Date: Fri, 8 Jul 1994 19:37:25 GMT From: Prairie Fire Organizing Committee Subject: AIDS in the World / book review /* Written 11:35 PM Jul 5, 1994 by pfoc in igc:gen.aidsinfo */ /* ---------- "AIDS in the World / book review" ---------- */ AIDS in the World: A Global Report book review by David Gilbert [This review originally appeared in the Spring 1994 issue of Breakthrough, a political journal published by Prairie Fire Organizing Committee. To respond to the article, to order a copy of the publication, or to subscribe, please send mail to pfoc@igc.apc.org.] AIDS in the World, A Global Report. Edited by Jonathan Mann, Daniel J.M. Tarantola, and Thomas W. Netter (Harvard University Press, 1992) $19.95 paperback As terrible as the AIDS plague and the inadequacy of the response have been in the U.S., the situation is excruciatingly worse in the Third World. Several African countries have astronomically high rates of HIV (the AIDS virus) infection, on top of wrecked economies and decimated public health systems. And the debilitation and death of so many citizens in their prime productive years will in turn further cripple the efforts for development. In the West, an eerie silence prevails about this incalculable human toll and social devastation. Jonathan Mann, the former director of the World Health Organization Global Programme on AIDS and currently a professor at the Harvard School of Public Health, and his two colleagues, Daniel J.M. Tarantola and Thomas W. Netter, have performed an invaluable service in drawing together a global overview of the AIDS pandemic. (The word "pandemic" is used to mean everywhere because AIDS is now present in 164 countries, on all inhabited continents and in the Pacific Islands.) They open their inquiry with a stark question: "Is the pandemic now out of control?" Their main conclusion, 841 pages later: "The pace of the pandemic is fast outgrowing the pace of the response, and the gap is widening rapidly and dangerously." It is not a simple matter to chart even the current scope of the pandemic, let alone to project its future course. Official figures for AIDS are notoriously low because many cases are never reported. The much larger number of people with HIV (most of whom won't be visibly sick) can only be estimated from fragmentary blood sampling of various populations. A prognosis entails taking this imperfect data and then assessing the likely rate of progression. AIDS in the World (AIW) contains a very thorough, careful, and reasonable compilation of the data and future projections. The editors provide an appendix that explains the basis for their model, which was developed between 1988 and 1990. Actual surveys from 1991-1992 show that AIW's projections were conservative. By early 1992, 12.9 million persons cumulatively worldwide had become infected with HIV, of whom 2.7 million had developed AIDS, of whom 2.5 million had subsequently died. Sub-Saharan Africa, with 10 percent of the world's population, has 68 percent of the total HIV infections (8.8 million persons), and 72.8 percent of the AIDS cases (1.9 million persons). Pregnant women provide a good indication of the overall adult infection rate. In the capital cities (the problem is worst in urban areas) of Uganda, Zambia, and Malawi, 20 percent of the pregnant women are HIV positive. AIW also cites a study indicating a nationwide infection rate of 5 percent in Uganda (other studies have revealed even higher estimates). Already, some 1.3 million African children have been orphaned by AIDS. Many areas of Africa don't even have the means to consistently screen blood, which means that HIV is still being transmitted through blood transfusions, and very few medicines or social services are available for persons with AIDS. By 1995, there will be 6.4 million cumulative cases of AIDS worldwide; that is to say that the new cases from 1992-1995 will outstrip the entire previous history of this plague. Eighty-four percent of these cases will occur in the Third World. Africa will have suffered 4.6 million cases of AIDS, eight times the U.S. total. Without dramatic changes to stanch the pandemic, we can expect cumulative totals by the year 2000 of up to 110 million HIV infections, 25 million AIDS cases, and 20 million deaths worldwide. Something like ten million orphaned children will exist in Africa alone. Currently, the U.S. is spending an inadequate $2.75 per capita on prevention efforts. For sub-Saharan Africa the figure is seven cents; for Latin America, three cents. For some of the African countries hit hardest by AIDS, their entire national health budget is equal only to that of a large hospital in the U.S. AIW's great contribution is in providing this statistical overview with all too rare attention to the Third World. They then go on, with a collection of essays by various experts, to try to provide a comprehensive report on all aspects of the worldwide AIDS crisis. In this respect, their efforts are uneven, and the studies tend to be broad and general rather than trenchant and critical. They would have served us better with a shorter, more focused work on prevalence, prevention, and public health in the Third World. Perhaps their promised future yearly editions will do so. Nonetheless, AIW contains a number of particularly valuable points that are worth underscoring. One is AIDS' mutually reinforcing relationship (synergy) with other diseases, particularly tuberculosis (TB) and certain sexually transmitted infections like syphilis. TB, although long considered under control in the industrialized world, is the leading infectious killer worldwide. One third of the world's population (1.7 billion people) carry the TB bacterium, but most healthy persons keep it in check and it just lies dormant. With AIDS, and the breakdown of the immune system, many more persons are progressing to active TB, and they in turn can transmit this airborne bacterium to others. Right now an estimated 4.6 million persons worldwide carry both the TB and HIV infections. In sub- Saharan Africa, active TB cases have doubled over the past five years. Also, new drug-resistant strains of TB have been found in the U.S. Synergy also occurs with various sexually transmitted infections because they leave people much more vulnerable to catching HIV; yet many of these 250 million new infections per year go untreated because of the public health crisis in the Third World...and within Third World communities in the U.S. AIW goes beyond a static view to analyze where there is dangerous vulnerability for the future spread of HIV. They ring a badly needed alarm about the densely populated countries of Southeast Asia where the incidence of AIDS is still low but where many factors point to a rapid burgeoning of the epidemic if concerted measures are not taken immediately. This book is also clear, contrary to the prevailing cynicism, in arguing that prevention efforts, if done right, can work. Not only has safer sex education had the effect of dramatically reducing the rate of transmission in the gay communities of San Francisco and New York City, but also a number of needle exchange programs, reviewed in a useful essay by Don Des Jarlais and Patricia Case, have had significant success in reducing HIV transmissions among injection drug users. However, a deadly irony prevails in current prevention efforts. The method proven to be the most effective in raising consciousness and initiating behavior changes in the various communities--peer support-- was the approach least used by the national AIDS programs that were surveyed. Finally, to its credit, AIW makes at least a formal statement about the costs of bigotry: "...societal discrimination in all its forms creates increased vulnerability to HIV infection. Therefore, efforts to protect human rights and to promote human dignity are extremely important for protecting public health in the HIV/AIDS pandemic." Despite its strengths, this tome has a number of problems, big and small. In covering such a broad area, there are bound to be gaps and inadequacies. For example, the serious problem of detecting TB infection in those with HIV is severely understated, and the effort to measure the important equity gap between rich and poor nations is distorted by only looking at the use of the expensive and problematic drug AZT rather than focusing on the very effective preventative medications for PCP (pneumocystis carinii pneumonia) and treatments for opportunistic infections. A broader weakness is that so much of the assessment is based on data provided by government surveys. Many of these statistics are worthless because statements about priorities and allocation of funds tell us next to nothing about what is actually getting done in the field. The assurance of prisons, for example, that "There has been real progress in bringing information on AIDS and risk behaviors to...prisoners" is rubbish because mainly what is measured is output of government literature--pamphlets that prisoners don't read, by officials they don't trust, in a language they don't understand, with no engagement of specific risk factors in prison. AIW's biggest problem is the social perspective of the editors and many of the authors. Despite the general statement against discrimination, the editors virtually ignore the forms of oppression that have acted as central causes of the pandemic-- the disdain for gays, drug users, and Third World people that lurked behind the initial criminal negligence, which allowed the infection to mushroom; this disdain continues today in the lack of adequate focus and resources to stem the tide of this mass killer. The editors provide no critique or even analysis of homophobia in AIW; instead they make reference to the subjective state of the victims: "Some gay communities...feared stigmatization..." They make rhetorical references to the need for "peer" support and "empowerment" of those affected, but permit little air time for actual voices from the grassroots, concrete studies of peer projects, or developed examples of organizing in the affected communities. In short AIW misses just how much AIDS has been a social epidemic and can't be stemmed without conscious mobilization against the structures of oppression and neglect. The clearest example is chapter six, which focuses on the cascading social and economic impact of this plague in Africa--a matter that should be at the heart of this book. This essay, written by two analysts with the World Bank, does list some of the effects of AIDS in Africa: loss of productive labor, decline of agriculture, strain on family structure, and overloading of an already stressed public health system. But this is a soulless exposition with little feeling for the harrowing human tragedy in progress. One must wonder what Africans will make of this dispassionate discussion of AIDS' effect on demographics given the World Bank's emphasis on limiting population growth there. Most fundamentally, this chapter says nothing about the reasons these countries are such economic basket cases in the first place--nothing about the incredible toll taken on Africa by the history of the Western-imposed slave trade, colonialism, and continued hemorrhaging under the auspices of the world market. Inexcusably, it says nothing about the "structural adjustment programs" (mentioned only once, in passing, in another section of the book) currently being imposed on these countries by the World Bank that have desiccated the public sector. To assess sub-Saharan African's ability to respond to the AIDS scourge, it's important to know, for example, that per capita food production there fell 9 percent over the course of the 1980s, and that average gross domestic production was declining by 2.9 percent a year. This studied obliviousness to social reality also undermines AIW's subsequent righteous appeal for a transfer of funds to the poorer nations. Without mention of the history and structures of exploitation, such a request sounds like a plea for charity, which will not receive much sympathy in these days of "tight budgets." In truth, a transfer of resources is a profound obligation as reparations to begin to meet human needs. Being honest about such institutions as the World Bank would also underscore why the best programs, the best use for resources, will be generated by the affected nations and communities themselves. Despite the elitist perspective of much of the book, there are important exceptions such as an insert on the role of ACT-UP activism in speeding drug development, a strong essay by Elizabeth Reid on the impact of women's social status, and a useful survey by Jeff O'Malley on the cutting-edge role of non-governmental AIDS service organizations. AIW, with its predominantly top-down perspective and excessive reliance on surveys of governmental programs, could be fairly characterized as "bureaucratic." But, to be fair, it is an unusually enlightened bureaucratic approach--not only because of the awareness of such concepts as anti- discrimination, peer support, and empowerment, but most particularly for its clarion call about the mounting conflagration in Africa and the ominous vulnerability in Southeast Asia. In this regard those of us who have been involved in AIDS and/or anti-racist activism have to be very self-critical that we haven't been screaming bloody murder about this unconscionable and preventable human tragedy. The urgent task remains to raise consciousness and fight for adequate resources and programs for the global AIDS pandemic. The last chapter of AIW reminds us of how much we live in one world. Laurie Garrett argues that a future viral epidemic is almost inevitable, given present policies. Many viruses lie dormant and localized, especially in viral rich tropical areas. Terrible health conditions such as malnutrition and poor sanitation make those populations much more vulnerable to succumbing to disease. Impoverished public health surveillance systems mean that serious new pathogens may well not be detected until they become widespread; modern transportation and intercourse mean that such infections can rapidly spread to other parts of the world. "From a microbial point of view, the global village of the 1990s is minuscule. Never has it been so obvious that poor health care and disease surveillance in one corner of the planet can imperil every person on earth, rich, as well as poor." As with problems of the environment, AIDS shows us just how much the fate of all humankind is interlinked. It is not just right and more fully human to respond to the plight and struggles of the oppressed, but there is no way the destruction and misery won't redound on us to the point where it will eventually threaten the coherent functioning of society and any chance for a decent future for our children. Unfortunately, the social structures and psychology of privilege are so entrenched that those who are presently comfortable don't seem capable of deeply identifying with the oppressed. The outlook for a timely and adequate response to the crisis is not bright. David Gilbert is a political prisoner, AIDS educator, and prisoner activist currently incarcerated in the Great Meadow Correctional Facility in Comstock, New York.