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J R Soc Med. 2002 October; 95(10): 516–517.
PMCID: PMC1279185

The contest between a clever virus and a facultatively clever host

Personal Paper

The world's attitude to the African HIV pandemic is scandalous. The task of dealing with it is judged hopelessly difficult. Yet this pandemic is not only an African disaster; it could affect a large part of the world's population; it threatens world peace and development; it could set back the human species more than the black death damaged medieval Europe. The stance of western governments is generating an ever-growing moral outrage but unfortunately this centres on a demand that HIV carriers and AIDS victims be given antiretroviral medication.

Many people in Africa and the world at large are under the impression that, if we supplied the 40 million with antiretroviral drugs, if we made sure that HIV-positive pregnant women were treated so that their offspring do not become infected, and if we reared the AIDS orphans, justice would have been done to Africa.

Virchow, in the 19th century, recognized that epidemics represent biological phenomena as well as social pathology. To understand the African HIV pandemic one has to grasp the environmental and the social changes that took place in Africa in the last 150 years. The colonization of Africa brought rapid and immense social and technological change which in turn had enormous impact on the environment. By the middle third of the 20th century this impact was felt in every corner of the continent and the last bastions of the old African environment began to fall. The great clearing of the forests was in progress. The retreat of the forests deprived countless species of their habitats. As the species dwindled, with them vanished the microhabitats in which specific organisms lived. Some of these organisms, in their search for a new host, did not need much ingenuity: their vectors carried them onto a new and increasingly abundant host—Homo.

Similarly sometime in the middle third of the 20th century, a peculiar retrovirus, independent of a vector, took the opportunity to leap the species barrier from the vanishing species of primates into man. This leap across a species barrier necessitated considerable adaptation and after a series of mutations a new species of microorganism evolved—the human immunodeficiency virus. Whilst the ancestral virus spread by being walked or jumped from tree to tree, the host of the newly evolved species, just about the time of the evolutionary leap, had begun to move about by train, steamboat, bus and, latterly, the wide-bodied jet. Many of the mass movements of the host, particularly those in the postcolonial era, have been displacements occasioned by the intrusion of armed hordes of the male now airlifted from one corner of the continent to the other. As the virus is transmitted by intimate blood contact, sexual transmission is the rule.

The Africans, broken by colonization, live in dysfunctional polities. The social pathology of the postcolonial era is the joint responsibility of the colonizer who walked away, the parasitic African oligarchies and the world economic and ideological environment. The outstanding characteristic of misdevelopment is the extremely unfavourable income distribution: the upper class, amounting to less than 5% of the population, commands more than half of the national incomes.

With regard to HIV, four glaring examples of social pathology deserve special mention.

The first is superstition and the proclivity to believe in all manner of hearsay, be it that AIDS is spread by deliberately infected condoms, that defloration of a virgin brings cure, that AIDS has nothing to do with a virus and so forth.

The second is denial. The connotations of homosexuality and apes amplified the abhorrence of acknowledging a sexually transmitted disease. Society, led by the churches and governments, denied first the very existence of the epidemic, later its magnitude, then its causation. Because of this denial nothing was done to limit the spread.

The third is religious influence. The Catholic Church, and to a lesser extent the Islamic clergy, bear responsibility for an undetermined but sizeable proportion of the pandemic. The clergy did not confine itself to condemning condoms on the customary ground that by preventing conception they deprive intercourse of its primary purpose; the clergy condemned condoms as unreliable and permeable to the virus, and in some instances went so far as to declare that condoms are deliberately contaminated, the intent being to wipe out Africans. (A cardinal and a Muslem religious leader burnt condoms and sex education material in the ‘Freedom’ park of Nairobi.) Not only did the Catholic Church wage a condom war; it also prevented, or at least delayed, the introduction of sex education in schools.

The fourth is exceptionalization. Eventually, when denial became impossible, the epidemic was exceptionalized. This was not just another disease: HIV positivity is not a state like diabetes, hypertension, or cancer; for testing, consent is required, counselling is mandatory. Euphemisms abound and find their way into medical reports and case notes. The vocabulary of the political-correctness movement accompanying AIDS has been transplanted from suburban San Francisco to the African slums and villages.

Such are the ecology of the virus and the social pathology that fuels the pandemic. In consequence, the pandemic cannot be stopped with drugs, even though antiretroviral drugs have proved useful in the west for treating sporadic AIDS and in preventing transmission from mother to child. An attempt to export western suburban experience to the African environment would fail. A sizeable proportion of the drugs would be stolen and sold on the roadside—the kind of behaviour that explains the resistance of microorganisms to chemotherapy, be it malaria, pyogenic infections or tuberculosis. Antiretrovirals are already sold in the markets and peddled as preventive drugs: ‘This is strong medicine, take it before sex and do not worry!’

And who should be given the drugs? Who is HIV positive? How many hundred million Africans will be mass screened? How? Who will pay for that? Will exceptionalization be terminated? Will HIV screening be made compulsory? Written consent and pre-test counselling abolished?

Suppose all these ethical, legal, organizational and financial difficulties can be overcome, how are we going to distribute the drugs, explain the complex schedule of administration? Where are the people going to keep their drug supply, for surely we cannot hope to give them weekly batches? Are they going to store the supply in the roof? What about heat? What about humidity? The rain?

And compliance? The other day a hapless United Nations official had to apologize for suggesting that Africans might have trouble with the time schedule. In truth, things seldom happen on time on this continent. From baptism to funeral, everything is delayed. It is not obvious that people who do not consider time to be important will take their drugs on schedule.

And are they going to swallow drugs with unpleasant side-effects when they did not comply with the simple and innocuous drug treatment for tuberculosis. And how are we going to monitor effectiveness, side-effects, complications.

It is a much easier proposition to provide antiretrovirals to the pregnant women who are HIV positive. But then many of them will infect their children with breast feeding. Are we going to teach them to boil their milk and sterilize pumps and feeding bottles, or are we going to give them formula foods free together with sterilizing equipment?

There are similarities between famine relief and trying to make available drugs to AIDS victims: in both instances the difficulties are corruption, storage, distribution and monitoring and in both instances the humanitarian measures do nothing to alter either the social pathology or the ecological disasters—the causes of famine and pandemic. The moral thrust of ‘treat the African HIV pandemic with drugs’ is misdirected: humanitarian measures, the treatment of millions of people, will do little to improve conditions in Africa. Africa is a victim of its biodiversity and history; a victim of missionaries and imperial administrators; a victim of the cold war; a victim of political correctness and latter-day missionaries who preach democracy whilst refusing to recognize their own continuing contribution to the state of the continent, of which the HIV pandemic is a mere symptom.

The decisions that keep the continent marginalized are made in Brussels and Washington, in the World Trade Organization—and in the Vatican. This is why we in the third world cannot export food to Europe and America. We cannot export our manufactured goods either, because of working conditions. We cannot export our workforce because of the persisting racial resentment and the dislike of immigrants. These then are the imbalances and the injustices that keep Africa poor, ignorant, superstitious and dysfunctional, and create the conditions in which the little virus triumphs. There is ample reason for indignation and outcry, and it long antedates the era of AIDS.

To curb the pandemic what we need is a change in socioeconomic (and the associated environmental) conditions. For this a new economic order is needed that ends the postcolonial status of Africa as an exploited society, producer of solely those unprocessed commodities that cannot be grown in the west. What is needed is a truly free globalization of world trade. The competitive movement of produce, capital, labour and inventiveness would lift the third world and with it Africa out of the quagmire.

The Doha Declaration gave a spark of hope. At the time of Doha the daily subvention to American and European agriculture amounted to one billion dollars. Since then President Bush has increased it—Bush raised precisely the trend which must be reversed. It will not be reversed out of magnanimity; but action could follow if western leaders saw the danger to their own populations. The new world order is not a matter of social justice and not a matter of humanitarian concerns. If we do not globalize welfare and redistribute wealth, the virus will globalize. In doing so, it will set back the whole species. Inscribed into its genetic material is the reliance on a host that is of limited intellect and prone to put emotion above reason.


Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press