After several chapters with at least a modicum of interesting arguments, Tom Bethell, in Chapter 7 of his book The Politically Incorrect Guide to Science, has published something for which he should be ashamed. I cannot find any other way to put it; this chapter is a disgrace of terrible journalism, rampant generalizations, biased presentation, outright deception, and implicit racism. Bethell argues not only that the numbers of AIDS patients in Africa is inflated, but that there is no AIDS epidemic in Africa. Along the way, he makes fallacious argument after misdirected fact after ridiculous generalization. Finally, he ends the chapter on an apparently ignorant and not-so-subtly racist note. But now (hanging out to that last thread of disinterested neutrality) for the gory details!
Summary of Bethell’s Points
- He first begins by arguing that since South Africa is 1/6th the size of the US, that it couldn’t be legitimately experiencing 20 times the number of deaths as here in America.
- Second, he spends several pages discussing the “redefinition” of AIDS according to the symptoms for clinical diagnoses published by the 1995 Bangui report. In those diagnoses, there is no mention of T-cell counts, HIV antibodies, or anything used here in the US to diagnose AIDS. Thus, he refers to Africans dying in hospitals as having symptons that are “superficially like” real AIDS here in the US.
- Then, he argues that this new clinical definition, and the millions of Africans that were diagnosed using it, was used to make AIDS “no longer a homosexual disease.” And, he repeatedly refers to this clinical “redefinition” as having been deliberately aimed at solving the “epidemiological problem” of the supposedly uncomfortable fact that AIDS used to be primarily a disease for gay men, at least here in the US.
- Then, arguing that false positives can result from conditions such as malaria and pregnancy (and many others), he infers that the ELISA tests and Western Blot tests are mis-reporting AIDS numbers. This is particularly important because the numbers of AIDS cases grew dramatically once real testing started to occur.
- Next, he moves on the journalism of a South African named Rian Malan who published a lengthy article about AIDS in Africa in the music and culture magazine Rolling Stone. Among other things, Malan conducted interviews of coffin makers and found that business was relatively dead.
- Continuing on, Bethell argues that since the population of Sub-Saharan Africa has dramatically increased, this must mean that there is no “plague” of AIDS.
- Finally, he makes the statement that life was better in Africa under colonial rule. Since the liberation of these nations largely in the 1960s, their physical infrastructure has significantly deteriorated.
My Response
I am going to do something I’d avoided in previous Chapter reviews. I am going to respond point-by-point, because nearly every substantive argument that Bethell presents is either fallacious or misrepresented.
- Of course South Africa can have 20 times the death rate from AIDS despite a smaller population, it depends entirely on rates of infection. This is a fallacious argument.
- Clinical definitions are very often used in the medical sciences to diagnose disease. Alzheimer’s currently has no means of non-symptomatic diagnosis except for an autopsy, yet we understand if our elders are dying of the symptoms, they are dying of the disease. This is a fallacious argument.
- The argument that the clinical symptomatic definition of AIDS was intended for anything other than providing health workers in extremely infrastructure-poor parts of the world from helping people is not supported by any evidence. This is an unsourced (possibly homophobic, it’s hard to decipher his true meanings at times) opinion, not a legitimate argument.
- False positives are indeed possible under current AIDS testing. However, the makers of the tests publish numbers for false positives, which Bethell does not provide. In fact, he makes no attempt to do anything other than cast aspersions on AIDS testing by stating these facts that AIDS clinics and epidemiologists are entirely aware of. Though I offer no evidence here, to assert that those qualified to study pandemic disease have not accounted for statistical uncertainty in the testing is far less believable than that there is some conspiracy afoot. This is a misrepresented statement of fact used to build a fallacious argument.
- Rian Malan may have done some fantastic journalism, but looking real hard for the answer and calling coffin makers doesn’t make a strong case against the work of thousands of dedicated medical professionals. Throughout the entire chapter there is only one doctor cited, who is trotted out to say that the clinical diagnosis is not necessarily definitive. Not scientists or doctors apparently wanted to contribute, which is something unique to this chapter. All others, Bethell has managed to find some inkling of dissent in the establishment. This is an extremely poorly-supported argument.
- Of course the Sub-Saharan population can increase despite the prevalence of HIV/AIDS. It’s a simple matter of the relative birth/death rates. This is yet another fallacious argument.
- Finally, and completely unnecessarily, Bethell uses the observation that African infrastructure has declined drastically since the pullout of the Belgians, in particular, to state that perhaps Africa just was better under colonial rule. Never mind the fact that the Belgians used the labor and resources of their colonies to extract resources, built railways that only led to the ports, and effectively plundered their colonies’ riches for their own benefit. Education was not encouraged and white minorities ruled permanently and forcefully impoverished black majorities. The West has much to answer for in the current state of Sub-Saharan Africa, and to haughtily decree that Africa was better under the patriarchal care of European colonial powers is more than snobbery, it’s borderline racist. This argument of Bethell’s is completely irrelevant.
I am only partially aware of the special meaning that Bethell intends with his constant mention of “condom distribution” or his assertion that the sexual transmission of AIDS is a “sweeping claim.” Perhaps it means more to the target demographic of this book, I’m not sure. Either way, this chapter had nothing to do with science, and everything to do with intentionally misleading readers about the true conditions in Africa. Virtually nothing of numerical or scientific importance is sourced, and his typical grossly editorializing style permeates this chapter. There still remain 7 chapters for which I now hold less hope may partially redeem what is rapidly becoming nothing more than series of partisan ideological myths masquerading as some particularly terribly reported science.
Sorry I’m posting so late, but I just got back from being out of town for 6 days, so I didn’t have a chance to read this before. But I am raving mad at Bethell at this point, as not only does he present deceitful evidence for his arguments, but he continues the miseducation of HIV and AIDS in a world.
For those of you that don’t know me, I am a social worker in a clinic for children with HIV, and I’ve written research papers on the HIV and AIDS epidemics in the U.S., South Africa, Botswana, and Ghana. I have participated in research projects for Johns Hopkins and the CDC concerning HIV. I also grew up in Cote d’Ivoire, West Africa, where my dad worked in the HIV field for some time.
First of all, Bethell’s argument that the Elisa test, used in both the U.S. and Africa, is probably showing many false positives, consequently recording too many HIV cases in Africa, shows a lack of understanding of the Elisa test. The Elisa test looks for a match of the HIV antibody created by the body in response ot the existence of the HIV virus. A false positive is possible, since the test does not look specifically for the HIV virus, and some other antibodies may look similar to the HIV antibody. More exact test that search for the virus itself are too expensive and take much longer to produce results, and are therefore not used in testing adults in most cases. However, Bethell does not include in his argument the Western Blot test, which is completed if the Elisa comes back positive. The WEstern Blot looks for a more specific match of the HIV antibody, and will come back negative or indeterminate if the Elisa was a false positive. In addition, people that get tested in Africa are usually already experiencing AIDS symptoms, so a positive Elisa plus opportunistic infections are very good markers for HIV infection. In addition, pregnant women are tested in the U.S. using an Elisa all the time (I work primarily with women who tested positive during pregnancy), and i have never heard of pregancy causing a false positive.
Secondly, Bethell argues Africa is using a different diagnosis system for AIDS than the U.S. is false. In the U.S., people who are 13 yrs and older (i.e. adults) can be diagnosed with AIDS either due to a T-Cell (CD4 count) of under 200 OR the occurrence of 2 or more opportunistic infections (infections associated with AIDS, including certain pneumonias and cancers, that infect those with very weak immune systems). Hospitals in Sub-Saharan Africa seem to be using the occurrence of opportunistic infections to diagnose AIDS. CD4 testing it expensive and requires high tech lab facilities, meaning that it is very difficult for poor nations to continually test their patients CD4 counts. However, the method of AIDS diagnosis still meets the CDC qualifications and is parallel to that used in the U.S.
Bethell also aruges that South Africa’s small size (compared to the U.S.) means they couldnt’ be having 20x’s the AIDS deaths of the U.S. This shows a basic lack of knowledge about HIV health care in the U.S. Since the mid 1990’s, starting with AZT, the U.S. health and pharmaceutical systems have created and utilized various HIV medications that prevent the replication of the HIV virus in people that have HIV. SInce the HIV virus replicates itself through the immune system, these medications not only prevent an increase in viral load of the HIV virus, but also protect the immune system and increase CD4 counts (T-cells) so that those with HIV can fight off infections and the opportunistic infections that lead to AIDS and later death. In fact, these medications have made it possible for people diagnosed with AIDS (due to CD4 counts below 200 - the normal adult’s CD4 count is around 700) to increase their CD4 counts back up to the point where they would no longer be diagnosed with AIDS just based on their CD4 count and can fight off infections. However, once diagnosed with AIDS, always diagnosed with AIDS. These medications, when taken by pregnant women, women in labor, and infants in their first 6 weeks of life, reduce the risk of HIV transmission from mother to infant from 20% to under 1% or 2%. Not breastfeeding, using infant formula instead, also reduces the risk of transmission. Health insurance, Medicaid, and the government program ADAP all provide funding for people who can’t afford HIV medications to be able to have them. All of these steps forward in HIV treatment and prevention have decreased the incidence of AIDS and AIDS-related deaths in the U.S. drastically. (Infection among gay men has also decreased, and the new population that is being most affected is African-American women, most likely due to issues of poverty, education, and lack of insurance. Thus, it is not a gay disease in the U.S., either.)
In sub-saharan Africa, however, the story is quite different. The HIV medications are very expensive, which can cost between $7,000 and $15,000 a year. In countries in which the average daily income is below $1 a day for a quarter to half of the population, this is impossible for not only individuals to afford, but the government to afford, too. The HIV epidemic in Africa caught international attention too late - it was not until about 1998 that the rest of the world started to care about the increasing prevalence of HIV in Sub-Saharan Africa. For example, last year, Botswana (in southern Africa) was experiencing a prevalence of HIV among about 40% of it’s pregnant women. Botswana on it’s own cannot fund the distribution of medication to all of these women, let alone their children and the men that spread the infection to them. While Botswana estimated the # of people infected in its country to be about 350,000, and the U.S. estimate is about 950,000, most of those that get HIV in Botswana progress to AIDS and eventually die. In the U.S., this is not the case. Consequently, Botswana with only 350,00 infected experienced 33,000 AIDS related deaths in 2003. The U.S. only experienced 14,000. In reality, there were probably many more AIDS related deaths in Botswana that the government doesn’t know about, since many people are not tested and their causes deaths would not have been diagnosed. In the U.S., most deaths and causes of deaths are recorded.
South Africa, which has a much larger population than Botswana, estimates about 21.5% of it’s population to have HIV (that’s 1/5 of the population!!!) and as of 2003, estimated that 5.3 million were living with HIV. This is over 5x’s the number of Americans even living with HIV, not even taking into account the higher rate of AIDS among the HIV-infected population in South Africa than the U.S. Consequently, it is clearly plausible that South Africa is experiencing such a higher number of AIDS-related deaths.
Finally (since this is turning into an essay that no one will read all the way through), I would just like to state that the argument that colonization was better for Africa ignores the fact that colonization is largely responsible for the current instability in most African countries as well as their poverty.
Anthony, I have to say, I can’t believe you’re still reading this book after this chapter.
I’ll stop now before I provide you with my 82 page research paper i wrote this year comparing the HIV health systems in Sub-Saharan African countries and the U.S…. But all I can say is that there is definitely an AIDS epidemic in Africa, and to ignore it, as many governments did, is only to increase its prevalence and destruction of such a beautiful continent.
- Ariane
See this post by Tara Smith in Aetiology that follows a very similar vein as my criticism but is done by an epidemiologist who is a bit better versed in the field than myself.