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?

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."

So Kanki sets her sights on western Africa, where there is still a chance to avoid the fate of the south. Katzenstein admires her resolve, if he isn't a little bit envious of her opportunity. Yet he notes her limited financial resources -- $25 million to spend in a country of 120 million people equals about 20 cents per person. "I'm sure Phyllis will be very thoughtful and come up with the best way to spend that quarter to stop something bad from happening," he says. "But how to evaluate if it is the right way is a very difficult question."

Indeed, Kanki will have to face the same hard choices in her prevention efforts that Katzenstein faces every day as a doctor treating those already diseased: deciding who lives and who dies.

Dr. Kanki uses a piece of scrap paper to sketch her model for how best to direct AIDS prevention in Nigeria. She draws a glass beaker mostly full of water. Above it she adds a large faucet that pours a strong, continuous flow. She labels the container "high risk population" to signify the people already infected by HIV, for whom prevention is moot. Next to that beaker she draws another, which holds just a puddle of water. She puts a faucet over it, too -- a tiny spigot, really -- trickling just a few drops at a time to account for the inevitable infections in this "low risk population." Then she adds a conduit connecting the tops of the beakers, symbolizing what she calls the "bridge population." As the water reaches the top of one beaker, it spills over and flows through the conduit, rapidly filling the other. This spillover is what Kanki hopes to prevent. While there is not much that can be done for those already drowning in the first beaker, Kanki thinks she has a chance to spare the people in the second -- if she can keep that bridge population from becoming the channel to everyone's demise.

The tricky part is figuring out who belongs to which group. Many assumptions -- some of them wrong -- have been made in Africa about high- and low-risk populations, while not much attention has been paid to bridge groups. Kanki plans to start afresh with scientific investigation. "To find the real movers of the epidemic, we have to look beyond the groups most people think of as high-risk. We have to be more honest about who the real culprits are," she says. "One conventional wisdom says we should exclusively target the so-called high-risk groups, and another says just deal with the kids. I think both are incorrect. My conventional wisdom says that this epidemic has lots of different interplays between all the risk and bridge groups. And if we don't try to understand that from the outset, we will not be maximizing our chances to stop it."

Kanki is prepared to redefine what "risk group" means. For example, she says it is typical to single out prostitutes, but few have looked at the men who go to them -- men who span the gamut of society. She also notes that such studies do not account for all the women who are paid for their services, like teenage girls who prefer an older man with status to act as a "sugar daddy," or the single mothers who seek a boyfriend to help pay for their children's care, in exchange for sexual favors. These women are hardly commercial sex workers, but the men in their lives usually have many such girlfriends -- and visit bona fide prostitutes on the side, Kanki says. "There are a lot of behaviors defined by culture and modified by religion and economic standing that haven't been considered," she says. "Most people view Africa as one monolithic place. But in order to really be effective, you have to appreciate that Africa is a patchwork of thoroughly individual places and behaviors. To go in and blindly apply any one principle across the board has proven to be nothing more than disastrous."

As the most populated country in Africa, Nigeria is as complex as the issue of risk groups. The percentage of infection rates varies widely between the country's northern and southern states, as well as between its urban and rural areas. While a particular group could be labeled high- or low-risk in one place, it may not be so somewhere else, for any number of different reasons. That's why Kanki hopes to catalog all the possible scenarios before she implements any prevention programs. She has to determine what groups have which strain of the HIV virus, engage in which behavior, and contribute how much to the epidemic as a whole. The novelty of her approach lies in its precision: Every endeavor funded by the Gates Foundation will be tailored to a specifically identified group. "We need to know who is most important to the overall goal, because ultimately, we need to know where to put the money," she says. "It is like triage: deciding where to go first to have the most effect."

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