Debating the Obvious
JOHANNESBURG, SOUTH AFRICAThe most surreal moment happened right on the first day.
South African president Thabo Mbeki convened a panel of scientists to advise him on how to handle his country's surging AIDS epidemic, and it met on July 3 and 4 in Johannesburg. This panel has sparked a firestorm of criticism, because many of the invited scientists, who met for a first round in May, are so-called "dissidents" who cling to the fringe view that HIV does not cause AIDS and that AIDS in Africa does not exist but is instead just a new name for the old diseases of poverty and lack of hygiene. The meeting, attended by the South African minister of health, was closed to the press except for a handful of invited observers, including this reporter.
On the first day, prominent dissident David Rasnicka California biochemist whose advice President Mbeki had sought out earlier this yearmade the proposal that all HIV testing be banned. Stunned, South African scientists on the panel asked if Rasnick meant banning the test even to screen the nation's blood supply. "If I had the power to outlaw the HIV antibody test," said Rasnick, "I would do it across the board."
Rasnick also denied that he had seen "any evidence" of an AIDS catastrophe, despite the testimony of African physicians about the drastic change AIDS has caused in their clinics and hospitals. More evidence emerged from South African mortality records, showing a shocking rise in deaths among adults in the prime of their life. In 1990, 48 percent of deaths among men occurred in the 1549 age group, but by 19992000, that age group accounted for 87 percent of the deaths. For women, the rise has been just as alarming, from 27 percent to 68 percent.
Publicly, the ministry of health applauded the robust debateand, indeed, the most extreme dissidents, like Rasnick, may have discredited themselves. In private, health department officials veered between amazement and ridicule of Rasnick's proposals, and Peter Duesberg, the most famous AIDS dissident, gave a presentation so removed from African medical reality that it left several local doctors shaking their heads.
But while the vast majority of South African AIDS researchers know that HIV causes AIDSand certainly know the disease is ravaging their countrythis panel was not for them. It was for their president, who desperately needs a way to save face for giving credence to people who deny the very existence of the worst danger facing his country, and for Africans who may be hearing the dissident ideas for the first time and need to know the evidence for and against ["Proof Positive" and NIAID Web Site]. Winstone Zulu, a prominent HIV-positive activist on the panel, welcomed the discussion because it gave him hope. "For 10 years I've lived with HIV," he told the Voice, "and for 10 years I've preached the main line. To hear that I could be wrong is good news. If you were in my shoes, you could understand." Indeed, Zulu comes from Zambia, where people are so poor that the costly drugs that have reduced the AIDS death rate in rich nations amount to a cruel mockery. Yes, people must "face reality," Zulu said, but added, "Ideas from the other side will find very fertile ground in Africa because the conventional thinking hasn't been of much use."
That's one reason why Joseph Sonnabend, a South Africantrained doctor practicing in New York, was so angry about the strategy adopted by most mainstream panelists toward the Internet debate set up by the South African government. They decided not to contest every dissident pointpartly because they have been exhaustively debated among scientists for more than 10 yearsbut instead to prepare broad responses to questions posed by the president and the panel moderators. Sonnabend, one of the few mainstream members to participate wholeheartedly in the Internet discussion, called the limited involvement by his peers "unconscionable." The minister of health, Manto Tshabalala-Msimang, went further, saying her government felt "betrayed" by unnamed South African scientists for discouraging foreign panelists from joining the debatea charge South African researchers flatly denied.
Yet, in the end, there was something to show for it all: research proposals put together by both sides. Ministry of health official Khotso Mokhele hyped the planned studies, which he said he expected to be completed by the end of the year, as so rigorous a test of the hypothesis that HIV causes AIDS that afterwards one side might "shut up once and for all."
"He was a bit overexcited and overspoke," said Harvey Bialy, Duesberg's biographer and the dissident scientist who worked hardest on designing the study. What Bialy hammered out with Helene Gayle, head of the AIDS program at the American Centers for Disease Control, and Malegapuru Makgoba, president of the South African Medical Research Council, is a broad proposal on how to test the testspecifically, to see whether the standard antibody test concords with other HIV tests, including isolation of the virus, a laborious and expensive process that is usually done only for research purposes. Obviously, this study will not determine if HIV causes AIDS, but it could give fresh credence to a test that the dissidents have steadily tried to undermine.
The other proposed study was more a sharing of data. Some dissidents, such as Bialy and Rasnick, had theorized that HIV is a harmless "passenger virus" that is inherited at birth and causes no disease. To test this hypothesis, they proposed a telephone survey of people who had been rejected in the 1980s from enlisting in the American army as a result of testing HIV-positive. If the vast majority were still alive, then that would suggest that HIV is harmless.
Aside from the fact that there are no records tracing such people, there are much simpler ways to determine whether HIV is deadly. Researchers at Chris Hani Baragwanath hospital in Soweto followed children born to HIV-positive mothers and found that infected babies had a death rate more than 19 times higher than uninfected babies. The CDC has provided the dissidents with its vast data on children born to infected mothers, which also shows that babies with HIV have a higher death rate than those without the virus.
But the dissidents claim that HIV might not be what is killing the babies; for example, they argue that the AIDS drug AZT can cause AIDS diseases. And so, holding the CDC data in his hand, Duesberg asked Gayle whether the babies with HIV had received AZT. Gayle started to answer, but Bialy cut in, saying yes, the babies had received the drug. Duesberg then shouted that AZT was what probably killed the babies, and, as Gayle kept trying to answer his original question, Duesberg stormed out of the room. Eventually, Gayle explained that some of the babies had received the drug while others hadn't, and that the CDC was preparing a breakdown for the dissidents to analyze.
And so it went. Makgoba asked the dissidents to come up with an explanation better than AIDS for the grotesque spike in deaths among young adults. Rasnick tried, saying it was simply because the apartheid government had kept poor records of black people and so "we're now seeing what's been going on for the last 20 or 30 years." But that wouldn't explain why young people are dying more than the elderly, nor why young people are dying at rates that continue to increase even as the new South Africa improves access to clean water and decent housing. Nor would it explain the similar rise in deaths among young people in neighboring Botswana, which has had a stable and relatively prosperous democracy for more than 30 years.
Some dissidents, such as Duesberg, suggested a toxin or a lack of nutrients might be causing the increase in deaths, but they were unable to specify what exactly the toxin or nutrient deficiency might be in Africa, nor why it should strike mainly young adults while sparing those who are traditionally the most vulnerable to malnutrition, the very young and the very old. Duesberg also argued HIV cannot cause AIDS, because a single virus causes only limited, specific symptoms whereas AIDS comprises many diseases. In fact, HIV is exquisitely specific; it destroys the immune system, leaving the body unable to defend against numerous microbes, which in turn cause the many symptoms of AIDS.
But beyond an explanation, asked South African panelist Salim Abdool-Karim, "what are the positive recommendations" the dissidents would make to curtail the problem? Here, at least, there was some common ground, because dissidents and mainstream panelists alike favor the apple-pie goals of alleviating poverty and improving basic health care. But most of the dissidents argued against providing anti-HIV drugs, which they claim are so toxic that they do more harm than good, despite evidence from all over the world that they reduce AIDS-related death and disease.
What will the panel's convener, President Mbeki, conclude from all this? Just before his panel met, more than 5,000 scientists released a declaration stating why they know HIV causes AIDS. The president's office was reportedly furious, fearing that it presaged a bashing of Mbeki by the huge International AIDS Conference, set to open on July 9 in the South African city of Durban.
Yet there are also signs that Mbeki is realizing that the fundamental dissident tenets will not help his country. His ministry of health recently launched a new five-year plan to combat AIDS that stresses such mainstream tactics as safer sex, and South Africa continues to invest in developing an HIV vaccine. According to Seth Berkley, president of the International AIDS Vaccine Initiative, Mbeki recently stated in public that he believes HIV causes AIDS and that the main problem is treatment. Mbeki has also pointed out that even if the price of anti-HIV drugs fell by half, providing them for all his infected citizens would consume South Africa's entire health budget.
This Sunday, just before the huge International AIDS Conference opens, the price of drugs will be catapulted into the headlines by a large protest march. Immediately after that march, Mbeki will step to the podium to deliver the opening address of the conference. What will he say? Will he endorse the recommendations of those who deny that an epidemic even exists? Almost certainly not. But will he throw his full weight behind what the overwhelming body of scientific evidence shows? Will he face reality?
MORE VOICE COVERAGE OF AIDS IN AFRICA BY MARK SCHOOFS:
How African Science Has Demonstrated That HIV Causes AIDS
AIDS: The Agony of Africa
The Pulitzer Prize-Winning Series by Mark Schoofs
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