Al-Ahram Weekly   Al-Ahram Weekly
2 - 8 December 1999
Issue No. 458
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A matter of involvement

By Mariz Tadros

Last week, a two-day national AIDS conference was held in Aswan under the auspices of the Ministry of Health and Population, based on the theme "Sharing the Challenge". Not many believe, however, that AIDS does represent a challenge to Egypt. Dr Ismail Sallam himself, the minister of health and population, is sceptical: "AIDS is a problem in Africa, not in Egypt. In Egypt we have identified 466 foreigners infected with AIDS and 382 Egyptians. Ninety-five per cent of the foreigners were Africans and have been deported." The minister, however, pointed out that in all likelihood, there are more cases that have not been identified.

Dr Sallam believes that the key to preventing AIDS from spreading in Egypt is to raise awareness among young people who work in tourism or travel frequently. In his statement, he repeatedly stressed the importance of chastity in preventing the spread of the infection.

Neither the figures nor the minister's stand are new: most Egyptians believe that AIDS is not a threat because it is spread through promiscuous behaviour, alien to the culture, customs and norms of Egyptian society.

Hussein Gezairi, regional director of the WHO (World Health Organization), suggested that Egypt and the East Mediterranean indeed show one of the lowest rates of AIDS prevalence, but warned that this should neither be seen as indicative of the real situation on the ground nor taken for granted: "To deny the existence of AIDS in our countries and to claim that it is a disease of one region or another is to bury one's head in the sand and to ignore the facts. The result will be a wider spread of the disease, affecting sections of the population that would not otherwise be affected," he warned. Gezairi also emphasised that AIDS "is now an endemic disease in our region. It is no longer an imported disease. Indeed, there are indications from one or two countries that the disease is now following the same trends as in sub-Saharan Africa."

Dr Zuhair Hallaj of the WHO also stressed that intravenous drug use in many countries in the region could trigger an outbreak, because of the prevalence of practices such as reusing syringes.

Professor of psychiatry Dr Adel Sadeq urged the minister of health to initiate a national campaign before it is too late: "If we have just one patient today, tomorrow we will have 10 and in a year 100. Let the rapid spread of [Hepatitis] C be a lesson. Some indicators now show that 30 per cent of the Egyptian population have Hepatitis C."

Sadeq asserted that no one is immune to the virus, and that promiscuity is not the only cause: "No one is spared. AIDS can be transmitted from mother to child, from husband to wife, from dentist to patient, from contaminated blood in transfusions..." Doctors at the conference also pointed out many careless practices which can be sources of infection, like the reckless disposal of syringes by hospitals which could infect garbage collectors, and the use of unsterilised equipment in beauty salons.

To many Egyptians, however, AIDS is still synonymous with promiscuity, but especially with homosexuality. Dr Nasr El-Sayed, head of the National AIDS Programme, emphasised that recent survey results revealed that only 14 per cent of the total number of AIDS victims were homosexuals. Fifty per cent of infected patients were heterosexual, 13 per cent intravenous drug users, 14 per cent had been infected prenatally and in nine per cent of cases the cause of infection was unknown. El-Sayed added that despite the low prevalence rate, Egypt is still vulnerable.

The National AIDS Programme, explained El-Sayed, has two objectives: preventing transmission and reducing mortality among HIV-positive patients. It seeks to achieve the former by raising the awareness of high-risk groups and through a hotline set up to answer queries on AIDS from 9.00am to 9.00pm. The Fevers Hospital also has a special section for AIDS patients, he added, although this section holds only seven beds. "In the early 1990s some of these beds were empty, but now they are always full; and just so we don't bury our heads in the sand, they are all occupied by Egyptians, not foreigners," he declared.

One particularly contentious issue is the spread of the virus that causes AIDS through transfusions of contaminated blood. The minister of health refuted such allegations. "What blood transfusions are we talking about? During one and a half years we have only had one case...We check samples scrupulously every year to make sure the supply is not contaminated," Sallam asserted. El-Sayed admitted that there had been cases of contamination in dialysis machines in 1990, 1993, and 1997, but now great care is being given to analysing and checking the blood samples.

The Ministry of Health came under attack earlier this year when HIV-contaminated blood was found in the blood banks of four major hospitals. An elderly woman receiving dialysis treatment was infected. Investigations confirmed that she had contracted the disease during treatment. Five lawsuits have been filed against the Ministry of Health by HIV-positive patients, who believe they caught the virus during treatment in government hospitals. Last month, another scandal erupted when an imported dialysis machine was found to be contaminated. Although it was found at a private medical centre, it cast doubt on the government's ability to protect patients.

Many doctors also fail to make an early diagnosis of the disease because they do not consider it likely that a patient is HIV-positive. According to El-Sayed, in 95 to 97 per cent of cases, no specific symptoms suggest the existence of the virus. "When patients complain of symptoms like diarrhoea, skin infections or chronic fatigue, doctors often overlook the possibility of AIDS, so it takes a very long time before patients discover they are HIV positive," he explained.

When patients are diagnosed, adequate medical care is not guaranteed: medication is rare and very expensive. This was the most heatedly debated issue during the conference: should the government be subsidising AIDS medicine for victims who cannot afford the costs? Dr Abdel-Rehim Abdallah, professor of skin and venereal diseases at Ain Shams University, did not think so. He argued that available medication is not curative, requires constant supervision, and costs a prohibitive amount. Nor does he believe the government is ethically bound to assume the costs: "Did [the patient] not act recklessly? Then he must spend recklessly, too," he maintained. "If the patient needs medication worth LE6,000 every three months, should we spend it on one person, or use it to treat 30 cases of diarrhoea?"

Another participant, however, argued that "recklessness" has nothing to do with the right to medical care. "As a doctor, I must give my patients equal treatment," he argued. "If I just let one patient die because he should be held accountable for his actions, then I might as well deny lung cancer patients treatment because they chain smoked although they knew the risks, or bilharzia patients because they wash in the canals."

Minister of Health Sallam believes that free trade policies, not the ministry, have denied patients the right to free health care. The companies who have patent rights on medication insist on imposing high prices, he explained. "Every time a treatment is discovered, patent rights prevent us from providing cheap medication. What can we do?" he argued.

But when 80 per cent of the Egyptian population earn less than $1,200 a year, is subsidising medicine not a vital priority? The minister told the Weekly that the battle against AIDS in Egypt should not be about subsidies but about prevention.

El-Sayed said that while the ministry subsidises medication for illnesses associated with AIDS, like tuberculosis, it cannot subsidise antiretroviral medication [which slows the progression of the illness considerably] because it is simply too expensive. "Together with the regular blood analysis, the cost per person would be $8,000. This is too much, and if the patient stops the medication, he dies," he explained.

Sadeq, however, pleaded with the minister not to be "stingy" with spending on AIDS and urged him to consider the importance of investing in human capital. He added that providing medicine and care for AIDS patients prevents the spread of the virus. "We have invested in medication for depression, liver failure and schizophrenia despite the costs. Should we not be willing to pay for AIDS, when it affects the lives of so many?" he pleaded.

At the heart of the debate is the fact that some of the poorest countries in the world have been forced to cut public expenditure on welfare, including health, by the IMF-prescribed economic reform programmes. Many developing countries have been forced to cut back on primary public health services despite the poverty of their constituency. In many Western countries, where AIDS medication is subsidised, results have been noted. According to the WHO, in industrialised countries, the number of AIDS cases has decreased because of combination antiretroviral therapies and preventive measures undertaken in the mid-1980s. In developing countries, the number of AIDS cases is increasing because of limited access to antiretroviral therapies, and the lack of effective preventative measures.

Hallaj explained that available medication can reduce the risk of transmission from mother to child by 50 per cent and by a third more if a substitute for breast milk is used.

But the full costs of this medication tend to be high. Although in some cases, costs have been cut from $1,000 to $100 per pregnancy via an intensive combination course, the government must still decide to allocate a budget for such medication, he insisted. "In Sudan, for example, it costs less than $1 to treat a mother and her child against malaria; so, do you invest thousands in a campaign that will affect the masses, or do you spend it on a few AIDS patients? If you use that logic, however, then you should apply it to the end: should you spend millions of dollars on warfare, or on both malaria and AIDS patients?"

Moreover, counseling and psychological support are lacking. Sadeq pointed out that the trauma of dealing with AIDS can sometimes result in denial. "Many patients will act as if they are perfectly normal, they will get married, have children and pretend nothing is wrong." Others, he said, may become aggressive, hostile, and vengeful. A young homosexual man infected with AIDS recently made the headlines when it was discovered that he had donated blood 120 times in a single year. "Patients may wonder why they should die alone. They may spend much of their energy in transmitting the disease to others," explained Sadeq.

Helping people understand that AIDS can be contracted in many ways is difficult, but conveying targeted messages to high-risk groups is even harder, especially if society ostracises them. Homosexuals and prostitutes are particularly vulnerable, for instance. It is equally difficult to advocate safe sex, when society places a high premium on chastity and does not recognise pre- or extramarital sex. Certainly, the government has taken a first step in recognising the existence of the phenomenon, as evidenced by Sallam's remarks regarding the tourism industry. But many issues remain social taboos, and the task of providing honest, non-sensationalist information remains very difficult.

One prominent television presenter attending the conference said he would never think of discussing AIDS now. "To discuss the transmission of the disease from mother to child is fine, but to talk about homosexuality in Egypt will outrage the public," he said. Mass awareness campaigns are also shunned because they could create a panic. So while Earth Day or the Day of the Child can mobilise celebrities and increase awareness, AIDS Day still triggers too much controversy to be of much help to the sufferers themselves.

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