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?

Kanki rolls her eyes when she recalls the campus rallies where thousands of "safe sex" T-shirts were handed out to students. She understands the notion was to raise awareness, but in her view, the best way to grab the attention of someone is to test him for HIV. "Testing works, because it is very personal," she says. "You have to acknowledge the situation when you go and stick your arm out. You have to say, "Yeah, I want to know.'"

But it is not easy to convince students to get tested; most don't want to know. Yet students in Africa do want to know about the Internet, and Kanki intends to use Net access as an incentive for AIDS testing. For example, students would be prompted to take an on-screen quiz about HIV risk before being able to log on to the computer. Still, there are hurdles: When it comes to tests, many are suspicious of anything requiring a signature, since it is unclear what the government might do with the information. That's why Kanki wants to set up anonymous HIV testing sites that also offer peer counseling. She thinks a place where students guide each other, with free and unsigned testing -- a service for and by young Africans -- would be welcomed.

Kanki likes to use insiders as more effective purveyors of her message. For instance, when she sees a need to reach rural populations, she taps into the well-established network of African agricultural teachers who visit outlying areas, training farmers how to grow better crops. "I use them to teach about HIV -- when they're done talking about the fertilizer and the plows," Kanki says. "It's sort of cool. The farmers listen, because there is a built-in respectability that goes with people they are familiar with and trust."

Kanki also believes in giving African doctors and researchers a stake in the success or failure of the initiatives. She tries to avoid making dumb mistakes by relying on their know-how. "You always want to ask local people what they think, involve them in all the work, and let them own it," she says. Getting the country's politicians on her side is equally important. "Resources aside, the government has to step up to the plate to do something -- even if just to acknowledge the problem -- if there are going to be any meaningful results. That's why countries like Senegal are touted as doing so well."

Kanki has seen some promising returns on the 16 years she's spent trying to fend off AIDS in western Africa. But she had some key factors already going for her in Senegal. Among them were a less virulent strain of HIV than that found in the south (suggesting that a slower spread of AIDS in the west may have had as much to do with the virus itself as with prevention efforts), a highly competent native medical community, and a stable government supporting the work from the earliest days of the epidemic.

The situation has been less ideal in Nigeria, where there has been a long history of political chaos and corruption. Before democratic President Olusegun Obasanjo took power three years ago, the Nigerian government under military rule had almost completely neglected AIDS. Kanki finds the new leader's interest in AIDS encouraging and is banking on his support (last week, Obasanjo met with President Bush at the White House to discuss a global AIDS fund that emphasizes the fight in Africa). Kanki is also working with some very good Nigerian physicians and virologists, and she is hopeful that she'll have an effect similar to the one in Senegal.

But in southern countries like Zimbabwe, Kanki's colleague Katzenstein has not been so fortunate. He says that involving government officials or even local doctors in relief efforts can be a drawback, especially when the former are too corrupt and the latter too burned-out to be of much help. Given the AIDS crisis there, Katzenstein has even advocated suspending some common ethical standards. For example, it may be infeasible to do things in a developing country the way they are done in the U.S., as with full-scale clinical trials and informed consent. Those methods take too long and get in the way of tending to the overwhelming masses of infected people, he claims. Kanki bristles at this notion, and they spar on the point. While Kanki concedes that an initiative may fail due to local ignorance or ineptitude, she is adamant that if African doctors and politicians are left out, it is destined to fail. As for methodology, she believes in going by the book. She reasons that shortcuts will not really save more lives, since there is no cure for AIDS; in fact, they'll only result in bad data to add confusion down the line. Katzenstein argues that his situation is different, reminding Kanki that she hasn't yet had to work in an environment of utter despair.

"You mean these people are so bad off, and their doctors so incompetent, that anything you can do -- no matter how small -- will help them?" Kanki asks him. "You don't live in Zimbabwe, you don't practice medicine in Zimbabwe, but you will go there from your Stanford lab and try to save them?"

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