(Circulation. 2000;102:e9005.)
© 2000 American Heart Association, Inc.
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Cardiovascular News
International Conference Spotlights Disaster in Sub-Saharan Africa
As the 13th International Conference on AIDS convened in Durban, South Africa, on July 9, 2000, hundreds of attendees walked out on the speech by the nation’s controversial president, Thabo Mbeki, as he attempted to defend his policy that includes skepticism about the association between the human immunodeficiency virus (HIV) and AIDS and a refusal to provide antiviral drugs to prevent infected pregnant women from passing the organism to their children. Earlier, thousands of people infected with the disease marched in protest, demanding more equitable pricing for the drugs that fight HIV.
"Some in our common world consider the questions that I and the rest of our government have raised around the HIV/AIDS issue ... as akin to grave criminal and genocidal conduct," the Associated Press reported that President Mbeki told delegates at the opening ceremony of the 13th International AIDS Conference. "What I hear said repeatedly, stridently is ‘Don’t ask questions.’"
As delegates to the meeting left the room, President Mbeki attempted to defend his action as seeking an African solution to the problem. Africa’s AIDS crisis came into clear focus this year when the international conference was held for the first time in a nation in which a significant percentage of the population carries HIV. Of the 34 million people infected with HIV worldwide, 70% live in sub-Saharan Africa, according to information released by UNAIDS, the United Nations program that oversees the fight against the disease worldwide. More than 2 million people died of the disease in the southern area of Africa last year alone.
South Africa’s AIDS problem, which had been denied during the apartheid era, is as threatening as it is in the rest of southern Africa. An estimated 4.2 million South Africans are believed to carry the virus, meaning that that nation has the largest number of infected people in the region. In some nations, the infection rate is as high as 1 in 5. Some urban areas have infection rates as high as 1 in 3 adults. The southern African nation of Botswana has the worst rate, with more than 1 in 3 adults infected.
The youth of South Africa and other southern African nations are most at risk, according to a recent study performed in South Africa by Abt Associated South Africa Inc. The study found that 60% of all adults who acquire HIV are infected before the age of 25, with young women the most vulnerable. Even those youngsters who do not become infected face a dubious future, with more than 800 000 orphans under the age of 15 anticipated by the year 2005. By 2010, the number will rise to nearly 2 million.
"The probability that you die from AIDS when you are 15 today is over 50 percent in these countries," Peter Piot, MD, executive director of UNAIDS, said during a press conference reported by the Associated Press. "We are going into societies where there are more people in their 60s and 70s than there are in their 40s and 30s," he said. "This is unheard of."
Dr Piot pleaded with western nations to forgive the billions in debt owed by the sub-Saharan nations. He also said that at least $3 billion is needed for basic care and prevention activities in Africa, and that does not include the cost of the expensive drugs that fight HIV. Those funds will be needed to fight the epidemic, which is already threatening fragile economies in that part of the world. AIDS infection is making it difficult to fill professional positions. UNAIDS noted that teachers are dying; in Côte d’Ivoire, 7 in 10 teacher deaths are due to HIV. In the first 10 months of 1998, Zambia lost 1300 teachers to AIDS. Throughout the continent, increased demand for health care for HIV-related illness is adding pressure to already overextended health services. In some countries, HIV-positive patients occupy 40% to 70% of all beds in big city hospitals. Like teachers, hospital staff deaths are on the rise. In Zambia, researchers found that deaths among hospital workers, largely due to HIV, increased 13-fold over a 10-year period.
Combined with continual warfare that has rocked the region, AIDS has dramatically reduced the quality of life in an area already known for poor living conditions. Twenty-four sub-Saharan African countries ranked on the bottom of the list in the United Nation’s quality-of-life ratings that were issued in early July 2000.
"What is happening in southern Africa should be a lesson for countries today which don’t have a big problem yet," Dr Piot said. "I’m thinking of Asia, I’m thinking of Eastern Europe, I’m thinking of the Caribbean."
It should also have a sobering effect on the United States and other parts of the industrialized world where improved treatment has made some populations complacent. Public health officials like Helene Gayle, MD, AIDS chief at the US Centers for Disease Control and Prevention (CDC) in Atlanta, Ga, have said that they are worried by evidence that some with risky drug habits or sexual practices are forgoing safe sex.
"I’m scared by the trends we are starting to see," said Dr Gayle. Her remarks, reported by the Associated Press, were made at a conference sponsored in Durban, South Africa, by the American Medical Association.
Surveys analyzed by the CDC indicated that between 4 and 5 million people still practice risky behaviors that put them at increased risk of acquiring the virus. Although there are indications that the message of safe sex has stayed with much of the population, Dr Gayle said, "We have seen troubling signs over the past year that we fear could signal a resurgence of the epidemic among gay men." In San Francisco, Calif, public officials have seen an increase in HIV infections between 1997 and 1999, along with a sharp rise in the numbers of sexually transmitted diseases.
Community Program Increases 9-1-1 Use but Does Not Shorten Time to the Hospital
A community education program designed to reduce delays in seeking care for heart attack symptoms increased the use of 9-1-1 services, but it did not reduce the number of minutes people waited before they sought care for chest pain.
The report, published in the July 5, 2000, issue of the Journal of the American Medical Association (JAMA. 2000;284:60–67), reported on the Rapid Early Action for Coronary Treatment (REACT) study that was funded by the National Heart, Lung, and Blood Institute (NHLBI). "Although the hoped-for improvements in delay time were not realized, the 20 percent increase in use of emergency medical services (EMS) is encouraging. An ambulance can bring medical care to the patient quickly, and patients who arrive at the emergency department in an ambulance get taken care of faster. Early treatment is vitally important for both survival and limiting damage to the heart muscle," said NHLBI Director Claude Lenfant, MD.
The study documented a 20% increase in ambulance use among patients who were admitted to the hospital with a heart-related diagnosis. This was measured against baseline data collected before an intensive community education program was undertaken. The REACT study was conducted by 5 field centers: the University of Alabama at Birmingham, the University of Massachusetts Medical School, the University of Minnesota, the University of Texas in Houston, and a combined site at the King County (Washington) Department of Emergency Medical Services and the Oregon Health Sciences University.
HMO Enrollment Numbers Take a Dip
The number of people enrolled in health maintenance organizations (HMOs) dropped 0.6% during the first 6 months of 1999, the first such decline ever recorded for HMOs since InterStudy Publications, a Minnesota-based research company, began tracking the figures. The decline, reported in the July 10/17, 2000, issue of American Medical News (business page), was attributed to rising premiums and not consumer dissatisfaction.
In 1998, HMO premiums rose 1.6% on average, according to the William M. Mercer Survey of Employer-Sponsored Health Plans, and in 1999, the increase was 5.4%. Another reason for the slight drop is consolidation in the managed care industry, which caused some people to leave the market.
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