|
Historical Interviews
This issue of the Epi Monitor is
a special double issue featuring an interview with Jonathan
Mann describing recent developments in the global AIDS
epidemic and providing a comprehensive review of the World Health
Organization’s activities over the past year. Dr. Mann is currently
head of WHO’s Special Programme on AIDS, and will be familiar to our
readers as the former editor of our MMWR Recap feature.
The interview is remarkable
because of the clarity of thought and expression that is in evidence
throughout. It makes for highly recommended reading and is reproduced
here in its entirety.
Epi Monitor:
What is the global overview of the AIDS pandemic as it stands now?
Mann: When we
take a look at the AIDS problem worldwide, we can actually distinguish
three separate epidemics which are related to each other and which
have followed each other.
The first epidemic is the
worldwide epidemic of infection with the human immunodeficiency virus
(or HIV), called the AIDS virus. We don’t know where the AIDS virus
started and we may never know. But we do know it was already causing
infections in people in several parts of the world by the mid-1970s.
Since then, the AIDS virus has probably spread to every country. And
even though in some countries there has been little or no effort to
determine whether the virus is present, wherever the effort is made
the virus is usually found.
The second epidemic is the
epidemic with AIDS itself and diseases associated with the virus. In
most infectious diseases, we think of days or weeks between the time
the person is infected and the time he or she develops the disease. We
don’t know how long the AIDS incubation period may ultimately be in
some people. But since we are talking about the possibility of years
you can see that the epidemic of infection will be followed several
years later by an epidemic of the diseases the virus causes,
particularly AIDS.
When AIDS was first recognized
in the United States in 1981, it was also already occurring elsewhere
in the world. The worldwide epidemic of HIV infection started in the
mid-1970s and the epidemic of the disease started in the late 1970s or
early 1980s in various parts of the world. One distinction that we
often make is between an epidemic and a pandemic. A pandemic is an
epidemic affecting multiple continents. So you’re really talking, as
we are with AIDS, of a pandemic, a worldwide problem.
The third epidemic is the
epidemic of reaction and response to the first two epidemics: in other
words the cultural, social, economic and political impact of AIDS.
This impact is very widespread and even involves areas not yet
strongly affected by the virus or the disease.
In any event we must consider
all three epidemics together because we cannot begin to control this
problem if we don’t understand the virus, the disease and the social,
political, economic, and cultural context in which the disease is
occurring.
Epi Monitor:
What is the situation as it exists right now as far as the number of
(reported) cases of AIDS is concerned, and how rapidly is that number
increasing?
Mann: As of
December 1987, there were over 66,000 AIDS cases reported officially
to WHO from more than 125 countries. But that number is not accurate
because there remain many barriers to the diagnosis, recognition and
reporting of diseases in the world. Even in countries like the United
States with its very highly developed AIDS surveillance network, an
estimated ten percent of the AIDS cases are not reported to the
national government. In some countries, particularly in the developing
world where the tools to make a firm diagnosis or a disease reporting
infrastructure may be lacking, the reported number of cases may
represent only a small fraction of the actual total.
Therefore, we estimate that
rather than 66,000, between 100,000 and 150,000 cases of AIDS have
probably occurred since the beginning of the epidemic. And the number
may actually be higher. More important, though, is that over three
quarters of the world’s countries have reported cases of AIDS. The
fact that nearly 160 countries are publicly recognizing and speaking
of their AIDS problem is testimony to the increased openness
characterizing the international scene. A little over a year ago, only
about sixty countries reported cases to WHO. The increase does not
mean that AIDS has spread to sixty new countries in the course of the
past year. Rather, it means there has been an epidemic of openness, if
you will, and that is indeed something we at WHO have been working to
improve. We all need to know this information, and a country that
hides its AIDS cases is hurting both itself and the international
community.
Epi Monitor:
How difficult, in fact, is it to determine the real number of persons
infected with the AIDS virus worldwide?
Mann: One of
the questions we often ask is how many infected people there really
are. The reason we don’t know is because we can only know what
individual countries can tell us. There is no country in the world
today, including the United States, France, Sweden, and the United
Kingdom, with a really accurate estimate.
Nevertheless, despite these
difficulties we would broadly estimate that from five to ten million
people are infected with the AIDS virus today worldwide. If that is
true--and that is an if--then we could predict the number of new AIDS
cases that are likely to occur in the next five years. This is because
studies in various parts of the world suggest that between 10 percent
and 30 percent of HIV-infected people will develop AIDS over a period
of five years. If that’s true through- out the world, and there are
five to ten million people infected today, we could estimate that
between 500,000 and three million new cases of AIDS will emerge over
the next five years from people already infected with the AIDS virus.
If this estimate holds true, there will be anywhere from ten to thirty
times more AIDS cases in the next five years than there have been in
the last five years. So we are imminently facing a large number of
AIDS cases regardless of whether we are stopping the further spread of
the virus.
Epi Monitor:
There has been a debate in the industrialized world over whether the
AIDS virus infection will ‘break out’ of high-risk groups like
homosexuals and intravenous drug-users into the heterosexual
community. Some say this fear is overdone. Based on your knowledge of
global patterns, what do you think?
Mann: I think
it’s important first to get back to the basic science and epidemiology
of AIDS. The virus spreads in three ways: sexually, through contact
with blood, and from infected mother to child. As far as sexual
transmission is concerned, first, this is the major mode of spread
throughout the world, and second, there is probably as much or more
heterosexual transmission of AIDS worldwide as there is homosexual
transmission of AIDS. AIDS can be transmitted from any infected person
to his or her sexual partner through sexual contact.
The second mode of spread, blood
exposure, primarily involves ways in which blood is injected into
people. Specific examples of this kind of transmission include
transfusions of blood which hasn’t been screened for HIV. This also
includes intravenous drug-users who may share needles and syringes
without sterilizing them between each use. And it can include needles,
syringes or other skin-piercing instruments used for medical,
paramedical, cosmetic or ritual purposes in the developing world if
they are not discarded or sterilized carefully after each use.
The third mode of spread from
mother to child involves women who are infected and who become
pregnant. These women can infect their child before, during, or
shortly after birth.
Reviewing the global situation,
we can distinguish three broad patterns of infection. The first
pattern, typified by North America, Europe, Australia, and New
Zealand, involves areas where the virus has been present for several
years and where the major groups infected are homosexual and bisexual
men and intravenous drug-users. Of course, in these areas there are
also people who acquire the virus through heterosexual contact.
The second pattern is typified
by Africa and Haiti. There, the major mode of spread appears to be
heterosexual from man to woman and from woman to man. There are very
few intravenous drug-users but the virus can be spread through
non-sterile injection equipment for example, either in medical care of
among traditional healers. In Africa, blood may not be screened so it
is possible to get infected from a transfusion. And, finally, because
an equal number of women and men in Africa are infected, spread to
infants also occurs much more frequently.
The third pattern is what we
might call an Asian pattern. In these parts of the world the virus is
still relatively rare. There are infections with the virus, many of
which have resulted from exposure to blood or blood products from the
industrialized countries, or occur in people who have had sexual
contact with men or women from countries where AIDS is more prevalent.
Thus, these different patterns reflect at least three factors: where
and when the virus entered into the population, and the influence of
social practices. For example, it seems clear the virus has only
entered the Asian population relatively recently, compared with the
United States, Europe, South America, or Africa.
So, AIDS is already spreading
heterosexually in the industrialized world. How fast, nobody can say.
Individual cases clearly show the potential for heterosexual spread
and our experience in other parts of the world suggests that
heterosexual transmission can be just as efficient as homosexual
transmission. We don’t expect a major epidemic in North America and
Europe among heterosexuals in the next few years, but it is terribly
important to take steps now to prevent such an epidemic which could
indeed happen.
Epi Monitor:
How do you see WHO’s role at this point, how is it evolving and what
are your goals?
Mann: As soon
as it became clear in late 1983 and 1984, that AIDS was a worldwide
problem, and particularly as further information was developed in
1985, WHO began holding preliminary meetings and discussions to
determine how it could be most useful in confronting this new
epidemic. By early 1986, it was clear that a WHO programme on AIDS
would be useful and a small unit was set up in WHO headquarters in
Geneva. On February 1, 1987, the Special Programme on AIDS (SPA) of
the World Health Organization was established, developed the global
AIDS strategy and very quickly won the support of every country of the
world, the World Health Assembly in May 1987, The Venice Summit in
June 1987, and the Economic and Social Council of the United Nations
in July.
Many people may not be fully
aware of WHO’s responsibilities. WHO has a constitutional mandate to
direct and coordinate international health. And for that reason we
have been given the mandate to coordinate and direct the global fight
against AIDS. We have created the Special Programme, raised sufficient
funds to begin implementing that programme, and marshalled the support
of every country in the world. WHO’s global strategy has three goals:
first, to prevent new HIV infection; second, to take care of those
people already HIV-infected (and this includes not just medical care,
but also social support in counselling for AIDS patients and all
HIV-infected people); and third, to unify the AIDS control efforts at
the national and international levels.
Specifically, the way we carry
out this mission at WHO is, first, to provide support directly to
countries for establishing and strengthening national AIDS programmes.
Every country in the world needs a national AIDS programme. WHO has
designed a blueprint for such programmes and can provide both
technical and financial support to countries throughout the world.
Thus far this year, we have sent about three hundred expert missions
to countries on various continents and started collaborating with 91
countries. Of these countries, 50 have already developed written plans
for AIDS prevention and control. In five countries in Africa
(Tanzania, Uganda, Kenya, Ethiopia, and Rwanda) a five-year,
medium-term plan has been written and adopted by the government, with
our support. Meetings with external donors have been held in those
countries and pledges have been received allowing them to implement
the first year of their national AIDS programme. In each instance, at
government request, we are providing staff to help further strengthen
those national programmes. Finally, we will be involved in these
countries and many others in evaluation.
So WHO’s role goes all the way
from providing technical guidance and financial assistance, to
supporting the development of a plan at the national level, and
finally, to helping the government coordinate and get the external
support needed to implement and evaluate the national AIDS plan.
The other side of our work
involves global activities and priorities. It’s extremely important
that the best information available on AIDS be shared throughout the
world. WHO collects and exchanges information not only about AIDS
cases and studies on virus infection, but also about issues of social
and behavioral practice and research. WHO creates guidelines,
consensus statements on such issues as HIV and international travel or
screening criteria for HIV infection, and addresses other issues of
global significance.
Epi Monitor:
Such as research for a vaccine or treatment?
Mann: Yes, but
first, I would like to re-emphasize that our strategy is to act as if
vaccine and treatment will not be available for at least another five
years. We feel that if people are led to believe that a vaccine or
treatment is right around the corner they would be discouraged from
adopting the changes in behavior needed to protect them from exposure
to the virus. It is also true, in the opinion of virtually all
scientists involved in vaccine development, that even if everything
goes exactly as one would hope, it’s extremely unlikely that we would
have a vaccine available for large populations in the world before
five years from now. And even that estimate is challenged by some as
being too optimistic.
A drug called zidovudine (AZT)
prolongs the life of AIDS patients. But questions on how safe this
drug would be if used on a large scale, how long the benefits would
last, its side-effects, and the high cost of the drug, all limit its
potential. Despite a great deal of research under way in different
parts of the world, there are no break throughs yet to report.
WHO’s role in biomedical
research and development is to facilitate the exchange of viruses and
other important scientific reagents and tools, to help facilitate the
flow in information and to support in a variety of ways the kind of
international collaboration that we all believe will help us more
rapidly find the solutions; the technologies that would help us stop
AIDS.
Epi Monitor:
How about testing for AIDS, and screening of blood? What is WHO’s
stand on this constantly developing issue?
Mann: Screening
or testing for infection are two different processes. Screening
implies taking groups of people and testing all of them, perhaps
voluntarily, perhaps involuntarily. Testing occurs when an individual
seeks to find out if he or she is infected. In any event, testing and
screening are well known public health tools that have been used in
many other areas of public health and disease control. WHO is not for
or against screening. It all depends on why and how it is done. In
order to help countries look at the screening issues, we held an
expert meeting, and the report of that meeting includes criteria or
standards for HIV-screening programmes.
Let me give an example.
Screening is thought by some to be a very simple answer to the very
complicated disease control problems in AIDS. In fact, screening
itself is very complex. Let’s use first an example of screening in
blood banks. If you screen blood in a blood bank and if the testing is
done inaccurately, then everybody would agree the programme was
useless. If the screening was done in a way that violated the
confidentiality or the rights of the people that are being screened,
the whole screening process would not be useful and would not
accomplish its task.
If you look at questions of
screening different groups, you have to consider who will be screened,
how they will be screened, by whom, and who will have the information.
For example, if a man is found to be seropositive, is it the
responsibility of the organization that has performed the screening to
inform that person’s wife? These are very delicate and complex ethical
questions.
Will the quality control and the
testing itself be adequate to ensure that the test was valid in the
first place? This process of quality control is simple. So when you
add it all together, we say: if you are going to screen, you must
examine the key issues and questions in our screening standards. When
you decide to proceed with screening, well that’s a national decision
obviously, but I think it’s important that screening be done properly,
not just proposed in a reflex manner because it may sound like a
simple solution. Therefore we think the WHO standards will help
countries deal with the many calls for screening from the medical
community, the general community or the political community.
Epi Monitor:
What do you think about the screening of immigrants proposed by
certain countries?
Mann: The
expert committee also discussed the issue of screening international
travellers for HIV infection. They concluded that the idea of
screening tourists was wasteful in the extreme and ineffective.
Therefore, we strongly oppose any proposals to screen tourists or
short-term visitors. It was also intended that countries realize that
screening of students, for example, is also not likely to be an
effective disease control strategy. What’s much more important is the
education of the general public, the education of people whose
behavior puts them at high risk, making condoms available, helping
intravenous drug-users either stop their habit or, if they cannot or
are unwilling to stop, making sure that they adopt practices that will
protect them from the spread of AIDS, and finally, helping prevent
transmission of the virus from mother to child. This is the way that
prevention can take place. Nevertheless, some countries elect to
screen students and immigrants.
Epi Monitor:
What do you see as the social danger in screening? What does this
mean?
Mann: I think
that the way we as individuals and societies react to AIDS and
HIV-infected people will probably make the difference between success
or failure of AIDS prevention programmes on the national and
international level. Let me explain. AIDS has unveiled thinly
disguised prejudices about race, sex, religion, and national origin.
When people hear about AIDS and become frightened, they want to blame
someone and almost always blame “the other”, which can mean people of
another race, religion or national origin, or with different sexual
practices. It is terribly important that we proceed beyond that stage
of blaming or stigmatization to a stage of realizing that AIDS is
everybody’s problem. This doesn’t mean that AIDS doesn’t affect
certain groups in the society more than others, but if we continue to
see AIDS falsely as a problem restricted to only one group in society
we will not be able to take effective measures to prevent its spread
throughout society.
Another way of putting this is
in the form of a paradox, or at least a statement that appears to
sound like a paradox. To the extent that we exclude the HIV-infected
people from our midst we endanger the rest of society. To the extent
to which we include those HIV-infected people in our midst we protect
our society. Let me explain. Excluding HIV-infected people from our
midst endangers us all because it sends a clear signal to those who
are HIV-infected or whose behaviors put them at risk of HIV infection,
to hide to otherwise avoid being identified. Otherwise, they could be
uprooted from their jobs or their lives and sent away, so to speak. It
would also encourage people who are concerned that their behavior
might expose them to the virus, to think that those people who are
infected have been sent away and therefore the people who remain in
society are not infected, which, of course, would not be true. Second,
if they might be exposed, under no circumstances would they have
themselves tested because of the dangers in the event that they are
infected. So the signal that’s been sent becomes counterproductive to
the protection of public health.
On the other hand, if society’s
signal is that there is compassion and N0 reason for fear, this will
indeed bring people to programmes of voluntary testing so they can
identify themselves and take appropriate steps to prevent
transmission. It’s tolerance based on knowledge rather than ignorance
and fear that allows us to keep the HIV-infected people in our midst,
keep them in their jobs, keep them in their homes. That tolerance
translates into a more effective national programme of education and
prevention than trying to exclude HIV-infected people.
Epi Monitor:
Once somebody has AIDS, how important is it that they be provided with
good care?
Mann: When a
person is HIV-infected, society’s attitude towards them may determine
the success or failure of an AIDS control program. We have to avoid
stigmatization and discrimination at all costs. When the HIV-infected
person begins to develop symptoms, particularly when they develop the
disease AIDS, there is the need not only for medical support but also
social and psychological support. AIDS patients describe the
heartbreak that they feel when they offer to shake hands with an
acquaintance or a friend and that person holds back and doesn’t want
to touch them. One of the most horrible things that can happen to a
person is to feel ostracized, isolated and discriminated against in
that way. It’s a terrible feeling of loneliness and it’s unjustified
by the facts which tell us that you can be with an AIDS patient,
except for sexual contact or needle sharing, without fear. So it’s
terribly important not only from the medical viewpoint but from the
social and psychological viewpoint that people be educated about this
disease. When people truly understand, we will be in the best position
to stop the spread of infection through counselling and dominate this
disease rather than letting the disease and the fears that accompany
it dominate us.
Epi Monitor: Do
you see international cooperation growing, and what is WHO doing to
promote this?
Mann: AIDS
affects the industrialized countries at least as severely as it
affects the developing countries. AIDS is not a poor people’s problem,
not a problem just for ‘the South’, but for North, South, East and
West. We are all truly in it together. We need international
collaboration because we believe not only that a worldwide effort will
stop AIDS, but that AIDS cannot be stopped in any one country until it
is stopped in all countries. We also believe that the international
cooperation required to fight AIDS successfully will be, in a sense,
another step toward closer international collaboration on other
issues, including health. AIDS has the potential to bring us together
if we can thwart those who would use it to drive us apart.
Another way of looking at the
whole AIDS situation is to ask ourselves a question: What would have
happened if AIDS had struck 50 years ago? Well, we would have been in
great difficulty. First, we would not have had the biomedical science
and virology to understand this particular kind of virus, so we would
not know what was causing the problem. Second, we would not have had
the social and behavioral research base that we have now. And we know
a great deal now about how behavior can be influenced through such
tools as the media, a tool which really did not exist at all in its
present form 50 years ago.
Another way in which we are in a
better shape now than 50 years ago involves international cooperation
and collaboration. Fifty years ago there really were no programmes of
foreign aid or assistance. Now, programmes of foreign assistance are
well established so that a health problem in a given country can
receive tremendous financial support through the generosity of others.
Finally, there are the
international organizations. Fifty years ago there really was no
international organization like WHO capable of assuming the complex,
difficult, and expensive task of leading a global AIDS prevention
effort. These organizations now exist, and have already proven their
worth in ways such as WHO’s eradication of smallpox throughout the
world. We have to harness these forces, we have to use the resources
available to us to realize our belief that AIDS can be stopped, even
without a vaccine. We have the knowledge, the information and the will
to do the job.
Epi Monitor:
What’s ahead for the WHO Special Programme on AIDS?
Mann: The
Special Programme, with its global leadership capabilities, is open to
collaboration with every country in the world. We hope to be working
with every country in the world by the end of 1988. In order to stop
AIDS, a combination of committed and comprehensive national AIDS
programmes is needed in every country, along with strong international
leadership, cooperation and collaboration. With the combined efforts
of national governments, multilateral and bilateral agencies,
non-governmental organizations and millions of concerned and creative
people, and with our current knowledge, political and social will,
AIDS can be stopped through a worldwide effort.
Published December
1987 & January 1988
|
