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AIDS

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AIDS Is Not Over

Four years ago optimism was high that AIDS was in retreat, and could ultimately be eradicated. Back then the Joint United Nations Programme on HIV/AIDS (UNAIDS) was boldly predicting “the end of AIDS by 2030.” Nobody is feeling that optimistic now.

New HIV infections, after dropping steadily for the ten years to 2005, more or less stabilised at 2 million a year in the last decade, and the annual death toll from AIDS has also stabilised, at about 1.5 million a year. But the future looks grimmer than the present.

Two-thirds of all HIV-positive people (24 out of 36 million) are in Africa, and an even higher proportion of the AIDS deaths happen there. If it were not for Africa, the predictions of four years ago would still sound plausible. So what’s wrong with Africa? Two things: it’s poor, and there are “cultural practices” that facilitate the spread of the HIV virus.

The great achievement of the International AIDS Conference that was held in Durban sixteen years ago was to break the grip of the big pharmaceutical companies on the key drugs that were already making HIV-positive status a lifelong nuisance rather than a death sentence in other parts of the world. Unfortunately, the drugs were so expensive that the vast majority of Africans simply could not afford them – so they died instead.

In a diplomatic and media battle that lasted for almost a decade in the late 1990s and early 2000s, African countries managed to shame the big pharmaceutical countries into accepting the importation of much cheaper “generic” versions of the main anti-retroviral drugs, mainly from Brazil, India and Thailand, for use in poor African countries.

The Western drug companies not only dropped their collective lawsuit against the South African government in defence of their patents. Some of them even began providing their own patent drugs to the African market at one-tenth or even one-twentieth of the price they charged elsewhere. A widely used course of treatment that cost $10,000 a year in the US at the time became available to Africans at a price of about $100 a year.

Many HIV-positive Africans could not even afford that amount, but Western governments and private foundations also began providing major funding for anti-HIV programmes in Africa: $8.6 billion in 2014. (80 percent of the money comes from the United States and the United Kingdom)

Even today half of Africa’s HIV-positive population is not using the basic cocktail of anti-retroviral drugs on a regular basis. There is still a stigma attached to having the virus, and many of the non-users who have been diagnosed as positive don’t go the clinics to collect their drugs because it involves standing in line and being seen by people they know.

The continent’s death rate from AIDS went into a temporary steep decline, but it is now heading back up for a number of reasons. The main one is that resistance to the standard mix of drugs has grown into a major problem.

The second-line treatment, using newer drugs that are still available at the “African discount”, costs $300 per person per year – and resistance is also apparent in 30 percent of those cases. The third-line or “salvage” treatment costs $1,900 a year even in Africa. The governments can’t afford it, and very few Africans have medical insurance.

Drug resistance has been growing in the developed world too, of course, but the solution there is to move HIV-positive people onto newer combinations of drugs that are far more expensive. The cost of treatment in the US today can be higher than $20,000 a year, and not one African in a thousand can afford that.

African governments will probably have to wage another long diplomatic and media battle to access generic or cut-rate versions of the best new drugs. In the meantime, a great many people will die. And this is happening just as the amount of funding from Western sources for anti-HIV programmes in Africa has gone into decline: donations last year were down by almost one billion dollars.

The other specific reason for sub-Saharan Africa’s much higher rate of HIV infections is “cultural”. What that means, in plain English, is that sexual traditions are different there: pre-marital and extra-marital sex is commonplace. Moreover, older men often exploit their relative wealth and power to have unprotected sex with many young women and girls.

This may explain why in southern Africa, uniquely in the world, 60 percent of new HIV infections are among young women. And it is striking that HIV infection rates are far lower in those parts of the continent that have been Muslim for many centuries – or Christian for many centuries, like Ethiopia – and where the sexual rules of engagement are therefore much stricter.

The situation in sub-Saharan Africa is almost bound to get worse, not better, because the 15-24 age group, the most likely to become infected, is growing explosively fast. They number about 200 million now, but that will double to 400 million by 2040. Africa has long been the world capital of HIV and AIDS, and it will remain so for the foreseeable future.
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To shorten to 725 words, omit paragraphs 8 and 14. (“Even…know”; and “This…stricter”)

Zika: Don’t Panic

Zika, the mosquito-borne virus spreading through the Americas that has been linked to thousands of babies born with underdeveloped brains (microcephaly), is just the latest new disease to spread panic around the world. And wait! News just in that it can be sexually transmitted too!

There is real cause for concern here. The virus is almost bound to spread to the rest of the world, except those parts with winters severe enough to kill off the two species of mosquito that bear it, Aedes aegypti and Aedes albopicti. And these mosquitos are active during the day (unlike the Anopheles mosquitos that spread the malaria parasite), so insecticide-treated bed nets don’t offer much protection.

The World Health Organisation has declared a global public health emergency, and the media panic is building: first AIDS, now this. We are too many, we travel too much, and new pandemics are Nature’s retaliation for our many sins. Clearly the apocalypse is upon us.

Well, no, actually. New diseases have been devastating human populations for at least three thousand years, but no modern pandemic compares with the Antonine Plague of the 2nd century CE, the Justinian Plague of the 6th century, or the Black Death of the 14th century, each of which killed between a quarter and a half of the populations affected.

The worst pandemic of relatively modern times was the “Spanish Flu” outbreak of 1918-19, which killed between three and five percent of the world’s people. It was bad, but it hardly compares with the older plagues.

The slow-moving Aids epidemic has killed about 30 million people since the 1980s, or less than half of one percent of the world’s current population. Two million people died of AIDS in the peak year of 2005, but the number of deaths in 2015 was only 1.2 million. New infections are also falling.

And Zika? So far as we know, it doesn’t kill anybody – apart from some of the microcephalic babies, about a quarter of whom die because their brains are too small to control their bodily functions. The majority, who do survive, face intellectual disability and development delays

Four-fifths of the adults who are infected experience no symptoms whatever, and the fever in those who do usually burns out in less than a week. Nor does the Zika virus remain in the body permanently: women who have been infected are advised to wait six month before becoming pregnant (although many will probably choose to wait longer).

Zika has been around for quite a while. It was first identified in monkeys in Uganda in 1947, and the first human case was detected in Nigeria in 1954. It gradually spread east across Asia, and started crossing the Pacific early in this century. But by the time it reached Brazil last year, it had suddenly mutated into a form that causes microcephaly in some of the babies of infected mothers.

The link between Zika and microcephaly is only statistical for the moment, but it is pretty convincing. Brazil had only 150 cases of microcephaly in 2014, but it has had more than 4,000 cases in the past four months, and the Zika virus has been found in the brains of some of the afflicted babies.

This recent mutation in the Zika virus is not part of the endless seesaw battle between viruses and human immune systems. It is just a random event. It doesn’t even make Zika more infectious and thereby serve the “purposes”, so to speak, of the virus. It just has this deeply unfortunate side-effect of damaging the development of human embryos. And these days we have ways of dealing with it.

Infectious diseases were probably not a problem for our pre-civilised distant ancestors, but since we began living in dense populations highly infectious diseases have been civilisation’s constant companions. And for most of our history we had no way of controlling these diseases except quarantine.

In the past century, however, science has begun to get on top of the problem. Killer flu epidemics are still possible because the highly unstable influenza virus can mutate faster than we can create and mass-produce the appropriate vaccine, but smallpox has been eradicated and polio is on the brink of extinction: new polio cases have fallen 99 percent in the past 25 years, and Africa is now entirely polio-free.

Even the ancient scourge of malaria (not a viral disease) is in retreat. Deaths from malaria have halved in the past fifteen years, and the new “gene-drive” technology opens up the prospect of eventual eradication of the disease

Now that Zika has become a problem researchers have started working on a vaccine, and in due course one will almost certainly become available. Another approach may be to target the species that propagate it by releasing genetically modified sterile mosquitoes to reduce the size of the insect population. It will take time, and it may be necessary to use both approaches, but we are not facing a permanent global threat.

The glass is not half-empty. It is half-full, and still filling up.
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To shorten to 725 words, omit paragraphs 9 and 10. (“The link…with it”)

The Fat and the Starving

18 August 2006

 The Fat and the Starving

By Gwynne Dyer

Being fat is the new normal, but it won’t last. The global surge in overweight people is concentrated among lower-income city-dwellers, and some may choose to slim down as they climb further up the income scale. (“You can never be too rich or too slim.”) But the real guarantee of a slimmer world, unfortunately, is climate change.

“Obesity is the norm globally, and under-nutrition, while still important in a few countries and in (certain groups) in many others, is no longer the dominant disease,” said Dr. Barry Popkin of the University of North Carolina this week at a conference in Queensland, Australia. Dr Popkin studies “nutrition transition,” the changes that accompany the shift from a traditional rural diet to a modern urban diet, and he has concluded that thanks to high-speed urbanisation, the fat now outnumber the starving.

We have grown accustomed to Americans who look almost perfectly spherical, and we are seeing more and more Europeans who seem to aspire to the same goal. Popkin’s point is that this is not due to some moral failure in the American and European populations, but to the changes that come with urbanisation: higher incomes, mass marketing of processed foods, and work patterns involving much less physical labour. His proof is that the rates of obesity in developing countries undergoing rapid urbanisation are rapidly catching up with the levels in the rich countries.

Mexicans of all ages and both sexes are now on average as fat as Americans. In Kuwait, Thailand and Tunisia, 25 to 50 percent of the population are suffering not only developed-world levels of obesity, but also similar plagues of “non-communicable” obesity-related diseases like diabetes and heart failure. South African and Egyptian women are as fat as American women (although their men lag behind their American counterparts).

In some places, specific local factors play a role as well. In much of Africa, for example, fatness in women was traditionally seen as testimony to the wealth and generosity of their husbands, and recent research in South Africa has revealed a new, additional factor: the fear that being slim will make people think you have AIDS.

Half of all women in South Africa are overweight, compared to only a third of South African men, and the problem is particularly acute among black women, one-third of whom are clinically obese. “Regretfully,” says Tessa van der Merwe of the International Association for the Study of Obesity, “there is a perception that if a black woman is thin, she might have HIV/AIDS or that her husband can’t afford to feed her well.” So South Africans, with far lower average incomes than Americans, are only 20 percent less overweight than people in the United States, generally conceded to be the world’s fattest country.

But the shift in dietary patterns and the consequent rise in obesity among the urban population affect the great majority of lower- and middle-income countries in Asia, the Middle East, Africa and Latin America. Moreover, this is happening at a much earlier point in the economic and social development of these countries than was the case in the “old rich” countries.

The typical pattern in nineteenth-century Europe was that the high-income groups put on weight first. (Think of the stereotypical cartoon plutocrat — he’s always fat.) Only much later, when cheap fats and sweeteners became generally available to the working class, did the urban poor start to bulk up as the rich slimmed down. But this pattern is now kicking in at a point in countries’ development where malnutrition is still widespread.

In urban Brazil, for example, the poor are now on average significantly fatter than the rich, even though the same slum households may also still contain some malnourished people. Urban adults in China and Indonesia are twice as likely to be obese as rural adults. In the Congo, city-dwellers are SIX times likelier to be fat.

It’s not a pretty picture — a world full of Michelin men and women — but the alternative is worse: a world of very hungry people. And the alternative, alas, is far more likely by the end of this century.

Cheap and plentiful food for the urban masses of a multi-billion-population world is an astonishing achievement, but it is probably in its last few decades. Most of the world’s great fisheries are nearing collapse due to overfishing and pollution, and a couple have already died (like the Grand Banks off Newfoundland). More worrisome still is the likely impact of global warming on the great agricultural regions that feed most of those billions of people, like the Chinese river valleys, the American Midwest, and the north Indian plain.

A couple of years ago Dr Jyoti Parikh, director of IRADe (Integrated Research for Action and Development), a New Delhi-based NGO, did a detailed study for the World Bank about the probable effects on Indian agriculture of a two-degree (Celsius) rise in average temperature. The impact was different for different regions of the country, of course, but she concluded that overall Indian food production would be about one-quarter less than at present.

The world is probably going to get considerably hotter than that, and most of the other great bread-baskets of the world will be similarly affected. Obesity is not our long-term problem.

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To shorten to 725 words, omit paragraphs 6 and 9. (“Half…country”; and “In urban…fat”)

The South African Succession

10 May 2006

The South African Succession

By Gwynne Dyer

You couldn’t make it up. Former South African deputy president Jacob Zuma, defending himself in court against a charge of rape, explained that the woman who brought the complaint, a family friend less than half his age (she is 31, he is 64) who was staying in his home, had signalled that she wanted to have sex with him. How? By wearing a knee-length skirt and sitting with uncrossed legs. So what was a gentleman to do?

If the woman truly wanted to have sex with him, Zuma pointed out, then the rules of Zulu culture obliged him to oblige her. Not to have done so when she so clearly wanted it would, by the rules of Zulu culture, have been tantamount to raping her. In other words, he had to have sex with her in order not to rape her.

Indeed, so great was Zuma’s desire to do the right thing that he had unprotected sex with her despite the fact that she is an AIDS activist who makes no secret of the fact that she is HIV-positive. There was no condom handy, he explained, and “everybody knows” that men don’t often get the HIV virus from women, and besides, he had a shower afterwards.

Jacob Zuma has had no formal education, but he is not generally seen as a stupid man. Perhaps he really believes that heterosexual men who take showers are safe from AIDS (despite the fact that he was married for almost two decades to a medical doctor who ended up as minister of health). Or perhaps he is secretly HIV-positive himself, and so he doesn’t give a damn. We’ll never know, because the prosecutor didn’t demand a blood sample from him.

Her only justification for doing so would have been that he had recklessly endangered the health of another person (which could lead to a life sentence). But it wouldn’t have led to a stiffer sentence in Zuma’s case even if he had been convicted, since the woman he was accused of raping was known to be HIV-positive already.

In the end, on 8 May, Zuma was found not guilty by the judge, Willem van der Merwe, who explained his decision by saying that “it would be foolish for any man with a police guard at hand and his daughter not far away to surprise a sleeping woman and to start raping her without knowing whether she would shout the roof off.” Van de Merwe added that the alleged victim “has a history of making false accusations of rape.”

This history was helpfully provided by a string of defence witnesses who claimed to have been accused of raping or trying to rape the complainant, though she mostly denied knowing them. They did not face strict cross-examination, however, since by the rules of the court (not to be confused with the rules of Zulu culture) if she denied knowing them, there was no more to be said. Just choose to believe them or to believe her. The judge believed them.

Zuma emerged from the court to be greeted by the usual mob of cheering, mostly Zulu supporters, and joined them in a rousing rendition of “Awulethu Umshini Wam” (Bring Me My Machine-Gun). And although he still faces a further and quite separate trial on corruption charges in July, it already feels as if he is back on track as the leading contender for the presidency of South Africa when Thabo Mbeki retires in 2009. Goodbye “rainbow nation”, hello Zimbabwe South.

Jacob Zuma was a real hero in the anti-apartheid struggle. He spent ten years imprisoned on Robben Island and almost twenty years in exile, ending up as the Chief of the Intelligence Department of the African National Congress. As the highest-profile Zulu in an organisation whose leadership has been dominated by Xhosas (including both Nelson Mandela and Thabo Mbeki), his ascent to the posts of deputy president of South Africa and deputy leader of the ANC was swift and smooth. The problem is that he is a ruthless demagogue and, in many people’s eyes, a crook.

Last June Zuma’s financial adviser, a Durban businessman called Schabir Shaik, was sentenced to fifteen years in prison for corrupt dealings in connection with the government’s purchase of warships, a proposed waterfront development in Durban, and lavish spending on Zuma’s residence in Nkandla. The trial judge described the relationship between Shaik and Zuma as “generally corrupt”, Mbeki asked for his resignation as vice-president, and he was committed for trial this July on corruption charges.

His supporters on the left of the ANC and his devoted Zulu followers claim that the rape charge was further evidence of a plot to thwart Zuma’s presidential ambitions, but it was actually an unfortunate coincidence. The case had little chance of success (the vast majority of accused rapists in South Africa go free), but it was a huge distraction from the corruption issue, and his exoneration on the rape charge will cast doubt in the public’s mind on any subsequent conviction for corruption. So Zuma may really be back in business, with a good shot at the succession when Mbeki retires in 2009.

That would not be happy news for South Africa.

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To shorten to 725 word, omit paragraphs 4 and 5. (“Jacob…worse”)