Newsday - December 28, 1988
Laurie Garrett. Newsday Staff Correspondent

But that unique testing program was stopped when Uganda ran out of money.

Earlier this year, Namagosi Lusakulira, of Zaire's School of Public Health, tried to study 150 people who tested positive for HIV but had not yet developed symptoms of AIDS. She wanted to see what happened to them after they left the hospital, how their disease progressed and whether they passed the virus to their sexual partners. But once patients left the hospital, difficulties emerged.

Eighty-one patients - more than half her study pool - couldn't be located. "It's a big problem," Lusakulira said, "people change addresses, their spouses kick them out of the house when they find out they have AIDS, or they simply move, and there is no way to find them."

For lack of forwarding addresses, updated telephone directories and reliable hospital records, Lusakulira's study had to be terminated.

At the remote Catholic missionary hospital of Moranga, Tanzania, attempts to send one of the two laboratory technicians to a major medical center for a month of training in AIDS blood testing were resisted despite the need.

"We cannot spare him, even for one day," declared the exasperated hospital director, Dr. Anna-Maria Rauch, "we have too many needs here. Everything is increasing now - syphilis, measles, gonorrhea, Trichomonas, Candida, polio, malaria, herpes - we have more work for this man than ever before. We cannot spare him, even for AIDS."

Given such woes as lack of money, poor infrastructure and other diseases, Subsaharan Africa would be in trouble even without a pandemic of an incurable, rapidly spreading disease.

But with AIDS, says Pauline Baker of the Carnegie Endowment for International Peace, the future looks horrendous.

"I see two scenarios. By raising the alarm level about the epidemic, the rest of the world may respond by trying to quarantine off Africa.

"The other scenario is that by raising the alarm we will see a commonality of interest, since the United States is the worst affected country from the disease, and scientists will see that if we want to cure this thing we have to work together.

"We have to go to Africa."

But that is easier to say than do for a variety of political and economic reasons. And while African leaders call for more financial help for a variety of ills - including funds for research and treatment - few expect that help on the scale needed will come soon.

Most African countries hard hit by the epidemic are handling AIDS the same way they cope with all their other health crises - with a combination of outdated technology and foreign aid. According to Lannon Walker, U.S. ambassador to Senegal from 1985 until August, western countries realize that battling AIDS has made fighting problems of infrastructure and AIDS on delivering health care more difficult.

"In my experience, twenty-seven years in Africa," said Walker in a telephone interview from his office in Washington, "I would say the international donors for a long time have recognized that the most effective way to deal with health problems is to deliver health care to the countryside and deal with the basic diseases before they become major health problems in hospitals.

"But now here comes AIDS."

Even if donors were willing to provide African nations with the funds needed to combat AIDS, it is unknown how to best spend the aid, he said.

Some African nations have already taken steps to minimize costs for AIDS care through creative uses of low-cost alternatives. For example, Harvard-trained cancer specialist Dr. Jeff Luande, of the Cancer Research Center in Dar Es Salaam, Tanzania, has successfully treated Kaposi's sarcoma, a skin cancer commonly found among AIDS patients. In the United States, therapy involves a combination of expensive drugs. But, Luande explained in Arusha, "In Africa, where the costs of chemotherapy are too high, radiotherapy offers an excellent alternative."

Last year Luande began treating patients with cobalt radiation, using a device that is, by U.S. standards, an antique. After treating 46 patients and following their health for more than a year, Luande has achieved results comparable to those obtained in the United States with far more expensive care. More than 90 percent of his patients think they feel better, and the sizes and numbers of tumors were significantly reduced in 83 percent of the cases.

"We have prolonged lives considerably with this treatment," Luande said. "We are not talking about a cure, but an effective therapy."

Luande, who has maintained professional ties with colleagues in the United States and Europe, is an exception. Although western research on AIDS in Africa has grown in the past three years, African researchers, smarting from past abuses, are often suspicious of the motivations of foreign scientists.

As a result, said Dr. V.M. Eyakuze, of the World Health Organization research station in Brazzaville, Congo, the onus is on western scientists to prove they are not racist and will not try to exploit Africa's AIDS epidemic to advance their scientific careers.

"Africans are not innocent and naive about international collaboration," he said. "The alleged African origin of AIDS - that was a stigma Africa could do without. Then the early bad serosurveys made it look like everybody was dying of AIDS. Africa would like genuine, equal partnership. Even if the African scientist is not at the level of the European, he should be brought up to that level."

In September, more than 500 of Africa's top scientists and their western colleagues gathered here to discuss the epidemic in Africa. Their mood was grim.

"Though there are regions with a low prevalence of AIDS infection in Africa," Dr. Lars-Olov Kallings of Sweden's Karolinska Institute told the Third International Conference on AIDS in Africa, "there are many with frightening levels. There are many areas where a third or more of the adults are infected at this moment.

"I am afraid the numbers of cases will be high in a few years," he said. "Are we prepared for this? Why is there not a greater sense of urgency!"

On the walls of the conference hall hung posters in Swahili which stated: "AIDS is a threat to mankind. Men and Women must be careful so they can produce the next generation for the nation."

A similar theme was struck in an editorial in the Times of Zambia immediately after the meeting, which warned that Africa's youth faced extinction from AIDS: "Are we shocking you? We hope so! Because unless we all wake up to the dangers that is threatened by AIDS there will be no teenage generation maturing to take up adult responsibilities."

But despite the sense of urgency, Africans find coping with the epidemic very expensive and resources very limited.

When President Ronald Reagan told federal health officials two years ago that he wanted to know how many Americans were infected with the AIDS virus, he caused a major panic in the federal health bureaucracy.

Meetings were held in three cities separated by several hours of air travel. Research contracts worth hundreds of thousands of dollars were let. Dozens of epidemiologists and statisticians were pulled from other work and given full time to just planning the task.

Two years later the first sample studies are just under way - in the United States, which last year spent $1.1 billion battling AIDS.

In Tanzania, which spends $1 per person on direct health care each year, no one can afford to even ask how many people are infected by the killer virus. And if they did decide to ask, there probably is no way to get a definitive answer. In a country where telephone communication is a sometimes thing at best, roads are often impassable and the relative handful of doctors are paid the equivalent of $50 a month, AIDS becomes just one blow to an already overburdened health care system.

For example, the cost of treating 10 American AIDS patients is greater than the entire annual budget of Zaire's largest hospital, Mama Yemo, where up to a quarter of all patients are infected with the virus.

But for many African countries, problems of dealing with other killing diseases are so pressing and massive that they overshadow even the greater disaster that AIDS is expected to become in the 1990s.

In the face of such enormous problems, some countries have resorted, as Uganda once did, to denying the existence of their epidemics. Earlier this year, for example, the government of Zimbabwe announced that no suspected AIDS cases would be reported unless they had been confirmed not only by the standard ELISA blood test, which has an accuracy rate of 98 percent and is readily available in most of the country, but also by the more expensive and tedious Western Blot test for AIDS infection. This double verification procedure is established practice in the United States and Europe, where it is both affordable and accessible. But in Zimbabwe, where Western Blot analysis is prohibitively expensive for most citizens, it has resulted in a dramatic reduction in the numbers of AIDS cases reported to the government. Since the policy was instituted in early 1987, Zimbabwe has not reported a single additional case of AIDS to the World Health Organization.

Few countries have taken such a drastic position. Most African governments in countries hard hit by the epidemic find, instead, that they continually walk a tightrope, trying to balance their general health care needs against those posed by this new disease.

AIDS is spreading almost three times as fast in such countries as Uganda, Tanzania and Zaire, as in the United States. Allocating resources for AIDS education, the only weapon available to slow the epidemic, is daunting. Even more difficult is the task of providing AIDS treatment on a continent where AIDS drugs used in the United States are unaffordable.

The World Bank, International Monetary Fund and donor organizations all over the world have tried to calculate the economic impact AIDS is having now, and will have in the future, on Africa. The numbers, estimated by Michael Over of the World Bank, Ann Hardy of the U.S. Centers for Disease Control and David Bloom of Columbia University, are staggering.

To begin with, African countries are already severely impoverished. The GNP per capita in the United States is $16,690. In contrast, Tanzania's GNP per capita is $290, and Zaire's is a mere $170.

Direct hospital costs for AIDS treatment vary from country to country based on, among other things, which medications are available and the salaries of medical staff. In the United States direct AIDS care costs range from $27,571 to $168,000, with costs rising annually as new expensive drug treatments are developed. In Zaire the range is $132 to $1,585. In Tanzania it's $104 to $631.

While the ratio of GNP to the cost of treating one AIDS case is about the same whether in the United States and Zaire, the ability of the nations to handle the economic impact is vastly different. Zaire can't afford to devote that proportion to any single case or disease, experts say.

The World Bank's Michael Over said in an interview that these figures, startling as they may be, do not represent the real financial danger of Africa's AIDS epidemic.

"We know now that in Zaire, Zambia, Rwanda and most other African countries seroprevalence [the rate of AIDS infection] is highest among the higher socioeconomic groups. Indirect costs are twenty times as important as direct costs because AIDS is striking people in their productive years. That is the real problem." AIDS, said Over, is wiping out the educated elite of Subsaharan Africa's cities, upping the indirect cost of the epidemic.

Indirect costs are based on the lost earning power of people who die, and the economic impact to society of their lost skills and education. In such cold calculations the premature death of a rural farmer is not as costly to society as that of a computer programmer or bank manager.

"I think the impact of the indirect costs on a typical East African country over the next twenty years," Over said, "could be to reduce the growth rates of the national economies from two to three percent, where they are now, to close to zero percent. That means a zero GNP growth. That's a worst-case scenario.

"So what we've got is a menace on the horizon."

And Africa cannot handle zero growth.

Social services, including health care, are the first things cut in African countries when belt tightening is necessary, said Baker, of the Carnegie Endowment for International Peace.

"Money won't come from anywhere to help Africa," she said. "People will just die without necessary health care. It will overwhelm most of these countries."

In addition to Africa's acknowledged AIDS epidemic, of the virus HIV-1, there is another virus present on the continent that presents an unpredictable future burden to African health care systems. Last spring, doctors at the main hospital in the capital of Kampala tested patients not only for the primary AIDS virus, HIV-1, but also for the recently discovered HIV-2. HIV-2 is genetically similar to HIV-1, though scientists have yet to determine how lethal the new strain will be.

The doctors were astonished to discover that 19 percent of the patients carried HIV-2. They would like to know how widespread HIV-2 infection is throughout the country, but they can't afford to find out.

"Let me tell you one fact," said Ugandan Health Minister Samuel Okware. "AIDS is here as a medical emergency, and it is here to stay. We will soon reach the point where we can't do anything. And what do you do for these people? They are human beings! So we rely on the world community."

Salim Salim, deputy prime minister of Tanzania, echoed Okware's cry, saying: "AIDS has come at a time when we are least prepared for it in terms of our health facilities. It is stretching out limited resources. And because it is a global threat, it must be fought, cooperatively, globally."
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