After decades of errors and delays in responses to Africa’s HIV epidemics, new policies and programs extending testing, antiretroviral treatment (ART), and prevention of mother-to-child transmission are saving lives. AIDS deaths per year among adults and children in sub- Saharan Africa reached an estimated peak of 1.31 million in 2004, but have since fallen 66% to 440,000 in 2019.[1]

New infections per year have fallen as well, but not as much. Estimated new infections peaked in 1996-97 at 1.97 million, then fell 51% to 970,000 in 2019. An old and ongoing error – seeing unexplained HIV infections without asking for investigations to find and stop their source – largely explains continuing high numbers of new infections.

Continuing high numbers of new infections are motivating new errors: International and foreign health organizations are promoting dangerous and unnecessary medical interventions to the African public as ways to reduce HIV from sexual risks.

Old and continuing errors in responses to Africa’s HIV epidemics have been particularly harmful for women.

Early errors

Error: accepting HIV from health care

After finding HIV-positive children with HIV-negative mothers in DRC and Rwanda in 1984-86, experts from the US and Europe accepted that reuse of contaminated instruments in health care would continue to infect an unknown number of Africans with HIV (Chapter 3). This was decided without investigations, which were required to protect public health in any case, but which would have also given not only researchers and public health officials but also the general public some idea of the scale of the problem.

Africa’s epidemics might have developed differently if experts had instead recommended governments to investigate to find and fix bloodborne risks. Although governments of DRC and Rwanda may not have investigated at the time, a clear and repeated recommendation could have made it easier for one or more governments in sub-Saharan Africa to investigate in later months and years. In addition, experts could have challenged donors to immediately stop accepting unsafe skin-piercing procedures in health aid programs. That did not happen. Unsafe immunization injections continued on a massive scale until the end of the century (Chapter 3). There was no urgency to change.

With an alternate response, experts could have (and should have) articulated the hypothesis that HIV transmission through skin-piercing medical and cosmetic procedures could be driving Africa’s HIV epidemics. (A hypothesis does not say anything is true, but rather that it might be.) That hypothesis agreed with evidence available at the time from the US and other countries outside sub-Saharan Africa with good information about sources of HIV infections. In the US, for example, as of 1988, 62% of AIDS cases were in men who have sex with men (MSM; excluding MSM who were also injection drug users [IDUs]); 31% were in people with blood exposures (IDUs, people who had received blood transfusions or blood products, and people with other healthcare risks), and only 2.8% were attributed to heterosexual contact, mostly in women partnered with IDUs and MSM. (These percentages exclude small numbers of HIV-positive people from Haiti and Africa whose risks were not known.)[2]

From the perspective of 2020, the hypothesis that bloodborne risks drive Africa’s epidemics fits accumulating evidence (Chapter 6). If in the mid-1980s experts had respected that hypothesis and had encouraged governments to investigate unexplained infections, the reduction of HIV transmission through skin-piercing medical procedures might have changed the course of Africa’s HIV epidemics. Africa’s epidemics might well have developed just like HIV epidemics in the US and elsewhere: more HIV-positive men than women, and far less than 1% of adults infected. Considering that the risks accounting for most HIV infections outside Africa (MSM and IDU) are not so evident in Africa, the percentage of adults who are HIV-positive in Africa should be lower than elsewhere. But that is not what happened.

Error: blaming HIV-positive Africans for sexual misbehavior

Beginning in the 1980s, HIV prevention messages for Africans focused on sex. The claim that almost all HIV infections came from sex had a paralyzing effect on HIV prevention in Africa. Based on their sexual behaviors, most people considered themselves to be safe (see Annex 1). People did not realize they were at risk to get HIV from skin-piercing procedures in hospitals and clinics. And so HIV spread, unrecognized, through the general population. Paradoxically, focusing on sex increased sexual risks; warnings about bloodborne risks as well as sex would have alerted people that virgins or monogamous spouses might be infected, so that sex with anyone could be a risk for HIV.

Public health messages blaming almost all HIV infections on sex encouraged people to consider an HIV infection to be a sign of sexual behaviors – pre-marital or extra-marital sex, buying or selling sex  – widely considered to be misbehaviors in societies with conservative social norms. Such messages extended into Africa stigmatizing opinions that were common in the US and Europe: that HIV infections came from “bad” behaviors.

WOMANKIND Worldwide defines sexual bullying to include: “a range of behaviours such as… spreading rumours about someone’s sexuality or sexual experiences they have had or not had…”[3] Public health messages that blamed almost all HIV infections on sex, despite evidence to the contrary, were equivalent to malicious and unfounded rumors. Although such public messages were impersonal, they encouraged people to think they knew something about the sexual behavior of specific HIV-positive people and to believe and spread similarly unfounded rumors about them.

Error: discouraging HIV tests

As the AIDS epidemic emerged in the US in the 1980s, many MSM wanted to keep their male-male sexual behavior secret. Their desire for secrecy led to “AIDS exceptionalism.” HIV tests were considered sensitive and dangerous, because an HIV-positive result could expose a man as an MSM. Public health officials treated test results as personal secrets, recorded and reported without names. Tracing and testing sex partners, which was standard for syphilis and other sexually transmitted disease, was seldom done for HIV infections.

Accepting and extending AIDS exceptionalism into Africa, WHO’s Global Programme on AIDS cautioned that “National AIDS programmes that decide to develop voluntary testing and counselling services where none now exist should proceed cautiously by initiating a trial project.”[4] When a 1994 article in The Lancet proposed “voluntary home testing” to allow people in developing countries to see if they or their sexual partners were infected,[5] experts from WHO’s Global Programme on AIDS attacked. They characterized testing as the “The policeman’s response to HIV/AIDS” and rejected the suggestion that testing could help to slow HIV transmission as an “old fallacy.”[6] But the only article they cited to support that statement reported “substantial risk reduction among heterosexual partners with one infected partner.”[7]

AIDS exceptionalism influenced international and foreign organizations to recommend special arrangements for HIV tests, including counseling before and after. Because of all the regulatory obstacles together with limited donor support, testing facilities were few and far between, and getting an HIV test was difficult in most African countries until some years after 2000. Because public health messages blamed HIV on sexual risks that most Africans did not have, most people saw no reason to go through the trouble of getting a test.

Not testing and tracing partners of persons found HIV-positive was  a limited problem in the US and other rich countries where infections concentrated in populations with specific behaviors (MSM and IDU). But in Africa, limited testing left many millions of people in the general population unaware of their infections (Figure 7.1) and not knowing if their partners were infected. As late as 2000, Peter Piot, the head of UNAIDS at the time, estimated only about 5% of HIV-positive Africans knew they were infected.[8]

Error: not preventing mother-to-child transmission

If a woman who is not aware she is HIV-positive has a baby and breastfeeds it for 1-2 years, there is roughly a 35% chance she will transmit HIV to her baby, 20% at birth and 15% from breastfeeding. Almost all of that can be prevented. As early as 1994, a study found that giving women the antiretroviral drug zidovudine (AZT or ZVD) as pills for five months when pregnant and intravenously during delivery, and then giving the baby ZDV could reduce by two-thirds mother-to-child HIV transmission at birth. This was widely adopted almost immediately in rich countries. In the US, for example, more than 60% of HIV- positive pregnant women received ZDV in 1996.[14]

Giving HIV-positive women intravenous ZDV during delivery to protect their babies was considered too difficult for Africa. In any case, much better – and easier – drug plans soon followed. Two trials in 1998 showed that a shorter course of oral ZDV or single oral doses of nevirapine, another antiretroviral, to mother and baby reduced mother-to-child transmission by about 50%. Combined, they gave better results. Regimens of three oral drugs to the mother and ZDV and/or nevirapine to the baby did even better, cutting transmission at birth to near 1% as early as 2004 in Thailand.[15]

In 1998, USAID proposed to scale up programs to prevent mother- to-child HIV transmission (PMTCT) in Africa. In 1999, interested donors established an Inter-Agency Task Team on PMTCT. In 2000, WHO recommended giving HIV-positive pregnant women and babies antiretroviral drugs to protect babies. But several more years went by before more than a small minority of HIV-positive pregnant women in Africa could get the drugs needed to protect their babies (Figure 7.1).

Error: not allowing antiretroviral treatment (ART) for Africans

Giving HIV-positive people antiretroviral drugs to suppress their infections began on a big scale in the US in 1996. From 1995 to 1998, deaths from AIDS in the US fell by 64%.[16] In 2003, seven years after antiretroviral treatment (ART) had been widely adopted in rich countries, less than 1% of HIV-positive Africans were on ART (Figure 7.1). The delay in getting drugs to Africans was due to artificial barriers: intellectual property rights forced market prices far above production costs; and national regulations controlled imports. At the end of the 1990s and early 2000’s, the usual price for a year’s supply of ART drugs for one person was $10,000-$15,000 in rich countries. These prices far exceeded the cost to produce the drugs.

Early errors violate human rights

Not finding and fixing bloodborne risks in health care and not warning Africans about such risks violates human rights (Chapter 3). Blaming HIV-positive Africans for sexual misbehavior violates human rights.

In 1994, Jonathan Mann, an influential architect of these errors, assessed that lack of respect for human rights contributed to HIV epidemics: “the evolving HIV/AIDS pandemic has shown a consistent pattern through which discrimination, marginalization, stigmatization and, more generally, a lack of respect for the human rights and dignity of individuals and groups heightens their vulnerability to becoming exposed to HIV.”[17] Although Mann did not intend it, his criticism applies to the double standard in healthcare safety and victim blaming (and stigmatizing) he had helped to introduce into responses to Africa’s HIV epidemics. Aside from those human rights violations, his assessment did not fit sub-Saharan Africa, where HIV invaded the general population, and where infections were more common in people with more than average wealth and education. 

2000-05: Turning some corners, correcting some errors

Testing, preventing mother-to-child transmission, and treatment (ART) arrived after long delays due to policies and regulations blocking private initiatives as well as to donors and governments taking time to design  and fund public programs.

 Finally allowing and promoting testing!

In 2002, Kevin De Cock and colleagues published an impassioned criticism of AIDS exceptionalism in Africa: the current response to Africa’s HIV epidemics was not adequate for a “public health and infectious disease emergency” which was the leading cause of death in Africa. As part of an adequate response, “routine diagnostic HIV testing will have to become standard practice in medical care.”[18] In the ensuing debate about whether and how to increase HIV testing, De Cock’s and colleagues’ proposal was characterized as “provider initiated testing” or “opt out” testing – with doctors routinely testing patients for HIV as they would for other conditions, and with patients opting out if they wished.

Most African governments readily accepted provider initiated testing. During 2003-8, 37 African countries established policies for provider initiated testing in at least some settings.[19] By 2010, almost all African countries had adopted provider initiated testing for pregnant women, and more than half had done so for all adults attending a health facility. On the other hand, WHO and UNAIDS had more  trouble letting go of AIDS exceptionalism. In 2004 and 2007 they endorsed provider initiated testing in some settings (for example, in antenatal care) but with caveats, including detailed pre-test counselling[20] and the availability of a “recommended package of HIV prevention, treatment and care.”[21]

Whatever the caveats, the battle was won. AIDS exceptionalism was defeated in Africa. Expanding programs to prevent mother-to-child transmission and to keep HIV-positive Africans alive with ART soon ended opposition to provider initiated testing. The percentage of HIV-positive Africans aware of their infections reached an estimated 49% in 2013 and 83% in 2019.

Aside from signaling a need for treatment, testing has an important role to play in preventing sexual transmission. This role was overlooked in Africa for decades. Not until 2012 did WHO finally endorse couple counseling: “Couples and partners should be offered voluntary HIV testing and counselling with support for mutual disclosure.”[22] Four years later, in 2016, WHO made further recommendations to give testing an even bigger role in HIV prevention. Specifically, WHO urged governments: to help people who test HIV-positive tell their sex partners; and to allow sales of self-testing kits.[23] In 2016, the US CDC initiated programs with partner organizations throughout Africa to trace and test contacts of people who tested HIV-positive.[24]

Self-testing can make a big difference. In a 2017-18 study in South Africa, young women given self-testing kits (for own use, with extras to distribute) were much more likely to test and to get their sex partners and others to test compared to young women referred for tests at government clinics.[25] One continuing snag with respect to testing has been the myth that almost all infections come from sex. Even with an estimated 83% of people who are HIV-positive in sub-Saharan Africa knowing their status as of 2019 (Figure 7.1), that still leaves one-sixth who are not aware. Many do not think to test because they have had no or low sexual risks.

Prevention of mother-to-child transmission (PMTCT)

At the beginning of the twenty-first century, the Irish singer Bono got together with Jesse Helms, a notoriously conservative US Senator, to promote prevention of mother-to-child transmission (PMTCT) in Africa. In 2002, the US government approved $500 million for PMTCT. One year later, President Bush proposed $15 billion over five years for HIV/AIDS programs in 15 countries (12 in Africa). Congress agreed.

The $15 billion went through a new office, the Presidents’ Emergency Program for AIDS Relief (PEPFAR). Along with other activities, PEPFAR supported PMTCT.

Through 2005, many mothers and babies received single doses of nevirapine. As PMTCT programs expanded, drug regimens got better, further cutting HIV transmission from mothers to babies. WHO’s 2004, 2006, and 2010 recommendations for PMTCT proposed various options for drugs to give mothers and babies.[26,27] In 2012, WHO recommended starting all HIV-positive pregnant women on ART, to be continued for life. WHO called this the B+ option.[28] ART for life can reduce a  mother’s risks to infect her baby at birth and through breastfeeding to only a few percent.

PMTCT has made a huge difference in Africa, but it was delayed. In 2010, 12 years after research had confirmed that several simple oral regimens protected babies, less than half of HIV-positive pregnant women in sub-Saharan Africa received drugs for PMTCT. In those 12 years, more than four million children aged 0-14 years in Africa got HIV (UNAIDS estimates). The extension of PMTCT reduced the estimated annual number of new infections in children age 0-14 years by over 60%, from 430,000 in 2000 to 126,000 in 2019 (Figure 7.2; UNAIDS estimates). Considering what can be achieved with B+ (putting pregnant women on ART for life), numbers of new infections in children can go much lower.

Antiretroviral treatment (ART)

From 1996, when ART was introduced in rich countries, through 2004, more than eight million Africans died of AIDS. Because AIDS in Africa concentrates in urban and mid-level or wealthier adults and in wealthier countries, the political implications were untenable. AIDS in Africa was killing community and national leaders, their families, and friends.

Shortly after ART was adopted in rich countries, companies in Brazil, Thailand, and India began to produce generic drugs with or even without the approval of companies holding patents. Because of legal barriers created by intellectual property rights, it took time for generic antiretroviral drugs to get to Africa.

In 1998, Partners in Health, a US-based non-government organization led by Paul Farmer and Jim Kim, began to provide ART to poor Haitians, demonstrating the feasibility of getting ART to Africans.[29] In 2001, Cipla, an Indian company producing generic antiretroviral  drugs, offered to sell them to African governments for $600 per patient per year and to Partners in Health for $350 per patient per year.[30]

In 2003, Jim Kim moved to WHO. He became head of WHO’s AIDS office in early 2004. With Kim’s lead, WHO and UNAIDS in 2003 initiated an ambitious 3 by 5 program: to provide ART to “3 million people living with HIV/AIDS in poor countries by the end of 2005.”[31]  In three years, from 2002 to 2005, the percentage of HIV-positive Africans taking ART increased from 0.3% to 4.2%. Although the 3 by 5 program missed its target by a few years, it transformed attitudes about ART for Africans – they were going to get ART. In pressing  international agencies, companies, and donors to figure out how to get ART to Africans, Paul Farmer and Jim Kim made a huge contribution to Africans’ health.

In 2003, WHO recommended ART for only a minority of HIV- positive people, those with already weak immune systems, identified by having less than 200 CD4 cells (a type of white blood cell) per cubic millimeter of blood (about 1/20th of a drop). Over the next 11 years, WHO and UNAIDS recommended ART for progressively more HIV-positive people with newer infections and stronger immune systems.

In 2014, WHO and UNAIDS recommended ART for everyone who is HIV-positive. This recommendation was motivated in large part by the recognition that people with less virus in their blood (with suppressed viral loads, commonly defined as having less than 1,000 HIV per milliliter, or about 50 HIV per drop of blood) almost never transmitted HIV to sex partners. ART for all HIV-positive adults and children has been promoted as “treatment as prevention” and described as “test and treat.”

WHO and UNAIDS packaged their recommendations for ART into 90-90-90 goals for 2020: 90% of people who are HIV-positive know it; 90% who know are on ART; and 90% of people on ART have suppressed viral loads.[9] In 2016, the UN General Assembly endorsed 90-90-90 goals for 2020.[32] Although not many countries have been on track to reach these targets, they motivated rapid expansion of testing and treatment in countries with the worst epidemics. Through 2019, the percentage of HIV-positive Africans taking ART increased to an estimated 69%. Among the four countries with the worst epidemics, eSwatini (96% on ART) and Botswana (82%) did better than South Africa (70%) and Lesotho (65% on ART).[1]

With governments and donors aiming for 90-90-90 targets, large majorities of HIV-positive people are getting tested and treated, allowing near normal life expectancies and opportunities. But the continuing treatment challenges are daunting, including: reaching more people; changing ART drugs as people develop resistance and as better drugs come along; and helping people with HIV deal with drug side-effects and HIV-related health problems.

Old errors beget new ones

In contrast to good progress with treatment, prevention has lagged. In 2016, the UN General Assembly set a target to cut new HIV infections among adults aged 15 years and older in sub-Saharan Africa to 277,000 in 2020 (see para 65a in [32]). According to UNAIDS’ estimates for 2019, this target will be badly missed. Estimated new infections among adults aged 15-49 years in sub-Saharan Africa fell only 30% from 1,210,000 in 2010 to 850,000 in 2019 (Figure 7.2).[1] Despite disappointing progress, there is room for optimism. Based on the evidence presented in Chapter 6, there is reason to hope that the UN’s target for 2020 and even much greater cuts in numbers of new infections could be achieved within several years through large reductions in bloodborne transmission guided by investigations of unexplained infections.

Based on the same evidence from Chapter 6, the UN’s proposed reductions in new infections are likely to be impossible if all the cuts  have to come from sexual transmission. All along sex has very likely been responsible for a minority of HIV infections in Africa. Moreover, the risk to get HIV from sex is a personal risk that people can and do control with multiple options: testing partners, using condoms or avoiding people who may be infected, and ART as prevention for recognized HIV-positive partners. In recent years, people have gotten even more able to control their sexual risks with governments promoting couple counseling and allowing self-testing kits[25] and with more HIV-positive people taking ART.

How much sexual transmission continues to slip through all the various ways people have to protect themselves? Probably not much. Nevertheless, ongoing old errors – ignoring HIV from health care and blaming sex – have led to new errors. These new errors are dangerous and unnecessary medical interventions proposed to reduce what is already a much diminished number of sexual transmissions. The situation is akin to the old joke about someone looking for lost keys on one side of the road under the streetlight because that is where the light is rather than on the dark side of the road where he dropped them.

New error: circumcising men to reduce their risk to get HIV from sex

In 2007, WHO and UNAIDS recommended “male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men.”[33] Subsequently, WHO and UNAIDS endorsed programs to circumcise 20 million men in 14 countries in sub-Saharan Africa during 2008-15.[34] After 11.7 million circumcisions were reported through 2015, UNAIDS set a new target to circumcise another 25 million men in 15 countries during 2016-20.[35,36] Through 2017, the US government supported more than 80% of these circumcisions.[37]

WHO’s and UNAIDS’ recommendation was based on three studies in Africa that reported circumcised men were less likely to get HIV than intact (uncircumcised men). But what happened in those studies? In two of the studies, men who reported no sexual risks (no partners or 100% condom use) got HIV at rates more than half as fast as the rates for men who reported any unprotected sex.[38.39] The third study did not report men’s sexual risks.[40] One study tested most wives, but has not said if the wives of men getting new infections during the study were known to be HIV-positive or HIV-negative.[39,41]

But criticizing these studies – how they were badly managed and reported – does not get to the heart of the problem with circumcising millions of men to prevent HIV. Insofar as sex is a risk, men already have multiple options to protect themselves. And because there is overwhelming evidence bloodborne risks – most likely in medical  settings – drive Africa’s epidemics (Chapter 6), it is irresponsible to put millions of men at risk for HIV and other bad outcomes from unnecessary operations.[42,43]

New error: promoting pre-exposure prophylaxis (PrEP) to women in the general population to protect them from HIV via sex

Giving HIV-negative people drugs to prevent infection is known as “pre- exposure prophylaxis” or PrEP. The most common PrEP drugs currently in use are oral, taken daily or intermittently around the time someone is exposed to HIV. Other PrEP options may be useful in the future. PrEP can protect people exposed to HIV from either sex or blood.[44,45] In 2015, WHO proposed offering PrEP to “all population groups” getting HIV at rates of at least 3% per year, or even less if prevention costs less than lifetime treatment after infection.[46]

Most PrEP users in the world are MSM. Within Africa, some programs target PrEP to MSM and sex workers, who have sexual risks not common in the general population. Those programs are as sensible  in Africa as elsewhere.

However, much of the effort to promote PrEP in Africa is based on the expectation that widespread PrEP use could protect women in the general population, especially young women, from getting HIV via sex and thereby have a big impact on numbers of new HIV infections. Those hopes are ill-founded. According to the best available evidence (Chapter 6), most women’s infections likely come from bloodborne risks; and women already have multiple options to protect themselves from HIV via sex.

In recent studies, efforts to persuade women in the general population in Africa to use PrEP to protect themselves from sexual risks have been running into a wall of indifference. For example, during 2009-12, two trials among women in Kenya, South Africa, Tanzania, Uganda, and Zimbabwe recruited HIV-negative women, gave some women PrEP and others a placebo (a pill designed to do nothing), and then followed and retested them to see if PrEP protected them from HIV. The trials failed: women got HIV at similar high rates with either PrEP or the placebo.[47,48] Some women said they skipped pills when they had  no sexual risks, such as when their partners were away.[49] Did women who skipped pills get HIV from bloodborne risks? Neither study considered that possibility or reported women’s bloodborne risks.

Similarly, a 2017-18 study promoted PrEP to pregnant women and mothers in Kenya to protect them from HIV via sex.[50] Twenty-two percent accepted a month of pills, but less than 3% continued for six months. Clearly, most women were not interested. More than half of those who continued had partners of unknown HIV status, something that could have been resolved by testing the partners, thereby saving women from the side effects and nuisances of PrEP.

Many women did not like PrEP’s common side effects (nausea, vomiting, tiredness, etc.). Reports from these studies do not say what women knew or thought about less common but more serious side effects (weaker bones, possible kidney damage).

Generalizing from studies to date, most women are not interested in PrEP to prevent HIV from sex. In some special situations, of course, some women may want PrEP to protect them during sex, for example, if they want to get pregnant by a man with an uncontrolled viral load.

Because much if not most of women’s HIV infections likely come from bloodborne risks, PrEP could be considered to protect women from bloodborne risks. Any thoughts about how that might be done are beyond the scope of this book.

Not protecting women

International and foreign organizations and governments have not done what is needed to protect women, and have even harmed them:

• • No government has investigated unexplained HIV infections in self- declared virgins (Chapter 4) or new HIV infections in young or pregnant women getting HIV at rates too high to be explained by sex (Chapters 4 and 6).

  • Donors promote Depo-Provera injections for birth control despite evidence Depo use increases women’s risk to get HIV by 40%-50% (Annex 2).

  • Donors and governments promote circumcising men, even though the one study that looked at the matter found that newly circumcised HIV- positive men were 49% more likely to infect their wives than were intact men (the study recorded only 25 new infections, so that result may be a statistical accident).[51]

  • Among couples in Africa in which only one partner is infected, the wife is often the one infected (Figure 6.4). The myth that almost all HIV infections come from sex threatens women with disrespect and suspicion about their sexual behavior and truthfulness – adding insult to injury.

The consequences of such policies have been tragic. Women account for more than 60% of HIV-positive adults in Africa. In the four countries with the worst epidemics, by the time women are 20-24 years old, from 14.6% to 20.9% are infected, and by the time they are 35-39 years old, from 39.4% to 54.2% are infected (Figure 7.3). These are national averages from the latest national surveys! HIV/AIDS policies and programs have failed them and harmed them.

What happens next?

I end this book as I began. I hope that what I have written here will help people who are aware of unexplained HIV infections in themselves, their families, or friends to get others in their communities to believe them and to join them in digging for answers. I hope that by working together, communities aware of unexplained infections will be able to convince their governments to investigate to protect public health.

Africa has outspoken media and strong civil society organizations, including churches, political parties, universities, and business associations. When people in a community ask for help with an investigation, they may initially face opposition from parts of the government attentive to national, foreign, and international health experts and organizations. But with support from local media and civil society organizations, I expect government officials can be persuaded to do right by their citizens, to help them investigate to protect public health.

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