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?

"It's certainly not cost-effective if treatment dollars take away from prevention dollars," Kanki says.

But just as Katzenstein begins to erupt in an arm-flailing shout of dismay, Kanki digs in: "People die with AIDS, David. Even on treatment. This is not a cure," she says. "I'm not saying we shouldn't prolong life. I'm talking about a whole other issue. Drugs are not saving anybody. Prevention efforts can. That's a huge difference, and it's a hard message for people to take."

For a moment Katzenstein is silent, preferring to reach for a chicken skewer rather than respond. Kanki calls a truce, noting a third option they haven't even broached. "Going down this road is a no-win situation," she says. "That's why there are people who say, "Forget prevention, forget treatment, and spend all the money on a vaccine.' You have to agree; a vaccine is really the only way we're going to stop AIDS."

Katzenstein doesn't let Kanki finish without invoking more of the Marcus Welby creed. But he respects his colleague's point of view, and the tremendous work she has done in western Africa. He even praises her for having the forward vision to avoid the pitfall in which he finds himself in the south. "Education studies with biological outcomes should have been done a long time ago," Katzenstein says. "The travesty is that in our interest to develop low-cost interventions we have failed -- except for Phyllis in Senegal, and now Nigeria -- to even do epidemiology studies. Now we find ourselves asking, "How can we give drugs to people when we don't even know if they have the same disease?' If we had done what Phyllis did, we wouldn't be wondering if our drugs will even work."

Kanki's methods are bolstered by a recent government report issued in March. The U.S. General Accounting Office investigated the effectiveness of money spent by the U.S. Agency for International Development to battle AIDS in Africa. The study concluded that the programs' success has been limited because their funders paid insufficient attention to whether the programs work. "The missions do not always use consistent indicators to measure progress in combating the disease," the report says, "and do not routinely gather comprehensive program performance data."

Kanki has long been critical of USAID's efforts, and she makes it a point to model her programs differently. Katzenstein admits this tack has worked for her so far. "Some say what Phyllis did in Senegal was integral to that country's handle on AIDS," he says. "Whether it was cause-and-effect or just plain luck, I don't know. Maybe the same thing will happen in Nigeria."

But Kanki is loath to be pegged as someone with the Midas touch.

"I don't have a magic wand," she says. "I'm just going to go in and see what the data tells me. What I decide to do with it might not even work."

Katzenstein laughs. He has learned not to underestimate his colleague. "Of anyone I know," he says, "Phyllis will probably guess right."

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