Article by Konotey-Ahulu FID. (Guest Editorial). The AIDS Letter - Royal Society of Medicine 1989, No 11, Feb/March 1989, pp 1-3 with permission from the Royal Society of Medicine. Copyright remains with the Royal Society of Medicine.

AN AFRICAN ON AIDS IN AFRICA

Although an account by an African of how he sees AIDS on his continent is less likely to be objective, the defect of subjectivity can be counter-balanced by the fact that he sees, hears, assesses, and feels things about the scourge of which perhaps the non-native is incapable.

• Background
• Fact-Finding Mission
• Findings
• Synoptic Observations on AIDS in Africa
• Preventive programmes and research
• Bibliography

Background
First, take the setting in which AIDS occurs. As depicted in Figure 1 below, the health of a nation depends on the control of the Three Ps (Population, Poverty, Politics).

Figure 1 The Three Ps and their effect on a nation's health.
(Reproduced from Konotey Ahulu 1985)

The developed countries have managed to hold, and continue to hold, the Three Ps in rigid confines so that the nation's health is not eroded. Not so the developing countries. The Three Ps have so often got out of hand that a wholesome national health hardly exists. The more out of control the Three Ps are in a country, the less there is of a nation's health to speak of. So if the developed countries are reeling under the heel of AIDS, how will African countries fare? Secondly, the African does not speak of Africa as if it was 'a little country somewhere in Timbuktu'. Africa is a massive continent with 600 million people in 2,300 tribes distributed in 53 different, sometimes very different, countries. For example, the difference between Ghana and next-door Ivory Coast vis a vis the sex trade is the difference between Ghana's ex-colonial master Britain and Cote d'ivoire's France. Scientific and media descriptions of Africa's 'AIDS elephant', with its 53 body parts, have sometimes been like those of the proverbial blind men surveying an elephant. Most researchers concentrate on the tusk and, not surprisingly, come out with 'the AIDS problem in Africa is very sharp and pointed; the whole continent is like that'. Even when experts from Nigeria, the large body-part of the elephant, confirm with seropositivity studies that there is not yet an AIDS problem in their country, they are shouted down with "Under-reporting! Under-reporting! The whole beast has a sharp profile." To these safari experts, Tanzania and Sierra Leone, Uganda and Gabon, Zaire and Ghana, Rwanda and Gambia, are all the same-so much 'the same' that British medical students must be banned from setting foot on the continent.

Fact-finding mission
Reports I was receiving from my tribe back home did not tally with what the scientists were saying. For instance, one leading authority reported in an American medical journal of world repute that there was no AIDS in Ivory Coast; rather that Ghana and Nigeria were full of AIDS. Yet the truth was quite the reverse. Ghanaian females who went to do sexual business in the ex-French colony were being transported back home in Mummy lorries to die; not one of an equal number who went to Nigeria in search of strong currency has been sent back home with AIDS. Other scientists, using their findings in the tusk region of the African elephant, make statements like: ' The sex ratio for seropositivity and disease is almost equal with a small excess of men'. Again quite wrong for some other parts of Africa, and this was confirmed by news from Kroboland that'AIDS is a female disease; not one Krobo man is with it yet.' I learnt that the AIDS girls had 'all just been dumped from abroad' When the media began to report that whole generations in Africa were being wiped out, and that the continent was suffering a population collapse, I decided to travel; not in search of invisible seropositivity but to use the well attested tools of British undergraduate and postgraduate clinical medicine, namely history-taking, physical signs and detective epidemiologic work to formulate principles and assess the extent of what was obviously a new phenomenon. I went from London to Geneva (WHO), Congo Brazzaville (WHO), Kenya, Uganda, Rwanda (Kigali/Butare/Kigali), Burundi , Tanzania, Zambia (Lusaka/Ndola/Lusaka), Zimbabwe, Kenya (Nairobi/ Mombasa/Nairobi), Cameroon, Nigeria, Ghana, Ivory Coast, Liberia, Sierra Leone, Gambia, Senegal, Ghana, Geneva and back to London. I was refused a visa for Zaire but I met residents visiting London who had valuable information. I also communicated with doctors in Ethiopia, Gabon,Nambia, South Africa, Sudan, Lesotho, Botswana, Seychelles, Upper Volta, Malagassy, Mozambique, and Egypt.

Findings
For a more complete description of Africa's AIDS beast, the synoptic observations given below should be supplemented with the less subjective accounts of researchers resident in Africa (see Bibliography). But first a preliminary discussion. Definition of terms and criteria of assessment (a) For 'heterosexual practice' I use m-f sex, and for homosexuality m-m sex. Interviews with more than 120 prostitutes in 1987 and 1988 taught me that the widespread use of the term 'heterosexual spread' to mean 'penovaginal' is wrong, for m-f sex can be other than penovaginal: 'It depends on what the client wants' was a common retort to questioning.
(b) For 'iceberg' I use aidsberg, the former being a tropical misnomer.
(c) The Introduction phase of AIDS in my tribe ceases the day AIDS, as clinically defined by the WHO, is found in a patient who has never been outside the tribe. Propagation phase begins the day the introduction phase ceases. (Seroepidemiologists object to this definition but then there are no seroepidemiologists in my tribe; blood is taken from the sick, not the healthy, except when donated for transfusion.)
(d) I use the term formportucolo virus for HIV-2, because whenever the virus is found it can be traced back to a former Portuguese colony, or to Portugal itself.
(e) The criterion of problem assessment which divides the number of AIDS patients n, by the population N, and then arranges all the countries of the world in order of merit, placing the Congo Republic top of the AIDS class is, to epidemiologists, rather naive. It is quite obvious from a visit to the Congo that unlike the situation in the USA, France, UK, or Belgium, the bottom of Congo's aidsberg is largely ectopic - i.e. across the river in Zaire. The former Belgian Congo which, like Rwanda and Burundi, reflects the AIDS burden of Belgium, is quite unique in the world in having more countries surrounding it than does any other - 9 in all (10 if one counts Angola's Cabinda). The porous boundaries freely admit young women, driven by poverty to go to Zaire for foreign exchange. Just as the bottom of Ghana's aidsberg is ectopic Cote d'Ivoire (which mirrors the AIDS problem of France, leader of Europe), so is Congo's in Zaire. Therefore, counting 1,250 Congolese AIDS patients and calling this the visible tip of a colossal aidsberg in a population of 1,750,000 is quite wrong.
(f) I have proposed that AIDS figures always be presented as n (m.f.c.); so that if, as in February 1988, we had in the Krobo tribe one male pimp, 28 prostitutes , and one child of one of the sick girls, all repatriated from Abidjan desperately ill, this would be documented as 'Repatriation AIDS 30 (1,28,1)' . One suspects that if this was done for all African countries including Congo, beginning at the grass roots, the true adult sex incidence would emerge. (g) For assessment of the gravity of the AIDS problem both at the tribal and national levels I have proposed a 5-tier grading system not based on seroepidemiology: Grade I = AIDS not much of a problem; Grade II ='a problem'; Grade Ill ='a great problem'; Grade IV 'an extremely great problem'; Grade V= 'a catastrophe'. Taking cognizance of local circumstances, the health workers of the tribe or the country must themselves decide what their criteria for grading are and plot a graph with 'time in months' as abscissa, and 'grade' as ordinate to see when things change from one grade to another, and why. To accept the grading of experts who live outside the country with little knowledge of local circumstances, and who make the whole continent equivalent to Grade IV or V, could lead to accepting prescriptions for prevention which may not work in the African milieu.

Some synoptic observations on AIDS in Africa
The problem is not at all uniform on the continent. In large parts of most countries AIDS has not yet been shown to be in the propagation phase. The factors that determine how severe the problem is in a country include:
(a) Colonial relationship to high-frequency countries in Europe, e.g. Zaire, Rwanda, Burundi, Ivory Coast.
(b) Contiguity with countries in (a) above without border restrictions, e.g. Tanzania (with Burundi and Zaire), Zambia (with Zaire and Tanzania), Uganda (with Rwanda and Zaire).
(c) Intense poverty through political upheavals with predominantly female population dispersion to AIDS afflicted neighbouring countries and moving back home when ill, e.g. idiaminism and its aftermath in Uganda, coups d'etat in Ghana.
(d) International ports with frequent, substantial foreign military presence, e.g. Mombasa (Kenya), Abidjan (Ivory Coast).
(e) Stronger currency than surrounding countries, thus attracting predominantly female personnel from other African countries (no skills required), e.g. Kenya, Cote d'ivoire, Zaire.
(f) Tourists attracted from Europe and USA (e.g. to Kenya, Tanzania, Rwanda, Cote d'Ivoire, Senegal, Gambia) with prostitute migration from other African countries near and far, e.g. Kenya, Ivory Coast, Senegal, Gambia.
(g) International industry and development , e.g. mining in Zambia and Zaire.
(h) Cross-border long-distance lorry driving, smugglers, armed robbers, freedom fighters, (e.g. Zambia, Tanzania, Rwanda, Burundi, Uganda, Zaire, Angola).
(i) Combinations of the above. It also follows that a country with none or few of these combinations, e.g. Nigeria, will have less of an AIDS problem. Islamic North Africa may have tourism and industries but little of the other things apply, hence there is not an AIDS problem.

Thus female prostitution for foreign exchange is by far the most important AIDS spreading factor in Africa. That promiscuity per se is less important is shown by the fact that promiscuous men who do not include prostitutes in their exploits are less likely to develop AIDS than a non-promiscuous man who visits an international prostitute only once (Krobo tribe experience). In the propagation phase, part-time prostitutes, i.e. those who double as housewives or girlfriends, can be the most dangerous in m-f spread. It is the size of this pool rather than the extent of promiscuity that determines the gravity of the problem.

Male-male sex in Africa. Male-female prostitution in Europe. Apart from the increasing number of African men in cities who rent their bodies to expatriate men for foreign exchange, there are at least two foci of traditional homosexuality in black Africa - one in East Africa and the other on the West coast. Tribal terms exist which differentiate the active male-male partner from the passive one, indicating centuries of tradition. But while AIDS has not yet been introduced from outside into these traditional groups, which keep to themselves, the rent boys are quite exposed to the disease. Since both groups of homosexuals are expected by tradition to acquire wives and have children, dangerous propagation of AIDS is theoretically possible through m-m sex in some African countries. There is a disturbing European extension to African m-f prostitution, which was recently exposed on British television: Asian and African women are imported into Europe to undercut competitors by being made to work without condoms.

Complete herbal-cure anecdotes are circulating in Uganda, Rwanda, Tanzania, Ghana and Congo (related to tuberculosis treatment). Results are eagerly awaited of the first group of patients from the USA to go to an African country for the treatment of AIDS. The patients, all homosexuals, were due back home on 20 December 1988. It is worth noting that claims by African herbalists such as 'we have the means to cure AIDS except when it occurs with Kaposi's sarcoma', need to be interpreted in the light of the fact that many tribes use the same word for 'treat' as for 'cure'. To 'treat a disease' is easily interpreted to mean 'to cure the disease'.

Preventive programmes and research
These are under way in most countries through national AIDS committees. Educational schemes are best tackled both at the national and grass roots level. Tribal slogans are to be preferred to national ones, which are often in English or French, and sometimes miss the point. In my opinion the massive help being given Africa by the WHO, UNDP, World Bank, and the African Development Bank should first be used to screen every blood-transfused person and to supply sterile hypodermic needles before any consideration of population screening. In Africa condom use is primarily a man's responsibility. Prostitutes have been thrashed before for suggesting their use, so pimps and the 'queens' who direct much of Africa's sex trade should be the first to be targeted in the educational programme. Any directive of the Church on condoms in a predominantly Roman Catholic country like the Congo needs clarification.

Finally, the kind of research that will help Africans curtail AIDS does not have to be the vaccine-orientated research of the developed countries. Public health methods and clinical epidemiology are the best tools. Ultimately, modification of sexual behaviour through secular and spiritual education, backed by provision of light industries to generate the kind of foreign exchange in search of which the girls go into prostitution, is by far the best approach to AIDS prevention in Africa. I know that in addition to the multitude of Africans living abroad, there are many non-African friends of the continent who, when told what is happening, are prepared to donate their help at the grass roots level on the lines mentioned above.

Dr F I D Konotey-Ahulu was born in Ghana. He is Consultant Physician, Cromwell Hospital, London, and former Physician Specialist Korle Bu Teaching Hospital, and Director, Ghana Institute of Clinical Genetics.

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