Category: HIV/AIDS

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Enforcing Uganda’s Anti-Homosexuality Act

Kim Yi Dionne and I wrote a piece for the Washington Post’s Monkey Cage blog analyzing US-Uganda relations in the wake of Uganda’s newly passed Anti-Homosexuality Act, and in particular, following the raid of the Makerere University Walter Reed Project. The post is copied below.

Kim is Five College Assistant Professor of Government at Smith College. She tweets at @dadakim.

U.S. foreign policy and Ugandan domestic politics collide

By Melina Platas Izama and Kim Yi Dionne

Just weeks after the United States announced additional American troops and aircraft would be deployed to Uganda to hunt rebel leader Joseph Kony, Ugandan officialsstormed a U.S. military-affiliated research institution, the Makerere University Walter Reed Project, in the country’s capital, Kampala. The Walter Reed Project raid highlights challenges to U.S.-Uganda relations, strained both by the fractured nature of U.S. foreign policy toward security allies like Uganda and the lack of coordination across Uganda’s numerous security agencies.

Why was the Walter Reed Project raided? And by whom?
The Walter Reed Project was raided on Thursday, April 3, by plainclothes state agents without a search warrant, reportedly on account of the Walter Reed Project’s work with the LGBTI community. Uganda’s recently enacted Anti-Homosexuality Actprohibits both the practice of homosexuality as well as “aiding and abetting” and “promoting” homosexuality. The law is vague on what constitutes the promotion of homosexuality, leaving interpretation to Ugandan law enforcement. Walter Reed Project staff members were whisked away in an unmarked car and interrogated at a police station. American embassy officials subsequently contacted the Inspector General of Police, Kale Kayihura, who was unaware of the incident. Kayihura then instructed the police station to release on bail the Walter Reed Project staffer who had been placed under arrest.

Screenshot of New Vision article taken from <a href="http://webcache.googleusercontent.com/search?q=cache:http://www.newvision.co.ug/news/654211-panic-at-makerere-as-quack-cop-arrests-staff.html">Google Cache</a> on April 7, 2014 (Melina Platas Izama and Kim Yi Dionne/The Monkey Cage)

The next day, the government-owned daily newspaper New Vision reported that the raid was conducted by a “quack cop,” with one police spokesperson, Patrick Onyango, denying responsibility. The same day, government spokesman Ofwono Opondo said in a tweet that the Walter Reed Project was raided for “training youths in homosexuality.” He also accused a top diplomat of being involved. Another police spokesperson confirmed the arrest in a segment by Ugandan media house NTV.

tweet1

tweet2
By Monday, April 7, the New Vision story had been pulled from the newspaper’s Web site and both of the tweets above (screenshots) were taken down.

Public opinion toward same-sex practicing people is generally negative, with 97% of Ugandan respondents in the 2007 Pew Global Attitudes Project agreeing with the statement, “Homosexuality is a way of life that should not be accepted by society.” In the days before the raid, Ugandan President Yoweri Museveni was the chief guest of a “Thanksgiving service” to celebrate the passing of the Anti-Homosexuality Act. Hundreds of people swarmed Kololo airstrip in the center of the capital, many bearing signs with direct messages to President Obama. All heads of religious institutions, including the Catholic and Anglican churches, and the head mufti of the Muslim community, not to mention the evangelical bodies who played a key role in the bill’s success, were in attendance.

(Data: Pew Global Attitudes Project 2007; Figure: Kim Yi Dionne/The Monkey Cage)

U.S. response to anti-gay legislation
Obama released a statement condemning Uganda’s Anti-Homosexuality Bill before it was signed into law, and initiated a review of American aid to Uganda immediately following the bill’s passage. At the same time the aid review was taking place, however, the United States announced a significant increase in military aid to Uganda. As activists and observers have noted, the announcement was poorly timed if Washington wanted to send a clear message to the Ugandan government. Instead, the State Department’s actions look like a slap on the wrist quickly followed by the extension of an olive branch by the U.S. military establishment.

If mixed messages are an ineffective means of impacting policy, however, so too may be the economic sanctions and bullish diplomacy the State Department has attempted to employ thus far. American foreign policy must consider the constraints faced by those who publicly and privately oppose the anti-homosexuality law, including politicians. American policy must find ways to assist those who support rights for sexual minorities without creating a stand-off with either the Ugandan government or public. Such a stand-off can alienate Ugandan rights activists and also whip up nationalist sentiments, bolstering the anti-homosexuality movement.

How is Uganda’s domestic security structured and why does that matter?
The Walter Reed Project raid and initial response by the police and government spokespersons suggest an additional complication — the lack of coordination across branches of the Ugandan security establishment. As noted above, the Inspector General of Police was unaware of the raid until after it had taken place and in the day following the raid, government officials were both claiming and refuting that the Ugandan police had been involved.

An investigative report by The Independent in 2009 found no fewer than 30 separate security agencies operate in Uganda, both constitutional and unconstitutional. The proliferation of security agencies, like the proliferation of districts, cabinet portfolios, and members of parliament, serves to bolster a patronage system and ensure that no one institution or individual is strong enough to challenge the executive. However, such fractionalization comes with considerable financial costs, and is both inefficient and unpredictable, as the raid on the Walter Reed Project demonstrates.

Another potential by-product of the proliferation of security agencies is the bungling of international relations. It is entirely possible that, rather than an overarching government strategy to target organizations who serve LGBTI clients, a particular branch or branches of the security sector have taken matters into their own hands. The raid comes at a critical point in Washington’s review of programing in Uganda. Amulti-agency team of Americans was in Kampala last week for the explicit purpose of reviewing U.S. commitments in the wake of the Anti-Homosexuality Act. Meanwhile, Uganda’s Ministry of Health has been at pains to assure international partners that the law will not affect Ugandans’ access to health services. Thus, last week’s events suggest an internal struggle in government, between those playing to populist sentiments and those trying desperately not to irrevocably sever relations with donors.

The details of the raid suggest that at least some components of the state, much to the chagrin of the United States, have every intention of enforcing the anti-homosexuality law. Some hoped that the law would remain on the books but largely out of everyday activities of law enforcement. The plainclothes officers involved in the raid were in possession of personal information about Walter Reed Project staff, including where they live, suggesting substantial efforts have gone into gathering intelligence not only on members of the LGBTI community but also individuals who work with the community. Sources inside the police say that they have video recordings showing that the Walter Reed Project is a “gay training and recruiting center.” Some of the videos apparently feature American nationals.

The raid of a U.S. military-affiliated facility is a bitter slap in the face to Uganda’s longtime ally, but perhaps serves well to highlight the failure of U.S. policy on human rights in the region, particularly the protection and promotion of gay rights. Uganda’s political landscape and that of the region is complex. The United States has yet to demonstrate that it has a strong grasp on the stakes or dynamics at play. In the case of the anti-homosexuality law, U.S. sanctions, whether verbal or economic, may be ineffective at best and harmful at worst, as journalist Andrew Mwenda has argued. As noted in an earlier Monkey Cage post, the vast majority of Ugandans support anti-homosexuality legislation, some with fanatic zeal. This is true not only in Uganda but across Africa. U.S. policy must consider the public pressure and incentives the president and other politicians face. Attempting to strong-arm a president or others into overwhelmingly unpopular positions domestically, such as the protection of sexual minority rights, may backfire.

 

 

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The Academy in the time of Influenza: American medicine and the Great Pandemic

American medicine up until the twentieth century was an unmitigated disaster. Or so argues (quite convincingly) John Barry in his fascinating book, The Great Influenza: The Story of the Deadliest Pandemic in History. The first two sections of the book cover a brief history of American medicine and medical research, and I’ve only just gotten to the outbreak of the pandemic that killed between 20 and 50 million people, according to the best estimates. For comparison’s sake, WWI claimed 16 million lives, and AIDS an estimated 33 million.

Barry highlights a strong link between war and disease, namely, the emergence of epidemics or even pandemics. I’ll return to a discussion of this thesis when I’ve finished the book, but for now, what has been most striking is the utter catastrophe that was American medicine up until relatively recently. While scientists and physicians in Europe, including Robert Koch, Pierre Louis, Louis Pasteur, and John Snow were pioneers in epidemiology, germ theory, and more, the study of medicine in America was stagnant, suggesting the importance of healthy academic and scientific competition on the European continent.

Evidence of the United States’ relative backwardness is abundant. Charles Eliot, who became president of Harvard in 1869, wrote in his first report as president that, “The ignorance and general incompetency of the average graduate of the American medical Schools, at a time when he receives his degree which turns him loose upon the community, is something horrible to contemplate.” When Eliot proposed reforms within Harvard, including examinations (of all things), Professor of Surgery Henry Bigelow, had this to say:

Charles Eliot, Harvard President 1869-1909

“[Eliot] actually proposes to have written examinations for the degree of doctor of medicine. I had to tell him that he knew nothing of the quality of Harvard medical students. More than half of them can hardly write. Of course they can’t pass written examinations…No medical school has thought it proper to risk large existing classes and large receipts by introducing more rigorous standards.”

At the end of the 19th century, Barry reports that American universities had “nearly two hundred endowed chairs of theology and fewer than five in medicine…” showing where both the money and the power lay.  It was ultimately the initiative of a few individuals, combined with big money from illustrious families such as the Hopkins and Rockefellers, that turned the ship around.

The Great Influenza is an excellent read, and fodder for thought not only for those interested in medicine, epidemiology, and virology (guilty as charged), but also for those interested in the academy as an institution – how it evolves or stagnates, and the factors that generate innovation and massive leaps forward in our understanding of the world.

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Health information leads to…cheating!

Well, this is disappointing. A recent study in Uganda supported by Google and the Grameen Foundation, and implemented by Innovations for Poverty Action, has found a way to…increase infidelity.

When provided with information about sexually transmitted diseases via text messaging, cheating among participants more than doubled. Why?

Although the study and its findings have yet to be published, Bloomberg reports:

With the program in Uganda, which began in 2009, infidelity may have risen as women became more aware of the risks of cheating and insisted on going for testing with their husbands, said study author Dean Karlan, an economics professor at Yale University in New Haven, Connecticut. Some men resisted, leading women to deny them sex, which the men then sought from other women, Karlan said.

Basically, it appears that women wanted safer sex, while many men did not.

At first, this struck me as a classic case of unintended consequences, of good intentions paving the proverbial road to hell. However, having finished tearing my hair out (actually, gunning it through Ntinda wondering, what is wrong with these men?!), I realized we have actually learned something important despite the perverse effects of this intervention. Two things, actually. 1) men and women have different preferences regarding safe sex, and 2) women are willing and able to stand up for and protect themselves, at least in Uganda.

Now we need to understand why, faced with the same information as women, men made choices that did not improve their health and did not reduce their risk of contracting a sexually transmitted disease. We also need to find ways to support women to protect themselves and their families.

Looking forward to reading the paper; will update accordingly.

UPDATE: Ungated version of the working paper available here.

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Uganda: The Health of the Nation

Published online Nov. 4, 2012 in The Independent.

The Health of the Nation
By Melina Platas Izama

Since Uganda hit 50 recently, it seems as good a time as any to check its vitals. There is the heartbeat of the economy and the temperature of the masses, the pressure of the politics and the weight of history. The health of this nation in one word? Resilient.

The Jubilee celebration was not made up of unfettered jubilation, as one might expect at 50 years of independence, but instead doused with a heavy coat of introspection.

The pristine Kampala Road, captured in black and white photos, is hardly recognisable today – a bustling, grating and downright stressful stretch of earth.  Cynics wandered and wondered aloud, are we better off now than we were a half-century ago? Teachers are striking, projects stalling, health clinics leaking staff, money, and drugs. This version of events is familiar. We listen to it every morning and read it every day. Frankly, it’s exhausting.

The health of the nation is in part a function of the health of its people. And here we have some great stories to tell. The greatest story of all is the about the survival of children. In the last fifteen years, death in infants and young children has fallen by nearly 40%. The drop in child deaths was faster in the past five years than it has been in decades.  This is fantastic news.

When Uganda raised her flag for the first time, mothers across the newly birthed state could expect more than one in five of their children to perish before age five and 13% of newborns would not survive their first year. This year, as the flag was raised once more, the death of a child is not foreign, as it should be, but neither does it go hand in hand with motherhood.

The results of the most recent round of the Demographic and Health Surveys (DHS), which have been instrumental in documenting these trends, have just been released for Uganda. Conducted across the country in more than ten thousand households, the DHS has been conducted in 1988, 1995, 2000, 2006 and 2011. While there are a number of improvements to report, the story of child survival, particularly in the last decade, stands out. It is perhaps the greatest achievement of the new millennium in Uganda. Continue reading “Uganda: The Health of the Nation”

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Faith in Politics

I’ve been traveling and have fallen a bit behind in posting my columns. Below is my article published a couple of weeks ago, and published online March 27, 2012. I’m starting to think a lot about the intersection of religion and politics, so there should be more on this topic soon.

Faith in Politics
The strategic and influential role of religion within our political systems

There is a certain structure religion gives to our lives. At the birth of a child or death of a loved one, we turn to some sort of faith more often than not. When oaths are sworn in courts of law, it is a holy book on which we swear to remain truthful. And when politicians promise to abide by the earthly laws we create, they raise a hand and address a god somewhere.

Faith shapes our lives, but not our governments – at least not directly, and not on paper. Laws uphold and protect only the legal separation of church and state in most countries. This formality can trick us into thinking that religion keeps its distance from politics. But the truth is that the two have never really been separated.

Simply take a look.

There are prayer breakfasts, the invocation of god’s name in such places as national anthems and currencies, and prayers at the start of government meetings and functions. Heaven forbid a U.S. president should end a national address without the words, “God bless America”. Although these are benign examples of the blending of church and state, the clashes can be much more fierce when religion comes head to head with public policy.

In the United States, there are vicious, and even deadly, battles over abortion laws and the teaching of evolution, as opposed to the more biblical creationism, in schools. In France, veils that cover the face (such as the hijab or burka) are banned in public places. In a number of African countries, including Uganda, marriage laws have been unsuccessful at prohibiting polygamy because such a ban is seen to violate religious practices.

These are perhaps some of the most blatant and controversial clashes between faith and the state, but the religious beliefs of political leaders can also sneak into their public policy in less obvious ways. The support of evangelical Christian groups for HIV/AIDS advocacy played a significant role, for example, in shaping and promoting U.S. President George W. Bush’s global HIV/AIDS initiative, The President’s Emergency Plan for AIDS Relief (PEPFAR). Even groups like Invisible Children, responsible for the viral Kony2012 video, are not outwardly evangelical, but are nonetheless headed by individuals whose religion plays a prominent role in the way they view their purpose in the world.

While it is tempting, especially for dispassionate analysts and policymakers, to take the separation of church and state at face value, it is necessary to more closely interrogate the ways in which faith shapes not only individual actions, but political systems. How does religion affect our political, social, and even philanthropic lives?

In an environment where voters have precious little information about their elected officials, apparent adherence to religious beliefs and practices can give some indication of the quality of a candidate. In an era of rampant corruption, a candidate who is perceived as religious may be more trustworthy than his or her atheist or less devout counterpart. U.S. presidential candidates, for example, must repeatedly discuss and proclaim their faith. Stories of redemption and renewal, often brought about by religious transformation, also win votes. A story of salvation from alcoholism and other exploits painted an inspiring image of former President Bush that many Americans admired, and one where faith featured front and center.

Indeed, many voters use faith as a prerequisite for their support of a political candidate. 35% of Americans and 45% of Rwandans surveyed by the World Values Survey believe that “politicians who don’t believe in God are unfit for office.”  Moreover, 62% of Rwandans and 42% of Americans agreed that it would be better if more people with strong religious beliefs held public office. As a politician in either of these countries, it only makes sense to announce your faith publicly.

At the same time, going into too much detail about your faith can be almost as career-killing as not mentioning it at all. It is one thing to be Christian, but quite another to be Mormon, much less Muslim. Most Americans and Rwandans are Christian, either Protestant or Catholic. About half of all Americans are Protestant, while a quarter are Roman Catholics, and less than 1% are Muslim. In Rwanda, the numbers are flipped – nearly 60% of Rwandans are Roman Catholic and 26% are Protestant. Another 11% are Adventist, and 5% are Muslim.

Politicians who do not come from the predominant Christian denominations are hard-pressed to demonstrate that their beliefs are not far removed from “mainstream”. U.S. Republican candidate Mitt Romney, for example, has been at pains to assure voters that as a Mormon, his beliefs to not differ greatly from those of more mainstream Christianity. But if Romney thinks he has a hard time, his experience would surely pale in comparison to a Muslim candidate. I would wager the U.S. is about as far from electing a Muslim president as any country on earth.

Perhaps it is not surprising that faith plays an important role in shaping people’s political preferences, even in a secular state. Nevertheless, the process by which faith seeps and soaks into politics and policy is not straightforward. Anecdotal evidence suggests that churches and religious leaders are a powerful force driving the political behavior of their followers. After all, from their pulpits, religious leaders have a great and even unique opportunity to shape public opinion. At the same time, however, most people do not react favorably to the explicit interference of the church in political behavior. About 60% of both Americans and Rwandans believe that religious leaders should not influence how people vote, and nearly 70% of Rwandans do not think religious leaders should influence government.

Thus, there is an ideological tug-of-war underway. On the one hand, citizens living in secular countries subscribe to values of religious tolerance and even the religious agnosticism of the state. On the other hand, they often favor politicians who declare their faith, and punish those whose faith is not in the mainstream. To understand how faith intersects with politics, these two conflicting preferences must be reconciled. The question remains, to what extent do we have faith in politics?

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Do medical injections spread HIV in Uganda?

A study by Mishra et al (2008) using data from the 2004-5 Uganda HIV/AIDS Sero-Behavioral Survey (UHSBS) suggests medical injections are positively associated with HIV status among Ugandan adults, even after taking into account other HIV risk factors and reverse causality (i.e. HIV positive individuals seek more medical care). Even if iatrogenic transmission is not the primary mode of transmission of HIV today (though Pepin argues it played a pivotal role in the early spread of HIV), this finding is worrisome. The authors conclude:

Our analysis showed a strong positive association between number of medical injections and HIV infection. Receiving frequent medical injections was significantly positively associated with HIV positive serostatus among Ugandan adults. Even after controlling for several potential confounders, and accounting for possible reverse causality from HIV infection to increased use of medical injections, men who received five or more medical injections in the previous 12 months were 2.3 times more likely to be HIV infected, and women 1.5 times more likely to be infected, compared with men and women who received no medical injections.
Our results are consistent with the literature showing a positive association between medical injections and HIV infection (Mann et al. 1986; Deuchert and Brody 2006; Barongo et al. 1992), and provide further evidence that medical injections may increase the risk of HIV infection.

…our finding of consistent and strong positive association between multiple medical injections and HIV infection reinforces the need to strengthen programs to promote injection safety and reduce non-sexual modes of HIV transmission. Medical injection as a potential mode of HIV transmission deserves continued research and programmatic attention. Program priorities for Uganda may include focus on rational use of injections, implementation of the national injection safety guidelines, and further scale up of medical injection safety programs.

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Explaining health behavior

Pascaline Dupas has an excellent paper in the Annual Review of Economics: Health Behavior in Developing Countries. It’s well worth reading. Conclusion below:

Good health is both an input into one’s ability to generate income and an end in itself. As such, it is not surprising that a relatively vast literature is devoted to understanding the determinants of health behaviors. This literature has recently expanded to the study of health behaviors in low-income settings, for which good data are becoming increasingly available. This review is too short to be exhaustive, but it tries to present the most compelling evidence to date on this issue. The important thing to take away from this review is that when it comes to health behavior in developing countries, there are a substantial number of deviations from the neoclassical model. First of all, people seem to lack basic information, and sometimes have limited ability to process information, because of low education levels. Second, there are market imperfections and frictions, especially credit constraints, affecting people’s ability to invest in health. Finally, there seem to be some deviations from the rational model, with, as has been widely shown in developed countries, a nontrivial share of people exhibiting time-inconsistent preferences as well as myopia.
Overall, this suggests an important role for public policy when it comes to health. Above we identify four important demand-side policy tools: information, mandates, price subsidies, and financial incentives. All appear to have the potential to increase the sustained adoption of preventive behavior. But the success of these demand-side strategies is contingent on the supply side being adequate: on health services and products being available, with delivery and/or enforcement institutions that are effective. The issue of how to improve service delivery in health is outside the scope of this review, but it has been the focus of a number of recent and ongoing studies that will soon need a review of their own.

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2012: the raw and promising new year

Best wishes to you and yours as we bring 2011 to a close and ring in the new year. Thanks for reading and sharing, and I look forward to another year with you in 2012.

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An excerpt from my final column of 2011 for The Independent (Rwanda Edition):

Shuffling through memories of the past twelve months, one is reminded of the heaving, tumultuous and heady days that made up the molding of global and local politics, innovation, and society. Almost every year feels exceptional at its end, and this one is no different. Exceptional for the unexpected uprisings, reassuring surprises, and most of all, the untimely, or perhaps just sobering, deaths.

A remarkable feature of the human brain is that emotion triggers extraordinary powers of memory – emotional events, traumatic or ecstatic, are captured in a different way from ordinary occurrences. I have many such memories this year. I can recall vividly the walls and tables of a classroom at the moment I heard that Tunisia’s Ben Ali stepped down, the living room and footage on Al Jazeera of Mubarak’s fall, the computer screen announcing Bin Laden’s death, and the Twitter feed of my phone as I scrolled through news of Gaddafi’s brutal demise early one morning, all in 140 characters or less. I also recall the unusually grey and rainy Palo Alto morning marking the first day in 57 years of a world without Steve Jobs, just a few days after the passing of Wangari Maathai. I see clearly the words of Christopher Hitchen’s last column staring back at me, in stark and final relief.

There are of course many other memories, moments captured with friends and family, as well as moments alone, preserved not as events in their entirety, but as a series of snapshots. At the end of every year, as now, there is more time to sit and shuffle through them. It feels like an exceptional year, and the past ten have felt like an exceptional decade.

The pace of progress, innovation, and change makes each decade, and increasingly, each year, feel remarkably different from the previous. In the first decade of the twenty-first century, we experienced tremendous economic growth worldwide, a sharp break from the previous several decades. By the mid-2000s, nearly every single country in the world experienced positive economic growth. The number of new infections of HIV is falling by the year, and deaths due to HIV peaked in sub-Saharan Africa and worldwide in 2004/5. Around the same time, Google went public, and together with Facebook, is now a household name in the global village. Mobile phone use has increased exponentially worldwide. In 2000, there were 12 mobile phone users for every 100 people. Today, there are around 69 mobile phone subscribers for every 100 individuals around the globe.

Change, therefore, is brazenly constant. Anyone who suggests otherwise is either deluding themselves or not paying attention. This is as true in Africa as in the rest of the world, although many both in and outside of the continent have been slow to recognize that the former has not, in fact, been standing in place while the latter dashes on.

The churning and surging marketplace for ideas is open. The stepping-stones placed by yesterday’s innovators serve as a launching pads for vaulting into the next year and decade. Even in the destruction strewn by mad and ordinary men lie the pieces that will build society anew. One can pick them up, or stargaze at glittering towers and soaring skylines far from home.

Entering the new year, we are without many of those who began 2011 with us just one year ago. The most memorable deaths on the news circuit were violent, painful, or both, untimely or just-in-time. The world is short a few tyrants, but short a good many great and beautiful minds too. Their exit is a reminder of the inexorable march forward that spares no one. There is no standing still, but there are choices, and our own expectations.

Here is to the raw and promising new year.

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HIV in colonial Africa

Online this week in The Independent (Rwanda Edition): How public health efforts likely contributed to the early spread of HIV.

The Tragic Amplifier

Published online December 8, 2011.

This year marks the 90th anniversary, approximately, of the introduction of human immunodeficiency virus (HIV) into the human population. It also marks thirty years since HIV was first scientifically recognized in 1981. Since the 1920s, this virus has spread across the globe and become the HIV/AIDS pandemic we are all too familiar with today. Most people consider the 1980s to be the beginning of the HIV/AIDS pandemic, but the virus had been prevalent in populations living in parts of central Africa for decades before it became a global nightmare.

New evidence from epidemiologist and international health expert Jacques Pepin suggests that human efforts to improve public health in central Africa were critical in facilitating the early spread of HIV, which has since claimed nearly 30 million lives. In the past two decades, massive coordination, mobilization, innovation, and investment have managed to slow the epidemic and save millions. As we mark World AIDS Day on December 1, 2011, HIV/AIDS is a reminder to us all of the tremendous power of human folly, but also of human triumph.

The Origins of AIDS, by Pepin, is a remarkable new book that pieces together the emergence of HIV in the human population, and its subsequent spread across the globe. HIV is the human version of simian immunodeficiency virus (SIV), which has been present in chimpanzee populations of central Africa for hundreds of years. Human contact with chimpanzees led to at least one transmission of SIV to HIV in a human in the early 1920s, most likely a hunter or a cook living in central Africa, where the majority of SIV-carrying chimpanzees live. This transmission alone was extremely unlikely to have triggered an HIV epidemic, and indeed chimpanzee-to-human transmission could have occurred on separate occasions prior to the 1920s, but would not have spread far. An infected hunter may have passed HIV to his family members, but in all likelihood, the virus would have stopped there. Why did HIV begin to spread beyond a few infected individuals in the early 1920s?

Pepin argues that heterosexual transmission, which is the predominant mode of transmission of HIV today, could not alone have led to an outbreak of HIV on a scale that would trigger a pandemic. Thus, there must have been some kind of “amplifier” that allowed for very rapid transmission of HIV to many people at a time. And what was the mostly likely initial culprit in the amplification of the virus? Colonial public health campaigns involving widespread use of unsterilized syringes and needles.

In the 1930s and 1940s, colonial administrations in French Cameroon, the Belgian Congo, and elsewhere began massive public health campaigns to treat various infectious diseases, including yaws, syphilis, malaria, leprosy, and sleeping sickness, using syringes and needles which were not sterilized regularly, if at all (oral tablet versions of treatments were not available for these diseases at the time). Although there are no blood samples from this time period still in existence (the oldest blood sample in which HIV has been detected dates back to 1959, taken from a man living in Leopoldville, Congo, now known as Kinshasa), it is well documented that other less lethal viruses, like Hepatitis C, were transmitted via syringes in Cameroon, Gabon, and the Belgian Congo, among other colonies. It is not difficult to imagine that HIV could have been passed quickly through a population via syringe as well.

One clinic to treat sexually transmitted diseases (STDs) in Leopoldville treated up to 1000 patients a day by the mid-1950s, with documented evidence that medical equipment was not sterilized between patients. To make matters worse, HIV was likely introduced into Leopoldville/Kinshasa at a time when there was a dramatic gender imbalance due to colonial policies. Urban areas like Leopoldville were often the equivalent of “work camps” in which wives and children were not welcome, which resulted in widespread prostitution, further facilitating the spread of HIV through heterosexual transmission.

HIV, which first spread through non-sterile syringes, often in clinics aimed at treating sexually transmitted diseases among men and sex workers in urban areas, kept at a steady prevalence through heterosexual transmission among the same population. In the colonial period, female sex workers, or “free women”, had only a few regular clients each year, but by the time of independence, female prostitutes would often see up to 1000 clients per year. This new type of prostitution greatly facilitated the transmission of HIV to populations beyond urban areas, and spread along major trades routes and cities in central and eastern Africa, including Kigali.

By 1984-85, Kigali, which at the time had a high ratio of males to females, and thriving prostitution, had the highest recorded HIV prevalence in the world, with 80 percent of prostitutes, 50 percent of STD patients, and 15-20 percent of blood donors, factory workers, and hospital employees testing positive for HIV. By 1987, HIV prevalence was at 17.8 percent in urban areas and jumped to 27 percent in urban areas by 1996.

From central Africa, HIV soon spread to Haiti, before being transmitted via multiple routes to the United States and beyond. Today, 34 million people are living with HIV/AIDS, and another 29 million have perished. That the spread of this virus was likely facilitated, and perhaps only possible, with the help of human technology and early public health campaigns should give us pause, and remind us of the terrifying potential for destruction due to human folly. As Pepin writes, “When humans manipulate nature in a way that they do not fully understand, there is always a possibility that something unpredictable will occur.”

Turning the tide on the spread of HIV/AIDS has taken decades, and millions have tragically lost their lives in the process. But the HIV/AIDS epidemic also demonstrates the amazing power of human innovation and cooperation that can take place on a global scale. Today, there are 6.6 million people receiving life-saving antiretroviral treatment, and both AIDS-related deaths and new HIV infections are declining in most parts of the world. The time, research, energy and money that have gone into tackling HIV has been phenomenal. If anything, we are now in danger of devoting too few resources to other health challenges that must also vie for the attention of the global health community and domestic health budgets.

HIV/AIDS is an extraordinarily painful reminder of the good intentions that can pave the road to hell, and of the unique capability of humans to create as well as destroy.

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HIV/AIDS: Human folly and triumph

Today is World AIDS Day. HIV has taken the lives of an estimated 29 million people around the world, and currently around 34 million people are infected. The effort of many individuals, organizations, and governments has led to a turnaround in the pandemic, infection rates and deaths due to AIDS are falling in most parts of the world. Still, there is a long way to go, and many people still do not have access to life-saving drugs.

A new book by Jacques Pepin, The Origins of AIDS, provides a remarkable account of how HIV initially spread among populations in central Africa, and later became the pandemic we know today. His sobering finding is that human efforts to treat and prevent disease with the use of non-sterilized syringes in colonial Africa very likely facilitated early and rapid HIV transmission. I discuss his work in this week’s column, excerpts of which is below.

HIV/AIDS: Human folly and triumph (published in this week’s Independent Rwanda Edition)

This year marks the 90th anniversary, approximately, of the introduction of human immunodeficiency virus (HIV) into the human population. It also marks thirty years since HIV was first scientifically recognized in 1981. Since the 1920s, this virus has spread across the globe and become the HIV/AIDS pandemic we are all too familiar with today. Most people consider the 1980s to be the beginning of the HIV/AIDS pandemic, but the virus had been prevalent in populations living in parts of central Africa for decades before it became a global nightmare.

New evidence from epidemiologist and international health expert Jacques Pepin suggests that human efforts to improve public health in central Africa were critical in facilitating the early spread of HIV, which has since claimed nearly 30 million lives. In the past two decades, massive coordination, mobilization, innovation, and investment have managed to slow the epidemic and save millions. As we mark World AIDS Day on December 1, 2011, HIV/AIDS is a reminder to us all of the tremendous power of human folly, but also of human triumph.

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Turning the tide on the spread of HIV/AIDS has taken decades, and millions have tragically lost their lives in the process. But the HIV/AIDS epidemic also demonstrates the amazing power of human innovation and cooperation that can take place on a global scale. Today, there are 6.6 million people receiving life-saving antiretroviral treatment, and both AIDS-related deaths and new HIV infections are declining in most parts of the world. The time, research, energy and money that have gone into tackling HIV has been phenomenal. If anything, we are now in danger of devoting too few resources to other health challenges that must also vie for the attention of the global health community and domestic health budgets.

HIV/AIDS is an extraordinarily painful reminder of the good intentions that can pave the road to hell, and of the unique capability of humans to create as well as destroy.

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