TO Westerners, the repatriation of five nurses and a doctor to Bulgaria last week after more than eight years' imprisonment meant the end of an unsettling ordeal. The medical workers, who in May 2004 were sentenced to death on charges of intentionally infecting hundreds of Libyan children with H.I.V., have been freed, and another international incident is averted.
But to many Africans, the accusations, which have been validated by a guilty verdict and a promise to reimburse the families of the infected children with a $426 million payout, seem perfectly plausible. The medical workers' release appears to be the latest episode in a health care nightmare in which white and Western-trained doctors and nurses have harmed Africans — and have gone unpunished.
The evidence against the Bulgarian medical team, like H.I.V.-contaminated vials discovered in their apartments, has seemed to Westerners preposterous. But to dismiss the Libyan accusations of medical malfeasance out of hand means losing an opportunity to understand why a dangerous suspicion of medicine is so widespread in Africa.
Africa has harbored a number of high-profile Western medical miscreants who have intentionally administered deadly agents under the guise of providing health care or conducting research. In March 2000, Werner Bezwoda, a cancer researcher at South Africa's Witwatersrand University, was fired after conducting medical experiments involving very high doses of chemotherapy on black breast-cancer patients, possibly without their knowledge or consent. In Zimbabwe, in 1995, Richard McGown, a Scottish anesthesiologist, was accused of five murders and convicted in the deaths of two infant patients whom he injected with lethal doses of morphine. And Dr. Michael Swango, ultimately convicted of murder after pleading guilty to killing three American patients with lethal injections of potassium, is suspected of causing the deaths of 60 other people, many of them in Zimbabwe and Zambia during the 1980s and '90s. (Dr. Swango was never tried on the African charges.)
These medical killers are well known throughout Africa, but the most notorious is Wouter Basson, a former head of Project Coast, South Africa's chemical and biological weapons unit under apartheid. Dr. Basson was charged with killing hundreds of blacks in South Africa and Namibia, from 1979 to 1987, many via injected poisons. He was never convicted in South African courts, even though his lieutenants testified in detail and with consistency about the medical crimes they conducted against blacks.
Such well-publicized events have spread a fear of medicine throughout Africa, even in countries where Western doctors have not practiced in significant numbers. It is a fear the continent can ill afford when medical care is already hard to come by. Only 1.3 percent of the world's health workers practice in sub-Saharan Africa, although the region harbors fully 25 percent of the world's disease. A minimum of 2.5 health workers is needed for every 1,000 people, according to standards set by the United Nations, but only six African countries have this many.
The distrust of Western medical workers has had direct consequences. Since 2003, for example, polio has been on the rise in Nigeria, Chad and Burkina Faso because many people avoid vaccinations, believing that the vaccines are contaminated with H.I.V. or are actually sterilization agents in disguise. This would sound incredible were it not that scientists working for Dr. Basson's Project Coast reported that one of their chief goals was to find ways to selectively and secretly sterilize Africans.
Such tragedies highlight the challenges facing even the most idealistic medical workers, who can find themselves working under unhygienic conditions that threaten patients' welfare. Well-meaning Western caregivers must sometimes use incompletely cleaned or unsterilized needles, simply because nothing else is available. These needles can and do spread infectious agents like H.I.V. — proving that Western medical practices need not be intentional to be deadly.
Although the World Health Organization maintains that the reuse of syringes without sterilization accounts for only 2.5 percent of new H.I.V. infections in Africa, a 2003 study in The International Journal of S.T.D. and AIDS found that as many as 40 percent of H.I.V. infections in Africa are caused by contaminated needles during medical treatment. Even the conservative W.H.O. estimate translates to tens of thousands of cases.
Several esteemed science journals, including Nature, have suggested that the Libyan children were infected in just this manner, through the re-use of incompletely cleaned medical instruments, long before the Bulgarian nurses arrived in Libya. If this is the case, then the Libyan accusations of iatrogenic, or healer-transmitted, infection are true. The acts may not have been intentional, but given the history of Western medicine in Africa, accusations that they were done consciously are far from paranoid.
Certainly, the vast majority of beneficent Western medical workers in Africa are to be thanked, not censured. But the canon of "silence equals death" applies here: We are ignoring a responsibility to defend the mass of innocent Western doctors against the belief that they are not treating disease, but intentionally spreading it. We should approach Africans' suspicions with respect, realizing that they are born of the acts of a few monsters and of the deadly constraints on medical care in difficult conditions. By continuing to dismiss their reasonable fears, we raise the risk of even more needless illness and death.