- AN AFRICAN ON AIDS IN AFRICA -
by Konotey-Ahulu FID. (Guest Editorial). The AIDS Letter - Royal Society
of Medicine 1989, No 11, Feb/March 1989, pp 1-3 with permission
from the Royal Society of Medicine. Copyright
remains with the Royal
Society of Medicine.
AN AFRICAN ON AIDS IN AFRICA
an account by an African of how he sees AIDS on his continent is less
likely to be objective, the defect of subjectivity can be counter-balanced
by the fact that he sees, hears, assesses, and feels things about the
scourge of which perhaps the non-native is incapable.
First, take the setting in which AIDS occurs. As depicted in Figure 1
below, the health of a nation depends on the control of the Three Ps (Population,
Figure 1 The Three Ps and their effect on a nation's health.
(Reproduced from Konotey Ahulu 1985)
developed countries have managed to hold, and continue to hold, the Three
Ps in rigid confines so that the nation's health is not eroded. Not so
the developing countries. The Three Ps have so often got out of hand that
a wholesome national health hardly exists. The more out of control the
Three Ps are in a country, the less there is of a nation's health to speak
of. So if the developed countries are reeling under the heel of AIDS,
how will African countries fare? Secondly, the African does not speak
of Africa as if it was 'a little country somewhere in Timbuktu'. Africa
is a massive continent with 600 million people in 2,300 tribes distributed
in 53 different, sometimes very different, countries. For example, the
difference between Ghana and next-door Ivory Coast vis a vis the sex trade
is the difference between Ghana's ex-colonial master Britain and Cote
d'ivoire's France. Scientific and media descriptions of Africa's 'AIDS
elephant', with its 53 body parts, have sometimes been like those of the
proverbial blind men surveying an elephant. Most researchers concentrate
on the tusk and, not surprisingly, come out with 'the AIDS problem in
Africa is very sharp and pointed; the whole continent is like that'. Even
when experts from Nigeria, the large body-part of the elephant, confirm
with seropositivity studies that there is not yet an AIDS problem in their
country, they are shouted down with "Under-reporting! Under-reporting!
The whole beast has a sharp profile." To these safari experts, Tanzania
and Sierra Leone, Uganda and Gabon, Zaire and Ghana, Rwanda and Gambia,
are all the same-so much 'the same' that British medical students must
be banned from setting foot on the continent.
Reports I was receiving from my tribe back home did not tally with what
the scientists were saying. For instance, one leading authority reported
in an American medical journal of world repute that there was no AIDS
in Ivory Coast; rather that Ghana and Nigeria were full of AIDS. Yet the
truth was quite the reverse. Ghanaian females who went to do sexual business
in the ex-French colony were being transported back home in Mummy lorries
to die; not one of an equal number who went to Nigeria in search of strong
currency has been sent back home with AIDS. Other scientists, using their
findings in the tusk region of the African elephant, make statements like:
' The sex ratio for seropositivity and disease is almost equal with a
small excess of men'. Again quite wrong for some other parts of Africa,
and this was confirmed by news from Kroboland that'AIDS is a female disease;
not one Krobo man is with it yet.' I learnt that the AIDS girls had 'all
just been dumped from abroad' When the media began to report that whole
generations in Africa were being wiped out, and that the continent was
suffering a population collapse, I decided to travel; not in search of
invisible seropositivity but to use the well attested tools of British
undergraduate and postgraduate clinical medicine, namely history-taking,
physical signs and detective epidemiologic work to formulate principles
and assess the extent of what was obviously a new phenomenon. I went from
London to Geneva (WHO), Congo Brazzaville (WHO), Kenya, Uganda, Rwanda
(Kigali/Butare/Kigali), Burundi , Tanzania, Zambia (Lusaka/Ndola/Lusaka),
Zimbabwe, Kenya (Nairobi/ Mombasa/Nairobi), Cameroon, Nigeria, Ghana,
Ivory Coast, Liberia, Sierra Leone, Gambia, Senegal, Ghana, Geneva and
back to London. I was refused a visa for Zaire but I met residents visiting
London who had valuable information. I also communicated with doctors
in Ethiopia, Gabon,Nambia, South Africa, Sudan, Lesotho, Botswana, Seychelles,
Upper Volta, Malagassy, Mozambique, and Egypt.
For a more complete description of Africa's AIDS beast, the synoptic observations
given below should be supplemented with the less subjective accounts of
researchers resident in Africa (see Bibliography). But first a preliminary
discussion. Definition of terms and criteria of assessment (a)
For 'heterosexual practice' I use m-f sex, and for homosexuality m-m sex.
Interviews with more than 120 prostitutes in 1987 and 1988 taught me that
the widespread use of the term 'heterosexual spread' to mean 'penovaginal'
is wrong, for m-f sex can be other than penovaginal: 'It depends on what
the client wants' was a common retort to questioning.
(b) For 'iceberg' I use aidsberg, the former being a tropical misnomer.
(c) The Introduction phase of AIDS in my tribe ceases the day AIDS,
as clinically defined by the WHO, is found in a patient who has never
been outside the tribe. Propagation phase begins the day the introduction
phase ceases. (Seroepidemiologists object to this definition but then
there are no seroepidemiologists in my tribe; blood is taken from the
sick, not the healthy, except when donated for transfusion.)
(d) I use the term formportucolo virus for HIV-2, because whenever
the virus is found it can be traced back to a former Portuguese colony,
or to Portugal itself.
(e) The criterion of problem assessment which divides the number
of AIDS patients n, by the population N, and then arranges all the countries
of the world in order of merit, placing the Congo Republic top of the
AIDS class is, to epidemiologists, rather naive. It is quite obvious from
a visit to the Congo that unlike the situation in the USA, France, UK,
or Belgium, the bottom of Congo's aidsberg is largely ectopic - i.e. across
the river in Zaire. The former Belgian Congo which, like Rwanda and Burundi,
reflects the AIDS burden of Belgium, is quite unique in the world in having
more countries surrounding it than does any other - 9 in all (10 if one
counts Angola's Cabinda). The porous boundaries freely admit young women,
driven by poverty to go to Zaire for foreign exchange. Just as the bottom
of Ghana's aidsberg is ectopic Cote d'Ivoire (which mirrors the AIDS problem
of France, leader of Europe), so is Congo's in Zaire. Therefore, counting
1,250 Congolese AIDS patients and calling this the visible tip of a colossal
aidsberg in a population of 1,750,000 is quite wrong.
(f) I have proposed that AIDS figures always be presented as n
(m.f.c.); so that if, as in February 1988, we had in the Krobo tribe one
male pimp, 28 prostitutes , and one child of one of the sick girls, all
repatriated from Abidjan desperately ill, this would be documented as
'Repatriation AIDS 30 (1,28,1)' . One suspects that if this was done for
all African countries including Congo, beginning at the grass roots, the
true adult sex incidence would emerge. (g) For assessment of the
gravity of the AIDS problem both at the tribal and national levels I have
proposed a 5-tier grading system not based on seroepidemiology: Grade
I = AIDS not much of a problem; Grade II ='a problem'; Grade Ill ='a great
problem'; Grade IV 'an extremely great problem'; Grade V= 'a catastrophe'.
Taking cognizance of local circumstances, the health workers of the tribe
or the country must themselves decide what their criteria for grading
are and plot a graph with 'time in months' as abscissa, and 'grade' as
ordinate to see when things change from one grade to another, and why.
To accept the grading of experts who live outside the country with little
knowledge of local circumstances, and who make the whole continent equivalent
to Grade IV or V, could lead to accepting prescriptions for prevention
which may not work in the African milieu.
synoptic observations on AIDS in Africa
The problem is not at all uniform on the continent. In large parts of
most countries AIDS has not yet been shown to be in the propagation phase.
The factors that determine how severe the problem is in a country include:
(a) Colonial relationship to high-frequency countries in Europe,
e.g. Zaire, Rwanda, Burundi, Ivory Coast.
(b) Contiguity with countries in (a) above without border restrictions,
e.g. Tanzania (with Burundi and Zaire), Zambia (with Zaire and Tanzania),
Uganda (with Rwanda and Zaire).
(c) Intense poverty through political upheavals with predominantly
female population dispersion to AIDS afflicted neighbouring countries
and moving back home when ill, e.g. idiaminism and its aftermath in Uganda,
coups d'etat in Ghana.
(d) International ports with frequent, substantial foreign military
presence, e.g. Mombasa (Kenya), Abidjan (Ivory Coast).
(e) Stronger currency than surrounding countries, thus attracting
predominantly female personnel from other African countries (no skills
required), e.g. Kenya, Cote d'ivoire, Zaire.
(f) Tourists attracted from Europe and USA (e.g. to Kenya, Tanzania,
Rwanda, Cote d'Ivoire, Senegal, Gambia) with prostitute migration from
other African countries near and far, e.g. Kenya, Ivory Coast, Senegal,
(g) International industry and development , e.g. mining in Zambia
(h) Cross-border long-distance lorry driving, smugglers, armed
robbers, freedom fighters, (e.g. Zambia, Tanzania, Rwanda, Burundi, Uganda,
(i) Combinations of the above. It also follows that a country
with none or few of these combinations, e.g. Nigeria, will have less of
an AIDS problem. Islamic North Africa may have tourism and industries
but little of the other things apply, hence there is not an AIDS problem.
prostitution for foreign exchange is by far the most important AIDS spreading
factor in Africa. That promiscuity per se is less important is shown by
the fact that promiscuous men who do not include prostitutes in their
exploits are less likely to develop AIDS than a non-promiscuous man who
visits an international prostitute only once (Krobo tribe experience).
In the propagation phase, part-time prostitutes, i.e. those who double
as housewives or girlfriends, can be the most dangerous in m-f spread.
It is the size of this pool rather than the extent of promiscuity that
determines the gravity of the problem.
sex in Africa. Male-female prostitution in Europe. Apart from the
increasing number of African men in cities who rent their bodies to expatriate
men for foreign exchange, there are at least two foci of traditional homosexuality
in black Africa - one in East Africa and the other on the West coast.
Tribal terms exist which differentiate the active male-male partner from
the passive one, indicating centuries of tradition. But while AIDS has
not yet been introduced from outside into these traditional groups, which
keep to themselves, the rent boys are quite exposed to the disease. Since
both groups of homosexuals are expected by tradition to acquire wives
and have children, dangerous propagation of AIDS is theoretically possible
through m-m sex in some African countries. There is a disturbing European
extension to African m-f prostitution, which was recently exposed on British
television: Asian and African women are imported into Europe to undercut
competitors by being made to work without condoms.
herbal-cure anecdotes are circulating in Uganda, Rwanda, Tanzania,
Ghana and Congo (related to tuberculosis treatment). Results are eagerly
awaited of the first group of patients from the USA to go to an African
country for the treatment of AIDS. The patients, all homosexuals, were
due back home on 20 December 1988. It is worth noting that claims by African
herbalists such as 'we have the means to cure AIDS except when it occurs
with Kaposi's sarcoma', need to be interpreted in the light of the fact
that many tribes use the same word for 'treat' as for 'cure'. To 'treat
a disease' is easily interpreted to mean 'to cure the disease'.
programmes and research
These are under way in most countries through national AIDS committees.
Educational schemes are best tackled both at the national and grass roots
level. Tribal slogans are to be preferred to national ones, which are
often in English or French, and sometimes miss the point. In my opinion
the massive help being given Africa by the WHO, UNDP, World Bank, and
the African Development Bank should first be used to screen every blood-transfused
person and to supply sterile hypodermic needles before any consideration
of population screening. In Africa condom use is primarily a man's responsibility.
Prostitutes have been thrashed before for suggesting their use, so pimps
and the 'queens' who direct much of Africa's sex trade should be the first
to be targeted in the educational programme. Any directive of the Church
on condoms in a predominantly Roman Catholic country like the Congo needs
the kind of research that will help Africans curtail AIDS does not have
to be the vaccine-orientated research of the developed countries. Public
health methods and clinical epidemiology are the best tools. Ultimately,
modification of sexual behaviour through secular and spiritual education,
backed by provision of light industries to generate the kind of foreign
exchange in search of which the girls go into prostitution, is by far
the best approach to AIDS prevention in Africa. I know that in addition
to the multitude of Africans living abroad, there are many non-African
friends of the continent who, when told what is happening, are prepared
to donate their help at the grass roots level on the lines mentioned above.
Dr F I
D Konotey-Ahulu was born in Ghana. He is Consultant Physician, Cromwell
Hospital, London, and former Physician Specialist Korle Bu Teaching Hospital,
and Director, Ghana Institute of Clinical Genetics.
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