The London School of Economics and Political Science AIDS Denialism In
Total Page：16
File Type：pdf, Size：1020Kb
The London School of Economics and Political Science AIDS Denialism in South Africa: A case study in the rationality and ethics of science policy Katherine Furman A thesis submitted to the Department of Philosophy, Logic and Scientific Method of the London School of Economics for the degree of Doctor of Philosophy, London, September 2016. 1 Declaration I certify that the thesis I have presented for examination for the MPhil/PhD degree of the London School of Economics and Political Science is solely my own work other than where I have clearly indicated that it is the work of others (in which case the extent of any work carried out jointly by me and any other person is clearly identified in it). The copyright of this thesis rests with the author. Quotation from it is permitted, provided that full acknowledgement is made. This thesis may not be reproduced without my prior written consent. I warrant that this authorisation does not, to the best of my belief, infringe the rights of any third party. 2 Abstract From 28 October 1999 to 26 September 2000 Mbeki publically endorsed the position of ‘denialist’ AIDS scientists – a marginal group who oppose the claim that HIV causes AIDS – and used their views as the basis for a policy of not providing ARVs (antiretrovirals – the treatment that prevents HIV from replicating) via the public health system. This policy persisted until 2004, with severe consequences – best estimates indicate that it resulted in 171, 000 avoidable new infections and 343,000 deaths over the 1999 – 2002 period. I use this case to address two questions. First, is it reasonable for policy makers to consult non-mainstream scientists in the process of policy development? Second, can they be held personally morally responsible for the consequences of having done so when things go very badly wrong? I begin by providing a motivation for why philosophers should be interested in real-world cases. Having justified the philosophical “methodology” of this thesis, I move on to describing the specific case of South African AIDS denialism in the early 2000s. I then take a chronological step back in order to assess the rationality of accepting HIV as the sole cause of AIDS in 1984, when the virus was first identified. I argue that it was rational, but that some explanatory power was lost when other competing accounts of the disease’s aetiology were discarded. I argue that this explanatory loss can be accounted for by re-considering the way causation is understood in biomedicine and epidemiology. Having settled the scientific issues of the case, I then move on to the question of moral responsibility. I specifically look at when an agent can be held morally responsible for their ignorance, and the role of suppressed disagreement in the production of that ignorance. 3 For Richard, who always believed in this thesis. 4 Acknowledgments A great many people have made this thesis possible, and I am grateful for all the love and support I have received. My supervisors, Luc Bovens and Katie Steele, have been extremely generous with their time, and have patiently helped me through this project. I cannot fully express all the gratitude I feel toward them both. I have been lucky to have many smart and patient friends, who have talked through the problems in this thesis with me, and have read and commented on its various component parts. Special thanks must go to the following people for all the help you have provided in bringing this document into being: Asbjørn Schmidt, Mary Carman, Joe Roussos, Laura Sochas, Stuart Theobald, Stefan Schubert, Rebecca Swartz and Gordon Inggs. You have given me many of your good ideas, and saved me from many of my bad ones. Very special thanks must go to Deirdre Morgan, who offered me support every day during the final months of my thesis – thank you, you saved me. Thanks to the LSE and the Oppenheimer Memorial Trust for funding this work. And thanks to the LSE Mobility Scholarship for funding my research at the University of Cape Town in 2015. This was an extremely productive and creative time for me, and many of the ideas that I stumbled upon while there are in this thesis. Thanks to my family – Roslyn Furman, Elaine McDermid, and Elaine Stupart for not giving up on me. I am especially grateful to Elaine McDermid for all the prayers she sends to St Jude (the patron saint of lost causes) on my behalf. Most importantly, thanks to Richard Stupart. Without him this thesis would not exist. His support and cooking and proof-reading all made this work possible. And his endless sense of good cheer and humour kept me sane. I am so grateful that I get to spend my time with you. 5 Table of Contents Introduction 9 1. What use are real-world cases for philosophers? 15 1.1 Introduction 15 1.2 Starting with thought experiments 22 1.3 The smuggled intuition worry 25 1.4 Support factors and thought experiments 31 1.5 In search of an appropriate supplement 34 1.6 A criticism 38 1.7 External validity 40 1.8 Hypothesis generation and conceptual modification 44 1.9 Conclusion 47 2. The Case of Thabo Mbeki’s AIDS Denialism 49 2.1 Introduction 49 2.2 Pre-denial (1980s – 1999) 50 2.3 Denial (1999 – 2000) 53 2.4 Post-denial (2000 – present) 56 2.5 Conclusion 59 3. Was it rational to accept the viral account of AIDS? 60 3.1 Introduction 60 3.2 Setting out the philosophy: Lakatos and the demarcation problem 64 3.3 Early AIDS science in the 1980s 69 3.4 Enter the AIDS denialists 74 3.5 Assessing the Immune Overload and Viral research programmes 79 3.5.1 Appraising the viral account of AIDS 79 3.5.1.1 If HIV causes AIDS, then the virus will be in the T-cells of AIDS 80 patients 3.5.1.2 If HIV causes AIDS, then ARV treatment will be effective 81 3.5.2 Appraising the immune overload account 86 3.6 What motivates the denialists? 92 3.7 Where does this leave us? 93 6 3.8 A final worry: loss of explanatory content 96 3.9 Conclusion 96 4. Thinking mono-causally and multi-causally about 99 disease in the case of AIDS 4.1 Introduction 99 4.2 Mono-causal and multi-causal approaches to disease 102 4.3 Was there really an explanatory gap in the HIV/AIDS case? 107 4.4 Explaining the South African case in terms of mono- and multi- 114 causal accounts of disease 4.5 An attempt to resolve the mono-causal/multi-causal divide 118 4.5.1 Different accounts for different diseases 119 4.5.2 The multi-causal account of disease subsumes the mono-causal 121 account 4.5.3 Joining mono-causal and multi-causal accounts. Preserving 122 causal salience 4.5.3.1 Susser’s multi-level multi-causal model 123 4.5.3.2 Causes and enabling conditions 126 4.6 Conclusion 131 5. Moral Responsibility, Culpable Ignorance and 133 Suppressed Disagreement 5.1 Introduction 133 5.2 Moral responsibility, culpable ignorance and disagreement 134 5.3 Is there a distinction between actual and merely possible 142 disagreement? 5.4 Actual, but suppressed, disagreement 149 5.5 The circumstances of silence 154 5.6 Did Mbeki really express disagreement? 159 5.7 Conclusion 164 6. Concluding remarks 166 6.1 Philosophical methodology and engagement with the world 166 6.2 Was Mbeki reasonable in consulting non-mainstream scientists? 167 6.3 Was Mbeki morally responsible for the consequences of his 169 7 policy? 7. References 171 8 Introduction From 28 October 1999 to 26 September 2000 the South African President, Thabo Mbeki, endorsed the position of ‘denialist’ AIDS scientists – a marginal group who oppose the claim that HIV causes AIDS. Throughout this thesis the term ‘AIDS denialist’ will refer to anyone who adopts the position that HIV does not cause AIDS, even though they might accept both the existence of AIDS and the existence of HIV, as Peter Duesberg, the most prominent of the AIDS denialists, does (more will be said about this in Chapter 3). Individuals who believe that HIV does not cause AIDS prefer to refer to themselves as ‘AIDS dissidents’, rather than ‘denialists’ (Kalichman, 2009, p. 12). Using either term is value laden. Referring to those who accept this position as ‘dissidents’ casts them as valiant heroes, standing up for their beliefs against the oppressive force of mainstream science, and draws on associations with political and religious dissidence. The term ‘denialist’ implies that they deny obvious and well-established pieces of evidence, similar to Holocaust denialists (Kalichman, 2009, p. 11). Using either term implies the rightness or wrongness of the position from the outset. However, in order to write intelligibly, I need to call those who support the position something. I could introduce a third more neutral term, but to do so would be a departure from the current nomenclature and literature on the subject. I anticipate that as this thesis progresses, readers will be in increasing agreement that ‘denialist’ is the more appropriate term. Two claims constitute Mbeki’s particular brand of denialism: 1) ARVs (antiretrovirals – the treatment that prevents HIV from replicating), specifically AZT (azidothymidine), are toxic; and 2) HIV is not a necessary condition for AIDS (Cherry, 2009, p. 16). On the basis of these beliefs, Mbeki adopted a policy of not providing ARVs via the public health system. It is important that he held both beliefs (that HIV is not a necessary condition for AIDS, and that ARVs are toxic) at the same time.