Pin It

Out of Africa 

Some say Phyllis Kanki saved Senegal from AIDS. But can the controversial triage approach she's developing at Stanford protect the continent's western edge from the devastation suffered in the south?

Wednesday, May 16 2001
Comments
From a window table overlooking the tree-lined stretch of boutiques, bookstores, and cafes near the Stanford University campus, two professors dine on spring rolls and tom yum soup as they ruminate on life and death half a world away. Drs. Phyllis Kanki and David Katzenstein often work on opposite ends of sub-Saharan Africa, where the effect of the AIDS epidemic -- and their perspectives on it -- differs widely. Today they make time to compare notes at a small Thai restaurant in downtown Palo Alto. Their lunchtime conversation, laced with conflicting notions of hope and angst, shows how complex the state of AIDS in Africa really is.


Kanki's efforts are concentrated on the western side of the continent, where the prevalence of the AIDS-causing HIV virus is among the lowest in Africa -- in Senegal, it's under 2 percent. The Harvard virologist is hopeful. But Katzenstein works thousands of miles to the south, mostly in Zimbabwe, where a quarter of the adult population has HIV -- one of the highest infection rates in the world. The Stanford physician is troubled. Their outlooks are reflected in their spirited discussion, which makes for some good-natured indigestion.

"I don't know why things are going so well in Senegal," Katzenstein says in a sarcastic tone as he dips his spoon in the peanut sauce. "I'd like to think it was because of Phyllis' work in the west that fixed everything."

"Don't be such a boob, David," Kanki retorts.

If Katzenstein sounds bitter, it is because his work is in a land facing meltdown. He must deal with infection rates so high that prevention efforts are moot, as the nation -- like so many in southern Africa -- loses the healthy citizenry needed to maintain a functioning government or economy. Of the nearly 22 million people estimated to have been killed by AIDS worldwide since the epidemic began, 17 million were sub-Saharan Africans. In contrast, Kanki (a guest in Katzenstein's Stanford lab this year) wants to think certain devastation is not the continent's uniform fate -- at least not in the west, where a weaker strain of HIV predominates and governments have been more proactive in tackling AIDS. She is careful to sound modest, because she knows her attempt to replicate Senegal's success in neighboring countries, like Nigeria, could fall short. But as long as the infection rate remains stable in western Africa, she has time to implement some new prevention strategies rarely utilized in the far-gone south.

Kanki departs from the conventional method of supporting one-size-fits-all programs, most of which prove unfocused and ineffective, and provide little or no scientific data to help understand the true nature and trajectory of the disease. Instead, she advocates a potentially controversial triage approach that identifies and targets specific groups of people; groups that can benefit most from a customized message and in turn slow the epidemic for everyone else. Students, for instance -- the future doctors, teachers, and leaders of a country -- are an essential "bridge population" she hopes to keep alive. In support of this theory, Kanki has been given $25 million from the Bill and Melinda Gates Foundation with the goal of preventing Nigeria -- Africa's most populous nation -- from going the way of Zimbabwe.


Their lunch continues for hours, as does the argument.

Dr. Katzenstein is skeptical of his Harvard colleague's methods.

"Look where 15 years of prevention in Zimbabwe have gotten us," he says. "The question is, if what you are doing is not working, how long do you do it?"

"But no one ever asked if it was working," Dr. Kanki implores. "We could've found out what doesn't work, but no education or prevention studies ever looked at a biological outcome."

Kanki rattles off a long list of failed initiatives in which data were based on verbal surveys alone, without ever taking a blood sample. With such limited data, behavioral changes could never be proven or linked with infection rates. Worse, an accurate and scientific history of the disease -- caused by multiple strains of the HIV virus -- has never been recorded in Africa, which makes treatment all the more difficult.

"OK, so the prevention was done badly," Katzenstein says. "But effective prevention won't make a difference in the hyperepidemic situation we have now."

Maybe prevention won't help in Zimbabwe, where Katzenstein can only prolong some lives by dispensing a limited supply of drugs to an exponentially growing number of patients -- when he isn't wondering if the drugs will work at all, given that he's unsure which strains of HIV he is fighting. But it hasn't gotten to that point in Nigeria. Yet. With Nigeria's HIV infection rate already thought to be as high as 7 percent and growing, Kanki is well aware that the country is an AIDS time bomb. She is determined to be judicious in her approach, hoping for successful intervention while laying the proper scientific groundwork to collect data. That way, if AIDS does explode in the west, at least she will have reliable information from which to make a new plan.

Katzenstein understands her intentions, but they are too far from his own reality to embrace. "You're trying to treat an epidemic rather than individual patients," the physician Katzenstein tells the virologist Kanki. "The notion we can do scientific prevention is the great hope, but as a physician I am bound by the Hippocratic oath and the Marcus Welby approach: one person at a time. It may not be the most rational approach -- spending all the money on the last few months of life, instead of putting it all into prevention -- but we are not rational when it comes to our brothers, mothers, or sisters."

Such sentiment resonates with Kanki, though she doesn't shy away from what she sees as a stark truth: "I believe in tailored intervention, which can include treatment," she says. "But it is incorrect to imply we are curing people. Until there is a vaccine, everyone who gets this disease is going to die. There is no compassionate way to say we shouldn't be giving drugs to people."

About The Author

Joel P. Engardio

Comments

Subscribe to this thread:

Add a comment

Slideshows

  • Nevada City and the South Yuba River: A gold country getaway

    Nestled in the green pine-covered hills of the Northern Sierra Nevada is the Gold Rush town of Nevada City. Beautiful Victorian houses line the streets, keeping the old-time charm alive, and a vibrant downtown is home to world-class art, theater and music. The nearby South Yuba River State Park is known for its emerald swimming holes during the summer and radiant leaf colors during autumn. These days the gold panning is more for tourists than prospectors, but the gold miner spirit is still in the air.

    South Yuba River State Park and Swimming Holes:
    The park runs along and below 20 miles of the South Yuba River, offering hiking, mountain biking, gold panning and swimming. The Highway 49 bridge swimming hole is seven-miles northwest of Nevada City where Highway 49 crosses the South Yuba River. Parking is readily available and it is a short, steep hike to a stunning swimming hole beneath a footbridge. For the more intrepid, trails extend along the river with access to secluded swim spots. The Bridgeport swimming hole has calm waters and a sandy beach -- good for families and cookouts -- and is located 14 miles northwest of Nevada City. Be sure to write down directions before heading out, GPS may not be available. Most swimming holes on the South Yuba River are best from July to September, while winter and spring can bring dangerous rapids. Always know the current before jumping in!

    Downtown Nevada City
    The welcoming, walkable downtown of Nevada City is laid back, yet full of life. Start your day at the cozy South Pine Cafe (110 S Pine St.) with a lobster benedict or a spicy Jamaican tofu scramble. Then stroll the streets and stop into the shop Kitkitdizzi (423 Broad St.) for handcrafted goods unique to the region, vintage wears and local art “all with California gold rush swagger,” as stated by owners Carrie Hawthorne and Kira Westly. Surrounded by Gold Rush history, modern gold jewelry is made from locally found nuggets and is found at Utopian Stone Custom Jewelers (301 Broad St.). For a coffee shop with Victorian charm try The Curly Wolf (217 Broad St.), an espresso house and music venue with German pastries and light fare. A perfect way to cool down during the hot summer months can be found at Treats (110 York St.) , an artisan ice cream shop with flavors like pear ginger sorbet or vegan chai coconut. Nightlife is aplenty with music halls, alehouses or dive bars like the Mine Shaft Saloon (222 Broad St.).

    The Willo Steakhouse (16898 State Hwy 49, Nevada City)
    Along Highway 49, just west of Nevada City, is The Willo, a classic roadhouse and bar where you’re welcomed by the smell of steak and a dining room full of locals. In 1947 a Quonset hut (a semi-cylindrical building) was purchased from the US Army and transported to its current location, and opened as a bar, which became popular with lumberjacks and miners. The bar was passed down through the decades and a covered structure was added to enlarge the bar and create a dining area. The original Quonset beams are still visible in the bar and current owners Mike Byrne and Nancy Wilson keep the roadhouse tradition going with carefully aged New York steaks and house made ingredients. Pair your steak or fish with a local wine, such as the Rough and Ready Red, or bring your own for a small corkage fee. Check the website for specials, such as rib-eye on Fridays.

    Outside Inn (575 E Broad St.)
    A 16-room motel a short walk from downtown, each room features a unique décor, such as the Paddlers’ Suite or the Wildflower Room. A friendly staff and an office full of information about local trails, swimming and biking gets you started on your outdoor exploration. Amenities include an outdoor shower, a summer swimming pool and picnic tables and barbeques. Don’t miss the free vegetable cart just outside the motel in the mornings.

    Written and photographed by Beth LaBerge for the SF Weekly.

  • Arcade Fire at Shoreline
    Arcade Fire opened their US tour at Shoreline Amphitheater to a full house who was there in support of their album "Reflector," which was released last fall. Dan Deacon opened the show to a happily surprised early audience and got the crowd actively dancing and warmed up. DEVO was originally on the bill to support Arcade Fire but a kayak accident last week had sidelined lead singer Mark Mothersbaugh and the duration of the west coast leg of the tour. Win Butler did a homage to DEVO by performing Uncontrollable Urge.

Popular Stories

  1. Most Popular Stories
  2. Stories You Missed
  1. Most Popular