AIDS: A GLOBAL ASSESSMENT : Conquering Older Health Threats While Battling on a New Frontier

Instead of despairing that the AIDS epidemic will overwhelm the global efforts to contain it, the World Health Organization sees the mobilization against the disease as a window of opportunity to significantly improve the health of the world’s people.

Preventing the spread of a sexually transmitted and blood-borne disease such as AIDS may lead to better control of other widespread infectious diseases, including bacterial infections, hepatitis B, and venereal diseases such as gonorrhea and syphilis.

And because the control of AIDS is inextricably linked to strengthening basic health services throughout the world, more children may receive immunizations against childhood illnesses such as measles and polio and more patients may receive effective treatments for scourges such as tuberculosis, leprosy and malaria.

“There is absolutely no question that AIDS has the potential to be the reason why certain changes in health practice occur which have always been suggested but which have never taken hold,” said Dr. Jonathan Mann, director of WHO’s special program on AIDS.

“These changes may or may not happen with AIDS either. But if they are going to happen, they will happen through something like AIDS,” he said.

In a row of modest sixth-floor offices with a peaceful view of Lake Geneva, about 15 officials of WHO, a United Nations agency with primary responsibility for international health, are devising a global blueprint for the battle against AIDS.

The blueprint, established through long hours of work in the last six months, includes plans to help every nation in the world develop comprehensive AIDS strategies and to raise billions of dollars in new international aid to support AIDS control and basic health services in the developing world.

Already, the special program on AIDS is working with 78 countries, including almost all the African nations, to help them develop such strategies, Mann said. The program also has raised $37 million from member nations to fund its activities this year. Its efforts have been unanimously endorsed by the World Health Assembly, WHO’s 166-member nation governing body.

The World Health Organization plans to help every country gather accurate data about AIDS virus carriers and to prepare an international Kinsey-style report on sexual practices.

In January, WHO and the British government are to jointly sponsor an unprecedented international summit on AIDS in London, to which health ministers from every country in the world will be invited.

By the end of next year, WHO expects that almost all countries will have national AIDS control programs and that the development of rapid and inexpensive diagnostic tests will make it possible to perform tests throughout the world to identify infected persons.

But the special program on AIDS also faces formidable obstacles in its efforts to tame what Dr. Daniel Tarantola, director of national program support for the special program on AIDS, called the “most intelligent disease we could possibly invent.”

“Controlling AIDS is an immensely more complicated enterprise (than eradicating smallpox),” said Dr. Donald A. Henderson, dean of the Johns Hopkins University School of Public Health and director of WHO’s smallpox eradication campaign from 1966 to 1977. “A lot of not totally probable events have to happen simultaneously. One has to be not optimistic that we are going to see dramatic changes in any short period of time.”

For WHO’s strategy to succeed:

- Hundreds of millions of people of all religious faiths and educational levels will need to change their sexual behavior--not just for weeks or months, but indefinitely. Prior attempts to change sexual behavior by, for example, promoting the use of contraceptives for family planning, have met with widespread resistance in many African and Asian nations.

“It is mind-boggling the number of condoms you need,” said Dr. James Chin, a World Health Organization consultant from the United States. Moreover, it is expected to cost about $20 to provide a year’s supply of condoms to a Third World couple, along with related educational programs, according to Dr. Jeff Harris of the U.S. Agency for International Development. This cost is much greater than the per capita health budget of many developing countries.

- Doctors and patients will need to avoid unnecessary injections and blood transfusions and to convert to the exclusive use of sterile needles, syringes and screened blood for medical procedures--a goal many health authorities believe will be very difficult to accomplish. In India, for example, “disposable needles” costing 15 cents each are often reused hundred of times at rural clinics to cut expenses.

- Billions of dollars for international AIDS control programs will need to be raised. By 1991, the budget for WHO special program on AIDS may be twice as large as the entire budget for the rest of the organization.

- The World Health Organization itself will need to solve what Henderson of Johns Hopkins University called “major problems” with its management structure, particularly in Africa where the AIDS epidemic is very severe. The problems include poor communication links between many African nations and WHO’s regional office in Brazzaville, Congo, and political patronage that can result in the appointment of poorly qualified people to key positions.

Perhaps the greatest obstacle will be the political difficulties of maintaining international cooperation in support of its AIDS programs. The organization traditionally has had good relations with countries of all ideologies and levels of development. But, like all U.N. agencies, it has limited power to influence their actions.

For example, the Zaire government still has not officially reported any of its large number of AIDS cases to the organization. And the United States has failed to pay millions of dollars toward its assessed share of the organization’s budget for the last two years, as part of an across-the-board congressional funding cutback for U.N. agencies.

An increasing number of countries are also placing AIDS-related restrictions on international travel, in disregard of WHO’s view that such restrictions are at best ineffective and at worst counterproductive.

Instead, WHO says nations can help protect uninfected individuals from the AIDS virus through such minimal steps as educating their citizens and health professionals, assuring the safety of donated blood, semen and organs, making blood tests for AIDS antibodies widely available and gathering and publicizing accurate AIDS epidemiological data.

The organization has also distributed a step-by-step guide to help nations plan AIDS virus screening programs. In general, the guide favors “voluntary” over “mandatory” measures. But left for individual nations to answer as they see fit are two key but politically charged questions: Is widespread screening necessary for AIDS prevention programs to be successful? And if it is, which population groups should be targeted and how should this be done?

In addition, the organization is encouraging nations to come to grips with the inevitable economic, social and political fallout from the AIDS epidemic, which is only beginning to be appreciated in many areas of the world.

A full understanding of these dimensions “hasn’t been reached yet,” according to Dr. William H. Foege, executive director of the Carter Center in Atlanta and a former director of the U.S. Centers for Disease Control.

The difficulties that nations have had comprehending the many ramifications of AIDS are illustrated by the problems the World Health Organization had between June, 1981, when the first AIDS cases were reported, and February, 1987, when its special program on AIDS was established.

Throughout this period, the organization remained focused on its centerpiece strategy of “Health for All by the Year 2,000,” an ambitious effort formulated in 1978 to improve the quality of life for all citizens of the world by assuring they had access to basic health services, including safe water, childhood immunizations, essential drugs and trained personnel to care for pregnant mothers and children.

It was not until late last year that Dr. Halfdan Mahler, the World Health Organization’s director-general, and other high officials realized that the unchecked spread of the AIDS virus could overnight wipe out many of the achievements of “Health for All.”

As a result, the special program on AIDS was quickly created, and Mann was elevated from a relatively low-level AIDS control position in the World Health Organization bureaucracy to the top rank of administrators who report directly to Mahler.

According to Mann, an even more significant conceptual breakthrough has occurred in recent months. This is the realization that the AIDS fight might actually “galvanize support” for “Health for All” by catalyzing “unprecedented” changes in health care throughout the world.

The development of AIDS testing capabilities may strengthen basic laboratory services while the training of health care personnel to advise prospective mothers about AIDS may lead to better care for mothers and infants.

In the years ahead, the World Health Organization will try to make this vision of controlling AIDS as well as other basic health problems a reality.

“It is an organization with problems, but also with solutions that are not possible without it,” Foege said. “If we didn’t have the WHO, we would have to invent something like it.”