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 spent many years
working in Sub-Saharan Africa, mostly in the Republic of the Congo,
but also in Angola, Zaire, South
Africa, and Mozambique. I saw the AIDS onslaught first-hand. All
you had to do was to walk to the cemetery in Brazzaville once a
week and count the abundant fresh graves. All of us had friends
who were dead or dying from it.
Brazzaville was in many ways the best place to learn about AIDS,
because an excellent hospital and the regional headquarters of the
World Heath Organization were there, both staffed by some marvelous
doctors and researchers. Although they were very reluctant to talk
about it in detail (In those years African governments considered
it an embarrassment to confess the real dimensions of the epidemic),
over the years I learned a great deal from them, both about the
disease itself and about Africans' abilities to cope with it. There
is very little good news, and indeed the more you learn, the sadder
you become. Perhaps some of what I learned will help our well-intentioned
leaders grapple with their conscience, now that we seem hell-bent
on trying to "solve" the problem.
The first sad bit of wisdom is that Africans' immune systems are
not ours. We are vaccinated against many common diseases; we take
vitamins; we get regular health care from skilled professionals;
and our own defenses against attack from killer microbes are quite
strong. Africans are not vaccinated against much more than smallpox
(if that), and they are constantly assaulted by a rich variety of
nasty microbes. The assault is far more terrible than anything we
experience. An amazing percentage of Africans are infected with
malaria, and sexually transmitted diseases like syphilis and gonorrhea
(and others) are omnipresent. New drug-resistant microbes, from
tuberculosis to pneumonia, are flourishing. This relentless assault
on the human body inevitably weakens Africans' ability to fight
other diseases, even those few who have the money and access to
good medical treatment.
It follows from this that, even if all else were equal, it would
be harder to treat AIDS in Africa than here. We fight disease with
medicine and our own resources, and their resources are inferior
to ours.
There is a further nasty footnote: The symptoms of sexually transmitted
diseases greatly facilitate the spread of viruses like AIDS, because
the genital sores break during sexual intercourse, thereby creating
a blood-to-blood exchange that is ideal for the invading virus.
So, just as a matter of medical science, it's harder to fight AIDS
in Africa than in developed countries. And that's just the beginning
of the bad news. Chapter two of this heartbreaking story is that
African countries spend very little money on health care. The Congo,
which has long been one of the most advanced countries in central
Africa, as of a decade ago was spending less than one health-care
dollar a year per capita. That's less than a dollar, in one of the
best countries. And for all practical intents and purposes,
all that money was spent in the two biggest cities. The rural population
coped as best it could. There is no infrastructure capable of delivering
medicine to those who need it, nor to ensure that patients take
the full course of treatment. No matter how generously we donate
medicine to Africa, a huge bloc of Africans will never receive it,
unless we also create a vast infrastructure to deliver the medicine,
to administer it, and to advise the victims. That is a very daunting
task.
Worse than daunting, it is politically explosive. For if we come
to Africa with what many of them will consider white man's medicine,
distributed and administered by Western doctors and nurses, the
entire undertaking will inevitably be denounced as a new form of
imperialism. And every time we fail to reach a particular village
or township (and this will not be rare), we will hear cries of racism.
Chapter three is worse still. African governments have repeatedly
lied to their people about AIDS (the latest is President Thabo Mbeki
of South Africa, who denies that HIV causes AIDS), in large part
because they know they can't do anything much to treat it. It is
asking a lot of national leaders to expect they will suddenly recant,
admit that they have misled their people and then call upon them
to submit to treatment. The leaders will fear the inevitable question:
Why didn't we hear this before?
Chapter four is grimmer yet. Those same African leaders are famously
corrupt, and they will see the arrival of under-priced (or, better
yet, free) medicine from the West as a glorious opportunity to pad
their bank accounts. If these programs are run through African governments,
they will not be medical programs at all, but corrupt rackets.
Had enough? See Chapter five: The medicine will be used as a political
weapon, granted to allies and withheld from opponents. Imagine the
political fallout!
Is it hopeless, then? Most likely, it is, at least in the sense
of "solving the problem." That is not going to happen. We must not
create a ruinous fallout simply because our intentions are noble.
Some good things can be done, but they have to follow the painful
lesson of decades of failed foreign aid: Don't give anything to
a government. If we want to set up some treatment centers, run by
such wonderful organizations as Doctors Without Borders, I'm all
for it. If we want to give money and supplies to WHO operations
of the sort I knew and admired in Brazzaville, by all means do it.
But not one pill, not one vial of life-saving medicine, should be
sent to any government in Africa. That will make things worse, not
better.
If we're really serious about combating AIDS, we would better spend
our money on an intensive education campaign (building on the efforts
of some African governments) to try to change the sexual behavior
of the people. That will not produce quick results, to be sure.
(We haven't made sufficient progress with our own people, why should
we expect it to work any better in Africa? And how effective can
we be in preaching monogamy to polygamous cultures, which abound
on the dark continent?). But in the long run it's the best hope.
Alas, it seems certain that we will over-engage, at a huge cost
to our own treasury and to the countless millions of Africans who
have become the guinea pigs in one of the most dreadful plagues
in medical history.
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