Newsday - July 10, 2000
Laurie Garrett, Staff Correspondent

When nurse Sabina Laurenti enters, mothers pile their children's medical records on the wooden examination table. The weighing and cursory examination of the infants begins, punctuated by the periodic scream of a protesting baby.

In the next room, behind a screen, is the injection table where ailing children will get doses of antibiotics or malaria drugs. Half a dozen plastic syringes - meant to be destroyed after one injection - rest in a bedpan. Laurenti used these syringes the previous day to inject more than 20 youngsters with vaccines - the same visibly soiled syringes, employed over and over again. And now these needles will be used again for penicillin injections.

The clinic has no electricity, so Laurenti cannot employ an autoclave to sterilize the needles. She said she ran out of alcohol long ago and boiling isn't an option since a wood fire doesn't allow her to control temperature to prevent the plastic syringes from melting. Laurenti cannot recall the last time a shipment of sterile syringes arrived from the far away Tanzanian capital.

"AIDS is here, but I don't really know about it," Laurenti says as she places a 2-year-old in a swing attached to a scale. "I just care for the babies, so I don't know."

Given that many communities in Africa have HIV rates that exceed one of every four adults, experts have been asking whether the already sorely pressed health-care system is itself spreading HIV.

In these northern Tanzanian villages near the Uganda border, HIV has raged at levels claiming more than 10 percent of the population for three generations and now infects upward of a third-and perhaps as many as half-of the pregnant women, according to a recent survey conducted by local AIDS Control Programme official Dickson Kavakava. Nobody knows how many of these babies are carrying the virus, but typically in Africa some one of three babies born to HIV-positive mothers is infected. In this waiting room, then, statistics predict at least one of the babies into whose arm those needles sank is HIV- positive.

Here in the Kagera District of Tanzania the only government clinic that consistently has electricity and reasonable supplies of sterile equipment is Bukoba General Hospital, located about a mile from the shores of Lake Victoria. Recently modernized by Scandinavian donors, the hospital now boasts the region's first genuine blood bank, from which safe, HIV-tested plasma and blood products can be withdrawn. The blood bank refrigerator is sparsely stocked, with most of its shelves empty.

Across the border in Kamirampingo, Uganda, where adult infection rates now run about 18 percent, an overstuffed passenger bus careens around a dirt road corner too fast, losing a wheel and toppling over. By the time it is righted, two people are dead and 36 passengers are severely injured, bleeding profusely. It's an everyday occurrence in Uganda-indeed, all over Africa-where private bus drivers speed about in poorly maintained vehicles. When the injured passengers reach the nearby Masaka Hospital emergency room, they are processed by volunteers and medical staff who have no sterile gloves and must handle the bleeding patients at significant personal risk.

If these trauma patients need transfusions, odds are uncomfortably high that they will receive HIV-contaminated blood.

Recently the World Health Organization released a scathing report stating that 80 percent of the world's blood supply used for transfusions and blood products is still-two decades into the AIDS epidemic-untested for HIV contamination. Safe blood in most of Africa is unheard of.

WHO Director-General Gro Harlem Brundtland recently charged that as many as 10 percent of all new HIV infections last year were the result of exposure to contaminated blood supplies. And she said that inattention to this problem was due to "a lack of commitment and support on the part of many governments."

Australian AIDS policy analyst Kathleen Kay has been involved in the worldwide fight against HIV since the mid-1980s, when she helped found the original WHO AIDS Program. Kay, who advises United Nations agencies on AIDS, insisted, "There is no more glaring example of our failure in the global HIV/AIDS fight than needles and the blood supply. If we can't deal with those issues-and they are comparatively simple problems, about money, really-then how can we begin to develop effective strategies for changing complex human sexual and cultural behaviors that...lead to the spread of HIV/AIDS?"

Here in impoverished Kyaka, ignorance is rampant. People don't know much about the outside world, though they do know plenty about the horrors of AIDS. They have only the vaguest notions of the acute differences between what is available to them as AIDS patients, versus the sophisticated care HIV-positive people get in the West.

It would startle them to know that in America people are now living longer, healthier lives with HIV by taking complicated combinations of drugs, at an annual price tag that exceeds any amount a Kyaka resident could hope to earn in a lifetime. This gross disparity has prompted widespread demands for lower pharmaceutical prices and broader access to drug combinations that are keeping many alive today.

The U.S. Centers for Disease Control and Prevention has done clinical trials in Ivory Coast and Uganda, offering these sophisticated drugs in African medical settings to see if the infrastructures and patients can use them properly. So far, the CDC says, it's a good news-bad news situation. In the best clinics Africa has to offer, the drugs can be used well enough to radically lower the numbers of viruses pulsing through the patients' bloodstreams. But keeping patients on proper, consistent drug schedules is proving difficult, and mutant, drug-resistant strains are cropping up rapidly in most of the recipients.

In truth, Drs. Callixte Twagirayzu and Jonathan Stephen of Bukoba General Hospital say, physicians here are hard-pressed to provide an infrastructure that can adequately treat the most basic opportunistic infections that plague HIV patients: tuberculosis, candida and amoebic dysentery.

"We may have [parasitic] PCP pneumonia in our patients, but proper diagnostic equipment is limited," Twagirayzu says.

"If a patient has bacterial infection, we do have erythromycin and penicillin," Stephen adds. "But if they don't respond to those, well, the broad-spectrum antibiotics are too expensive. We don't use them."

It is the basics this large hospital needs, the doctors say, not the complicated and costly therapies used in the West. And that's the opinion of physicians who are, unlike most of their African counterparts, practicing medicine in a recently renovated hospital that has a steady supply of electricity and running water.

The problem is worsening. As the AIDS epidemic expands in poor countries, it places ever-greater financial pressure on those nations' overall health budgets and infrastructures. And that leads to even further deterioration in sterile practices.

In Uganda, for example, half of all hospital beds are now occupied by HIV-positive patients. Some cities in sub-Saharan Africa report that upward of 80 percent of hospital patients are suffering from AIDS. A recent World Bank study estimates that HIV/AIDS treatment already consumes 3 percent to 5 percent of the gross domestic products of 16 African nations-a staggering figure given that a decade ago few African nations spent 3 percent of their GDPs on all their health-care needs, combined.

A team of physicians from the Kenyan and Tanzanian Academies of Medicine penned a report recently that spoke of the "overcrowding of death," in which physicians and medical students find themselves so powerless to save their patients that they lose the ability to think clearly about what they are doing. Doctors are trained to cure or at least comfort: Neither option is open to them in Africa's AIDS pandemic.

"Thus," they wrote in the American humanities journal "Daedalus," "the moral sensibility of the physician is challenged...by the inability to do anything," and health providers become callous, careless and sloppy. Risks rise. Hope recedes. And the quality of care, across the board for all ailments, declines. In the end, the team wrote, "physicians in Africa face a fundamental moral crisis: Hospitals are overwhelmed by patients dying of AIDS...the very moral foundations of medicine as a scientific and caring profession are called into question."

Pressure is on to increase government health spending, but not for sterile syringes, protective latex gloves and safe blood supplies. Rather, African leaders and physicians, several UN agencies and the U.S. Congress favor increasing expenditures for those expensive antiretroviral agents that directly attack the HIV virus. Under such political pressure, the four largest drug companies in the world agreed in May to lower their prices for AIDS-related drugs sold in poor countries.

WHO's top policy analyst, Dr. Daniel Tarantola, says, "There's just no way to separate HIV prevention issues from treatment," and UN AIDS Programme director Dr. Peter Piot agrees. Both men argue that the very credibility of international efforts to control behaviors that lead to the spread of HIV rests, in return, with a global willingness to provide the poor-particularly Africans-with treatment opportunities that may never equal those available in the United States but do prolong their lives and limit their suffering. It is, they say, a quid pro quo.

Dr. Joseph McCormick, chief of epidemiology for the Avantis Pasteur pharmaceutical company in Lyons, France, was among the first western scientists to call attention to AIDS in Africa, back in 1983, when he worked for the CDC. Today, McCormick argues, it's reasonable to connect treatment with prevention, but only if the wealthy world is willing to subsidize the safe provision of medical care.

"If their leadership cannot give it to them, then who?" McCormick says. "It is us. We sell them guns to kill their neighbors and family, drugs they do not know how to use, needles that they are too poor to clean, and then we walk away and say we have no responsibility."

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