An interesting insight from South Africa....
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The headline figures are horrible: almost 30 million Africans have
HIV/Aids. But, says Rian Malan, the figures are computer-generated
estimates and they appear grotesquely exaggerated when set against
population statistics
By Rian Malan
Cape Town
It was the eve of Aids Day here. Rock stars like Bono and Bob Geldof were
jetting in for a fundraising concert with Nelson Mandela, and the airwaves
were full of dark talk about megadeath and the armies of feral orphans who
would surely ransack South Africa's cities in 2017 unless funds were made
available to take care of them. My neighbour came up the garden path with a
press cutting. 'Read this,' said Capt. David Price, ex-Royal Air Force
flyboy. 'Bloody awful.'
It was an article from The Spectator describing the bizarre sex practices
that contribute to HIV's rampage across the continent. 'One in five of us
here in Zambia is HIV positive,' said the report. 'In 1993 our neighbour
Botswana had an estimated population of 1.4 million. Today that figure is
under a million and heading downwards. Doom merchants predict that Botswana
may soon become the first nation in modern times literally to die out. This
is Aids in Africa.'
Really? Botswana has just concluded a census that shows population growing
at about 2.7 per cent a year, in spite of what is usually described as the
worst Aids problem on the planet. Total population has risen to 1.7 million
in just a decade. If anything, Botswana is experiencing a minor population
explosion.
There is similar bad news for the doomsayers in Tanzania's new census,
which shows population growing at 2.9 per cent a year. Professional
pessimists will be particularly discomforted by developments in the
swamplands west of Lake Victoria, where HIV first emerged, and where the
depopulated villages of popular mythology are supposedly located. Here, in
the district of Kagera, population grew at 2.7 per cent a year before 1988,
only to accelerate to 3.1 per cent even as the Aids epidemic was supposedly
peaking. Uganda's latest census tells a broadly similar story, as does
South Africa's.
Some might think it good news that the impact of Aids is less devastating
than most laymen imagine, but they are wrong. In Africa, the only good news
about Aids is bad news, and anyone who tells you otherwise is branded a
moral leper, bent on sowing confusion and derailing 100,000 worthy
fundraising drives. I know this, because several years ago I acquired what
was generally regarded as a leprous obsession with the dumbfounding Aids
numbers in my daily papers. They told me that Aids had claimed 250,000
South African lives in 1999, and I kept saying, this can't possibly be
true. What followed was very ugly - ruined dinner parties, broken
friendships, ridicule from those who knew better, bitter fights with my
wife. After a year or so, she put her foot down. Choose, she said. Aids or
me. So I dropped the subject, put my papers in the garage, and kept my
mouth shut.
As I write, madam is standing behind me with hands on hips, hugely irked by
this reversion to bad habits. But looking around, it seems to me that Aids
fever is nearing the danger level, and that some calming thoughts are
called for. Bear with me while I explain.
We all know, thanks to Mark Twain, that statistics are often the lowest
form of lie, but when it comes to HIV/Aids, we suspend all scepticism. Why?
Aids is the most political disease ever. We have been fighting about it
since the day it was identified. The key battleground is public perception,
and the most deadly weapon is the estimate. When the virus first emerged, I
was living in America, where HIV incidence was estimated to be doubling
every year or so. Every time I turned on the TV, Madonna popped up to warn
me that 'Aids is an equal-opportunity killer', poised to break out of the
drug and gay subcultures and slaughter heterosexuals. In 1985, a science
journal estimated that 1.7 million Americans were already infected, with
'three to five million' soon likely to follow suit. Oprah Winfrey told the
nation that by 1990 'one in five heterosexuals will be dead of Aids'.
We now know that these estimates were vastly and indeed deliberately
exaggerated, but they achieved the desired end: Aids was catapulted to the
top of the West's spending agenda, and the estimators turned their
attention elsewhere. India's epidemic was likened to 'a volcano waiting to
explode'. Africa faced 'a tidal wave of death'. By 1992 they were
estimating that 'Aids could clear the whole planet'.
Who were they, these estimators? For the most part, they worked in Geneva
for WHO or UNAIDS, using a computer simulator called Epimodel. Every year,
all over Africa, blood would be taken from a small sample of pregnant women
and screened for signs of HIV infection. The results would be programmed
into Epimodel, which transmuted them into estimates. If so many women were
infected, it followed that a similar proportion of their husbands and
lovers must be infected, too. These numbers would be extrapolated out into
the general population, enabling the computer modellers to arrive at
seemingly precise tallies of the doomed, the dying and the orphans left
behind.
Because Africa is disorganised and, in some parts, unknowable, we had
little choice other than to accept these projections. ('We' always expect
the worst of Africa anyway.) Reporting on Aids in Africa became a quest for
anecdotes to support Geneva's estimates, and the estimates grew ever more
terrible: 9.6 million cumulative Aids deaths by 1997, rising to 17 million
three years later.
Or so we were told. When I visited the worst affected parts of Tanzania and
Uganda in 2001, I was overwhelmed with stories about the horrors of what
locals called 'Slims', but statistical corroboration was hard to come by.
According to government census bureaux, death rates in these areas had been
in decline since the second world war. Aids-era mortality studies yielded
some of the lowest overall death rates ever measured. Populations seemed to
have exploded even as the epidemic was peaking.
Ask Aids experts about this, and they say, this is Africa, chaos reigns,
the historical data is too uncertain to make valid comparisons. But these
same experts will tell you that South Africa is vastly different: 'The only
country in sub-Saharan Africa where sufficient deaths are routinely
registered to attempt to produce national estimates of mortality,' says
Professor Ian Timaeus of the London School of Hygiene and Tropical
Medicine. According to Timaeus, upwards of 80 per cent of deaths are
registered here, which makes us unique: the only corner of Africa where it
is possible to judge computer-generated Aids estimates against objective
reality.
In the year 2000, Timaeus joined a team of South African researchers bent
on eliminating all doubts about the magnitude of Aids' impact on South
African mortality. Sponsored by the Medical Research Council, the team's
mission was to validate (for the first time ever) the output of Aids
computer models against actual death registration in an African setting.
Towards this end, the MRC team was granted privileged access to death
reports as they streamed into Pretoria. The first results became available
in 2001, and they ran thus: 339,000 adult deaths in 1998, 375,000 in 1999
and 410,000 in 2000.
This was grimly consistent with predictions of rising mortality, but the
scale was problematic. Epimodel estimated 250,000 Aids deaths in 1999, but
there were only 375,000 adult deaths in total that year - far too few to
accommodate the UN's claims on behalf of the HIV virus. In short, Epimodel
had failed its reality check. It was quietly shelved in favour of a more
sophisticated local model, ASSA 600, which yielded a 'more realistic' death
toll from Aids of 143,000 for the calendar year 1999.
At this level, Aids deaths were about 40 per cent of the total - still a
bit high, considering there were only 232,000 deaths left to distribute
among all other causes. The MRC team solved the problem by stating that
deaths from ordinary disease had declined at the cumulatively massive rate
of nearly 3 per cent per annum since 1985. This seemed very odd. How could
deaths decrease in the face of new cholera and malaria epidemics, mounting
poverty, the widespread emergence of drug-resistant killer microbes, and a
state health system reported to be in 'terminal decline'?
But anyway, these researchers were experts, and their tinkering achieved
the desired end: modelled Aids deaths and real deaths were reconciled, the
books balanced, truth revealed. The fruit of the MRC's ground-breaking
labour was published in June 2001, and my hash appeared to have been
settled. To be sure, I carped about curious adjustments and overall
magnitude, but fell silent in the face of graphs showing huge changes in
the pattern of death, with more and more people dying at sexually active
ages. 'How can you argue with this?' cried my wife, eyes flashing angrily.
I couldn't. I put my Aids papers in the garage and ate my hat.
But I couldn't help sneaking the odd look at science websites to see how
the drama was developing. Towards the end of 2001, the vaunted ASSA 600
model was replaced by ASSA 2000, which produced estimates even lower than
its predecessor: for the calendar year 1999, only 92,000 Aids deaths in
total. This was just more than a third of the original UN figure, but no
matter; the boffins claimed ASSA 2000 was so accurate that further
reference to actual death reports 'will be of limited usefulness'. A bit
eerie, I thought, being told that virtual reality was about to render the
real thing superfluous, but if these experts said the new model was
infallible, it surely was infallible.
Only it wasn't. Last December ASSA 2000 was retired, too. A note on the MRC
website explained that modelling was an inexact science, and that 'the
number of people dying of Aids has only now started to increase'.
Furthermore, said the MRC, there was a new model in the works, one that
would 'probably' produce estimates 'about 10 per cent lower' than those
presently on the table. The exercise was not strictly valid, but I
persuaded my scientist pal Rodney Richards to run the revised data on his
own simulator and see what he came up with for 1999. The answer, very
crudely, was an Aids death toll somewhere around 65,000 - a far cry indeed
from the 250,000 initially put forth by UNAIDS.
The wife has just read this, and she is not impressed. 'It's obscene,' she
says. 'You're treating this as if it's just a computer game. People are
dying out there.'
Well, yes. I concede that. People are dying, but this doesn't spare us from
the fact that Aids in Africa is indeed something of a computer game. When
you read that 29.4 million Africans are 'living with HIV/Aids', it doesn't
mean that millions of living people have been tested. It means that
modellers assume that 29.4 million Africans are linked via enormously
complicated mathematical and sexual networks to one of those women who
tested HIV positive in those annual pregnancy-clinic surveys. Modellers are
the first to admit that this exercise is subject to uncertainties and large
margins of error. Larger than expected, in some cases.
A year or so back, modellers produced estimates that portrayed South
African universities as crucibles of rampant HIV infection, with one in
four undergraduates doomed to die within ten years. Prevalence shifted
according to racial composition and region, with Kwazulu-Natal institutions
worst affected and Rand Afrikaans University (still 70 per cent white)
coming in at 9.5 per cent. Real-life tests on a random sample of 1,188 RAU
students rendered a startlingly different conclusion: on-campus prevalence
was 1.1 per cent, barely a ninth of the modelled figure. 'Doubt is cast on
present estimates,' said the RAU report, 'and further research is strongly
advocated.'
A similar anomaly emerged when South Africa's major banks ran HIV tests on
29,000 staff earlier this year. A modelling exercise put HIV prevalence as
high as 12 per cent; real-life tests produced a figure closer to 3 per
cent. Elsewhere, actuaries are scratching their heads over a puzzling lack
of interest in programs set up by medical-insurance companies to handle an
anticipated flood of middle-class HIV cases. Old Mutual, the insurance
giant, estimates that as many as 570,000 people are eligible, but only
22,500 have thus far signed up.
In Grahamstown, district surgeon Dr Stuart Dyer is contemplating an equally
perplexing dearth of HIV cases in the local jail. 'Sexually transmitted
diseases are common in the prison where I work,' he wrote to the Lancet,
'and all prisoners who have any such disease are tested for HIV. Prisoners
with any other illnesses that do not resolve rapidly (within one to two
weeks) are also tested for HIV. As a result, a large number of HIV tests
are done every week. This prison, which holds 550 inmates and is always
full or overfull, has an HIV infection rate of 2 to 4 per cent and has had
only two deaths from Aids in the seven years I have been working there.'
Dyer goes on to express a dim view of statistics that give the impression
that 'the whole of South Africa will be depopulated within 24 months', and
concludes by stating, 'HIV infection in SA prisons is currently 2.3 per
cent.' According to the newspapers, it should be closer to 60 per cent.
On the face of it, these developments suggest that miracles are happening
in South Africa, unreported by anyone save a brave little magazine called
Noseweek. If the anomalies described above are typical, computer models are
seriously overstating HIV prevalence. A similar picture emerges on the
national level, where our estimated annual Aids death toll has halved since
we eased UNAIDS out of the picture, with further reductions likely when the
new MRC model appears. Could the same thing be happening in the rest of
Africa?
Most estimates for countries north of the Limpopo are issued by UNAIDS,
using methods similar to those discredited here in South Africa. According
to Paul Bennell, a health- policy analyst associated with Sussex
University's Institute for Development Studies, there is an 'extraordinary'
lack of evidence from other sources. 'Most countries do not even collect
data on deaths,' he writes. 'There is virtually no population-based survey
data in most high-prevalence countries.'
Bennell was able, however, to gather information about Africa's
schoolteachers, usually described as a high-risk HIV group on account of
their steady income, which enables them to drink and party more than
others. Last year the World Bank claimed that Aids was killing Africa's
teachers 'faster than they can be replaced'. The BBC reported that 'one in
seven' Malawian teachers would die in 2002 alone.
Bennell looked at the available evidence and found actual teacher mortality
to be 'much lower than expected'. In Malawi, for instance, the all-causes
death rate among schoolteachers was under 3 per cent, not over 14 per cent.
In Botswana, it was about three times lower than computer-generated
estimates. In Zimbabwe, it was four times lower. Bennell believes that Aids
continues to present a serious threat to educators, but concludes that
'overall impact will not be as catastrophic as suggested'. What's more,
teacher deaths appear to be declining in six of the eight countries he has
studied closely. 'This is quite unexpected,' he remarks, 'and suggests
that, in terms of teacher deaths, the worst may be over.'
In the past year or so, similar mutterings have been heard throughout
southern Africa - the epidemic is levelling off or even declining in the
worst-affected countries. UNAIDS has been at great pains to rebut such
ideas, describing them as 'dangerous myths', even though the data on
UNAIDS' own website shows they are nothing of the sort. 'The epidemic is
not growing in most countries,' insists Bennell. 'HIV prevalence is not
increasing as is usually stated or implied.'
Bennell raises an interesting point here. Why would UNAIDS and its massive
alliance of pharmaceutical companies, NGOs, scientists and charities insist
that the epidemic is worsening if it isn't? A possible explanation comes
from New York physician Joe Sonnabend, one of the pioneers of Aids
research. Sonnabend was working in a New York clap clinic when the syndrome
first appeared, and went on to found the American Foundation for Aids
Research, only to quit in protest when colleagues started exaggerating the
threat of a generalised pandemic with a view to increasing Aids' visibility
and adding urgency to their grant applications. The Aids establishment,
says Sonnabend, is extremely skilled at 'the manipulation of fear for
advancement in terms of money and power'.
With such thoughts in the back of my mind, South Africa's Aids Day
'celebrations' cast me into a deeply leprous mood. Please don't get me
wrong here. I believe that Aids is a real problem in Africa. Governments
and sober medical professionals should be heeded when they express deep
concerns about it. But there are breeds of Aids activist and Aids
journalist who sound hysterical to me. On Aids Day, they came forth like
loonies drawn by a full moon, chanting that Aids was getting worse and
worse, 'spinning out of control', crippling economies, causing famines,
killing millions, contributing to the oppression of women, and 'undermining
democracy' by sapping the will of the poor to resist dictators.
To hear them talk, Aids is the only problem in Africa, and the only
solution is to continue the agitprop until free access to Aids drugs is
defined as a 'basic human right' for everyone. They are saying, in effect,
that because Mr Mhlangu of rural Zambia has a disease they find more
compelling than any other, someone must spend upwards of $400 a year to
provide Mr Mhlangu with life-extending Aids medication - a noble idea, on
its face, but completely demented when you consider that Mr Mhlangu's
neighbours are likely to be dying in much larger numbers of diseases that
could be cured for a few cents if medicines were only available. About 350
million Africans - nearly half the population - get malaria every year, but
malaria medication is not a basic human right. Two million get TB, but last
time I checked, spending on Aids research exceeded spending on TB by a
crushing factor of 90 to one. As for pneumonia, cancer, dysentery or
diabetes, let them take aspirin, or grub in the !
bush for medicinal herbs.
I think it is time to start questioning some of the claims made by the Aids
lobby. Their certainties are so fanatical, the powers they claim so
far-reaching. Their authority is ultimately derived from computer-generated
estimates, which they wield like weapons, overwhelming any resistance with
dumbfounding atom bombs of hypothetical human misery. Give them their head,
and they will commandeer all resources to fight just one disease. Who
knows, they may defeat Aids, but what if we wake up five years hence to
discover that the problem has been blown up out of all proportion by
unsound estimates, causing upwards of $20 billion to be wasted?
(c)2001 The Spectator.co.uk
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