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South Africa, drugs and AIDS

Print edition : Apr 29, 2000 T+T-

What is the real motivation behind the current international outcry against the questions that the South African Government has raised with regard to the causative and, consequently, management aspects of Acquired Immune Deficiency Syndrome?

IN many ways, South African President Thabo Mbeki has been the darling of the Western community, in particular of the rulers in Washington. He is urbane, intelligent, well-spoken. His views on economic reform in his country strongly correspond to those o f international finance, and he has been instrumental in pushing through many economic policies in the teeth of opposition from trade unions and people in his own party, the African National Congress. His foreign policy, especially as it relates to Sub-S aharan Africa, has also generally been such as to bring smiles on Capitol Hill. For these and other reasons, the mainstream press in the West has been almost unanimous in awarding him kudos.

Yet in recent weeks this approbation has quite suddenly been withdrawn. The international media have expessed not just scorn but distaste over some of his pronouncements, and others have reacted in a near-hysterical manner, threatening to boycott a major international conference that is to be held in Durban in July. What explains this sudden shift?

The issue at hand relates to one of the most pressing and urgent problems facing much of Sub-Saharan Africa today, the rapid and apparently uncontrollable spread of AIDS, or Acquired Immune Deficiency Syndrome. The proliferation of AIDS is most extensive and rapid in countries such as Zambia and South Africa, and this spread was aided until recently by government inaction or inability to take even minimal measures for its control. In addition, in this region it is a disease transmitted primarily by hete rosexual contact, unlike in the West, so that the size of the population at risk is far greater.

The current controversy relates to Mbeki's suggestion that the existence of AIDS may not necessarily be related to the human immunodeficiency virus (HIV). This is in fact a link which is currently taken for granted by most of the scientific and medical e stablishment, and forms the basis for almost all known methods of treatment of the condition. If this link is unambiguous, then South Africa's problems are already hair-raising. The government estimates that some 4.2 million South Africans have already c ontracted the HIV, with 1,700 people newly infected every day. The Ministry of Health has said the 10th national antenatal HIV survey showed that 22 per cent of all pregnant women tested in the country were HIV positive.

On the basis of this evidence of HIV in South Africa and other African countries, some estimates project that several Sub-Saharan nations, including South Africa, will lose a quarter of their populations to AIDS by 2010. According to some health speciali sts, the problem of the spread of infection is further compounded by the degree of denial on the part of the government and fatalism on the part of the general population, which have limited systematic efforts to contain the disease in the same manner as in (for example) Thailand.

Mbeki's recently expressed views have been strongly influenced by those of some dissident U.S.-based scientists who have been arguing for some time that there is no conclusive evidence that the virus is the necessary or sufficient cause of AIDS. The more prominent among these scientists is Dr. Peter Duesberg, Professor of Molecular Biology at the University of California, Berkeley, and one of the world's leading experts on retroviruses.

Duesberg's credentials are impeccable. He is a member of the National Academy of Sciences and a recipient of an Outstanding Investigative Grant from the National Institutes of Health in 1985. He was a candidate for the Nobel Prize for his work in discove ring oncogenes, thought to be a cause of cancer, in viruses. But he derailed his chances of winning when he cautioned that his findings did not prove that there were cancer genes in cells, as was popularly theorised at the time (and it is still an unprov en theory).

In a number of papers published in scientific journals, Duesberg has argued that HIV is too inactive, infects too few cells, and is too difficult even to find in AIDS patients to be responsible for causing AIDS. And since the virus is notoriously difficu lt to isolate, antibody detection has become the indicator of infection - something Duesberg protests is highly inconsistent. When antibodies are dominant over a virtually unfindable virus, this has always meant the immune system has triumphed over the i nvader, not capitulated to it. Finally, there are many established AIDS cases without any HIV, virus or antibody being present, further weakening the hypothesis.

Faced with these findings, the Centers for Disease Control (CDC) of the U.S. dealt with the issue by changing the definition of an AIDS patient to include HIV infections necessarily, so that most descriptions of the condition are now routinely as HIV-AID S. But hundreds of HIV-free but certified AIDS cases surfaced again at the 1992 International Conference on AIDS in Amsterdam, and now the number of such cases is estimated to be over 4,000. At that point the CDC changed the name of the condition. Duesbe rg contends that this semantic play only further distracts from the likelihood that HIV is not the cause of AIDS.

These views have been supported by other eminent scientists, such as Kary Mullis, Nobel Prize winner in Chemistry and David Rasnick, another expert in the area. However, the bulk of the scientific and medical community is firmly aligned on the other side . Mbeki has instructed the South African Health Ministry to set up a 20-member international panel, including Duesberg and Rasnick, to test the assumptions about the disease. In response to criticism about their inclusion, he said that "the matter is cri tical... The reason we are doing all of this is to be able to respond correctly to what is reported to be a major catastrophe on the African continent. You can't respond correctly by closing your eyes and ears to any point of view."

However, even a minority representation (two out of 20, after all) in such a committee seems too much for mainstream health specialists to handle. Mbeki's interest in the dissident views has been strongly criticised by the mainstream group, with many sci entists going to the extent of suggesting that President Clinton and other Western leaders should put pressure on him to conform to the current mainstream position, and others threatening to boycott the international conference in Durban.

Such reactions may have been what prompted the latest salvo by the South African President, a highly emotional letter sent on April 3, 2000, to various heads of state including Clinton, and Kofi Annan, United Nations Secretary-General. Besides detailing the country's efforts to battle the epidemic that has infected one in 10 South Africans, Mbeki also defended South Africa's contacts with scientists who argue that AIDS is not caused by HIV, and that AZT, a medication commonly used to prevent transmissio n of HIV from pregnant mothers to their children, does more harm than good.

"Not long ago, in our own country, people were killed, tortured, imprisoned and prohibited from being quoted in private and public because the established authority believed that their views were dangerous and discredited. We are now being asked to do pr ecisely the same thing that the racist apartheid tyranny we opposed did, because it is said, there exists a scientific view that is supported by the majority, against which dissent is prohibited."

Mbeki further argued that imposing a Western solution to the "uniquely African catastrophe" of fast-spreading heterosexually based AIDS transmission and infection would be absurd. "Such a proceeding would constitute a criminal betrayal of our responsibil ity to our own people." His spokesman subsequently said that Mbeki sent the letter "to explain his position because the reports that have been in the media have either been misleading or inaccurate."

CLEARLY, this is not an issue that can be discussed meaningfully by laypersons lacking the scientific background. What is interesting, however, is the reaction in the international media, which is presumably as ignorant as most of us are. These reactions have ranged from ridicule to vilification, and are so extreme as to suggest that there may be more to this than just a simple scientific dispute.

A significant issue in all of this of course is that of drug provision. Medicine is at the heart of the problem for South Africa, as for all developing nations. In the wealthy nations of the West, "cocktails" of anti-retroviral drugs have made it possibl e - at a cost per patient exceeding $10,000 a year - to live indefinitely with HIV-AIDS. Obviously such cocktails are simply not affordable for most individual South Africans and the public health system which at the moment is having difficulty even ensu ring the provision of relatively cheap drugs to treat tuberculosis.

And one of the more significant aspects of the controversy relates to certain drugs. There has been growing pressure on Mbeki to provide AZT or Nevirapine, two drugs that have been found to be effective in preventing mother-to-child transmission, through the public health system. AZT in particular is among the cheaper among anti-HIV drugs, but it would still impose a heavy burden on South Africa's fragile public health system. Some activists have argued that Mbeki is trying to save money by questioning its usefulness.

But there are also genuine debates about the effectiveness of the drug. It basically reduces the risk of foetal transmission, but it does not treat the actual patient, who may still die quite soon leaving behind an orphan. There is growing fear about its level of toxicity, especially among malnourished women (which is the norm among female sufferers in South Africa). And some like Dr. Duesberg have argued that it is actually one of the causes of AIDS transmission among adults, rather than prevention. Ho wever, the lobby of the pharmaceutical giant that makes the drug is a strong one.

THERE have been other problems related to drugs that treat some of the "opportunistic illnesses" that typically afflict AIDS sufferers and are the proximate cause of death in most cases. A common one in South Africa is cryptococcal meningitis. It can be treated, but one of the key drugs - fluconazole, which also works well against thrush, an extremely common ailment among HIV patients - costs the equivalent of about $7.50 for a standard dose. The pharmaceutical giant Pfizer holds the patent for fluconaz ole and sets the price in almost every country.

In Thailand, the government (through a system of compulsory licensing) permits local companies to make a generic form of fluconazole. As a result, the price there for the same dose is only the equivalent of about 70 cents. In South Africa, however, a sim ilar strategy has been beset by difficulties. Most significantly there has been pressure from multinational drug companies and their home governments to avoid such practices.

Thus, despite the legality of compulsory licensing and parallel imports, and despite the public health emergency enveloping much of the developing world, the U.S. has actively opposed the efforts of the developing countries to implement compulsory licens ing, parallel imports, or other measures to make life-saving HIV/AIDS drugs more affordable and available in their countries.

A report from the State Department says: "All relevant agencies of the U.S. government - the Department of State together with the Department of Commerce, its U.S. Patent and Trademark Office, the Office of the United States Trade Representative, the Nat ional Security Council and the Office of the Vice-President - have been engaged in an assiduous, concerted campaign to persuade the government of South Africa to withdraw or modify" the Medicines Act provisions that give the government the authority to p ursue compulsory licensing and parallel import policies. The State Department report explains how "U.S. government agencies have been engaged in a full court press with South African officials from the departments of Trade and Industry, Foreign Affairs, and Health" in order to pressure them to change the law. U.S. Vice-President Al Gore has raised the issue repeatedly with Thabo Mbeki.

The U.S has even withheld certain trade benefits from South Africa and has threatened trade sanctions (by putting South Africa on the "Special 301 Watch List" of countries receiving heightened U.S. scrutiny regarding trading practices) as punishment for Pretoria's refusal to repeal those provisions of its Medicines Act that offend the multinational drug companies. Washington has also enlisted the support of the French, Swiss and German presidents to raise the issue with top South African officials.

It is interesting that hardly any mainstream public health specialists made any noise about this appalling attempt to prevent the South African Government from making what they see as life-saving anti-HIV drugs affordable to a highly vulnerable populatio n. In the circumstance, it is difficult to accept, without a fairly liberal pinch of salt, that the current outcry against the South African Government is born entirely as a result of international concern for the AIDS victims in that country, and is not an orchestration by those who have a direct pecuniary interest in there being no questioning of the way in which the management of AIDS is currently being handled.