Archive for December 13th, 2008

The Tragic Human Cost of Political Idiocy and AIDS Pseudoscience

December 13, 2008

In which Dr Aust ruminates somewhat unoriginally on the desperate consequences of delusional thinking about medicine… when the deluded are the people running the country.

Somewhat submerged under the media storm over the Bombay terrorist attacks, last month saw the publication of a sobering estimate of the true human cost of the Mbeki government’s decade of incomprehensible HIV denialism in South Africa. The Guardian covered the story here.

The basic history is no doubt well known to most readers in the Badscience blogosphere; as the millenium dawned, South Africa faced an unprecendented AIDS crisis, with 10% of the population infected with HIV. However, seemingly enchanted by the claims of maverick scientists like Peter Duesberg, President Thabo Mbeki and his government decided to pursue a policy based on the view that HIV was not the cause of AIDS. They therefore failed to implement programmes of treatment with antiretroviral drugs – the drugs that had transformed the prognosis of HIV-positive patients in other parts of the world in the late 90s.

They continued with this policy as yet more scientific evidence accumulated that HIV was the cause of AIDS.

They continued as HIV-positive people in many other countries had their death sentences stayed by antiretroviral therapy.

They continued even when the cost of the antiretroviral drugs tumbled, and when global schemes were set up to fund the treatment programmes.

They continued even though studies showed antiretroviral treatment was cost effective in South Africa.

And they continued even when South Africa’s poorer regional neighbours, like Botswana and Namibia, managed to implement treatment programmes.

The authors of the recent estimate summarise some of the timeline in a handy diagram:

hiv-timeline

To see the original,  go to the paper, click the “Full text” link, then “Fig. 1”, and finally click the figure itself to get an enlarged version – or, when you reach the full version of the paper, click “View full-size inline images”.

Among the things the Mbeki government failed to do was implement programmes to treat HIV-positive pregnant women. An untreated HIV-positive woman has around a 25% chance of passing HIV on to her child during childbirth. With antiretroviral therapy, that transmission risk can be reduced to around 10% in developing world settings with vaginal delivery, or even to only a few per cent in some recent studies (for a medical review of some recent trials see here, or the Cochrane summary here). This is not enough on its own, sadly, as breast feeding can also pass on the virus – but it is a start. Around half to two-thirds of children who acquire HIV from their mothers in the developing world do so during delivery.


Estimating the true cost in lives

The stories that appeared last month centred round a new analysis, by a group of workers from the Harvard School of Public Health, that estimated how many lives the Mbeki regime’s failure had cost. They did this by assuming that South Africa could have achieved something approaching the kind of treatment coverage and results that proved possible in neighbouring Botswana and Namibia, countries with similar social and infrastructure “contexts”.

The authors estimate – and they make clear that their estimates are “conservative”, so likely to be on the low side – that each year from 2000 to 2005, about 7000 HIV-positive babies were born in South Africa who could have been born virus-free had their mothers been treated.

They also estimate that around a third of a million people in all died unnecessarily over these five years. People who might have lived had they got timely treatment with antiretroviral medication.

The terrible effects of this death toll, of course, go beyond the lives of those lost. In the Introduction of their paper, the authors note that:

Approximately 1.2 million children [in South Africa] younger than 17 years have lost one or both parents due to the [HIV/AIDS] epidemic”.

So what caused the Mbeki Government’s disastrousfailure? The authors of the study discuss one salient issue, that of the cost of the antiretroviral drugs, and conclude that this cannot account for the South African government’s actions. They could have afforded the programme, as their poorer neighbours ultimately did. The cost of the drugs has dropped dramatically over the last decade, largely due to pressure on the pharmaceutical companies from activists and campaigners – the real heroes of the hour – as well as from governments, NGOs and charities. So cost alone was unlikely to have been the decisive issue.

The South African government also chose to convince itself that the scientific consensus that HIV caused AIDS was uncertain.

One vehicle for this was Mbeki’s notorious Presidential Advisory Panel on AIDS in 2000. The Panel included Peter Duesberg and a bunch of other “HIV sceptics”, like Harvey Bialy and David Rasnick (the latter now seems to have fetched up working for the Dr Rath Health Foundation in South Africa).

As the British Medical Journal noted at the time:

“At least half of the Presidential Advisory Panel on AIDS, as the group is now known, are scientists and doctors who have disputed the orthodox views on AIDS. Many of these do not believe HIV causes AIDS.”

Unsurprisingly, the Panel rapidly split into two distinct groups; those who believed HIV was the cause of AIDS, and recommended rapid institution of retroviral treatment programmes along with public health measures; and those, like Duesberg, who denounced the HIV hypothesis and recommended (largely) public health measures alone. The Panel’s report, which can still be found online in full here (warning! – 1 MB PDF), makes bizarre reading; it is really two reports in one.

What appears nowhere in the report is any hint that the HIV sceptics, who were well represented and even in a majority on the Panel, were representative of a tiny – if vocal – minority of the scientists and doctors studying AIDS worldwide.

In a recent editorial, entitled “The Cost of Silence?” Nature suggests that the mainstream scientists and doctors might have done better to have refused to serve on the Mbeki Advisory Panel at all. Their participation, Nature says, led to the appearance in the Panel’s deliberations that there was a real scientific issue to be argued. The Panel’s report, in turn, presented this “dichotomy of views” – when really there was a massive preponderance of evidence, and expert views, on one side, and a lot of evidence-free fringe theorizing on the other. This appearance of an undecided issue gave the Mbeki government the fig-leaf it needed to state that the issue was still contested, and to stall on antiretroviral therapy programmes. While Nature does not state outright that it thinks the South African government had already made up its mind when it set up the Panel, the implication is clear.

Reading the Advisory Panel report, one can perhaps catch glimpses of why the “HIV is not the cause” case might chime with the thinking of some populist politicians. Since they had decided HIV was not the agent causing the AIDS epidemic, the “HIV sceptics” could instead call for progress on a long list of the kinds of things dear to politicians’ hearts:

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The recommendations listed below were proposed as necessary and sufficient to combat all the risk factors that are the real cause of AIDS:

1. Improving sanitation and public health measures to decrease water-borne diseases.

2. Strengthening health infrastructure.

3. Reduction of poverty and improving general nutrition and implementing nutritional education and supplements for the general population.

4. Improving screening for and treatment of sexually transmitted diseases.

5. Promoting sex education based on the premise that many sexually transmitted diseases and pregnancies could be avoided.

6. Implementing public education campaigns to destigmatise AIDS and reduce public hysteria surrounding the disease.

9. Treating infections vigorously and timeously (sic – possibly meaning “in a timely fashion”).

10. Increased support for and promotion of research into the development of drugs against AIDS, its cofactors and risk factors.

12. Implementing aggressive programmes to empower women and change the power relations between men and women.

13. Reducing the vulnerability of communities by improving access to health care.

14. Improving literacy.

[Presidential AIDS Advisory Panel Report: March 2001: pp 86-87].

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Now, none of these is a bad thing – far from it. Who could argue with any of it? All good stuff, and the “HIV causes AIDS” group on the panel said many of the same things in their recommendations.

But – and it is a very, VERY big “But”- these laudable measure were, sadly, just not what was needed as a first priority in the face of an unprecedented epidemic of a deadly but slow-acting viral disease. Or, at least, they were not enough, and never would be. They would do some good – but not nearly as much good as if they had been combined with an immediate and vigorous campaign of treatment with antiretroviral drugs.

There is also another side to the catastrophe, as noted by many commentators, including Bad Science’s own Ben Goldacre, and also the Harvard authors:

The South African government, through the Health Minister Manto Tshabalala-Msimang, …continued… to divert attention from ARV drugs to non-tested alternative remedies, such as lemon juice, beetroot, and garlic, sometimes even promoted as better alternatives and not supplements for AIDS treatment

Tshabalala-Msimang scores high on the infamy scales for me because she is, almost unbelievably, a medical doctor who trained in obstetrics and gynecology and later in public health. I am truly dumbstruck that a person with her professional background could have participated in such an orgy of delusion. Though if some of the stuff that newspapers in South Africa have printed about her is true (see e.g. here and here) it is pretty scary that she was a Minister in the first place.

Anyway, the quackery was doubtless not just Tshablala-Msimang’s idea; the promotion of alternative therapies was prominent in the recommendations of the HIV denier half of the Advisory Panel. The keen-eyed reader will have noted the omission of several numbered points from the list above. The missing ones are as follows:

———————————————————————————————–

7. Investigating the use of immune-boosting medications, such as interferons, growth factors, B-complex vitamins and herbs (such as ginseng, Chinese cucumber, curcumin, aloe vera, garlic and echinacea).

8. Encouraging the detoxification of the body through several inexpensive interventions, such as massage therapy, music therapy, yoga, spiritual care, homeopathy, Indian ayurvedic medicine, light therapy and many other methods.

11. Encouraging the involvement of complementary medical and health practitioners, including indigenous healers, in research and clinical fields.

(Italics mine)

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Following the embracing of this menu of delusion by the Mbeki government, Tshablala-Msmang enthusiastically promoted it – no doubt applauded by plausible nitwits, sorry, “Nutritionists”,  like Patrick Holford, and by the “Pope of Vitamins”, Dr med Matthias Rath. Both Holford and Rath have spent a lot of time in, and promotional effort on, South Africa these last eight years or so.

It does not take a genius to surmise that they would have seen a large market, full of often poorly-educated people, where their seductive nutritional remedies (“no nasty toxic drug side effects!”) would appear almost officially sanctioned.

Admittedly, the role of AIDS deniers, of alternative medicine idiots, and of vitamin pushers like Rath and Holford, are minor compared to the overwhelming responsibility of Mbeki, his Health Minister, and the rest of the President’s deluded inner cabal. But there is an obvious element of “toxic enabling” at work.Which suggests:

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A BadScience Formula:

Self-deluding scientifically illiterate politicians

+ vocal “skeptics of the scientific orthodoxy”

+ “traditional healing practices” enthusiasts

+ vitamin salesmen and Nutritionistas

+ endless ill-informed media reportage, especially of the previous three groups

= possibly catastrophic consequences

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Anyway, I would like to think that the next time dear old Patrick Holford says something mind-bogglingly dim like:

“[The retroviral drug] AZT is… proving less effective than vitamin C” [ in treating HIV]

– or the next time that Matthias Rath claims that modern medicine is a Pharma conspiracy to keep people sick – that someone will be there to remind them of just where their preferred nostrums and delusions can lead.

You might, for instance, like to ask Patrick:

“So can Vitamin C prevent mother-to-child transmission of HIV, the way that anti-retrovirals do?”

I would love to know what his answer would be.

Getting back to the paper, the authors’ conclusion is chilling:

“Access to appropriate public health practice is often determined by a small number of political leaders. In the case of South Africa, many lives were lost because of a failure to accept the use of available [antiretrovirals] to prevent and treat HIV/Aids in a timely manner.”

One can only hope that political leaders elsewhere have proper scientific and medical advisers. And that they can keep their minds free of the soothing claptrap peddled by the fans of Alternative Reality.

Although looking at the way that politicians in the UK these days persist in regarding CAM as purely an issue of consumer choice, with no health implications… sometimes I am not so confident

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Notes:

This post is not very original, and obviously owes a lot to Ben Goldacre’s coverage of the issue. Talking of which, word in the bookosphere has it that the revised edition of Ben’s Bad Science book, due out next Spring, will have an extra chapter devoted to Herr Dr Med Matthias Rath, in which the learned Herr Doktor’s South African activities can presumably be expected to feature prominently.

Another good guide to the history of the South African HIV denialism catastrophe is the Skeptical Inquirer article by South African economics Professor Nicoli Natrass.

Finally, a longer and more scholarly article written earlier this year by Prof Nattrass for the journal African Affairs, can be found here. It includes an earlier estimate of the human cost of Mbeki’s policies, broadly similar to the Harvard study’s conclusions. This article also has a section (pp 169-171) dealing with Rath and other peddlers of “nutritional solutions”, and their relationships with Tshabalala-Msimang.

[BPSDB]


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