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Why Aids Matters


new internationalist
issue 169 - March 1987

[image, unknown]

[image, unknown]

Contrasted with other diseases, AIDS is not yet a major killer. It will rapidly become so, however. Graham Hancock explains.

In a London suburb, people protest to their local council because a hospice for AIDS patients is under construction. The hospice is not financed by the council, but residents want it stopped anyway; they believe that if it's built it will bring down property values in their neighbourhood, and some of them are frightened that they might catch AIDS themselves. Meanwhile, in Manchester, Police Chief James Anderton goes public with the statement that 'degenerate conduct' is the prime cause of the epidemic in Britain and accuses homosexuals with AIDS of 'swirling around in a human cesspit of their own making'. In Sydney, a three-year-old girl who became infected with AIDS by blood transfusion is banned from attending her kindergarten; teachers are concerned that she might somehow infect the other toddlers. In Boston, health authorities are being badgered by a doctor who wants all homosexuals compulsorily quarantined on an island off the Massachusetts coast that was once a leper colony. In St Catherines, Ontario, a radio talk show host comments of AIDS: 'It's inventory time and we're getting rid of all the gays.'

Though exact figures are hard to arrive at, the World Health Organization (WHO) estimates that some 50,000 people around the world have so far died as a result of AIDS, with a further 50,000 terminally ill. That sounds a lot, but other diseases have killed far more.

In the two years 1918 and 1919, for example, Spanish flu killed 500,000 Americans in an epidemic that took 20 million lives worldwide. Over the previous 20 years, more than 10 million Indians had died of bubonic plague.

Up-to-date statistics of mortality provide further comparisons. Between 1981 and 1986, 15,000 people were killed in road accidents in Australia. Every day 27 French women die of cervical and breast cancers - an annual total of 9,855.1 Tetanus, measles, whooping cough and diphtheria annually kill 352,000 children in Nigeria, 85,000 children in Zaire and 61,000 children in Kenya In Africa as a whole, five million infants of pre-school age die each year as a result of malnutrition-linked conditions.2 The Ethiopian famine of 1984-1985 killed one million people.3

Set in such a context, do 50,000 AIDS deaths really justify the international outcry that the disease has provoked, the hysteria, the multi-million dollar advertising and education campaigns? Doesn't all this add up to much ado about nothing?

At one level the answer is almost certainly yes. There is too much sound and fury about AIDS - particularly when it comes to avoiding those painfully dying of it and to fear and loathing of minority groups like homosexuals or Haitians who have been wrongly blamed with starting the epidemic. What we are dealing with here is a disease and just a disease - not a disgrace, not a stigma, not a source for either blame or guilt.

Stripped of all the moralistic impedimenta that it has been loaded with, however, AIDS still remains truly terrible - a fatal infection which is spreading rapidly and which the best minds of modem medical science have been entirely unable to come to grips with. This is the sense in which much ado is certainly not being made about nothing. We have learned to live with other diseases and effectively to control most of them. We have not learned to live with AIDS. By the time we have a vaccine or a cure it will have killed tens of millions, devastated economies and changed the nature the of the social and psychological universe that we inhabit.

Some more numbers help to explain why. First, WHO's figure of 50,000 dead, 50,000 dying - 100,000 AIDS cases in all - is conservative and unreliable. Data from the industrialized countries is fairly accurate, but data from the Third World is not. No one knows for sure how many undiagnosed and unreported AIDS deaths there have been in Africa, for example.

What we do know, from statistics compiled over five years in many different countries, is that for every case of full-blown AIDS there are at least 100 carriers of the infection who as yet have not developed the disease.4 Of these 100, at least 10 have AIDS-related conditions (ARC), which result in varying degrees of disablement. The others presently have no symptoms but are infectious. If we accept the WHO figure of 100,000 AIDS cases, then this implies that there are a million people in the world with ARC, and ten million carrying the virus.

AIDS is always fatal once it develops, so how many of the ten million infected individuals are destined to progress to the full-blown disease and to die as a result?

Throughout the epidemic, doctors have been optimistic. They have not wished to compound the atmosphere of panic and they have been concerned about the morale of as yet healthy carriers of the Human Immunodeficiency Virus (HIV). To express a belief that most or all carriers will eventually die of AIDS would be to deprive these people of hope - one of the strongest weapons in their armoury. In the early years of the epidemic it was believed that only ten per cent of those infected would get AIDS; the rest would remain healthy. Dissemination of this comforting statistic was undoubtedly well-meant, but it was also highly irresponsible. A year, or even two or three years of study of a disease caused by a slow-acting virus is not a long enough period from which to derive any conclusions. And, unfortunately, as more time has passed since the first cases were diagnosed in the US in 1981, more and more previously healthy HIV carriers have developed full-blown AIDS.

The latest report by the US National Academy of Sciences5 concludes that between 25 per cent and 50 per cent will die within five years, and even more over a longer time span. Though little publicity has been given to findings like this, many medical experts now believe that the conversion rate from the carrier state to full-blown AIDS will approach 100 per cent over 10-15 years.6

AIDS - some basics

AIDS, Acquired Immuno Deficiency Syndrome, is a fatal disease caused by the Human Immunodeficiency Virus (HIV). Scientist are certain that the virus is new - tests on stored blood and sera show that it first infected people during the late 1970s. There is uncertainty, however, about its origins. It could be a mutation of a similar virus which causes immune deficiency in some monkey species in central Africa. But it also bears a very close genetic resemblance to visna, a virus that kills sheep. Visna does not cause immune deficiency but destroys the brain. Recent research has demonstrated conclusively that HIV, although better know for its devastating effects on the immune system, also has a direct action on the brain cells of infected individuals - leading to atrophy of cortical tissue and, eventually, to brain death. Like visna, also, HIV is slow-acting, it can lie dormant for long periods of during which carriers look and feel healthy but are capable of passing the infection to others. Transmisson of HIV is predominately though intimate sexual contact involving exchange of bodily fluids and through transfusions of infected blood and blood products. There have been no cases of transmission through routine close social contact.1

1 See AIDS - the facts for further details.

The implications are grave. WHO's 100,000 dead or dying from AIDS today, become 10 million dead or dying by the year 2000 - altogether a different ballgame. And WHO's figure is conservative. Research in Africa suggests strongly that ten per cent of the 100 million population of the worst-affected central zone are now HIV carriers - in other words there are ten million infected in central Africa alone.7 Add to this the infection in the rest of the world (including the US with an estimated 2.6 million carriers) and you get a global figure of 15 million or more HIV-positive individuals. All these people are infectious as well as infected, passing on the virus to others with whom they have sexual contact. So 15 million infected today implies a great many more infected a year from now and even more the year after that. Indeed WHO estimates a world total of 100 million infected within five to ten years.

Regrettably, the doomsday mathematics do not end here. Because it is predominantly a sexually transmitted condition, HIV infection singles out the sexually active age group - those between 15 and 50. This is the productive age group - the group upon which the young and the old depend for their survival. The consequences of a catastrophic epidemic focussed on this group will be immense - particularly in the Third World where producers are mostly peasant farmers. Here there is virtually no automation or mechanization to fall back on; it is the muscle-power of people alone that grows the food and creates the limited wealth upon which the developing nations depend. In badly affected African countries where an estimated ten per cent of the population are infected, the implications are, literally, decimation. Out of its seven million population, Zambia could have 700,000 people dead or dying of AIDS in less than a decade. In Zaire, with a population of thirty million, three million people could be lost to AIDS by the mid-1990s. The prospect of such an epidemic eroding the South's productive generation during a period that is already one of economic crisis - falling commodity prices, food shortages, burgeoning debt - is grim indeed. It is all the more serious because high birth-rates, reduced infant mortality and improved health-care for the elderly have conspired to produce every year more and more dependents, less and less producers.

In the industrialised countries, too, the twentieth century has witnessed important changes in the dependency ratio: more and more old people are living longer. In 1961, there were 26 million people over the age of 65 in ten Western European countries; by 1985 that figure had increased to nearly 37 million - almost 20 per cent of the population of the European Community.8

The economic implications of the greying of society are worrying. For example, West German workers now pay 18.5 per cent of their wages into the state pension scheme. By the year 2030 - when retirees will outnumber working people - that contribution will have risen to 35 per cent. No one has yet calculated the impact that AIDS will have on figures like these. But clearly, by killing the earners, AIDS will accelerate the trends that are already altering the shape of societies the world over. Indeed, AIDS will switch large numbers of young and healthy adults from the input to the output side of the dependency equation, transforming wealth producers into wealth consumers on a massive scale: in New York, costs of hospital care run as high as $100,000 per patient between date of diagnosis and death.

But AIDS hurts the poor more than the rich. In underfunded African hospitals and rural clinics the virus is being spread by the practice of reusing needles and syringes which, in better economic circumstances, would be disposed of after each injection. Another example is the cost of screening all donated blood for HIV infection - something that has been done routinely in the West, since 1984 - 85. Such screening has protected many hundreds of thousands of people from acquiring the virus from blood transfusions. Yet in Africa almost no countries can afford the cost of screening - estimated at roughly one quarter of the cost of running national blood banks. Accordingly blood transfusion remains an important - though entirely avoidable - source of infection. What Africa needs is a quick, simple and cheap bedside blood test for diagnosing HIV infection. International pharmaceutical companies, however, are more attracted to the $22.5 million annual market created by wealthy Japan's decision to run individual tests for HIV on all its blood donors.9

The response of the drug companies is mirrored by Western governments. Despite spending increasingly large amounts of money to control the epidemic in their own countries - on screening, on research and on education campaigns - little is being given to assist Africa. In November 1986 the World Health Organization, which should play a major role, had an AIDS budget of just $580,000 and confronted the epidemic with a global co-ordinating office consisting of just one medic and a secretary.10

The devastating potential of AIDS in the years ahead calls for a much more urgent response. But it is not just the future that is at risk. Because it transmits itself through sex, the most intimate of human relationships, because it kills and because it is at present incurable, AIDS has already debased the societies in which we live. Bonds of love and sympathy have been tainted with suspicion, and a plague mentality has been introduced in which we bring out our dead in fear and hatred. No statistical models or mathematical projections can count these costs.

Consider the changes that are already happening. Would you now hesitate, because of AIDS, to give mouth-to-mouth resuscitation to an accident victim? In many areas firemen and ambulance attendants are refusing to give this kind of first aid without special equipment. How would you feel about allowing your own children to attend school if there was a child with AIDS in the classroom? Be honest with yourself in answering questions like these. What about minor health problems? Suppose you were admitted to hospital for a hernia operation and learned there was an AIDS patient in the next ward? What about recreation? Would you play squash with someone who you knew or suspected to be a virus carrier? What would you do if a relative or friend developed AIDS? Would you rally round with love and support, clean them up when they were incontinent and staunch the blood from ulcers and sores, or would you prefer to stay away? And what about sex? Are you making sure to use a condom if either you or your partner have had intercourse with anyone else in the last five years? There are other dilemmas too. Do you suspect that you yourself might be a carrier? If so, what are you doing about it? Would you take the test, or would you rather not? And if not, what then?

We're all going to be answering questions like these over the next few years as the epidemic spreads, as we all come to know someone with AIDS. Even today in New York and San Francisco it's difficult to find people in their thirties who haven't lost at least one acquaintance to the virus. As it becomes more and more part of our lives we'll face painful choices: whether to be a Pharisee or a Good Samaritan; whether to retreat into self-imposed isolation or to treat this as a community problem to be faced in a caring and involved way. Our choices will change us and change our definition of the societies in which we live. It is not inconceivable that AIDS could become an agent of historical change, radically redirecting our energies and setting us on new paths in a way that no disease has done since the Black Death piled up 50 million corpses in Europe and ushered in the Renaissance.

As individuals we may feel powerless to redress the global crisis that the AIDS pandemic undoubtedly represents. Closer to home, however, within our own families and communities, we can take action by recognizing that we have a real responsibility towards one another, a responsibility to care and to give love, a responsibility not to let ourselves be carried away by blind panic and bigotry.

In the final analysis, I believe our interpretation and recognition of these responsibilities will bring out the best in us and not the worst.

1 World Health Organization.
2 United Nations Economic Commission for Africa.
3 The Challenges of Drought by The Ethiopian Relief and Rehabilitation Commission.
4 A diagnosis of full-blown AIDS is made when the patient teats positive for antibodies to the Human Immunodeficiency Virus (HIV) and presents one br more) of several Opportunistic infections' which can only become established in contest of severe immune deficiency.
5 AIDS and the Third World, Panos Dossier No.1, London, 1988.
6 Ibid.
7 For further details, see 'AIDS and the nations of the South'.
8 Time magazine, December 1985.
9 Panos Institute Dossier, op.cit. and see 'Red in Tooth and claw', for further details on the drug companies' response to AIDS.
10 Ibid.

No magic bullet

There is no cure for AIDS - yet. Various anti-viral drugs do exist, amongst them Ribavirin, Suramin, and Borroughs-Wellcome's AZT, but none of them - either alone or in combination with other treatments - are particularly effective. The main problem is that although they can kill the virus, or inhibit its spread in the body, none of them relieve that state of immunosuppression that HIV infection causes.

Scientists are more optimistic about the possibilities of creating a vaccine which would at least stop uninfected people from catching AIDS. Even here the difficulties are immense:

  • Anti-viral vaccines are generally made from the protein antigens on the outer coat of the infectious organism. To be effective, they must stimulate the creation of antibodies which 'fit' with the antigens, almost like a glove onto a hand. If the antibodies do not 'fit' then they will be unable to do their job - which is to combine with the antigens and render them harmless. HIV is particularly tricky because one of its characteristics is constant mutation into ever more heterogeneous strains which display marked differences in their outer coatings. In consequence, 'trying to develop a vaccine for AIDS is like trying to hit a rapidly-moving target' says Dr William Haseltine of Harvard University. 'The antigens keep changing, which could mean that today's vaccine will be ineffective tomorrow.'

  • With an extremely complex and dangerous retrovirus like HIV (see Facts Spread under 'What Causes AIDS?') the processes of testing and research pose serious ethical difficulties. Should researchers, for example, deliberately expose vaccinated volunteers to the virus knowing that the vaccination might fail and the volunteers die? On the other hand, without deliberate exposure, how could there be certainty that a vaccinated volunteer would ever meet the infection at all?

  • There is the possibility that the vaccination itself might be dangerous. If live virus is used, it could overcome the body's defences and go on to cause AIDS. There has never been a vaccine against a retrovirus - the least understood and most deadly members of the family of viruses. Even vaccines against better-known types of viruses, like polio and smallpox, can be dangerous; their safe development takes between ten and twenty years.

Despite these difficulties there is hope that a successful vaccine against HIV could be developed. An encouraging discovery made by Professor Robert Gallo at the National Cancer Institute in Washington is that the outer coats of the different strains of the virus all have important areas in common. 'If the constant regions are immunogenic in making the right kind of antibody,' Gallo says, 'a vaccine will be possible.'

Likewise, the use of vaccines which are neither 'live' no 'killed' but are the products of genetic engineering could speed up the research and testing process and make it safer. Under this procedure, a harmless 'carrier' virus (not HIV) would be tampered with so that its outer coat carried a constant immunogenic gene from the outer coat of HIV - a gene that will stimulate the production of effective antibodies and that will not endanger the human host.

The time-span, however, for the necessary testing and proof of effectiveness of such a vaccine is still estimated at five to ten years. It may take longer.

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New Internationalist issue 169 magazine cover This article is from the March 1987 issue of New Internationalist.
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