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?

The controversial nature of that statement is not lost on Kanki.

"People will want to know why we aren't focusing on everybody," she says. "But the reality is, we can't intervene in all populations if we're going to do it well. We have to be practical. We have to stop the bleeding. You can't save everybody, but you can save the people you have the best chance to do the most good for. I don't want to state it as letting some groups go. Instead, I would state that there are certain groups where the need is more urgent to stop the epidemic; groups for which a negative outcome will have more serious consequences for all."

Kanki won't say which Nigerian populations will benefit from her prevention efforts. Her research, only a few months old, hasn't determined that yet. But there is one group she will publicly mention as warranting special attention: students. In her view, high school and university students are sexually experimenting, mostly concentrated in urban environments, and influenced by Euro/American pop culture and mores. But she also sees them as uniquely African, many tempered by war, poverty, and the hardships of rural village life, part of a growing educated and professional class. In short, they're the ultimate bridge population -- a new generation connecting the disparate worlds of their homeland. "They are really the hope for their country. These are the future doctors, lawyers, engineers, and business leaders who will keep society going and maintain the stability of a young democracy," Kanki says. "Other parts of Africa have already lost so much of that segment of the population. The figures from Botswana and the south are scary: half of all 15- to 20-year-olds [will die from AIDS]."

Researchers at the University of California at San Francisco predict that in the next four years, AIDS will claim the lives of up to 25 percent of southern Africa's doctors. UNICEF reports that nearly a million sub-Saharan primary-school children lost at least one teacher to AIDS in 1999 alone. For Kanki, keeping enough students alive to replenish this dearth of doctors, teachers, and the like is paramount. "These are the people who will save the country in the end," she says, "if we can save them."

An impressive number of African educators and university officials met with their North American counterparts at a University of Florida-based conference in March to discuss the state of higher education in Africa. They talked about the usual critical topics: curriculum, information technology, donors. But the final seminar -- "Brain Drain: HIV/AIDS" -- cast an ominous pall on everything else that was said at the three-day symposium.

The African delegation openly expressed its fears that AIDS would undercut any hope to educate and train a population vital to the success of any country. P.J.M. Ssebuwufu, the vice chancellor of Uganda's Makerere University, spoke about the pain of having to attend as many as five AIDS-related funerals a week. His east African country -- where the adult HIV prevalence rate hovers above 8 percent -- is in better shape than the south but in a crisis compared to the west. Makerere University won't be included with Kanki's Nigerian initiative in western Africa, so Ssebuwufu has started his own AIDS prevention program on campus. The effort is having some effect, but doesn't yet offer much cause to celebrate: He still goes to two or three funerals a week.

"Setting up this program was one of the hardest things I've ever had to do in my educational career. I had much difficulty starting it at my university -- and I'm the vice chancellor!" Ssebuwufu says, referring to the trials of getting anything done in a country with its government and institutions often in political and financial turmoil. He also faces resistance to the AIDS message itself, from both administrators in denial and students who refuse to be tested or to use condoms for a plethora of cultural and social reasons.

Ssebuwufu hasn't met Dr. Kanki, but if he did, he might caution her against high expectations -- especially as an outsider to the people and customs she plans to influence. Kanki knows the drill. She is well aware of how hard it is to get students not only to listen to, but also to act upon, the lifesaving information they are told. And Ssebuwufu is an accepted local authority figure, unlike Kanki. As a third-generation Japanese-American born and raised in Chicago and educated at Harvard, the fortysomething doctor knows it is quite a stretch for her to relate to an African college student.

It's not just the attitudes of the students that Kanki worries about; the tactics of many international agencies also bother her. As she sees it, misinformed European and American philanthropists with bad data and questionable expertise parachute in to save a country, as if they know best. "How does anyone expect a bunch of old, white men from Virginia to promote condom use to 300 different African ethnic groups? That's beyond challenging. It's just plain bizarre," Kanki says. "Every poor country got crates of condoms -- the U.S. practically airlifted billions of condoms -- with not so much as an instruction manual. Never were any Africans involved. No one asked the people who actually live there how to best run the program. It was a silly exercise, and there's not much to show for it."

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