Moammar Gaddafi's regime has condemned to death five Bulgarian nurses and a Palestinian doctor for "deliberately" infecting Libyan children with HIV in a hospital in Benghazi. The media have reported confessions made under torture and systematic sexual abuse of the nurses by prison guards. The media's scrutiny of this sorry and tragic episode has called into question Gaddafi's credibility, weak government and corrupt judiciary.
But the real AIDS story is that Libya is not unique. Patients across the developing world are being infected with HIV in the same way that these unfortunate Libyan children were -- not through sexual relations, but through poor clinical and hygiene practice. Yet while this fact is known by many health experts, both in the West and in poor countries, the media and some donor agencies, including the UN, are concentrating on sexual transmission.
When it was discovered eight years ago that 426 children had been infected with HIV (of whom 53 have since died), a Libyan magazine suggested that poor clinical hygiene was to blame. Indeed, evidence presented at the appeal court by experts from Oxford University showed that the HIV and hepatitis C the children contracted had been prevalent long before the Bulgarian nurses came along.
Indeed, the tragedy in Libya is likely being repeated routinely in any clinic suffering from the euphemistic "lack of capacity." Simply put, needles are routinely re-used and unscreened blood is transfused.
In many developing countries injections and transfusions are both administered far more frequently than is common in western medical practice. The World Health Organization estimates that 10% of total HIV infections are caused by clinical practice -- so-called iatrogenic infections. Other evidence suggests the real rate is much higher, especially in the poorest locations. As the multiple authors in the prestigious British Journal of Obstetrics and Gynaecology highlighted in a 2003 paper (http://www.cirp.org/library/disease/HIV/brody1/):
"There is mounting evidence that rapid HIV transmission is fuelled by parenteral exposures in health care settings, especially medical injections but also including transfusion of untested blood and others.....The common belief that 90% of HIV transmission in Africa is driven by heterosexual exposure is no longer tenable."
The BBC, in a rare report on the issue, reviewed the above paper and other research and said:
"Some researchers believe as many as 40% of HIV infections in African adults are linked to injections. United Nations agencies have rejected this theory, saying most cases are linked to unsafe sex. Officials have also warned that the theory could damage campaigns to get people in Africa to use condoms to protect themselves from the disease."
Mark Dybul, the U.S. Global AIDS coordinator, has explained that sexual transmission of HIV was probably stabilizing in sub-Saharan Africa thanks to education programs. However, he also rightly points out that "the new task is to stop infections through blood transfusion, which is difficult for poor countries saddled with both decrepit medical facilities and HIV infection rates reaching as high as 40 percent in some areas."
So the real question is not whether the causes of HIV are just sexual - its obvious they're not - but how do proud nations admit that their own unhygienic clinics and outdated practices are often the cause?
One way forward is simply to tell the truth. A doctor working in India we spoke with (who wished to stay anonymous) explained the case of a boy so severely anemic with malaria that his death was imminent without a transfusion. The doctor had no access to testing facilities, or supplies of fresh, clean blood. His only option would be to hook up a family member directly for a transfusion or, in an extreme case, resort to buying blood from touts outside the hospital. In Uganda, brave efforts were made to regularize its blood bank service and to introduce volunteer blood donations after infrastructure and systems had broken down during and after the the Idi Amin years. When blood taken (initially for a fee) was first tested, 25% of samples were infected with HIV, many also had Hepatitis A & C, and other sexually transmitted diseases, such as gonorrhea. It is likely to be the same in any poor country. As the Indian doctor said of his practice, "I have the choice between letting the poor little fellow die tomorrow, or running the risk that he may eventually die of AIDS." Unfortunately this truth often remains hidden since doctors such as this one are afraid of being so candid publicly, for fear of losing their jobs.
Gaddafi's perverse flair in shifting the blame to "malign" foreigners has caused shock and outrage worldwide, and we fervently hope that these hapless health workers do not face a firing squad. Yet, his actions may have done some good in bringing the causes of HIV transmission into the open. It may be that western assumptions and expectations contribute to African leaders' reluctance to point the finger of blame at other African regimes or their own government's failings; but it is surely possible for NGOs, international donors, academics to help out without being offensive. Meaning well is not good enough if the actual results are poor or perverse.
As with most afflictions keeping populations sick and poor in the world, there is a well-proven solution. In this case it is not technically difficult nor even very expensive, but it is hampered by a lack of frankness and bravery. Education programs seem to be popular with donors, so we recommend one aimed at reducing patient demand for injections (90% of doctor visits in Africa feature an injection) and replacing it with a demand for sterile, single-use vials and hypodermics. Alongside efforts to guarantee safe blood these programs could eliminate iatrogenic transmission.
And while the Washington Post, for one, has done a good job of exposing the awful Libyan story, the bigger question is, Why have hospitals and clinics all over the developing world been allowed, and unwittingly encouraged, to transmit deadly disease for so long?
Lorraine Mooney is a medical demographer with Africa Fighting Malaria, Roger Bate a Resident Fellow of the American Enterprise Institute.