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?

"Yeah, if I can, why not?" Katzenstein replies.

"I'm sorry, that sounds so imperialistic."

Kanki's views of the ineffectiveness of the "imperialistic" method are borne out in studies. In one report released in March, the World Bank announced that after extensive review, it had determined that most foreign aid programs to Africa were failures. Outsiders were unable to wield much influence, according to the study, and aid was more often successful when the countries themselves had a direct role in affecting their own change and destiny.

Despite her impressive track record -- Kanki is credited with helping discover HIV-2 as well as the Simian Immunodeficiency Virus (she started her career as a veterinarian), and her Gates Foundation award is the largest single private grant to the Harvard School of Public Health to date -- she does not mean to imply she is the one with all the answers. "What irritates me the most is when people write editorials saying, "We know what works,'" she says. "I'm not convinced we're doing anything with certainty in Africa."

Perhaps the reason why most attempts to solve Africa's AIDS problem have resulted in nothing more than a glorified Band-Aid is no one has adequately pursued one major source: economic empowerment. Joseph Oppong, a native of the west African country of Ghana and a medical geographer at the University of North Texas, holds a view on the subject shared by many of his fellow experts. As he puts it, all the condoms in the world won't make a difference if a poor woman is not in the position to insist that her partner use one.

"University students, teachers, and doctors don't have to be exposed to the virus. They choose to be. So education for such people is appropriate," Oppong says. "But many women have no choice. When a sexual exchange means supper for her kids today, she lacks the power to negotiate safer sex. Education for these women will not change their behavior. They need to be empowered. Unfortunately, it is not as politically impressive -- or easy -- to empower 10 women as it is to distribute 500,000 condoms."

On empowerment, Kanki hesitates. "It's one of those things where you say, "Gee, that makes sense.' But then you immediately wonder, "How will it ever work?' I just don't know if it is feasible."

Katzenstein concurs with Kanki on that point, though he is much less diplomatic in his view of Oppong's opinion. "Poverty is the cause of AIDS? OK, I agree. That's absolutely true. But ... this is the job of revolutionary leaders, not doctors. Empowering women may be the right thing to do, but that's not what I'm trained in. It's not my specialty. I don't know how you change the culture."

Kanki, however, is willing to try. While she realizes it may be an impossible goal to guarantee every woman a livable income, she still sees merit in addressing the big picture of which Oppong speaks. "Nigeria is extremely important to the continent economically," Kanki says, offering one reason why she chose to follow her work in Senegal there. "How the economy and sociology of a country operates is part of the answer to fighting AIDS. But you don't see too many economists involved [in the fight], and that's too bad."

In Nigeria, Kanki plans to change that absence. For her initiative there, she has enlisted the help of Jeffrey Sachs, director of the Center for International Development at Harvard's Kennedy School of Government. Her philosophy is to get as many different disciplines as she can -- from anthropology to virology -- to collaborate.

Oppong knows of Kanki's work in Senegal and finds it worthwhile. He likes her approach and does not criticize her for directing resources to specific groups. "Targeting the elite of society is better than doing nothing at all. We must do something," Oppong says. "I don't even see the "classist' argument as valid." Besides, west Africa's university students hardly fit the definition of "elite" used by the rest of the world; if anything, they are decidedly middle class. They are the children of taxi drivers, machinists, and government bureaucrats. Saving them does not mean saving only the offspring of the truly elite, the top 1 percent who control the nation's wealth and power and whose kids generally go to schools abroad.

Oppong sees great value in what Kanki proposes for the local students. But he also knows that even if the future professionals do survive, they still won't number enough to save all the rural and poor.

"When it comes to AIDS, we keep trying to cut out the cancer without treating the cause, even when we know what the cause is," Oppong says. "Until we begin to deal with the basic issues of gender equality and poverty, I'm afraid we are not going to have a whole lot of success."

The Thai soup was not filling enough, so Dr. Katzenstein orders another round of satay. He continues to engage Dr. Kanki as the afternoon wears on and the lunch crowd thins at Palo Alto's Siam Royal restaurant. They are back to arguing over the advantages of treatment.

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