Through a glass darkly - the prism of AIDS

by John Kiwanuka Ssemakula

July 1st 2004

For over two decades years the HIV/AIDS epidemic has stubbornly refused to yield to the best efforts of thousands of researchers, scientists, doctors and other health personnel. In that time the victories have been few and far between, a mere handful to date. Despite the best efforts science has had to offer, only a small percentage of people are on treatment, the drugs though cheap are still toxic, must be taken carefully and only keep the virus at bay. We are no nearer to creating a vaccine; a cure appears to be wishful thinking.

According to the World Health Report 2004, HIV/AIDS is the most important health problem in the world and needs our attention. HIV/AIDS has effects that go far beyond the mere affected individual. “HIV/AIDS is changing the structure of populations leading to increased dependency ratios in many African countries; The crisis of children having lost either or both parents to HIV/AIDS has been afflicting Africa for a decade, and will get worse; the education sector is suffering as the loss of teachers exceeds those being trained’ In low-income countries which were already suffering from a lack of health care workers, health care systems are overburdened…”

HIV/AIDS diverts a great deal of resources, as people living with AIDS, their relatives and extended family, governments and society as a whole struggle to with the pandemic. HIV/AIDS has become so monolithic in the public health arena, that it is now warping the surroundings it appears in. It eclipses all other diseases.

And this is having unwanted and potentially dangerous effect of diverting attention and resources from other pressing concerns that are just as devastating in terms debility and mortality as HIV, but actually have treatment, cures and prevention methods that have been proven to work. A number of studies have already shown that AIDS is contributing to the mortality of patients who would have other wise survived.

In Africa, it increasingly appears that health and health related problems are only really given serious attention when viewed through the prism of HIV/AIDS. And the prism of HIV/AIDS is dark indeed, with little or no good news.

For example, food security when mentioned is now often viewed in the context of HIV/AIDS. Or take the Global Fund, launched amid much fan fair as the “The Global Fund to fight AIDS, Tuberculosis and Malaria”; you could be forgiven for thinking it only really refers to AIDS. When was the last time you heard malaria or tuberculosis mentioned – was it Malaria Day or World TB Day? And even then HIV/AIDS was lurking in the background, looming over everything.

Don’t get me wrong, I still think AIDS is an extremely important issue. But the danger of viewing health problems through the prism of AIDS is that it has the effect of making these health issues appear hazy and out of focus, while bringing AIDS into sharp relief. And this gives rise to the (false) impression that if we just find a solution to the AIDS problem, all other health problems, will also magically be solved. If only we could just find the magic bullet, or failing that the big-bang solution, the Marshall plan for AIDS, everything will work out. This is dangerous thinking indeed.

Over a decade ago when I first started writing about HIV/AIDS in Uganda, I was of the opinion though HIV/AIDS was a big problem, "HIV/AIDS should not be treated as a separate health problem, because this will lead to an unequal diversion or distribution of resources in favour of HIV/AIDS programs..."

I was concerned that the amount of attention afforded HIV/AIDS was distorting the minds of health officials and policy planners, diverting much needed attention from other health problems assailing Uganda.

At the end of 1999, the WHO reported in its 2000 World Health Report that HIV/AIDS accounted for 20% of all deaths in Africa. But at the same time almost half (46%) of all mortality was due to conditions such as malaria, childhood diseases, measles, diarrhoeal diseases. All of which can be treated, or can be prevented by relatively cheap, low cost methods. Three years on, the 2002 World Health report painted a similar picture, HIV/AIDS accounted for one fifth (21%) of the deaths in Africa at the end of 2001.Looked at another way, 80% of the deaths in Africa had nothing to do with HIV/AIDS and it hasn’t changed much in the past few years.

It is sometime easy to forget the vast majority of African’s (95%) do not have HIV. So what will those who have successfully steered clear of getting HIV/AIDS to look forward to, if we expend all our efforts and energies on the AIDS epidemic?

While acknowledging that many of the survivors who don’t have HIV are also affected by the epidemic, either directly through relatives who are infected, or indirectly by the socio-economic effects of AIDS; one must be mindful they are also assailed by a myriad of conditions which take just as great a toll. Malaria, that greatest of silent killers, takes 3,000 African children everyday. The ancient scourge of Tuberculosis is making a comeback in the world, while African Sleeping Sickness is silently stalking the continent.

I think it is extremely important that we also keep the focus on the needs of the many, while taking care of the few. And this is where the controversy starts some would say. The AIDS lobby is very vocal, able to keep it in a high profile in the media and therefore people’s minds, most importantly policy makers and funders. This is a good thing, because as it is, there is not enough funding for AIDS.

But even less attention is given to equally important issues that don’t enjoy the same support and therefore have a very low media profile. So while the issue of orphans and AIDS is front page news, you’ll rarely see diarrhoeal diseases, or malnutrition on the front page. And yet nutritional conditions contributed to the deaths of estimated 1.8 million child deaths in Africa in 2001; while unsafe water, sanitation and hygiene caused more than six hundred thousand deaths. You rarely hear mention of the horrific toll, maternal mortality is taking in Africa, leaving children orphaned in a similar fashion to AIDS. According to the WHR 2002

Elimination or reduction of childhood and maternal under nutrition combined with provision of safe water, sanitation and hygiene could reduce the burden of ill health in Africa by up to a third (33%)

The appearance of HIV/AIDS has raised ethical and moral dilemmas for health planners. The dilemma for health planners used to be this; is it right to spend a huge proportion of already scarce resources on a group of people whose lives at best will only be extended for a few years by these drugs, but who will provide an enormous social and financial burden in the meantime? This was when antiretroviral drugs were still very expensive. But they are considerably cheaper today.

There are very compelling reasons for using ART (anti-retroviral therapy. By prolonging lives, ART significantly reduces the worst short-term effects of the epidemic. There are also "hidden" benefits to treatment. For example, managing patients on ART may be less costly in the long term than managing patients not receiving therapy. Nonetheless, providing ART to those who need it is still a hideously expensive undertaking, both in terms of financial and manpower costs. It still means that significant health resources in the short term at least, will be devoted to HIV/AIDS, to the detriment of other health problems. And success is by no means guaranteed.

In my opinion it would be wrong to totally abandon fight against AIDS and the people suffering from AIDS. On the other hand it is foolhardy and equally wrong to focus on only HIV/AIDS as the main health problem in Africa. Public health planning is often about making choices, sometimes hard ones, and in this context, at some point policy planners will have to draw a line and say enough, we will have to give more attention to other health problems. And that may be the hardest thing of all, to go against the prevailing view. It will take a brave, brave soul to get up say it is time to call it a day.

As already stated, the vast majority of health problems in Africa are due to preventable causes. HIV/AIDS should not be treated as a separate health problem, but should be integrated into other health programs. It makes good sense to deal with other problems that have proven prevention and eradication methods. Reducing or removing preventable conditions such as diarrhoeal diseases, malaria, tuberculosis would free up much needed resources for the fight against AIDS. Because even if we were able to win the battle with HIV/AIDS, that would only be a fifth of the war; we would still have four fifths of the war left to fight, except we would have lost another 20 years.