In his new book, Denying AIDS, Seth Kalichman observes that people are surprised by the persistence of AIDS denialists:‘‘Are they still around?’’ he is often asked. And it is a good question. Given the large body of scientific and clinical evidence on HIV disease and treatment(expertly summarized by Chigwedere and Essex in this issue of AIDS and Behavior) it is indeed strange that Peter Duesberg and his followers still claim HIV is harmless and that antiretrovirals cause rather than treat AIDS. While such dissident views were intellectually respectable in the 1980s when HIV science was new, they make little sense today. Thus Joseph Sonnabend, a doctor who treated some of the earliest AIDS cases in New York and was well known for arguing that environmental factors may be more important than a virus in driving AIDS, was quick to change his mind once antiretroviral treatment was shown to act against HIV and transform the health of his patients. Peter Duesberg, by contrast, refused to accept the evidence, thereby earning the label ‘denialist’ rather than ‘dissident’.
Duesberg may be pathologically contrarian in this respect, but he has an enduring appeal. Kalichman argues that this is in large part because his claim that HIV is harmless reinforces the normal process of denial most people undergo when faced with traumatizing information—such as a positive HIV test result.
Another reason is that Duesberg’s views are promoted in books, on denialist websites and blogs and by a persistent trickle of ‘Duesbergas-oppressed-hero-scientist’ stories from independent filmmakers and journalists. It is precisely because he holds a post at Berkeley and is an elected member of the National Academy of Sciences, that Duesberg has been able to build the media profile that sustains him. As Epstein argues, by ‘using his scientific credentials to buy him popular support, then using the popular support to push for recognition by his colleagues—Duesberg gained staying power’.
This has resulted in HIV science being represented as fundamentally contested in ways which it actually is not. And because of the threat AIDS denialism poses both to public health and to the authority of HIV science itself,scientists have found it necessary, time and time again, to respond to Duesberg’s claims, despite their long having been demolished. Chigwedere and Essex’s paper in this issue is one more such refutation in a long line of refutations. What makes their paper different is that in addition to marshalling the key evidence in support of the scientific consensus on HIV, they criticize Duesberg for inspiring South Africa’s ex-President Mbeki AIDS policies (thereby causing hundreds of thousands of unnecessary deaths) and they take him to task for suggesting (in a co-authored paper initially published in Medical Hypotheses but subsequently withdrawn by the publisher) that the African AIDS epidemic does not exist.
Chigwedere and Essex are clearly angry—the emotion is evident on every page. This is not merely because of the dangers Duesberg’s intransigence poses for public health but because of his refusal to change his views when the evidence demands it. This has long been a source of frustration for HIV scientists. For example, Robert Gallo, the co-discoverer of HIV, has described him as ‘like a little dog that won’t let go’ and John Moore, an eminent virologist at Weill Cornell Medical School, has likened Duesberg to Monty Python’s black knight who keeps fighting despite having all of his limbs cut off by his opponent. And the problem is far more than intellectual because disregarding evidence not only undermines scientific progress, but it threatens the social basis which makes such progress possible. Respect for the evidence and for the people who generate it is a core value in the scientific community—and it is precisely this that Duesberg flouts. Warren Winkelstein, one of the early HIV epidemiologists, recalls how, at a meeting of the National Academy of Sciences in Washington to discuss Duesberg’s theories, Duesberg would frequently get up, wander around the room and start talking to reporters. In his view, Duesberg simply ‘wasn’t listening to what was being said’. The message Duesberg was broadcasting then, and in all his statements on AIDS, is loud and clear: he alone is correct and the work of others is not worth considering.
It is no wonder, then, that Duesberg has earned himself pariah status in the scientific community. Yet his views continue to be promoted over the internet. Unlike academic journals, where respectability is obtained through peer review,impact factors and the credentials of those on editorial boards, information on the internet is easy to post and difficult to assess for its quality. Credibility and authority in this domain is shaped and reshaped in everyday rhetorical battles for the hearts and minds of readers. Here, techniques of persuasion have very little to do with the August rankings of journals, or the CVs of scientists. Rather, a central rhetorical strategy is to cast Duesberg as modern day Galileo, to confuse readers with what Ben Goldacre calls ‘sciency-sounding’ misinformation on HIV, and to offer a range of soothing-sounding ‘natural’ and ‘alternative’ remedies.
This has forced HIV scientists and physicians to engage with AIDS denialism in new ways. They have, for example, teamed up with AIDS activists to create a website, www.AIDStruth.org, dedicated specifically to countering AIDS denialism. In fact, the first posting on AIDStruth.org was a detailed refutation of an AIDS denialist article promoting Duesberg’s views in Harpers Magazine. Scientists linked to AIDStruth.org have also responded to HIV misinformation in videos, for example complaining successfully to the British Broadcasting Corporation about a film falsely depicting antiretrovirals as having caused harm to children in New York, and more recently posting a critique of the documentary film, ‘House of Numbers’, for its misrepresentation of AIDS science. Other pro-science websites and bloggers also participate in the ongoing fight against AIDS denialism, notably: Ben Goldacre (a physician) on ‘Bad Science’ (http://www.badscience.net/), Seth Kalichman (a psychologist) on ‘Denying AIDS’ (http://denyingaids.blogspot.com/) and Nick Bennett (a physician) on ‘Correcting the AIDS lies’ (http://aidsmyth.blogspot.com/). Also important are blog postings by individuals in response to denialist views expressed on blogs and chat rooms. All are fuelled by a tangible sense of outrage over what they see as the dishonest tactics of AIDS denialism and the dangers it poses for those who are taken in by it.
Social scientists refer to activities in defense of science as ‘boundary work’. In the past, boundary work sought to develop and maintain public respect for science and to relegate ‘pseudo-science’, like phrenology, beyond the pale of academia. Such boundary work was conducted within academic institutions and in academic journals as well as in the public sphere through public lectures and in articles and letters in major newspapers. By contrast, boundary work in today’s information age is more diffuse, and decentralized—often fought at an individual level via cut and thrust debate on blog postings. Even so, classic forms of boundary work remain important—notably ensuring the quality of academic articles and responding to bad science when it does get published. Chigwedere and Essex’s paper in this issue falls into this latter category of boundary work. As they explain, their paper originated as a response to an article by Duesberg and others in Medical Hypotheses critiquing their earlier estimates of AIDS deaths attributable to Mbeki.
Medical Hypotheses has long been a source of concern in the scientific community because the articles are not peer-reviewed. When Duesberg’s paper appeared, restating his erroneous beliefs about HIV and denying the existence of the African AIDS epidemic, this was the last straw for many. In a classic piece of boundary work, twenty HIV scientists and activists wrote to the National Library of Medicine requesting that Medical Hypotheses be reviewed for de-selection from PubMed on the grounds that it was not peer-reviewed and had a disturbing track record of publishing pseudo-science. The National Library of Medicine responded by promising to review the journal, but in the meantime John Moore and Franc¸oise Barre´-Sinoussi (Nobel Laureat and codiscoverer of HIV), wrote to Elsevier, the publisher of Medical Hypotheses, about the issue. Elsevier immediately withdrew Duesberg’s article and instigated its own review of editorial policy at the journal.
This left Chigwedere and Essex in a rather strange position: their earlier article had been critiqued and used as a spring-board for further restating discredited claims about HIV medical science—but then withdrawn. How does one respond in such a situation? They could have ignored it on the grounds that the paper no longer had any published academic status. Yet precisely because AIDS denialists have alternative forums for promoting their views, and precisely because they regard such boundary work on the part of the scientific community and the publisher as evidence of the vast power of the so-called ‘AIDS establishment’ to suppress dissent, there remained a need to address Duesberg’s claims. Hence the publication of Chigwedere and Essex’s response in AIDS and Behaviour today.
It is also worth emphasizing that the Duesberg et al. paper was withdrawn because a group of credible AIDS scientists was able to point to a series of fundamental flaws that should have been picked up had the paper been peerreviewed. Although the paper contained a set of basic errors about the African AIDS epidemic (such as confusing adult HIV prevalence and population prevalence, misinterpreting death statistics and assuming that simply because the African population has risen that there is no epidemic), this was of minor concern in relation to Duesberg’s ongoing misrepresentation of HIV science and disregard for the evidence. Had AIDS scientists been asked to peer review the paper, they would have rejected it for its factual errors on the AIDS science alone.
Unlike HIV science, demographic modeling of the impact of AIDS and of HIV prevention and treatment interventions inevitably involves a range of assumptions and is much more contestable. Thus, while Chigwedere and Essex are on firm ground with regard AIDS causation and the clinical benefits of antiretrovirals, their earlier modeling of the number of lives lost due to Mbeki’s policies is less compelling. Indeed, one can contest their original analysis for estimating the impact of Mbeki’s policies over too short a period (2000–2005 rather than over the life of Mbeki’s presidency) and for using a rather simplistic and ad hoc demographic model rather than the more sophisticated and publicly available demographic models—such as the Spectrum model provided through UNAIDS and the ASSA2003 model provided by the Actuarial Society of South Africa.
Figure 1 shows that different demographic models can yield very different estimates of the number of AIDS deaths in South Africa and the number attributable to Mbeki. In earlier work, I used the ASSA model to argue that if Mbeki’s national government had rolled out antiretrovirals for HIV prevention and treatment at the same rate as the opposition-controlled Western Cape Province, then 343,000 AIDS deaths and 171,000 new HIV infections could have been averted. These figures are higher than those of Chigidere et al. [in part because of the longer projection period (1999–2007), but also because of differences in the design of the epidemiological models. This can be seen by comparing ASSA and Spectrum projections which used exactly the same policy inputs, but produced different outputs because of differences in the underlying modeling architecture. The ASSA and Spectrum estimates are more consistent with the general shape and pace of the AIDS epidemic than the Chigwedere et al. estimate, but even so, a large confidence interval should be placed around all such modeling work.
