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April 2, 2003

THE CRIME OF ASKING QUESTIONS AT AN AIDS PANEL DISCUSSION

By David Crowe

I almost got arrested for the first time in my life a few nights ago. My crime? Asking questions and pointing out speakers' errors at a panel discussion organized by the University of Calgary Global AIDS Action Group (GAAG).

It certainly isn't very Canadian to be so forward. I should have waited until question time, and then asked one question, maybe two, but only after complimenting the speakers for their erudition. But, I did not come to the panel discussion to be a polite Canadian. I suspected that the panelists would all fall over themselves agreeing with each other, and all would repeat dogmatic assertions about HIV and AIDS without contradiction from within or outside of the panel. The student moderators would be unfailingly polite and respectful, and everyone would go away believing that they could play a small part in mitigating an enormous medical tragedy. Well, I was right, except that possibly some members of the audience did actually leave with some nagging questions about HIV/AIDS.

I very much appreciated the irony of using tactics of civil disobedience against a group which probably would enthusiastically support the use of similar tactics against the military, multinational corporations and against government suppression of dissent Yet, these same people unquestioningly support a model of disease that makes billions of dollars in profits for multinationals.

My aim was not to interact with the panel or the moderators, to persuade them that there were holes in their knowledge, or flaws in their base of factoids. I only challenged them as a way to expose the audience to some alternative views. Hopefully by challenging the panelists with science-based evidence, I thought I could make the audience see that there was another side. I had no power or desire to impose my views, but I was not going to allow the one-sided affair to proceed as planned.

I allowed the first speaker, Le Ann Dolan of AIDS Calgary, the local HIV/AIDS service organization to speak for about five minutes about the burgeoning AIDS epidemic in Canada before interjecting my first question. "How many new AIDS cases were there in Canada last year?" She stopped, looked puzzled, and did not answer. I asked this question because I knew that the audience would be shocked to find out that there were only 221 new cases of AIDS diagnosed in 2001 (2002 figures are not available yet). And, that is no anomaly, the case count has declined every year from a peak of 1,759 in 1993 [LCDC, 2002] Now it is true that Health Canada will probably manage to double the number of 2001 cases by the next report, as they do most years, although they have never explained to me how their surveillance system can be so lousy that it takes over a year to report most cases (and I have asked). But even 450 cases in one year is probably far fewer than most in the audience would have guessed. The rarity with which the easily available annual case figures are reported in the media and at talks like this illustrates the power of misinformation by omission.

Le Ann continued for a while, emphasizing the danger of HIV to Canadian women and aboriginals and claimed, at least for women, that female cases were rising. This is an oft-repeated falsehood, encouraged by government reports that emphasize the percentage of total cases, not the actual number. The percentage of cases among women has admittedly risen from 7% in 1992 to 19% in 2001, but far more importantly, the total number of female cases has declined from a peak of 138 in 1994 to only 34 new cases in 2001. [LCDC, 2002]

Even in the annual Health Canada surveillance report, tricks with percentages are still used. Figures graph the percentage of cases in a number of categories, without reference to the actual number. The graphs give the impression of increasing epidemics in some categories with decreases in others. But, because the percentages always add to 100%, obviously you cannot have declines without exactly offsetting increases. This supports the categorization of a still flaring epidemic, unlike the actual number of cases, which are declining to ever more trivial numbers in all categories.

It would be interesting to compare the total number of new AIDS cases among women every year against the number of AIDS service organizations for this group. I suspect that the number of organizations long surpassed one per new annual victim.

At this point Sarah Stewart, the student organizer came over to me, shook my hand, looked me in the eye and with studied calmness addressed me by my name, asking me to stop interrupting the meeting. I was a bit surprised to hear myself say that I had no plans to do that, but if the speakers made errors I would continue to ask questions or make comments to combat the misinformation that was being spread.

Sarah returned to the other side of the room and had a hurried tête à tête with one of the other panelists, Dr. Don Ray, who was soon on the phone. I knew full well what he was doing. Shortly after, I turned around to verify that campus security had been called, and was a bit surprised to see two uniformed police officers standing in the back of the room.

Louise Lambert of the Women's Working Group on AIDS was now speaking about vaginal microbicides. I was trying hard to find something to disagree with, but she carefully went through a content-free presentation (I exaggerate, but only a bit). She did not mention any microbicides by name. I was hoping that she would mention Nonoxynol-9, because that one has been an utter failure. [Kreiss, 1992; Van Damme, 2002; Wilkinson, 2002] She did not report any successes (which I believe is correct). She did not promise anything really, except that more research might result in a vaginal microbicide that works against HIV and AIDS. Her main point seemed to be that if this technology could ever be made safe and effective, it would give women more control over the method of protection from HIV.

Unlike the speaker from AIDS Calgary, Lambert provided no specifics for me to push back against, so I remained quiet. Perhaps because of this, or perhaps because the next speaker announced that his presentation would be a slide show of his recent trip to Africa, the policemen left the room.

Dr. Ray's slides illustrated how grass-roots organizations of women in Ghana are looking after the so-called AIDS orphans. There was not much to criticize here, as any initiative to care for orphans is something that would be hard to argue against, and Dr. Ray did not provide any specifics on how it was determined that the parents had AIDS. I did later describe the World Health Organization's 'Bangui' definition of AIDS [WER, 1986] which is still used (with minor variations) to diagnose AIDS in Africa. No HIV test is required (and no HIV test is usually performed). All that is required is 3 of the following 4 symptoms: persistent cough, persistent fever, persistent diarrhoea and weight loss (greater than 10% of total body weight). A definition that stands in stark contrast with the US definition which allows the diagnosis of AIDS with no illness, just a low CD4 immune cell count (in almost 2/3 of cases according to the last published statistics) in combination with a positive HIV test. [CDC, 1998]

Finally, the three presentations were over, and it was question time. I assumed that now I could ask questions without fear of imprisonment. The moderator did her best to ensure that I didn't dominate the question period, looking desperately around the room for a raised hand from anyone but myself. Luckily for me, and unluckily for her, other questions were sparse.

I challenged Dr. Ray on his statement that clean needle programs are known to decrease rates of HIV infection. A study from Montreal, for example, shows spectacularly the opposite - exclusive clean needle users were 10-22 times more likely (depending on how the numbers were adjusted) to be HIV-positive than those that never used clean needle exchanges [Bruneau, 1997]. Those who sometimes or usually used the exchanges had intermediate levels of risk. I noted that similar, although not as dramatic results were found in Vancouver [Strathdee, 1997] and in Seattle against HIV, Hepatitis B and C [Hagan, 1999]. A female student from the audience challenged me on this, asking how IV drug addicts could be trusted to give accurate information. That was quite perceptive, although it is hard to see how normal lying could lead to these results. The majority of addicts would have had to give answers that were the opposite of the truth, in order to explain these results, which seems quite unlikely. The student would have done better to challenge me on whether the Seattle study really included an HIV arm. It did not; it only studied Hepatitis B and C.

I was challenged by the audience on a number of statements that I made. A few just felt that I was being rude interrupting the meeting, but some, such as on the issue of needle exchanges, wanted to challenge my data. One male student scoffed at my claim that there have been no studies that have shown adverse health outcomes from breastfeeding by HIV-positive mothers. "So what", he claimed, "better to be safe than sorry". A statement that shows such tremendous ignorance of the millions of children around the world who die from the adverse effects of formula (or alternatively, the billions of people around the world who are alive because they were breastfed) that it left me speechless for a moment.

The most important argument that I put forward in the context of this meeting was the challenge to the belief that HIV in Africa is heterosexually transmitted. Four papers recently published in the International Journal of STDs and AIDS (Brewer, 2002; Gisselquist, 2002; Gisselquist, 2003a; Gisselquist, 2003b) challenge this notion, estimating that instead of explaining 90% of HIV transmissions, heterosexual intercourse only explains 25%-29% of cases. The authors argue that most of the rest are caused by unsafe medical injections.

This is so critical because the panel basically supported a feminist model of AIDS, with women being the victim of sexual aggression by men, with HIV being transmitted as a side effect. Dolan related the story of an HIV-positive man whose wife had died of AIDS, who felt that he had a right to a woman to satisfy his needs, regardless of the fact that his HIV might kill her too.

The AIDS Calgary representative implied that women were being harder hit in Canada than men, something that is still patently false (although not as false as the statement would have been a decade ago). The 34 female cases of AIDS in 2001 are still significantly outnumbered by the 183 male cases. Louise Lambert from the Women's Working Group on AIDS focused on vaginal microbicides as a way to allow women to protect themselves against HIV in a culture where men are often unwilling to use condoms. She only vaguely hinted at the possibility that these chemicals might prove to be not only ineffective, but also toxic. The only man on the panel, Dr. Don Ray, a professor of political science, documented the empowerment of women in Ghana.

This feminist argument relies on heterosexual intercourse being the main means of transmission of HIV. Without this, the connection between sexual power politics and AIDS falls apart. The argument has two other weaknesses as well. It portrays men as incapable of love and fidelity, stereotyping them as interested only in satisfying their own lust, with no concern for women. Women on the other hand, are portrayed as sexually passive, as incapable of being sexually irresponsible or adventurous as men are of being responsible. Ultimately, it is a very Victorian view of both genders.

But a larger problem is the unspoken, racist, dark side to this view. If all men were like this, then AIDS should be evenly distributed around the world, not just in Africa. Consequently, a corollary of this argument is that it is largely black men who are insatiable sexual predators.

The meeting organizer, Sarah Stewart, challenged me when I mentioned these recent papers on heterosexual transmission. She had, she noted, recently talked to a professor, who had read one of the papers, and concluded that the authors were not really saying that heterosexual transmission was not the major cause of HIV transmission, just that its impact had been over-emphasized. Obviously, the professor had not read the papers.

Acceptance of third or fourth hand information, is a form of intellectual laziness that allows the widespread acceptance of current dogmas about HIV and AIDS. It was clear that only one member of the panel (Dr. Ray) had even a passing acquaintance with scientific literature on HIV and AIDS. Yet, the panelists, the organizers and some members of the audience had no trouble staunchly defending their beliefs, while being equally unable to produce any verifiable evidence.

This meeting illustrated to me how the AIDS dogma is reinforced at the very lowest levels of the scientific hierarchy. By repeating the same information over and over again, without fear of contradiction, meetings such as this one reinforce through repetition. Information flows through the system like a waterfall, always in one direction, and without barriers.

People who attend these meetings do care about the world, probably much more than average. Consequently, beliefs about AIDS have to be wrapped in a rhetoric that will appeal to them. The story that people are dying in Africa because men are irresponsible, and women need to be more empowered, is an attractive idea. None of these people would have likely attended if the panel spoke directly of how black men are sexually irresponsible. Yet, this is the racism underlying the feminist sugar-coating.

The people attending would all probably have labeled themselves as curious, thinking, scientific and skeptical. Yet there appeared to be a deliberate avoidance by panel members, organizers and the audience of the tough job of actually reading scientific papers, discussing them with others, reading commentaries on them, comparing opposite viewpoints, and most importantly making up their own minds.

Further Reading:

[Brewer, 2003] Brewer DD et al. Mounting anomalies in the epidemiology of HIV in Africa: cry the beloved paradigm. Int J STD AIDS. 2003; 14: 144-7.

[Bruneau, 1997] Bruneau J et al. High Rates of HIV Infection among Injection Drug Users Participating in Needle Exchange Programs in Montreal: Results of a Cohort Study. Am J Epidemiol. 1997; 146(12): 994-1002.

[CDC, 1998] HIV/AIDS Surveillance Report (through December 1997). CDC. 1998; 9(2).

[Gisselquist, 2002] Gisselquist D et al. HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission. Int J STD AIDS. 2002 Oct; 13(10): 657-66.

[Gisselquist, 2003a] Gisselquist D et al. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS. 2003; 14: 148-161.

[Gisselquist, 2003b] Gisselquist D et al. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD AIDS. 2003; 14: 162-73.

[Kreiss, 1992] Kreiss J et al. Efficacy of nonoxynol 9 contraceptive sponge use in preventing heterosexual acquisition of HIV in Nairobi prostitutes. JAMA. 1992 Jul 22/29; 268(4): 477-82.

[LCDC, 2002] Laboratory Centre for Disease Control. HIV and AIDS in Canada: Surveillance Report to December 31, 2001. Health Canada. 2002 Apr.

[Strathdee, 1997] Strathdee SA et al. Needle exchange is not enough: lessons from the Vancouver injecting drug use study. AIDS. 1997 Jul 11; 11(8): F60-5.

[Van Damme, 2002] Van Damme L et al. Effectiveness of COL-1492, a nonoxynol-9 vaginal gel, on HIV-1 transmission in female sex workers: a randomised controlled trial. Lancet. 2002 Sep 28; 360: 9338.

[WER, 1986] WHO/CDC case definition for AIDS. WER. 1986 Mar 7; 61(10): 69-76.