At Risk in Africa
Fighting AIDS in Africa is a losing proposition.

Mr. Ledeen is the holder of the Freedom Chair at the American Enterprise Institute
March 26, 2001 10:40 a.m.

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.