How to Fight AIDS in Africa

The infectious disease expert at the center of the latest Harvard controversy involving president Lawrence Summers is a deeply interesting person in her own right. Members of the intricately-linked public health community combating AIDS worldwide are subject to a continuous push-and-pull of appraisal and evaluation.

In that firmament, Phyllis Kanki is a star — a research scientist who helped identify a new family of HIV and demonstrated that it was less virulent; a top performer in Gates Foundation prevention initiative grant competitions; the woman who, by some accounts, “saved Senegal,” devising a novel and highly successful strategy of differential interventions among different groups.

So it was no surprise to the community last year when the US State Department called a press conference to announce that Kanki’s team at the Harvard School of Public Health had won a big White House grant to combat the spread of AIDS in Nigeria, the continent’s most populous country, and to tackle the problem with the same approach in two other African nations.

The nations’ different prevalence rates were noted. In Botswana, 40 percent, or 200,000 persons, had developed AIDS. In Tanzania, 10 percent of its population of 36 million; in Nigeria, 6 percent, or 7 million among its more than 115 million persons were sufferers.

And in Senegal, fifteen years after Kanki began working closely with the government there?  Less than 1 percent — one of the lowest rates in all of sub-Saharan Africa.

The population of Senegal is 94 pecent Muslim, according to the CIA Factbook. Nigeria is perhaps 50 percent Muslim. Islamic strictures against extra-marital sex make it easier to contain the epidemic is predominantly Muslim cultures.

“We are hoping to do the same in Nigeria,” Kanki had said, when the Gates Foundation first brought her into the country in 2000 to attempt to duplicate her success.

What was a surprise is the way the project hung fire for five months last year while Harvard’s central administration improvised a new layer of machinery to oversee the grant.

A crash program to treat and prevent AIDS in developing countries was first announced by President George W. Bush in his State of the Union Address in 2003 — some $15 billion in all, for what he called the President’s Emergency Plan for AIDS Relief (PEPFAR). In October of that year, Bush appointed Randall Tobias, former chairman of Eli Lilly and Co., to oversee the program as Global AIDS Coordinator.

In November of 2003, Tobias called for new proposals, a charette with a one-month deadline. In February, 2004, he named Kanki and three other longstanding programs the first recipients of the new PEPFAR grants. Columbia University, Catholic Relief Services and the Elizabeth Glaser Pediatric AIDs Foundation began spending immediately in March, expanding their existing programs.

But Harvard’s administrators in Massachusetts Hall complained that nobody at the School of Public Health had alerted them to expect the award — which turned out to be the largest in Harvard history.  So despite the school’s long experience in Africa, Harvard delayed acceptance of the commission for five months, while the president’s office considered the situation —  engendering a good deal of ill will in the process, both in Nigeria and at the Public Health school’s Boston campus.

Summers was said to have been upset by learning about the grant only after reading about it in the newspapers. Nigerian physicians later reported that an unknown number of patients died for lack of drugs while he stewed.

The controversy was first described by Richard Bradley in his book Harvard Rules.  Columnist Alex Beam surfaced the issue in The Boston Globe in March. Reporter May Habib followed with a careful and wide-ranging story in The Harvard Crimson in mid-April, reporting, among other things, that Massachusetts Hall initially had attempted to force Kanki to co-manage the grant with Bruce D. Walker, a Massachusetts General Hospital physician who had sought but failed to get a PEPFAR grant.

And last week The Globe’s highly-respected public health correspondent John Donnelly reported that Harvard provost Stephen Hyman had explained that Summers had delayed acceptance of the project because he was worried about potential legal risks to Harvard — its investigators’ conduct or their patients’ complaints.

Hyman mentioned the US government’s suit against Harvard for its aborted Russia Project in the 1990s, now inching its way towards resolution in US District Court in Boston. There, Harvard economics professor Andrei Shleifer and his deputy have been found to have committed fraud by investing in Russian securities, and the university itself to have breached its contract to provide disinterested advice. Only the question of damages (and the possibility of an appeal) remains.

“That lawsuit sensitized [Summers] enormously to the need for Harvard to do this right,” Hyman told Donnelly.

In the wake of the Russia scandal, Harvard president Neil Rudenstine disbanded a small internal bureaucracy that had evolved over a period of a quarter century to deal with such supervision, the Institute for International Development.  Many of its people and projects were reassigned to teaching faculties in the summer of 2000, including the public health school. A faculty task force had recommended the devolution. The Summers administration decided such decentralized supervision wasn’t the right answer after all.

Five months after the PEPFAR grant was announced, Harvard accepted it, ordering Kanki to stop complaining about its history, to cease talking about the project directly with the government itself, and to report exclusively to a new executive director, who had been hired to work for Hyman and Summers — long-time World Bank health and education specialist Richard Skolnik.

Since then, Harvard provost Hyman, who is himself a research physician, has pledged to re-examine the strictures, after a number of complaints, including one by an official of the American Association of University Professors.

Kanki, of course, retains the option of leaving Harvard. It is not unlikely that the grant would go with her, in due course — a highly disruptive process all around. Meanwhile, parties to the negotiations on all sides have buttoned up.

So what is so special about Kanki’s approach?  Thanks to a thoughtful account by Joel P. Engardio in the SF Weekly in 2001, the outlines of “tailored intervention” are clear enough. Engardio described a long lunchtime conversation he audited between Kanki and Stanford University MD David Katzenstein (whose lab she was visiting at the time).

The key to Kanki’s thinking is identifying “bridge groups,” cohorts whose behavior can affect the progress of the epidemic, and concentrating resources on protecting or treating them, including detailed surveillance through blood-testing: pregnant mothers, commercial sex workers and other high-risk populations. One group targeted for special attention: high school and university students — sexually active, concentrated in the cities, influenced by Euro-American pop culture, and precisely the pool from which future doctors, lawyers, executives and engineers will be drawn.

“You can’t save everybody, but you can save the people you have the best chance to do the most good for. I don’t want to state it as letting some groups go.  Instead I would state that there are certain groups where the need is more urgent to stop the epidemic; groups for which a negative outcome will have more serious consequences for all.”

Lifeboat ethics?  No doubt. Such a set of protocols requires continual scrutiny by physicians, philosophers and other ethicists who are deeply familiar with the situation in Africa and the rest of the developing world. It is also the case that the difficult job of forging closer alliances between schools and departments was high on the list of assignments given to Summers in the first place. It is too soon for outsiders to assess the role of pique in slowing Harvard’s participation in the PEPFAR project.

It is not too early, however, to gauge the value of Kanki’s work.  Hers is straightforward success story, a stunning example of the epidemiological imagination at work, crossing all kinds of frontiers, and with a low prevalence rate to show for it. Her success in the West Africa overshadows all of Harvard’s University momentary (if deep) embarrassment.