Dr Dominique Kérouédan, French physician, MD, then working in the Ivory Coast National AIDS Program, was writing in Société d’Afrique et SIDA over ten years ago, an amazingly powerful letter, which in a way, will echo to future generations as the courageous voice of a woman committed to truth:
“I have several questions addressed to the epidemiologists who are interested in the epidemic of AIDS in Africa; it seems to me, that if we had clear answers to these questions this would allow us to elaborate more pertinent and efficient communication strategies.
In front of the total failure of world strategy in this domain, let us accept to question ourselves.
If we were more modest, we would still be looking, and we would have other elements on which to build interventions:
On what studies does the WHO declare every time more loudly, than the HIV infection cases in Africa are 90 %, even 95 % of cases of heterosexual transmission?
None. Why you, epidemiologists, are you not interested in measuring and estimating the importance of the transmission through blood exposure in a country of high seroprevalence in Africa?
How we can assert so clearly that it is negligible when we know the conditions of exercise of the health professionals in the absence of blood banks certainly, but also deprived of equipment (when one birth delivery kit is used for up to 60 childbirths a day, we can still consider that the risk of transmission in a hospital environment is tiny, and why would it be tolerated here?), lacking of sterilisation equipments, decontamination products and gloves?” When we know the daily frequency of the traditional practices with blunt instruments and the seroprevalence in the general population? When we know the frequency of transfusions in the paediatric environment and the number of transfusions made in the absence of blood banks?
The studies of Western heterosexual cohorts showed that the risk of transmission of the HIV during a sexual intercourse is very small. Certainly the other studies showed that the STDs are an important factor of exposure to HIV and that they potentialise the risk of transmission by the sexual route. Is it sufficient to account for the speed at which HIV spread in Africa? Dont you think that it is a little bit fast and simplistic to explain this phenomenon by the inclination of the Africans to have multiple partners and too frequent relations? Don't you have the impression that there is something else happening and that your role would be to investigate this, that ‘other’ thing?
What do you make of unexplained cases of intrafamilial transmission?
Anecdotes told by the health workers on brothers and sisters who pass on the virus on to another, outside of usual excepted modes of transmission, HIV-positive children of seronegative parents who were brought up by an HIV-positive nanny? It is true these are anecdotes which we hear only if we live for a long time in the field, these cases are not numerous, but they deserve our attention all the same. If we admit that the HIV is passed on by the maternal milk, that what is what prevents us from saying, or even there from investigating that the HIV is passed on by digestive way? How can we be certain as well as not, on which foundations?
When science does not know, the authorities of public health have to inform the population that "we do not know". The population has to adapt itself. And thus, in history, did epidemics die off, by themselves.”
