1995 Global Cultural Diversity Conference Proceedings, Sydney
Health, Welfare and the Fight against AIDS
Dr Julian Gold
Director, Albion Street Centre, Sydney, Australia
I'd like to address today's theme 'From the Local to the Global'. I think that AIDS really is the newest truly global epidemic that has devastating effects on virtually anybody who is on this planet in one way or another.
I'd like to talk about three issues today. Firstly, I want to give an overview of the epidemic; secondly, its effect on health and welfare in diverse populations; and lastly, I'd like to talk a little bit about Australia's response. I believe that as a nation we've got a few things that we can teach other countries, and perhaps one of the few things we can impart some lessons in is the way we've handled the AIDS epidemic in this country.
As human beings on this planet we try to live our sixty or seventy years as best we can and stave off disease and death. When it comes down to it, in the eyes of disease we're all the same,whether we're black or white, short or tall, gay or straight. Whatever we do we're really just the same human beings in the eyes of an organism.
AIDS presents us with an opportunity to address the complex interaction between medicine and health and the social, economic, philosophical, legal and human rights issues that really underpin our existence on this planet.
As we approach the end of the 20th century, many of us assume that infectious diseases are no longer a problem, particularly in western countries. This is not an unreasonable assumption. We'll never again see anybody on this planet with smallpox, and part of the reason is that we've been quite successful in preventing many of the immunizable diseases, such as polio, smallpox, measles, whooping cough and many others.
Yet over the past ten years we've been barraged with headlines of new and unknown organisms that have emerged, causing widespread localised problems. Again and again we hear about the potential for organisms to go through a resurgence.
Today we're dealing with AIDS and AIDS is really the first truly global health crisis that we've had to face in this part of the 20th century. It is interesting because, when we look at AIDS, in some way we could say that it's Mother Nature's plan that this virus should appear on this planet at this particular time.
The human immunodeficiency virus (HIV) is a uniquely human virus. It doesn't survive in other species and, unlike most other organisms, which can be observed using animal models, the only way of observing the effect of HIV is by studying human beings. HIV is an interesting virus because it particularly attacks our immune systems, and it's our immune systems that protect us from other organisms in the environment.
It is also interesting that AIDS/HIV has appeared at this particular time in the 20th century. It started perhaps 30, 40 or 50 years ago,relatively recently in the general history of infectious diseases,somewhere in central Africa. It probably originated as an organism that used to live in one of the monkey species, since human and simian immunodeficiency viruses have been found in a whole range of different monkeys that exist in central Africa. These viruses exist in animals that probably lived in symbiotic relationships with different monkey species,perhaps for thousands of years and something happened 50 years ago that caused the particular virus that we call HIV to jump across the species barrier, from a particular sort of monkey to human beings, and HIV is now a uniquely human virus.
The particular type of cultural diversity that we're talking about at this conference,which is seen to be an advantage and something we should strive towards, something we should all aspire to,is, in fact, exactly the sort of thing that has allowed the HIV virus to spread from country to country, city to city and person to person.
About 30 or 40 years ago social upheaval and the push towards independence brought democracy to most African countries. This resulted in the displacement of rural populations into the city, increased poverty, and middle class and urban women being forced into prostitution to live and survive,allowing HIV to spread quite widely in African countries. Travel between African countries, Europe and former European colonies facilitated the spread of HIV. Widespread travel throughout the world over the past 10 years has facilitated the spread of this virus such that, in merely 10 years since the first case was reported in the United States, it's now obvious that well over
13 million people around the world have been infected with it.
Some figures are perhaps in order here. AIDS is a global health crisis and I think that this speaks for itself. By the end of this year it is estimated that 18 million people will be infected by HIV, but the World Health Organisation estimates that in another five years up to 100 million people will be infected. This virus is resulting in perhaps five million years of human life lost.
HIV is also called the poverty virus because it's a virus that predominantly affects people who have little or no access to adequate health care, or health education. A good example of this is the rising rate of infection of pregnant women in urban areas of Africa. In many African cities the rate of HIV infection of pregnant women has risen from one in 10 to one in three in merely 10 years.
As a poverty virus, HIV is something that should be taken into consideration by people involved in looking at social justice and equity. We see perhaps one very obvious situation that can be applied to many other social problems we face. But of the estimated 18 million people worldwide infected with HIV, those in the developing world account for approximately two-thirds. Yet only a $165 million flowed to the developing countries in 1994 for HIV programs. This is equivalent to the amount of money America spends in one week for HIV.
I remember three or four years ago that people were saying HIV would never come to South-East Asia. For various reasons there hadn't been reported cases and it was thought that people born in Asia had, perhaps, some kind of genetic protection that would stop them from getting HIV, that the epidemic would never spread.
They couldn't have been more wrong because certainly over the past four or five years we've seen a series of patterns of this disease in particular countries in South-East Asia. We've seen a rapid spread in countries like Thailand and Myanmar and India particularly. We're seeing a potential for rapid increase in Indonesia, Malaysia and Vietnam and we're seeing this disease increase although it is very difficult to get reports out of countries like China. Certainly it is increasing in Japan and South Korea, and we don't know what is happening in many other countries like Bangladesh, Bhutan, Brunei etc.
So there was nothing that protected South-East Asia from this epidemic except time. It was just a matter of time, and not a very long time either, before cases were reported of the epidemic spreading to this part of the world. In five years time it is estimated that there will be one million new cases of HIV infection in Asia each year. There will be more cases of HIV in Asia than in Africa by 1997. Two million people will die of this disease within another five years and five-and-a-half million cases of AIDS will be reported each year in these countries. In parallel, we will see an epidemic of tuberculosis, which is, of course, a disease that goes hand in hand with the later stages of HIV infection.
HIV is a poverty virus and any discussion about diversity, social justice and the development of cultural pursuits in countries can't be undertaken without considering where this virus affects most people.
In western countries HIV is a particular problem. A problem of those people who live on the fringes of society,those people who don't relate at all well with mainstream medical care or with mainstream social, educational or welfare structures,people who are suspicious of anything that society has got to tell them. Intravenous drug users are one particular group and, increasingly, while we see tolerance and acceptance of many groups in our society, we still find a tremendous amount of discrimination against people with HIV/AIDS.
It would be rare 10 years ago in this country, and even today in many other countries, to see condoms personified in advertising. Yet I think HIV has had the effect of changing many of our social perceptions, many of the interactions between 'fringe groups' and the medical care system. It is that sort of interaction that I'd like to discuss for a moment now.
Those of you who have followed the AIDS epidemic in Australia couldn't help but remember the most obvious internationally recognised symbol of our education program, the Grim Reaper in 1987. Anybody who turned on a television set in this country couldn't help but see an advertisement featuring the Grim Reaper. It was the beginning of a public perception of this disease in Australia. Many thought it was an inappropriate perception of the disease because it created a feeling in people's minds that people with AIDS were like this,that people with AIDS were not like everybody else, people with AIDS were like the Grim Reaper.
It was therefore followed up by headlines that many people would remember,panic and people rushing for tests,but out of it came Australia's response to this epidemic and I think the health minister at the time, Neal Blewett, and many of the state health ministers can take credit for one of the most enlightened views of this problem of any country in the world. What they developed was a true partnership between government, medical science and the affected communities, taking what I believe may have been a unique approach to this problem.
In the last 10 years in this country there have been about 5,500 reported cases of AIDS and about 18,000 people reported infected with HIV. This means that within about five kilometres of where we are sitting this afternoon there are probably 10,000 people living with HIV. In many ways we are at the epicentre of this epidemic in Australia.
We hope all of us can get to the age of 75. If we die when we're 74 we've lost one year of potential life. If we die when we're 20 we've lost 55 years of potential life. It's an important way of looking at why young people are dying early, why they're dying prematurely. If we have a look at why young men in New South Wales are dying prematurely and have done so over the past 10 years from 1983 to 1992, what we see is something quite interesting. Progressively over the last 10 years AIDS has become the second most important cause of premature death of young men in this state, followed or superseded only by suicide and far and away more important than traffic accidents as the cause of death. It is only by looking at the impact of this disease using the right epidemiological methodology that we can judge its true impact.
One of the things we are trying to do as a nation,and national reconciliation with Aboriginal people has been a theme throughout today,is to address the issue of HIV and AIDS in the Aboriginal community. Up till now I believe that, unfortunately, we've relied very much on the old adage of we'll produce another poster, we'll produce another pamphlet, and if we produce enough pamphlets and enough posters somehow people who are in decision-making roles in government and politics and education programs and advertising will be appeased that we have done enough. So we've produced a lot of posters, directed at the Aboriginal community. But the late Fred Hollows made a very telling pronouncement. He said that HIV in the Aboriginal community is like a dry, tinder dry, field and somebody is on the side of it with a match waiting to throw it in. If we look at the rate of sexually transmitted diseases amongst Aboriginal people and the lack of social infrastructure, health services and true education programs we can see that, once HIV becomes entrenched in that community, it will cause an epidemic unlike what we have seen in other communities in Australia, except perhaps in sections of the gay community. It will cause an epidemic like those in Africa and South-East Asia.
Rather than producing pamphlets we need to take a more practical approach. In 1987 Australia was perhaps the first country, and Sydney perhaps the first city that I know of, to institute a practical needle and syringe exchange program. Each year now we give out almost four million needles to intravenous drug users. This program has resulted in Sydney having one of the lowest rates of spread of HIV to intravenous drug users and therefore to their sexual partners, who are usually female, and therefore to their children. In Sydney we've kept the rate of spread of HIV to intravenous drug users down to five or six per cent in comparison to cities like Edinburgh, Rome, Madrid and other cities in Europe where the rate is somewhere around 40, 50 or 60 per cent.
That's largely because we've swallowed any of our moral judgements. We've adopted a system called harm reduction rather than decision-making for other people. We've distributed needles and these things called fit packs which allow intravenous drug users to put back used syringes, close them up and throw them away in bins called disposafit bins. If you walk around Sydney, have a look in many of the parks. You'll see disposafit bins where you can put fit packs which have got syringes and used needles in them. In many places around Sydney you will now find dispensing machines and, for a dollar, you can get condoms or clean needles and syringes in fit packs. There is almost nowhere in the United States now where you can get clean needles and syringes if you're an intravenous drug user.
In summary, I think that minimising the spread of HIV in Asia involves an acceptance by all governments that HIV will impact on their countries and that traditional values and isolation cannot protect any country from HIV, and certainly is not protecting any country from HIV.
At the Albion Street Centre in Sydney we manage about 2,000 patients with this disease and we are increasingly involved in health care worker training and providing advice and training for our counterparts in South-East Asia. I think that the issues raised by AIDS as an epidemic on this planet are exactly the same issues that we talk about in a more general sense under the heading of Global Diversity.
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