According to mainstream scientists, HIV transmission in Africa operates differently than elsewhere. An alternative view has been systematically ignored and silenced.

HIV prevalence in Africa

AIDS is the most deadly new disease in humans, with the estimated death toll exceeding 30 million. In order to restrain the spread of the infective agent HIV, scientists have tried to figure out how it spreads. The consensus is that HIV is most contagious via blood-to-blood exposures, such as through shared injecting needles, and in comparison the risks of transmission via heterosexual sex and childbirth are small.

However, there’s a mystery in relation to Africa. The scientific consensus is that in Africa, unlike elsewhere, HIV spreads mainly through heterosexual sex. Why should this be?

John Potterat is a public health researcher who spent decades tracking the spread sexually transmitted diseases in the US. He became interested in the African mystery and developed an alternative hypothesis. He and colleagues wrote many scientific papers about it, but were rebuffed by mainstream scientists. Here I will tell about Potterat’s experience drawing primarily on his engagingly written book Seeking the positives: a life spent on the cutting edge of public health, in particular the chapter “Why Africa? The puzzle of intense HIV transmission in heterosexuals”.

Some background

My own interest in research on AIDS derives from a different controversy, the one over the origin of AIDS. The standard view is that AIDS first appeared in Africa and was due to a chimpanzee virus, called a simian immunodeficiency virus or SIV, that got into a human, where it was called a human immunodeficiency virus or HIV. Chimps have quite a few SIVs, but these don’t hurt them presumably because they have been around long enough for the population to adapt to them, in the usual evolutionary manner. There are various species of chimps, and when a chimp is exposed to an unfamiliar SIV, it can develop AIDS-like symptoms.

            So the question is, how did a chimp SIV enter the human species and become transmissible? The orthodox view is that this occurred when a hunter was butchering a chimp and got chimp blood in a cut, or perhaps when a human was bitten by a chimp, or perhaps through rituals in which participants injected chimp blood.

In 1990, I began corresponding with an independent scholar named Louis Pascal who had written papers arguing that transmissible HIV could have entered humans through a polio vaccination campaign in what is present-day Congo, in which nearly a million people were given a live-virus polio vaccine that had been grown on monkey kidneys. The campaign’s time, 1957 to 1960, and location, central Africa, coincided with the earliest known HIV-positive blood samples and the earliest known AIDS cases.

            Despite the plausibility and importance of Pascal’s ideas, no journal would publish his articles, so I arranged for his major article to be published in a working-paper series at the University of Wollongong. Independently of this, the polio-vaccine theory became big news. Later, writer Edward Hooper carried out exhaustive investigations, collected much new evidence and wrote a mammoth book, The River, that put the theory on the scientific agenda. Over the years, I wrote quite a few articles about the theory, not to endorse it but to argue that it deserved attention and that scientific and medical researchers were treating it unfairly.

In the course of this lengthy controversy — which is not over — I became increasingly familiar with the techniques used by mainstream scientists to discredit a rival, unwelcome alternative view. I had been studying this, on and off, since the early 1980s; the origin-of-AIDS saga made me even more attuned to how dissenting ideas and researchers can be discredited.

With this background, when I read John Potterat’s chapter “Why Africa?” it was like he was providing a front-row seat for a tutorial on how an unwelcome view can be marginalised. I saw one familiar technique after another.

I’m not here to say that Potterat’s view is correct. Furthermore, unlike the origin-of-AIDS debate, I haven’t studied writings about HIV transmission in Africa. What I do here is outline Potterat’s account of his experiences and comment on the techniques used to dismiss or discredit the ideas he and his collaborators presented to the scientific community.

John Potterat

Contact tracing

HIV is infectious, so it is important to know exactly how it gets from one person to another. Knowing transmission routes is the basis for developing policies and advice to prevent the spread of the virus.

In Seeking the Positives, Potterat tells about his personal journey in scientific work. It was unusual. With a degree in medieval history, he ended up with a job in Colorado Springs (a moderate-sized town in Colorado) tracking down networks of people with sexually transmitted diseases (STDs). Learning from his mentors, the approach he developed and pursued with vigour was to interview infected individuals, find out their sexual or injecting-drug partners and proceed to build up a database revealing the interactions that spread the disease. The military base near the city meant there were lots of prostitutes (some permanent, some seasonal) and STDs to track. This sort of shoe-leather investigation (seeking those positive for disease) led to many insights reflected in a vigorous publication programme. For the Colorado Springs research team, AIDS became a key focus from the 1980s on.

When submitting a paper to a scientific journal, editors and reviewers are supposed to assess it on its merits. It should not matter whether an author has a PhD in epidemiology from Oxford or no degree at all. The test is the quality of the paper. Potterat became the author of dozens of scientific papers. However, his unusual background may have been held against him in certain circles.

In Seeking the Positives, Potterat doesn’t tell that much about his team’s clients/informants. Sensitively interviewing prostitutes, partners of prostitutes, drug users, gay men and others would have been a fascinating topic in itself, but Potterat focuses on the research side of the story.

A diagram from one of Potterat’s papers

            You might think that contact tracing is an obvious way to study the transmission of disease, especially a new disease for which the patterns of contagion are not fully understood. But what Potterat’s team was doing was unusual: mainstream AIDS researchers pursued other approaches. Because the mainstream researchers had lots of research money, they didn’t take kindly to a small, non-prestigious team doing something different.

Mainstream groups, both researchers and activists, raised a series of objections to HIV contact tracing. First they said there was no reason for contact tracing unless there was a test for HIV. Second, after a test became available in 1985, they said tracing would allow the government to compile lists of homosexuals. Third, they said that without effective treatment, notifying individuals would distress them and lead to suicides. Fourth, after the drug AZT became available in 1987, they said contact tracing would be too expensive.

            The interesting thing here is that none of the objections was backed by any evidence. Potterat says that in his team’s studies nearly all of those approached for contact tracing were very helpful.

“Contact tracing was generally opposed by AIDS activists, by civil libertarians, and (disappointingly) by many public health workers, who were often influenced by political correctness and by not wanting to offend strident constituencies.” (pp. 68-69)

Later, mainstream public health officials in the US took the line that AIDS was a danger to the heterosexual population, not just to gays and injecting drug users. If HIV was highly contagious in the wider population, this lowered the stigma attached to gays and injecting drug users, and coincidentally made it possible to attract more funding to counter the disease, a worthy objective. However, contact tracing showed that HIV transmission was far higher in specific populations. This was another reason the research by Potterat’s group, published in mainstream journals, didn’t lead to changes in research priorities more generally.

HIV transmission in Africa

In 2000, Potterat was approached by David Gisselquist about the spread of AIDS in Africa, questioning the usual explanations for why the mechanisms were claimed to be different from those in Western countries. After his retirement the following year, Potterat and some of his collaborators joined with Gisselquist in examining the studies that had been made.

David Gisselquist

            The orthodox view was that in Africa, uniquely, HIV transmission occurs primarily through heterosexual sexual activity. This, according to Potterat et al., was based on assumptions about high frequencies of sexual interactions and high numbers of partners, neither of which were supported by evidence. They said the evidence suggested that sexual activity in Africa was much like elsewhere in the world.

In this was the case, the orthodox view couldn’t explain HIV transmission in Africa, so what could? The answer, according to Potterat and his collaborators, was skin-puncture transmission that occurred when contaminated needles were reused during health-care interventions such as blood testing, vaccinations and dental work, plus tattooing and traditional medical practices. This was heresy. It was also important for public health. Potterat writes, “Only when people have accurate knowledge of HIV modes of transmission can they make good decisions to protect themselves and their families from inadvertent infection.” (p. 200)

Potterat’s team wrote dozens of papers, but they had a hard time getting them published in top journals, where orthodoxy had its strongest grip. Nevertheless, they were quite successful in publishing in reputable journals of slightly lower standing.

Responses

The most common response was to ignore their work. Even though Potterat et al. had poked large holes in the orthodox view, orthodoxy was safe if the critique was given no attention.

Another response was to try to prevent publication of orthodoxy-challenging research. One study was by a team, not Potterat’s, involving Janet St. Lawrence, then at the Centers for Disease Control and Prevention (CDC), and her colleagues. According to Potterat, St. Lawrence’s CDC superiors asked her not to publish the paper, but she refused. The paper was rejected by several journals, and then submitted to the International Journal of STD & AIDS. After peer review and acceptance, the CDC applied pressure on the editor to withdraw acceptance, but he refused. This is just one example of efforts made to block publication of dissenting research findings.

Janet St. Lawrence

“… it does not engender trust in the official view to know that our informal group has solid evidence of several instances by international health agencies actively working to suppress findings supportive of non-sexual transmission and to discourage research into non-sexual transmission.” (p. 221)

Another tactic was to misrepresent views. On 14 March 2003, the World Health Organisation held a meeting of experts to, as stated in a memo to participants, “bring together the leading epidemiological and modeling experts with Gisselquist and Potterat.” Potterat was dismayed by the consultation: data disagreeing with the orthodox view was dismissed. After the meeting, a statement was put out by WHO presented as representing a consensus. Actually, this so-called consensus statement did not represent everyone’s viewpoints, and was actually finalised prior to the conclusion of the meeting. (This was an exact parallel to what happened at an origin-of-AIDS conference.)

Potterat was surprised and disappointed to be subject to ad hominem comments, otherwise known as verbal abuse. He writes:

“Among other, less printable, things I was called ‘Africa’s Newest Plague’; ‘Core Stigmatizer’; ‘Linus Pauling—in his later years’ (when Pauling was thought to be advancing crackpot ideas); and [a reward being offered] ‘for his head on a platter’.” (pp. 193-194)

Potterat was surprised at this invective because none of his team had imagined the resistance and anger their work would trigger among mainstream agencies and researchers. He was disappointed because many of the comments came from colleagues he had previously admired.

Undone science

Researchers into the dynamics of science have coined the term “undone science” to refer to research that could be done and that people are asking to be done, but nevertheless is not carried out. A common reason is that the findings might turn out to be unwelcome to powerful groups. Governments and industry, through their control over most research funding, can stifle a potential challenge to orthodoxy by refusing to do or fund relevant research.

            Undone science is most common in areas where citizen groups are calling out for investigations, for example on the environmental effects of mining in a particular area or the health effects of a new chemical. Three research students who I supervised used the idea of undone science as a key framework for their theses, on drugs for macular degeneration, on vaccination policy, and on the cause of the cancer afflicting Tasmanian devils. My former PhD student Jody Warren and I, drawing on our previous work, wrote a paper pointing to undone science in relation to three new diseases. With this experience, I was attuned to notice cases of undone science in whatever I read. In Potterat’s chapter “Why Africa?” there were many striking examples.

In their papers, Potterat and his colleagues presented findings but, as is usual in scientific papers, acknowledged shortcomings. In one case, to counter criticisms, they reviewed research on the efficiency of HIV transmission by skin-puncturing routes, while admitting that new studies were needed to obtain better data. Potterat concludes, “To my knowledge, such studies have not been fielded.” (p. 199)

In another study, on discrepancies in studies of Hepatitis-C strains and patterns, Potterat writes, “In the intervening decade, however, no studies had been fielded to resolve these uncertainties.” (p. 199)

Potterat and his collaborators were unable to obtain external funding to carry out studies to test their hypotheses. So Potterat used his own money for a small study of HIV transmission in Africa. “Yet this pilot study supported our contentions and should have provoked the conducting of larger studies to confirm our findings. Regrettably, this did not happen.” (p. 205)

Similar responses

As stated earlier, I am not in a position to judge research about transmission of HIV in Africa. I approach the issue through Potterat’s account of the tactics used by supporters of orthodoxy against a contrary perspective. The tactics, according to him, included ignoring contrary findings, denigrating the researchers who presented them, putting out a misleading consensus statement, and refusing to fund research to investigate apparent discrepancies. I was struck by the remarkable similarity of these tactics to those used against other challenges to scientific and public-health orthodoxy. This does not prove that the dissident viewpoint is correct but is strong evidence that it has not been treated fairly. To be treated fairly is usually all that dissident scientists ask for. The hostile treatment and failure to undertake research (“undone science”) suggest that defenders of orthodoxy are, at some level, afraid the challengers might be right.

Potterat nicely summarises the multiple reasons why the findings by him and his colleagues were resisted.

“By their own admission, the international agencies feared that our work would cause Africans to lose trust in modern health care, especially childhood immunizations, as well as undermine safer sex initiatives. (Recall that their condom campaigns were also aimed at curtailing rapid population growth in sub-Saharan Africa.) We speculate that disbelief on the part of HIV researchers that medical care in Africa could be harming patients may have been a significant factor in their defensive posture. We were also impugning the quality of their scientific research and potentially threatening their livelihoods. In addition, our analyses also directly threatened the politically correct view that AIDS was not just a disease of gay men and injecting drug users, but also of heterosexuals. Lastly, our data were undermining the time-honored belief about African promiscuity, a notion that may well have initially contributed to the (pre)conception that AIDS was thriving in Africa because of it.” (p. 194)

The depressing lesson from this saga, and from the many others like it, is that science can be subject to the same sorts of groupthink, intolerance of dissent, and defence of privilege that afflict other domains such as politics. To get to the bottom of long-standing scientific disputes by trying to understand the research is bound to be time-consuming and very difficult, something few people have the time or interest to pursue. I aim at something easier: observation of the tactics used in the dispute. This doesn’t enable me to determine which side is right but does give a strong indication of whether the dispute is being pursued fairly.

Brian Martin
bmartin@uow.edu.au

Thanks to Al Klovdahl for valuable suggestions.

Obtain free downloads of John Potterat’s chapter “Why Africa?” or the entire book Seeking the Positives