ACCORDING to a paper published in last month's World Economics, there are four anomalies relating to the HIV/AIDS epidemic which make it unique and, crucially, question the policy approach in developing countries. The paper's varied authors — an English professor of public accountability; an Austrian obstetrician; a Canadian professor of pathology; and a retired Scottish professor of public health — have provided a fascinating insight into why HIV/AIDS is different, not only between rich and poor countries, but between neighbouring African countries.
This is a brave and important paper, not least because anyone contradicting AIDS orthodoxy is seen not unlike a Holocaust denier.
Crippling epidemics are not new: Europe's Black Death (bubonic plague) from 1347-51 killed two-thirds of Europe. Other less well-known examples often decimated populations — yellow fewer (1740-48), smallpox (1870-71), dysentery during the Crimean and Boer wars, and the famous 1918-19 influenza epidemic that killed more than the First World War. The most recent was the much less devastating severe acute respiratory syndrome outbreak of 2002-03.
All these epidemics share multiple characteristics, which HIV does not. All have an identifiable starting point, a verifiable end point, short duration, and require traditional policies of isolation, quarantine and hygiene to minimise transmission of the causal pathogen.
But what of AIDS? As the authors point out: "The HIV/AIDS epidemic began as a localised outbreak in California and New York (not in east Africa, as claimed) and became international within 15 years, with apparent devastating lethality in sub-Saharan Africa and some other developing countries. This complex syndrome is currently regarded as by far the greatest threat to economic and human survival in the affected countries."
First, the main AIDS-qualifying diseases in developing countries (such as tuberculosis, persistent fever and/or weight loss and diarrhoea) are totally different from the main AIDS-qualifying diseases in developed countries (such as Kaposi's sarcoma, pneumocystis carinii).
Second, a diagnosis of HIV and AIDS is very loosely defined in developing countries but is strictly defined in developed countries. In rich countries, an HIV antibody test is always done but in the poor world it is not "necessary" and has not been performed in millions of cases.
Third, AIDS is distributed and appears to be acquired overwhelmingly heterosexually in developing countries but overwhelmingly by homosexuality and by drug abusers in developed countries. Fourth, the definition of AIDS has been changed four times, so that we now refer only to HIV/AIDS rather than to HIV and AIDS separately. Thus, cases of asymptomatic HIV are called HIV/AIDS.
Furthermore, each change has broadened the definition of AIDS-qualifying diseases and caused the number of "cases" to rise continuously. For instance, cancer of the uterine cervix is classed as AIDS-qualifying, removing much of the skew to male prevalence in developed countries.
The authors conclude, in effect, that in developing countries endemic diseases — many linked to overcrowding, malnourishment, famine, war, sexually transmitted diseases etc — have been reclassified as AIDS. They say: "In economic terms, we suggest that the same asymmetry of information is being used to justify continuation and expansion of inordinate, ring-fenced, and inefficient policies for prevention and control."
The authors are not denying the syndrome in rich countries, are not saying antiretrovirals cannot control HIV, or anything else to deny the existence of HIV. But they are saying that "there is an alarming possibility that the opportunity costs of alternative interventions aimed at other more prevalent and equally dangerous threats to health are being denied comparable, or any, attention ... and vaccine research should be redirected from HIV vaccines towards more effective vaccines and treatments that can be administered to large numbers (millions) of people to control TB and malaria".
It may well be time to allocate some of the ballooning AIDS budget to measuring what is actually causing problems in Africa. Does the syndrome in Africa deserve the funding allocation it receives, or is it misallocated and should it be re-directed? This latest research suggests that it should be reallocated to old foes such as malaria and tuberculosis, and to water quality improvements.
Dr Bate is a resident fellow of the American Enterprise Institute.