HIV Prevalence In Africa Distorted By Statistics

I almost hit the roof when I saw a recent study presented in Durban, South Africa that 20 percent of the richest Africans have higher prevalence rate of HIV than the poorest 20 percent. This conclusion on its face may seem right because of the number of people interviewed and the amount of blood samples taken. The reputable Researcher, Vinod Mishra, raised eye brows because of the interpretation. Statistic is a wonderful tool in scientific study, but sometimes we get carried away by skewed data that is in variance to local established socio-economic culture leading to wrong interpretation.

The bigger picture that came to me was that of pharmaceutical companies that President Clinton has lobbied so hard to convince to forgo some of their profit in order to supply their expensive drugs to the very poor around the world. How do we shift focus to the richest 20 percent in Africa?

If this was a study that was limited to professional or scientific literature where it could be sorted out among peers, it would be hard to swallow and I would be less concerned. It has gained notice in newspapers and must have caught the attention of individual donors, many Non-Profit organizations, as well as generous businesses who donate to the poor countries. In United Stated States, the largest source of donors in 2005, are individuals who contributed over 76 percent of the total charitable relief gifts.

At the schools of Public Health, vital statistic is exactly that, vital in its interpretation of morbidity, mortality or incidence and prevalence of diseases. There has to be a deep understanding of what you are interpreting scientifically and socially. For instance, in a community where most of the infectious diseases have been eradicated, a few out-breaks of one of these exotic diseases may be declared as an epidemic with some experts set out to arrest the plaque and others running for cover. To gain the same status in an endemic environment, it would be more than a few break-outs.

The best way to put this into perspective is to ask who the 20 percent richest are in Africa. Can they be the ones that make more than a dollar a day to survive? Or we are talking about the one percent that steal the treasury blind and are seen as the rich in the Western world? They can also be the small business people that live the same way as most working class in the Western World but are seen as rich in Africa because they provide their own bore holes for water and generators for electricity with old Mercedes or BMW to match. Their fortunes change as the weather. Can you see the misunderstanding of underlining local socio-economic culture can affect straight statistical study?

We can illustrate the underlining sociology by extrapolating to the developed countries with some very poor areas. Since many of the grant donors also come from USA, New York or Boston or Los Angeles will do. The first noticeable prevalence of HIV in the United States was in the middle class gay communities in Los Angeles until it starts spreading to the poor areas. As the disease became poor people’s disease, the white middle class gays were able to take care of themselves because of access to health care and health insurance. They could also afford expensive drugs that kept them alive.

Indeed conservative attitude among blacks might have been responsible for lower incidence among them compared to rich or middle class gays at that time. So if a study was done then in a poor location where there were many Blacks or Hispanics, you could have guessed what statistic would show: A lower HIV prevalence among poor than among the middle class or affluent gay men.

In the Black and Hispanic communities, the virus itself spread more rapidly killing many before they could gain access to health care and many had no insurance anyway. The determinative factor that blacks are more conservative in the area of gay sex disguised the macho bisexual men with the virus not to reveal their sexual life style in the community. In many cases, by passing it on to their unsuspecting wives and girl friends resulted in higher incidence in this class and their children. In addition to drugs by needle sharing.

Back to Africa, the researcher gave reasonable reasons for the higher prevalence among the richest 20 percent as: men with multiple women, enough money to buy sex and afford travels. But that is true anywhere, not only in Africa. Western countries need to get off their high horse about the so called many wives. Women are women, no matter how many you have, and where. Sex is the end result and men seek that anywhere in the world as long as they desire sex and can afford it. Because Africans take equal responsibility for all their children and their mothers, some called those mothers many wives. They refer to their own many women as girl-friends, mistresses or the “other woman”.

In terms of the lowest or the poorest 20 percent in Africa or the lowest 40 or 60 percent, there is hardly any difference. It is when we start talking about 80 to 20 percent that we may start noticing some but not much difference. We have to realize that unlike other developing countries and the developed worlds, most of Africa’s middle class have been wiped out by imbalance trade and structural adjustment of their currencies that makes foreign products expensive. They can not join the rich clubs of the world and sell their products and when they do, they sell raw natural materials at buyers’ dictated price, except oil. It is then resold back to them as finished products at sellers’ price. The consequences of which, more is taken out of them than exchanged.

This study may have different interpretation if the next 20 percent is better off than the preceding 20 percent as in other countries. It is not so in most African countries. In that case, the study was actually comparing 80 percent of poorest Africans with 20 percent of not so poor. If we were talking about 90 - 99 percent of poor Africans to 1 - 9 percent of middle class and one percent of rich Africans, the study might have given opposite result.

It is not my intension to introduce statistics into an article like this but a very simple demonstration can not hurt even some of us not interested in mathematics or statistics.

In a population of a hundred, let us say we take 20 richest and 10 percent were HIV positive. That will be about 2 people. Among the 20 poorest let us say 5 percent of them are HIV positive. Say one person. The mistake here is to focus on 2 of the richest because they are more than 1 of the poorest. However, we are saying that the numbers of poorest with HIV are more if we realize that 80 percent of Africans fall into that same category.

Moreover, the 20 percent of the richest is fallacious because there are not that many rich as understood in, or compared to Western world. Indeed, more than 90 percent of Africans fall into the poor category since there are very few middle class left as stated.

Whatever the case, how are we going to sell the idea of cheap drugs or grants in the name of 20 percent richest people to individuals that contribute the biggest block of the funds? The principle of Public Health is to spend the greater part of the dollar/naira on the greatest number of people. Looking for rich people in Africa who hardly spend any time in African hospitals to spend money on is at the expense of the poor. If the reason is to reach them through health education to prevent the spread, they have more access to TV programs and newspapers worldwide than the poor. Saying that majority of HIV-infected people are the wealthiest in this study is nothing short of statistical distortion. 

There is one good interpretation for the study though. If we take the same number of poor and the same number of rich people, it seems that the rich are more promiscuous than the poor. That makes more sense since the poor are too busy with the task of everyday living than the rich who have more leisure time to travel out of their commune to exotic places.

It also demonstrates the fact that HIV virus is a sophisticated disease introduced to the poor by the sexual exploration of the rich. In South Africa, sexual promiscuity and intermingling of foreigners was an attraction in Soweto where the Apartheid Government tried to create a homeland for some Blacks who in turn cater for tourists’ needs and their desires in town. This could be how the incidence of HIV virus filtered to the rest of South Africa. It may support the notion that, indeed, it was an imported disease.

Nevertheless, we must take care of everyone, rich or poor within limited resources. It is only fair that we ask the rich to pay more for their healthcare. That is why it will be extremely difficult to present 20 percent of the richest Africans to the rest of the world as in dire need of cheap drugs. Those rich enough to buy expensive drugs as AZT are part of the one percent rich class in many African countries. Most are already doing that without donors’ contributions and can afford to travel out for treatment.

As more African countries take care of their own destiny, there will be less need to ask others for drugs or foreign aides that can be generated within their own local economy.

Locally produced and generated wealth creates the type of percentile where one economic class may be easier to compare to another as it is done in the Western world.