the sound and fury, it was a curiously empty conclusion.
The other issues that Mbeki raised in his talk, such as poverty, hunger and sanitation, are indeed critically important. But, as many researchers were quick to point out, these conditions long pre-existed AIDS and were no worse -- and often better today than 50 years ago -- yet the death rate is soaring today while life expectancy plummets. What's new, obviously, is HIV and AIDS. And this is what he failed to address. Instead, he wasted time defending his exploration of denialist views, sending a signal of confusion to patients and AIDS workers throughout Africa.
The harm done may extend beyond South Africa. When a respected head of state publicly muses about whether HIV might be harmless, it makes the job of prevention far more difficult. Unless he now makes clear and unequivocal statements to the contrary, many people -- themselves goaded on by the denialist literature -- may choose to take the easy way out and disregard the difficult messages and behaviors of prevention. His inaction has also at least delayed the initiation of government-sponsored preventive treatment against mother-to-child transmission and may ultimately make women fearful of the drugs used for this purpose.
President Mbeki had the right idea in seeking expert input, but the process was diverted by trying to address the AIDS denialist position rather than the real issues at hand. The true blame here lies not with Mbeki but primarily with the AIDS denialists themselves who have brazenly taken advantage of a lapse in presidential wisdom. Having failed to make their case in the courts of science, they changed the venue to one of politics. They placed their own narrow and repeatedly rejected views above the lives of tens of millions of African men, women and children.
The proper venue for the debate about the cause of AIDS is the scientific community, where differing views are subject to the scientific process and peer review. When a point of view fails repeatedly in this venue, its proponents have no business trying to sell their beliefs instead in the political or public arena where people lack the background and knowledge to evaluate it. If they still wish to pursue their opinions, they are ethically obliged to conduct further experiments, collect more data, and try once again to convince their colleagues. Some denialists like to compare themselves to Galileo or other famous scientists whose views were once considered heretical. But the comparison is false. Galileo and others eventually succeeded through the strength of the data they presented to their scientific peers, not by politics or rhetorical appeals to the public.
While the 13th International Conference on AIDS may not have offered as much new science of interest to western patients, it may offer the beginning of hope for tens of millions of people thus far left behind. Governments, companies, researchers and activists must now offer whatever help they can. (A special issue of PI Perspective will shortly follow this one summarizing research highlights from the meeting.)
Back to the Project Inform Perspective August 2000 contents page.