From the issue dated July 7, 2000

South African President's Views on AIDS Cloud International Gathering of Scientists


The disease's toll in the country grows, as does a gap between researchers and politicians

The Chronicle of Higher Education-From the issue dated July 7, 2000





Durban, South Africa


The sick baby flails like a fledgling bird, a feeding tube inserted in his nose and an intravenous drip in his arm. Around his neck is a piece of twisted brown fabric, an amulet. Hoosen M. Coovadia, professor of pediatrics and child health at the University of Natal Medical School, explains. "This is one of our H.I.V.-positive patients." The infant was admitted to the medical school's teaching hospital, King Edward VIII Hospital, with pneumonia, and was later moved to the gastroenteritis ward because of chronic diarrhea. Looking around the ward, which accommodates 30 infants and toddlers, Dr. Coovadia estimates that about 60 percent of them are infected with H.I.V.


Medical students, professors, and other hospital staff members, he says, are emotionally exhausted, for they "keep on and on treating children, who die, and for whom we can offer just immediate medication and very little else."


The hospital is only a few miles away from the conference center where the 13th International AIDS Conference will open July

9, the first time the premier gathering of AIDS researchers will be held in Africa, the continent hardest hit by the disease.


Although the conference has been organized not by the South African government, but by scientists, delegates risk getting

pulled into a debate that many AIDS researchers here and elsewhere regard as ended. The debate is over whether or not

H.I.V. causes AIDS, a point that all major organizations fighting AIDS consider proven. Debating the matter any further, many researchers on AIDS argue, is a dangerous distraction from the effort needed to combat AIDS.


The conference's organizers stress that the cause of AIDS will not be up for debate at the meeting. But South Africa's president, who is expected to make the opening speech, created an international outcry earlier this year because an advisory

panel he set up to review the causes and treatment of AIDS in Africa contains many who doubt that H.I.V. causes the syndrome. Because of his past role in freeing South African black people from apartheid, President Thabo Mbeki is considered an influential elder statesman. Some worry that the views he adopts on the cause of AIDS could influence the position other African countries take. They suggest that the South African government should follow the lead of Uganda, where policymakers hold more conventional views, and which has reduced its infection rate.


Dr. Coovadia is the chairman of the conference, which is expected to attract some 10,000 delegates to the KwaZulu-Natal

province where, due to AIDS, the death rate now exceeds the birth rate. The disease is still spreading rapidly. Dr. Coovadia

says tests in prenatal clinics in KwaZulu-Natal show that one in three pregnant women is H.I.V. positive, a rate higher than the 22-percent national incidence for pregnant women. The problems faced by students and professors at the University of Natal

Medical School mirror those that the delegates to the international conference will discuss.


Professor Salim S. Abdool Karim, chairman of the scientific-program committee for the AIDS conference, says mother-to-child transmission and vaccine development will dominate the 800 papers that will be presented. Dr. Abdool Karim is also a professor of clinical public health at Columbia University, an associate professor of infectious diseases at the University of Natal, and the head of the H.I.V. Prevention and Vaccine Research Unit of South Africa's Medical Research Council this country's equivalent of the National Institutes of Health.


Dr. Abdool Karim, a South African citizen, says that about four million South Africans are H.I.V.-positive. "AIDS is ravaging

this country, not only by consuming those who are in their most-productive years, but ravaging it because of the drain it's going

to place on our economy." The country's failure to act earlier to fight AIDS, he says, is "going to damn the next generation."


In the face of the epidemic, President Mbeki has angered academics by appointing the dissident scientists to his AIDS advisory panel. The 33-member panel includes some highly respected South African and American experts who hold conventional views on AIDS. But almost half the members are mavericks, including Peter Duesberg, professor of molecular and cellular biology at the University of California at Berkeley.


Mr. Duesberg says that the dissidents could offer alternatives to the "unproven and entirely unproductive H.I.V.-AIDS hypothesis." In a paper distributed to other members of the panel, he suggests that AIDS in Africa is caused by noncontagious factors such as malnutrition, parasitic diseases, and poor sanitation. H.I.V., he says, is merely a benign "passenger virus" that is present in patients but does not cause the disease.


Mr. Duesberg and some of the other researchers on the panel maintain that anti-retroviral drugs, such as the commonly used

AZT, are toxic, a position echoed by the South African health authorities, who have declined to provide it to pregnant women.

The internationally accepted standard of care is to give pregnant women AZT, after studies showed that it cut by half the

likelihood that women would pass H.I.V. on to their babies.


Professor Udo Schuklenk, professor of bioethics at the University of the Witwatersrand Medical School, admits that until four

years ago, he doubted the viral cause of AIDS and could understand how, as a layman, the president could be convinced that

the dissidents' views had substance.


But Dr. Schuklenk says that although AIDS dissidents make up almost half of the president's panel, among scientists they are "a remote minority, a small sect."


On the basis of the hypothesis that H.I.V.causes AIDS, he says, "drugs have been developed that keep people with AIDS

alive, that give them a perfectly good quality of life, that bring them back to productive working lives."


Parks Mankahlana, a spokesman for President Mbeki, says that although AIDS can be controlled in countries with elaborate health-care systems by a triple-drug therapy costing almost $600 per month, the treatment is too expensive for South Africa.

(Many South Africans earn less than $150 per month.) The panel was convened in part to find appropriate local treatments, he says.


Dr. Abdool Karim sees the presidential panel as a waste of money and energy that could have have been better spent fighting

AIDS. More than $291,000 has reportedly been spent on travel and other expenses of the advisory panel, he notes. "I think the president and this country will be judged by history for this folly."


Yet he and other orthodox scientists agreed to serve on the panel because they felt that they wanted "to assist South Africa in coming out of this mess."


Dr. Coovadia questions President Mbeki's attempt to bring together two groups of scientists who hold fundamentally opposing views, and doubts whether he can mediate a solution in the same way Nelson Mandela is trying to negotiate a political solution between two warring groups in Burundi. 'It shows," he says, "that politicians have a fundamental lack of understanding of how science works."


Dr. Coovadia says the money spent on the advisory panel could have been better spent on giving pregnant H.I.V.-positive women nevirapine, a drug that reduces the chance that women will transmit the virus to their babies, and that is cheaper than

AZT. In results that will probably be reported at the AIDS conference, Dr. Coovadia says a South African trial of nevirapine,

in which the medical school participated, proved that the rate of mother-to-child transmission could be cut by 40 to 50 percent.



Dr. Coovadia believes that just one dose to the mother and one to the baby, costing around $3.60 in total, would reduce transmission. He realizes that health officials are concerned about administering the drug, and about its cost, as low as it may seem to foreigners. "But we must show the determination to start somewhere," he says.


Dr. Coovadia, his colleagues, and their students, are confronted daily with the human toll of AIDS. "Our students are affected quite markedly by the epidemic. Other than the humanitarian concerns, they are exposed quite regularly, immediately, and much more dangerously than any of us are to infection through needle-prick injuries."


In between lectures and time on the wards, members of the medical school's students' representative council spoke about how

the epidemic affected their lives. Oscar Makhubela, general-secretary of the council, had a needle-stick injury three weeks ago. He had been taking blood from a pregnant patient and had pricked himself with the needle.


Although the patient had tested negative for H.I.V., Mr. Makhubela was immediately put on AZT as a precaution. To his

immense relief, a second test proved that the patient was H.I.V.-negative.


Heinrich Volmink, the president of the student council, says he first appreciated the tragedy of AIDS while treating a baby.

"There was this beautiful, wide-eyed little girl with tubes stuck in her everywhere, her chest going up and down, up and down. I realized she was going to die. The powerlessness I felt is difficult to articulate. You face it every day in your clinical rotations."


Mr. Volmink says that with up to 10 million people in South Africa expected to die of AIDS this decade, the government should not be subsidizing a futile scientific debate but should be paying for "real initiatives that make a difference to patients."




Copyright 2000 by The Chronicle of Higher Education