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Conversations |

Professor Max Essex

VISIONARY: Dr. Myron (Max) Essex, the Chair of the Harvard AIDS Initiative (HAI), the Lasker Professor of Health Sciences at Harvard University, and Chair of the Botswana-Harvard AIDS Institute (BHP).

Harvard Comes to Africa How the World’s Most Famous University and one of Africa’s Greatest Democracies Made History in the Fight against AIDS By WYCLIFFE MUGA

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hen the world marked Africa Malaria Day back in 2007, at the time when I first met Professor Max Essex, Chair of the Harvard AIDS Initiative and Co-chair of the Botswana-Harvard Partnership, an influential website dedicated to highlighting issues of science, agricultural, health and technology in developing

countries, featured an article by a Ugandan biotechnology entrepreneur. The gist of his article was that the search for a malaria vaccine should be led by African scientists and not by scientists from the West. He insisted that Africa should seek a “home-grown” malaria vaccine. And he argued that if African governments cut down on corruption, and


on lavish spending on presidential luxuries, there would be plenty of money to pay for such research. Anyone who has spent time talking to African intellectuals will probably have heard similar arguments many times. It is an article of faith among many of them that funding scientific and technological research is a sacred duty for all African governments, as this – and this alone – holds the key to what is generally defined as “catching up with the developed world”. But not everybody agrees. Re-inventing Critics accuse African scientists and researchers of having a vested interest in re-inventing the wheel, and point out that the new African research institutions would only duplicate work which is already being competently tackled in European or American laboratories. As one such critic, I would ask this: Given that malaria currently kills an

African child every thirty seconds, how can it possibly matter whether the malaria vaccine is “homegrown” or developed abroad? A compromise is possible, however, between these two opposing viewpoints. And an example of this is provided in the Botswana-Harvard Partnership. Between its launching in 1996 and the present time, the Botswana–Harvard Partnership has undertaken a series of vaccine trials, including one which involved a detailed genetic characterization of the participants. This involved the same level of sophisticated equipment and expertise as would be required for a kidney transplant, for example. And it was all done on-site by local experts. The results of this ongoing research have provided new ways to prevent and treat AIDS, and Botswana is now generally regarded as having the most successful

treatment program in Africa. And of the 200 employees at BHP, 80%, including the director, are citizens of Botswana. Most of the rest are from other African countries, and only about 5% are Americans. In total, more than 8,000 local nurses, physicians, and pharmacists have been trained by BHP in AIDS clinical care fundamentals. Partnership The significance of this goes well beyond the effective treatment of AIDS: This partnership provides a model for all who wish to see Africans having more and better opportunities to contribute to ground-breaking research that addresses local problems. What follows is a transcript of just one of many conversations that I have had with Prof Essex on my visits to Cambridge Massachusetts over the years. Turn to P54

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Professor Max Essex

Photography | Richard Feldman

STRATEGIC PARTNERSHIP: Prof.Essex and President Mogae confer.

Turning the Tide The Botswana/Harvard Partnership WYCLIFFE MUGA: Many of the people who read this will not know who you are. So I’d like you to answer this: How did you get into HIV research? Why AIDS and not something else? What have been your trials? What have been your moments of despair? Just say as much as you can. PROFESSOR ESSEX: Well, I got into AIDS research actually in a fairly different way…I started out – I was trained – as a virus expert. I was trained to understand how viruses cause disease, period. And the virus group that I specialized in was Retroviruses and at that time, of course, no one knew what caused AIDS; this was before anyone knew AIDS even existed as a disease. But at about the same time, I was looking at human leukemia and a bunch

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of viruses had been discovered that were retroviruses, one of which caused a type of human leukemia. These viruses were contagious from person to person and they do exist in Africa but they are not such a big problem. They were a bigger problem in places like Japan; North Eastern and North Western South America; places like Colombia and the Caribbean; and in those places, the virus, called human T-cell leukemia viruses type 1, causes a vicious type of leukemia and also some neurological diseases. Those viruses turned out to be distant relatives to the HIV virus; and we have found that those viruses also infect the same cell – the CD4 cell, or the T-cell – and the leukemia that occurs is the leukemia of that cell. And that’s one of the reasons why it’s such a bad leukemia, and people die rapidly from it.

Now, in the same time when I was studying those viruses, I also became very interested in Africa. So I was a virologist studying cancer, as it were, and the reason I became interested in the possibility of these viruses in AIDS in Africa was because one of the other things I was studying was Hepatitis B virus in liver cancer. And, as you probably know, Hepatitis B virus occurs all over the world, but it has a higher rate of infection in Asia and Africa. I’m sure the rates are high in Kenya but it’s probably highest in places like Mozambique and they are really high in southern Africa in general but West Africa too – a lot of parts of Africa. So I was studying the Hepatitis B virus and I was studying it in Africa because I was intrigued by the higher rate of infection in Africa and the association with liver cancer,


primary liver cancer; and then while I was doing those things, people in the US discovered AIDS clinically as a disease. They didn’t even call it AIDS initially; they called it the GRID – Gay Related Immune Deficiency – because it was clearly an unusual outcome of these combinations of lethal pneumonias with Pneumocystis and opportunistic things like Kaposi’s sarcoma and tuberculosis in gay men. So I was interested in the possibility that a virus related to human T-cell leukemia virus might cause that. I was interested in that possibility because it was clear earlier on that the main reason for AIDS in gay people and injection drug users subsequently and in hemophiliacs, etc, in this country, was a loss of those same cells that the human T-cell leukemia virus was causing an overgrowth of cancer in - and then full leukemia. So putting that together with the fact that I was interested in the Hepatitis B virus liver cancers in Africa, as soon as we did some studies that found an association with AIDS and this group of viruses in this country, one could look at the possibility that viruses like this were in Africa. The place where we were working most closely in Africa at the time was Senegal. Botswana came quite a bit later. It came quite a bit later because it was clear then that there was a higher rate of both AIDS and that virus that we were looking at, in Botswana, and that is how we connected the two together. I was doing cancer research with viruses like this. I was doing Hepatitis B work in Africa and that all sort of came in together as the reason to look much more carefully into these things.

Botswana came because it was clear by then that there were high rates of HIV and AIDS in Botswana and we wanted to know what was different about the HIV in Botswana. That was by then the middle ’90s, but the history I was giving you before was really the early and mid and late ’80s.

Below: Prof. Essex and Harvard President Drew Faust.

Q: Why Botswana? True it has the one of the highest incidences and prevalence of AIDS... A: It was very simple about Botswana at that point. And it was simple because, at that point, a group like the World Health Organization had done these countryspecific surveys in a lot of countries in Africa and had said what is the fraction of people with HIV, period. And, by that time, they could say the rates were really high in Botswana, South Africa, Namibia, Zimbabwe, Malawi and they are pretty high in East Africa too. But they were even higher in southern Africa. In fact, had it been done earlier, they probably would have been equally high in Uganda. But by the middle of the 1990s it was highest in southern Africa and so the same approaches we had used for other studies in Africa were based in part on the extent to which we could get political cooperation from high-level officials. And I had a friend in New York who had worked with us earlier to help us get started in Senegal, even when we were studying Hepatitis B. He was a kind of diamond trade and exploration guy; not as big as the Oppenheimer family and Debswana and DeBeers. Well, the next level in the diamond

Photography | JUSTIN IDE

world. He has a lot of connections as I am sure a lot of businesspeople do when they have industries like that in association with Africa. And he happened to help us get started in Senegal by introducing me to his lawyer who negotiated business agreements for us, and his lawyer in turn introduced me to the President of Senegal, Abdou Diouf. And I asked him which countries would be easiest to work in and where we would get high-level acceptance by the government. And he gave us two or three examples and said either Botswana or Namibia and he said he could introduce me to officials sometimes even the heads of State of these countries. And it so happened that not too long after the conversation with him, there was a dinner in Washington put on by the State Department for the visiting Head of State of Botswana, who was in before the immediate former President, Festus Mogae. This was President Khetumile Masire and this was a dinner put on for him by the State Department, in a fancy hotel in Washington, and this friend told me he could get an invitation for me – which he did – and so I went to this dinner and there were maybe about 100 people. I was obviously one of the least important people and I was seated on one of the last tables. And then in the reception line he began to introduce me to President Masire – who, as it turns out, is still a good friend of mine; he’s about 83, and he’s still in good shape. During the dinner, when everybody was eating, there were a few introductory speeches by the Secretary of State or somebody like that, and after the dinner the president would be called on to speak. And during the dinner, President Masire actually came back to my table and tapped me on my shoulder and told me he’d like to speak with me about the situation we face in Botswana. And I said ‘I’d be delighted’ and he said ‘What about tomorrow morning? Can we meet for breakfast’ and I said ‘You wouldn’t believe it but I’m scheduled to teach at Harvard and they would get very upset if I am not back in time to teach’, so I was scheduled to take the first flight in the morning. And he said ‘Well OK, maybe tonight we can meet after the dinner’. So after the dinner, we made arrangements that I actually rode back with him to his hotel in his car and he asked me if the physician who was traveling with him – he had an entourage of about 15 people with him, one of whom was his physician – and he asked if he could have Turn to P56

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Photography | JUSTIN IDE

From P54

him join us, and I said ‘Sure’. And he actually called him in his room and he woke him up and he came in his bathrobe and all, and it was kind of funny – and he’s been a very close friend now too, Joe Makhema, who works closely with us. And we talked for about an hour to an hour-and-a-half about what could be done, and he asked me to come to Botswana as a consultant as soon as possible and I did. I went there about 4-6 weeks later. And when I went, we made arrangements through his physician so I could collect blood samples so I could characterize the virus. That was a month or two after the dinner in Washington. And that was how it all started after that. It was clear those samples had an interesting virus. It was distinguishable from the other viruses we had from Senegal and from the US, and from other places, and we wanted to know why. Then we started going back after that, and went quite often and started to set up studies there. President Masire was stepping down a year or two later, and President Mogae was in his party and widely expected to replace him. And he asked me to stay in consultation the same way and he arranged for me to meet with him virtually every time I went to Botswana. Later it got so that if I went there maybe six times a year and I’d meet with him three times a year. So that’s how it started with Botswana.

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Above: Prof. Essex and Harvard President Drew Faust

About ‘Saturday is for Funerals’ Q: So why did you and Justice Unity Dow do this book? A: I teach a course here at Harvard on AIDS in Africa for students who have a real interest in doing something, in developing countries, especially in Africa; and we accept about 16 students into the class but we also have a great excess of students applying and I can select the ones I want. And I always take some students who are not just into science but a lot of them are pre-medical students. Some of them are in social sciences or economics or something like that; and some of those areas are important for the future of AIDS and so I have a schedule of topics that I want to cover. They range from the epidemic – from how it started and when it started, to how it expanded, and how different parts of Africa are different; when it started in relation to the epidemics in the West and all those kinds of things. And then all the questions about transmission; how viruses are transmitted from all routes from between adults and mother to infant or blood. And then there are all the questions about drugs and what you can do with them to treat people and problems you run into with toxicities and drug resistance and which kind of clinical outcome you get. Each one of those is sort of a different topic that I teach and so my goal was to have a story from someone who is from the country and in the situation where she has been observing the epidemic all along just

by virtue of living there, and to try and have a story that would help people to appreciate the importance of each of these topics and subtopics. So that was the goal of the book overall. Now there are a few topics I wanted to talk about where it was harder for her to find a story to fit that; like vaccine research because that’s not something that impacted people’s lives yet. The way to approach that was to introduce her to some people who have participated in vaccine trials, and that would allow me an entrée to talk about how important it is to make a vaccine and how research goes on to do that. And then, in our selecting of these topics which are primarily from the class schedule which I’ve used for the last several years, one of the problems we always ran into was how to avoid too much overlap because the question of how people infected each other is going to come up in a large number of stories but you can’t be too repetitive. Well, Unity Dow said she knew many people who had such tragedies among her family and friends, so that got us a start. The only problem we ran into I think was how I could modify my own comments to avoid too much duplication so that I didn’t repeat the same things in too many chapters. And there is a bit of repetition on infection and methods of transmission, but hopefully not very much. That’s the story behind it and how and why we did it. But obviously we wanted something that wouldn’t just be used for these college students. We wanted something that could be used to educate the public at large and could be interesting enough for the public to read to make them more interested in AIDS in Africa. Some of the publishers ask these very precise questions about how wide the readership could be and how specifically you can define the audience. And if you could say the audience would just be students or the audience will be people who are already interested in AIDS or in Africa they are not so interested. But if you could say that the audience might be people who would read all the books that people like Alexander McCall Smith write about Botswana, about social dimensions of past interactions in family problems in Africa anyway and all that, then you are looking at a larger audience and they can relate to that. So, our challenge was to make the stories interesting enough so that people who read books – like Alexander McCall Smith books – would get interested enough to read this and learn about the epidemic as a result. Q: I’m not presuming to know more than your publisher but would you not agree that the one place where this


But it’s so similar. Even the cultural practices, the paying of the bride price, the burdens of the extended family it’s all there. I could relate to it very easily. So books from West Africa are in the school syllabuses all over eastern and southern Africa for the reason that it is considered important that young people should understand how their ancestors lived, and there is no evidence left now except for what can be found in books. So what I was trying to tell you is that if someone in the West reads this book, they learn more about Africa, they learn more about AIDS in Africa and that’s it. But if someone from Africa reads this book, it may save his life. It may save the life of the person to whom he will talk. So I’d almost disagree with your publisher. The really important thing is that people from Africa should read this book. I speak as someone who’s read this book. A: Yeah, well that’s good to know.

book desperately needs to be read is in Africa. A: Yes. Q: Do you know what is the bestselling African novel ever? It’s the book Things Fall Apart by Chinua Achebe, a Nigerian. A: I didn’t know that. I’ve heard of Achebe. Q: Okay. It is said he was heartbroken when another Nigerian, Wole Soyinka got the Nobel Prize. A: I know much more about Soyinka because I know his brother personally. His brother, Femi Soyinka, is a physician. Q: Is that so? That’s a very clever family. Well I personally think that Achebe is a better writer. But still that’s just personal. The point is the reason why the book has proved so popular is because, all over Africa, it is a standard textbook for secondary school. Kenyans who are growing up now – some in desperately poor conditions, but others in cities not much different from Boston – the only way they know about African traditions is from books. So, African governments, as a matter of policy, make sure some books which talk about Africans of the past are included in the school curriculum. Chinua Achebe’s was the best, though it is based in Nigeria. Just like when I read your book – I’m from Kenya but your co-author was from Botswana.

Let’s talk: Prof. Essex in conversation with EA Flyer’s Muga

Q: It’s something which was long overdue. I’ve got a feeling that you are not the only one who is working on this. Anyone who has looked indepth at the AIDS epidemic must have wondered, over and over again, ‘How do you educate people?’, ‘How do you get them to understand?’, ‘How do you inject some part of this into the learning process?’ So that the understanding of what AIDS is and how its spread – and a little biology at least to explain it Photography | Kim Morrisseau

properly. And I don’t think anyone has come up with the formula that you and Unity Dow came up with of two parallel accounts, one scientific, one narrative and so many different examples of so many different people. And you can see why people behave the way they do. Let me give you an example: If this was Kenya right now and you and I were in a bar, and your young assistant in the other room was in the same bar; and two or three really pretty girls walked in; they are more likely to come and chat us up than to chat him up. That’s how it is in Africa. Because both you and I have got grey hair, and it suggests age; it suggests prosperity. It happens like that. And in your book there is a story like that, about a very pretty girl who always goes out with older men who could buy her things which her poor family could not afford. I forget her name now. Well, the young women in Africa, who come from poor families, need to read and understand that this is happening everywhere and what the consequences are. And as for a young American undergraduate, if she walked into a bar where the three of us were, she wouldn’t even notice that you and I were there. She would head for the younger man. So if such a young woman in America were to read that story of the very pretty African girl, who used to go out with older men, she would merely say, ‘That’s very interesting’ while an African girl would understand precisely how it is: that if you are from a lower-income family, and you’ve got looks, chances are you are going to end up going out with much older men.

About PEPFAR Q: Okay. So at some point we have to bring in the President’s Emergency Programme for AIDS Relief (PEPFAR). So tell me, in your experience how crucial was PEPFAR as a programme for Botswana because I gather there was money there – it’s a middle income country not like some poor African countries. Did PEPFAR play a big role? A: PEPFAR was not quite as important in Botswana as in the other African countries, but it was a very important programme for Africa and an extremely important programme for a lot of other countries. Turn to P58

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From P57

But the decision to treat patients with anti-retroviral drugs was a very important decision. Actually it was just before PEPFAR, in the case of Botswana, it was around late 2001 and early 2002, but everyone in Botswana and PEPFAR in the US wanted Botswana to be included in PEPFAR. And Harvard was one of the original four applications that were successful for PEPFAR programmes, where you had to have evidence that you had experience in at least three countries in Africa. And Harvard had such experience. And Phyllis Kanki, who was a student of mine and is a professor here still – she has an office just down the hall – she is the one who organized the PEPFAR application that included Botswana, Tanzania and Nigeria. Well, her programme was in Nigeria – it still is in Nigeria – which was started with a Gates [Foundation] grant. We did it in Nigeria because Gates felt that there wasn’t enough going on in Nigeria, and she volunteered to do that, and the dean of the school supported her. Another faculty member, Wafaie Fawzi, an epidemiologist, who was originally from Sudan but he spent time in Tanzania started the Tanzania programme. And I had obviously started the Botswana programme. So these three countries were together in that. Ric Marlink, another former student, actually ran the Botswana PEPFAR programme. Now in Botswana, we decided to do what you may call more advanced kinds of things for their programmes, which was monitoring and evaluation, which was training physicians in doing monitoring and evaluation of the treatment programmes that were ongoing to make sure they were working okay. But partly because they were a smaller country, and partly because they were a more advanced country, PEPFAR activities in Botswana were not nearly as big as they were in Nigeria and Tanzania. The usual annual expenditure was like $4 million or something like that in Botswana. It was $50 million in Nigeria and $20 or 30 million in Tanzania. The fact is we as a group at Harvard who worked in Tanzania, Nigeria and Botswana all knew each other very well, and we had worked together in research collaboration before that, I think this also helped the programme to keep growing more rapidly. And in fact I was also involved in Tanzania in research, and in helping the epidemiologist who ran the programme – who still runs it – to get started and establishing laboratory facilities and expertise and such. So that’s sort of how the connection was made.

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Prof. Essex and President Masire

Q: Okay. Now the reason I ask you this is maybe I’ve missed something – and please correct me if I have – but there seems to be a shift in donor funding of HIV prevention and education and treatment and all that, toward other diseases as well. In other words, it’s like they said ‘All right, when AIDS came and threatened the whole world, we reacted this way. But just a minute: far more children die of malaria or waterborne diseases which are easier to treat; and also much cheaper to treat; and in fact your colleague whom you introduced me to (back in 2007) Professor Dyann Wirth – she said as far back then that AIDS had received a disproportionate amount because

it afflicted the articulate and the influential whereas when you come to diseases like malaria, well a grownup African technocrat does not fear malaria. Even if he gets malaria, he will just take a tablet or get a drip. But the poor child out there in the village whose mother does not have a dollar or two with which to buy that tablet, that child dies before their fifth birthday for want of two or three dollars. She said it’s difficult to dramatize malaria in the same way that you can dramatize AIDS. Like when I was reading some of the descriptions that Unity Dow wrote (in the book you co-authored with her) of some people in their last stages of AIDS – when their mouths are all


slimy, skin all scaly, etc. I have seen cousins and nephews in that terminal stage. And that can be dramatized as this terrible thing which must be prevented. But some child, who nobody really knows, dying out there in the bush – no one really cares. I see a time coming when Western donor nations will no longer be giving large sums for HIV and meantime there are still plenty of people in Africa who are superstitious about AIDS and therefore will not take the measures which would prevent them from getting infected. So, here is, on the one hand, the budget of these poor African countries that cannot support what we could call a serious public health programme. On the other hand, the donors are now spreading their money a little more thinly. Where do you think all this will lead? A: Well, you know, we can look at this in many different ways and one argument is, some people would say ‘Why did they put so much into AIDS, while saving people with AIDS cost much more than saving people with malaria?’ as you’ve said. But another way of looking at it is, ‘Do we really think this country (the US) and most Western countries would have put as much into healthcare and health improvement and prevention of disease in Africa at all, if it wasn’t AIDS?’ Because malaria is much older than AIDS, but people don’t say ‘Why didn’t we do this 50 and 100 years ago?’ Because malaria and TB were just as bad then, and they were around then. They did it because they only appreciated the dilemma of these infectious disease problems in general being disproportionately in Africa, after AIDS pointed it out to them. But they realized that it was because they had seen firsthand the suffering from AIDS in those countries that they learned more about the suffering from infectious diseases in general, including malaria, TB and everything else as a result of AIDS. And it is arguable that were it not for the education that AIDS provided, the donor countries would still not be doing anything, or very much of it. They should have been doing more of course: they should have been long before. But it’s arguable that they wouldn’t, were it not for the way in which their eyes had to be opened around AIDS. That is still another way of looking at it.

A: Absolutely. That’s one way of looking at it, yes. The other way of looking at it, however, is that there’s all of these confusing emotions about HIV/AIDS in relation to sex or promiscuity or whatever else (lack of responsible sexual behaviour, etc) but the other fact is it’s really impossible, even now, to reproduce and to have subsequent generations of people in Africa or any other place, if you’re HIV infected and you don’t do something to control the HIV or treat the disease. That is not so with TB or with malaria. Meaning, if you use condoms in preventing transmission of HIV between sex partners, they can’t conceive because you prevent sperm too. But that’s not an issue with malaria or TB in and of themselves.

So there are differences. You can prevent reproduction for all the right reasons; you could be a very religious Roman Catholic and not have sex except to have children, but you still don’t use condoms. So how can you prevent transmission of HIV if you don’t prevent transmission of sperm to impregnate a woman and have a child? So there are differences with HIV also. And I think these paradoxes go back and forth in many different ways because one of the realizations now, I think, is that prevention itself has to become more important for sustainability in relation in AIDS. And there was all along great hope Turn to P60

Q: Okay. So you’re saying that it required something as new and as dramatic as AIDS to focus Western attention on the public health problems in Africa.

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From P59

Photography | Martha Henry

and excitement that the vaccine would work better and sooner and then we wouldn’t have to invest as large a budget on drugs as we have had to invest. And even though drugs are a lot cheaper now than they were in the past, they could be made quite a bit cheaper if people just had reasonable discussions and debate. But if it still costs $300 for drugs or $200 for drugs… Q: For a year? A: Yes. And $200 or $300 for other things around the drugs like medical testing and kits, nursing and physician care and whatever it takes to get started. These are unsustainable for many poor countries that have incomes of $300 or $400 per person per year. And that is causing people to think more carefully and conscientiously about prevention mechanisms again. And I think in what we might call “donor fatigue.” Some of these larger organisations like the Global Fund or the Gates Foundation would say that we are running into problems with donor fatigue and the world economy being down and therefore sustainability for treatment programmes is decreasing. But at the same time, I think you’ve now got a lot of researchers involved and a lot of donor organizations involved in addressing the costeffectiveness of new prevention methods even in the absence of a vaccine. And one of the things I learnt a long time ago is that as medical research improves for any treatment and prevention of disease, you learn a lot that has cross-benefit like a polymerase chain reaction methodology to diagnose exactly who is infected when you just can’t do it with antibodies those same tools work across diseases. You develop them for one disease and you can modify them quite well to fit other diseases. And that approach, I think, is proving its value for malaria, TB and a bunch of other things. And I think that one can look at these things in a very optimistic and constructive way as to how investigations and donations and activations of political organizations, and so on, will help other diseases as well. Or one can look at it in a very narrow sense and say any value spent on AIDS is taken away from malaria or infant care or something else. And I have found it’s not very productive to do that. You can even argue that some of the critical facilities and some of the physician, nurse and healthcare worker education in general, even though it was built around AIDS, it’s proving to be valuable for providing antenatal care in general. And everyone is now aware of ways to prevent transmission of HIV from mother to infant and yet, to do that, you have to have sufficient antenatal care to find out whether or not the woman is 60 |

Journey of a thousand miles: Prof. Essex teaching his Freshman Seminar, “AIDS in Africa”, at Harvard

HIV-positive. Therefore, you build a structure that primarily exists to identify women when they are pregnant before they just come into the clinic on the day of birth and if you’re doing that, you’re helping them in general in relation to decreasing infant morbidity and mortality. And so I think when people only focus on parts of how AIDS research and treatment might have been taken away from the rest of healthcare, they are not being realistic, unless they recognise the ways that AIDS research has added to the rest of healthcare in general. The Failure of Communication in the Fight Against Aids Q: Let’s go back to your book briefly, because, over and above the actual medical treatments such as the one you’ve described, one of the great failures in the fight against AIDS in Africa is the failure of communication. Every African mother knows that your child should ideally sleep under a bed net if you have one. They may not know that if a child is feverish, that doesn’t mean its malaria, and they may not know about Oral Rehydration Therapy which is a very easy way to treat cholera, but they do know about bed nets. So, my question is in two parts. First, why was not a bigger effort made to just bring about a clearer

understanding of AIDS because the focus has been on treatment and yet prevention has to be rooted in understanding? And second, going back to your book, do you have a strategy as of now for ensuring that it is widely read in Africa? (The book Saturday Is For Funerals came out in paperback in September 2011) A: Well, unfortunately for the Part Two, we don’t know how to make it better read. And to expand on that a little bit, I and several others edited this book called AIDS in Africa and that book we specifically decided that we would make it free in Africa to all libraries and medical faculties and any place where physicians would congregate. And nobody had any profits from it or anything like that. And I could never tell to what extent that worked. We worked with several agencies and distributed it. All I know is that it’s available in a lot of medical schools and libraries. That’s not the people we’re talking about at this instant. So I don’t know who to go to for any kind of distribution in a situation like this, or if it is the Internet or some other way or Kindle. So, it’s not the same kind of distribution, it’s not easy to make that kind of distribution, but I would be very curious to get your opinion because maybe in a year or less there will be a paperback version, and maybe there is a way we could do something with that, or some mechanisms that I’m not sufficiently familiar with. And there is some discussion about Francophone countries and a French


translation but even then it might not be the best thing. Then there is Swahili, but I know languages could be just as important in passing a message. Q: Could I interrupt you? But what you say about the importance of local knowledge comes in, the largest selling Kiswahili paper in Kenya barely sells 10,000 copies a day, whereas among the English language papers, the highest selling one sells about 150,000200,000 copies daily whereas the next one sells about 80,000 copies; the next one sells about 50,000 copies. So in Kenya, Uganda and, increasingly, Rwanda, English would matter far more than Kiswahili. And secondly I’d like to see the translator who would manage your section of the book – the scientific explanations about polymerase this and that etc. The English language edition is more than enough for most of Anglophone Africa and the French translation would be more than enough for Francophone Africa. A: In relation to communication in the context of prevention, I think that’s something that should be raised at a high level in the Gates Foundation. Maybe somebody else, maybe the Gates Foundation and maybe other groups and I’ll tell you why I say that. As you may know, if you talk to the Gates Foundation or Bill Gates himself

Below: Prof Essex with Dr. Joseph Makhema in Botswana

– a week or so ago there was an interview with Bill Gates Junior and Bill Gates Senior on Larry King Live. And he started out with the first question everybody always asks Bill Gates, which is, ‘How do you decide which foundation needs help?’, And he said, “Well, we have made a very clear distinction: In the developing world it is healthcare; in the US, it’s education”. And nobody said, “Well, in the developing world, how much of that healthcare is education? Or, at least, prevention education?” Nobody got into that but in reality I suspect it’s very, very little. I think it’s important that they appreciate something like this and how much of prevention is education and not just purchasing that medicine. And I think that’s something that’s a very important point, that hasn’t been appreciated adequately, and has to be appreciated more as time goes on, with this paradigm of donor fatigue, and having to switch more maintenance of treatment to prevention. Let me just give you one other anecdote or explanation I sometimes use in the context of Botswana: I probably mentioned this before, but one of the dilemmas of a situation where treatment is so successful is afterwards people underestimate how successful it has been. If we take the usual life charts of those in the US, somebody being treated for AIDS is going to live for 20 to 25 years. In Botswana, you already have 25%

of your population infected. You treat it as a disease and after they have the disease, they can live for another 20 to 25 years and, therefore, you’ve got these poor people being treated for 20 to 25 years. At the same time, you’ve got more people growing into the age category – we think we have ways to prevent the motherto-infant transmission for the most part – but you’ve got this pool of people growing into sexual maturity where they can still get infected. And so if you consider all the people infected with HIV and on treatment as a vat that is 25 per cent and the out-spout to the vat is death; and the in-spout to the vat is new infection. If you cut down deaths by three-quarters, or 80 per cent, then you have to cut down new infections by 80 per cent or 75 per cent just to stay even on the vat. If you cut down deaths by 80 per cent and you cut down new infections by 50 per cent or 60 per cent, you say ‘Wow! That’s pretty good’. You’ve reduced the infection by 50 per cent, but the total number of infected people continues to go up. Even a good vaccine may only reduce it by 75 per cent or 80 per cent. So that’s another illustration of how people have to learn the importance of prevention. The other anecdote that I often mention, is when President Mogae – he really does deserve the credit for this – started the optout programme of convincing people and Turn to P62

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Conversations |

Professor Max Essex

Photography | Ryan Louis Hurley

From P61

convincing the government (and he took some flack for it initially), to adopt an opt-out programme, which says that anybody who comes to the government for any reason in relation to healthcare, whether for an emergency or non-emergency or whatever, be asked if they refuse to have an HIV test: Not if they would like to have an HIV test, but if they refuse to have a HIV test. If they say, ‘Yes, I refuse to have a HIV test’, the health workers say ‘OK’, period. They go on anyway and provide them with whatever healthcare of other things they would have had. But that in a sense reverses the stigma argument. It says ‘If I say, ‘No’ I’m not going to have an HIV test’ it makes some people even more suspicious. It says they are living in fear because they are HIV-positive or because they don’t want people to know about their lifestyle or something else. And I think that in itself had a huge effect in raising the fraction of adults who get themselves voluntarily tested to 6070 per cent in Botswana now, which is going to have a significant impact on prevention. But one of the other aspects of that is there clearly is evidence of reduced cases of new infections among younger people who are sexually active in Botswana – the cohort is 17-25. The problem is that when they get

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Co-authors: Unity Dow and Prof. Essex wrote the book Saturday is for Funerals, a study of people living with AIDS

to 25 or 26, the mentality of prevention seems to wear off. And my possible explanation for that is, when they are younger they are more often having sex for fun or whatever else; and when they are a little older and they really want to have kids, they know they can’t use condoms because they want to have kids. And so this points us back to another need for research in prevention to address this issue. It would have been great if we had a 95 per cent efficacious vaccine but we don’t – and most likely won’t have it for the next 10 or 15 years – and so we have to have some other approaches to that problem. Q: Okay, but one thing you did not effectively answer is “Why wasn’t communication given more emphasis from the start? Why was it, ‘Let’s find a vaccine’, or, say, ‘Let’s treat those who are ill’, or ‘Let’s have some sort of prevention?’ As in Kenya, in every place there’s a VCT (Voluntary Counselling and Testing Centre). It’s got a purple background, yellow color letters, and everyone recognizes it. And, initially, the counselors would just sit and wait; but later on they started going door-to-door; but still the number of Kenyans who know their HIV status is statistically very

small. And the reason for this is there’s still stigma first and foremost. But over and above that, I’d say there’s superstition. I know I’ve met enough HIV people to know that it’s not a death sentence anymore but, at the back of my mind, I’m really wondering, ‘What is HIV?’ And I’ve heard this, I’ve heard that, and all sorts of rumours which will flourish if there isn’t enough clear information. For example, any woman whose child is protected from malaria by mosquito net knows and believes in her heart that malaria is spread by mosquitoes. It’s not a curse; it’s not an evil eye but it’s mosquitoes. It’s not a myth, it’s a scientific fact. Now, there are some scientific facts about HIV. Why wasn’t a bigger effort made to explain this to ordinary people? I consider your book to be one of the first serious attempts to reach ordinary people with narratives they can relate to, with an explanation they can understand. You don’t need to have a PhD in virology to understand it. A: I think it is because behavioural interventions in general in this country have not been so successful. And most researchers who are serious researchers doing quantifiable studies, are not doing


behavioural research in Africa. And they are not doing it either because they don’t know how, in the same sense that I didn’t know how to reach enough people with some of the science without having Unity Dow draw them in with real-life stories. Or, because they are afraid of repercussions from the political establishment in the countries, I think it could be either or both. And I think there are not enough Africans who are well trained in quantifiable behavioural sciences. The Africans trained in the US and Europe, the few who have gained enough knowledge and expertise in AIDS, very, very few of them are going to gain that expertise in educational and behavioural sciences and go back and practice this. I think that an increasing number of people are being educated about medical practice and what to do. Even some of them about voluntary testing and counseling techniques and that sort of stuff. But I think it requires something like a political link and political commitment by some regional if not continental organization like, for example, the Southern Africa Heads of State and parliamentarians have their regular meetings. And I think if some of them were to endorse some mechanisms for this, it might work whether or not there were analogous groups in eastern Africa and western Africa who do that sort of things, I don’t know.

Centre of excellence: BotswanaHarvard Partnership building in the grounds of Princess Marina Hospital in Gaborone, Botswana.

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Harvard Comes to Africa