What is AIDS?: DR. F.I.D. KONOTEY-AHULU MD (Lond) FRCP (Lond) FRCP (Glasg) FWACP DTMH Fellow of the Ghana Academy of Arts and Sciences
(Published by Tetteh-A'Domeno Co, PO Box 189, Watford WD18 7NF. ISBN 0-9515442-41)

Experts generally find it easy to expatiate on their subjects to the comprehension of their fellow experts. But it takes a truly first-rate expert to make a highly technical subject understandable to laymen, without either trivialising the issues involved or sounding condescending in the process. When the technical subject in question happens to be as emotive and encrusted with irrational fears and deeply ingrained prejudices, as is the case with AIDS, then it requires not just deep knowledge but also exemplary courage to undertake the task of discussing and explaining it to the uninitiated. And to be able to do this successfully calls for unique literary skills which one does not normally expect from practising scientists.

Fortunately for the reader, Dr Konotey-Ahulu brings to the task of writing about Acquired Immune Deficiency Syndrome (AIDS) an unusual combination of professional expertise, rare courage and integrity and supreme gift of language and style. The flip-cover advertisement of his book: WHAT IS AIDS? states that the book 'has a two-fold objective: first to explain the phenomenon of AIDS to the educated African by describing the clinical features and secondly to identify and discuss some of the major problems which the disease poses to Africans. Having regard to the many myths and the heated controversies which have surrounded the AIDS phenomenon in Africa for such a long time, it would have seemed a hopelessly impossible task for any African to attempt to deal with the subject in an informative way and with any degree of scientific detachment. Yet this is what Dr Konotey-Ahulu has managed to do in a highly admirable manner. WHAT IS AIDS? is an extremely well written book which amply repays reading and re- reading. It gives the reader, in clear and uncomplicated language, the essential facts about AIDS and the virus which causes it. And it explains the special features of the epidemic in Africa. In the process it succeeds in disposing of some of the petty prejudices and fanciful notions which have bedevilled discussion of the disease, both inside and outside Africa. What is even more remarkable, the author finds the time to examine in detail, and in some cases refute conclusively, many false theories and claims about AIDS which have been bandied about by careless researchers and unscrupulous propagandists - theories and claims which could seriously complicate and make more difficult the fight against a disease which poses the most serious threat to Africa and the world in general.

Given the extremely technical nature of the subject and the rather involved opinions and theories which he seeks to elucidate and refute, one expected Dr Konotey-Ahulu's presentation to be couched in abstruse scientific language and even technical jargon. In the event the contrary is the case. For the explanations and expositions in the book are so clear and so simply presented that any reader of average intelligence should be able to understand the basic issues in contention, and even form opinions of some at least of the various positions.

The main thesis of the author is that "abnormal sex" is the chief cause of AIDS. He explains that abnormal sex is of two kinds: first "qualitative', such as homosexual practices and secondly "quantitative" such as prostitution. He is able, by means of very cogent argumentation and an impressive citation of data and scientific writings from all over the world, to present a case for this view which, to this reviewer at least, appears to be wholly unanswerable. Since the almost universally accepted view appears to be that the alarming spread of AIDS in Africa is due entirely to what is referred to as normal "heterosexual" behaviour, the pin-pointing of "abnormal sex" as the culprit is of great scientific as well as sociological significance for Africa.

In the process of explaining and demonstrating his central thesis, the author goes to great lengths to provide comprehensive and well-documented information of AIDS and the AIDS virus, the pathways by which the virus is transmitted from person to person, the clinical features of AIDS as well as the epidemiology of the disease in different parts of the African continent. An interesting part of the exposition is the chronicle he gives of how some researchers and writers have been misled into naively confusing AIDS with a number of diseases endemic in Africa such as Kwashiorkor, Sickle-Cell Anaemia and Diabetes, merely because these ailments happen to have symptoms and other clinical indications which are simiiar to those associated with AIDS. The impressive body of research data he cites and the careful way in which he marshalls his facts and arguments are sufficient to convince even a non-medical layman that some of these foreign researchers and writers have, at best, been very careless in their methods and, at worst, approached their subject with preconceived notions and prejudices.

A particularly refreshing feature of the book is the author's readiness to accept unpalatable facts and his unwillingness to flinch from drawing the necessary conclusions from them. For example, he chronicles and draws repeated attention to information which he has obtained from prostitute patients from his own ethnic group in Ghana, with very little regard to the possibility that some readers might draw the wrong but unflattering conclusions about his people. A writer of less intellectual and scientific integrity might have been tempted to gloss over much information or play down its significance. A corollary of this scientific attitude is the candour and "frankness" with which he describes and explains some sexual practices and clinical facts which the reader needs to understand in order to appreciate the special problems associated with AIDS in Africa. (He in fact seeks to apologise for this by resorting to the Africans' practice of excusing unavoidable use of frank and explicit language by means of sanitising expressions, such as the Ghanaian expression TAFRACHER. But he need not have bothered. His frankness is necessary and in a good cause!)

With the aid of his considerable medical knowledge, his indefatigable research efforts, his encyclopaedic scholarship and his lucid prose and superb descriptive powers Dr Konotey-Ahulu is able to advance and support a number of major views about AIDS the truth validity of which he is obviously convinced. Among them are the following:

1. That the main cause of AIDS is abnormal sex, although certain other pathways of the virus such as drug abuse and accidental infection through blood exchanges can play a significant role in some cases.
2. That a major explanation for the so-called heterosexual transmission of AIDS in Africa is international prostitution, and that accordingly "repatriation AIDS", as opposed to "resident AIDS", is mainly to blame for the increasing number of AIDS patients in the continent.
3. That international prostitution has helped to bring AIDS to Africa and to spread the disease because of the practice of "abnormal sex" - both qualitative and quantitative - by the prostitutes. He shows how many of these African prostitutes, in or outside Africa, are obliged to indulge in or tolerate sexual practices, such as "anal sex", which would be unknown in Africa and considered to be "unnatural" there.
4. That the bald claim that AIDS in Africa is mainly transmitted through normal heterosexual behaviour is incorrect and misleading because it fails to take account of the crucial role which international prostitution, and the practices associated with it, have played in the introduction and spread of the virus and disease in Africa.

In addition to the purely informative parts of the book, Dr Konotey-Ahulu finds it necessary to consider and deal with a number of controversial issues which have arisen in recent discussions of the subject of AIDS in Africa. These include an iriteresting examination of what he called RETRO-RACISM (or the tendency for Africans to blame all their ills on the white man) and AFRICAN PARANOIA (or the penchant to look for a continuing "white conspiracy" against Africa in all spheres of life). He also devotes considerable time and space to the claims of some Western apologists that the AIDS virus originated from Africa. Whilst Dr Konotey-Ahulu's treatment of these sensitive subjects is, as usual, balanced and pragmatic, it may be argued that this could. well have been avoided without detracting from the essential message of his book. It may also be noted that, by raising these matters in the context of what is a very important and scholarly book, he might give them an importance and legitimacy which they may not deserve. On the other hand, there may be those who will consider that these matters touch very sensitive nerves with many Africans and that, in calling attention to them and dealing with them with such understanding and balance, he has made it easier for Africans to confront the problem of AIDS without some of the confidence-sapping complexes which have made a meaningful discussion on AIDS so difficult for many Africans. These are matters on which reasonable minds can and will differ. Suffice it to say that Dr Konotey-Ahulu did not shirk what he considers to be his duty to raise and address these issues and to point out their implications for Africa's fight against the AIDS phenomenon.

Dr Konotey-Ahulu does not only give information and explanations which should help to debunk many of the pseudo-theories and claims rampant in the West about AIDS in Africa, he also looks to the future and examines the possible ways by which Africa and the world can halt the spread of the menace whose seriousness he does not seek to diminish. While he recognises that effective measures for combating AIDS in Africa will vary from country to country, he is also bold enough to put forward his own view of what needs to be done. He says that public health methods and clinical epidemiology are the best tools: that ultimately "modification of sexual behaviour through secular and spiritual education", backed by effective economic and related means to prevent international prostitution, is by far the best approach for the prevention of AIDS in Africa.

Like the true scientist that he is, Dr Konotey-Ahulu would be the last to claim that his is the final word on the subject or that the prescriptions he suggests for prevention will be either successful or even feasible. What cannot be denied is that he has set the problem of AIDS in a totally different context by giving the individual African man and woman, as well as African Governments and the world Community in general, the information and perspectives on which to formulate a strategy for the future. For this, he deserves the gratitude of all of us.

Thomas. A Mensah

His Excellency Dr Thomas A. Mensah is the first Ghanaian High Commissioner to South Africa. He was once Dean of the Faculty of Law, University of Ghana, and later served as Assistant Secretary General of the International Maritime Organisation in London. He has just been appointed (October 1996) the first President of the Intemational Tiibunal for the Law of the Sea.

What others said about the book:
Prof. Maya Angelou (USA): Compulsive reading. I could not put it down.

Mr J. G. Amamoo (London): Scholarly. A remarkable book.

Dr Bill Turner (UK): Excellent! A must for every medical student.

Dr Fred Wurapa (Congo): The story of AIDS in Africa as it should be told.

Mr Louis Obosi (Nigeria): Written for Africans, but should find its way to U. N. O.

Professor George Fraser (Oxford): Excellent book... the most important topic in medicine currently.

Group Captain John Weir (London): Remarkable book. Easily understood.

Mr K Gyan-Apenteng (London): The most commendable aspect is its sheer readability.

Prof. Geraint James & Prof. Dame Sheila Sherlock (UK): Superb in every way.

Dr Nam Dunbar (Oxford): Clearly dispelled many false notions about the causes and spread of AIDS.

Marion McTair (London): ...a masterpiece of good descriptive writing. Dr Ann Rudwick (London): ...a tour de force.

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