African epidemic

The economic cost of AIDS in Africa is devastating. Fewer teachers are trained each year than the number of teachers dying from AIDS. AIDS has already orphaned 14 million African children, and an estimated 22 million additional orphans are predicted. In Zambia, Robert Bona tested 200 girls in Luanshya, and 196 were HIV-positive. In South African opinion polls 85 percent know how HIV is transmitted, but only 10 percent used a condom in their last sexual encounter. We cannot let Africa become a medical archipelago dubbed the hopeless continent.

Out of intense complexities intense simplicities emerge. The best method to prevent AIDS in Africa is the condom plus health education. The majority of teen girls still think that a man cannot have AIDS if they look healthy. The majority of boys this year will not wear a condom because you don’t shower with a raincoat and you don’t eat candy with the wrapper on. Rap groups openly ask to spread the thin disease and kill as many girls as possible. One told me that for an orphan dying at 19 is the plan. We must help change sexual behavior and attitudes.

UNAIDS reports that a teen girl in sub-Saharan Africa has a 50 percent chance of becoming HIV-positive and dying before the age of 25. The best success story for the benefits of a nationwide safe sex program is Uganda where teen HIV rates are now 1.5 percent. The adult HIV infection rate in Uganda has been cut from 14 to 8.1 percent in nine years.

The second under-financed method for preventing AIDS is offering a $4 dose of nevirapine to stop perinatal infection. The German pharmaceutical company that produces the drug has agreed to provide nevirapine for free. This year, 680,000 perinatal HIV infections from mother to child are predicted. The cost of testing and counseling pregnant women is about $8, but no African nation can currently afford this expense. In 27 nations $8 is over half the per capita health care budget per year. Almost 95% of people with HIV have never been tested. Few children are born in hospitals. Labs and test kits must be built, and nurse midwives must be trained for home delivery.

The third method of prevention, developing an AIDS vaccine, will take a minimum of ten years. Even when we have a vaccine, inoculating everyone will take time. The Harvard School of Public Health has a rule of thumb: it takes 25 years to inoculate half the population as we have seen with measles and 180 years to inoculate 99 percent of the public as evidenced by our experience with smallpox.

We must be our brothers’ keepers or fiddle together as fools. It is not only morally right, but medically necessary to appropriately treat African patients. Without adequate African health system infrastructure, potent drugs are counterproductive. If anti-HIV drugs are not monitored by lab tests and every pill taken at the correct time, a low level of viral production continues in the patient. African patients would grow mutant HIV strains resistant to current medications. It is in our enlightened self interest to not allow Africa to become the petri dish for mutant strains that immigrate to America. How much patient compliance would be an appropriate target? In the best American settings, 84 to 89 percent is typical, and without much patient education and support three African trials have achieved 71 to 80 percent compliance. We should stop politicians who whisper that African patients are too dumb to take their medicine. Africans can reasonably follow a two-drug regimen without weekly supervision. With appropriate funding for education and primary care, African patient compliance can achieve near parity with American levels. Drug firms and governments must invest in Africa or existing medicines to fight this world pandemic will become worthless. Let us disregard comfort and racism: it is time to dare and endure. The world must invest $6 billion annually in health care delivery system improvements in Africa.

American generosity is not a coat to be put on and off at will. Its seat is in our soul, and it must be an inseparable part of our national spirit. When America annually spends $33 billion on weddings and $16 billion on pizza and baldness, it might be nice to invest $3 billion on AIDS in Africa and help 40 million plus people. The federal budget surplus for the next decade is $4,241 billion. Can we afford $3 billion a year for AIDS in Africa? With a huge budget surplus, is the U.S. as generous today as we were in rebuilding Europe wit the Marshall Plan in 1948? In current year 2000 dollars, Americans invested $5,283 per capita in white European towns and cities. Judging by the yardstick of our 2001 budget for Africa, black people in 2001 are only worth two percent of what white Europeans were worth in 1948. Have we no shame? Truman, Marshall, Eisenhower, and Kennedy would have been willing to spend $3 billion a year. You do not offer a thimble of water to a dying man when you can afford to give a gallon.

-The writer is professor of public health.

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