Q&A with Hans Rosling (Part 1): A deeper look at AIDS transmission and disease stats

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On Monday, the TEDBlog had a long chat with Hans Rosling, the extraordinary global health professor that makes data come alive. He had his third TEDTalk posted yesterday and again wowed us all, explaining complex information with animated graphs — and humor. In this interview, he delves into his theories on concurrency and AIDS transmission, our ideological ruts and developing the Obama-meter!

Hans had so much interesting news to share, that we had to split our interview in two! Return tomorrow for Part 2 of the interview, when Hans will recount meeting Fidel Castro, explain how cancer changed him and divulge the secret of why we love him so.

So, you’ve seen your TEDTalk already?

Oh yes, and I got so disappointed because, first, I went over the time. Also, we had technical problems and spent the last two hours before my talk debugging the presentation. So, the presentation I gave is not as good as the version that was on my computer. It just did not come out well at all. You know, it’s a real challenge to talk about a subject as complicated as AIDS in front of a large audience.

And I made that one mistake. I said male circumcision prevents HIV transmission when really it reduces it in a population. And when someone hears this, he will think, “If I have a circumcision, I can’t contract HIV,” and this is not the case. However, at least this part was edited out of the talk.

I thought the talk was very good. Do you always feel this way about your talks? Have you given a talk that you thought was good?

The TED Talk from 2006 is almost perfect. Even the mistakes I made in that talk were almost perfect. Then, the screen was low and you could see the graphics around me while I was talking. It was so good for my style of presenting. But in 2007, you raised the screen.

Anyway, I didn’t know that format was going to be so good. This was a technique I discovered by serendipity, like the joke in my talk about solidifying the beam of the laser. People really liked that, because they are so fed up with laser pointers which are such an overused technology. Now, I’m working on a bamboo version so that it will be biodegradable.

We know AIDS spreads more rapidly with concurrent sex partners, but what exactly do Africa’s concurrent partner relationships look like?

Well, this concurrency I have only observed in some parts of southern and eastern Africa. You must remember that there are tremendous variations between practices in all of Africa. Remember in the talk, I spoke about the difference between Salt Lake City and San Francisco. For example, the gay community in Salt Lake City is not that strong. But where there is the practice of concurrent partners, between the ages of 15 and 30 you may have less partners and less intercourse and have 50 times more HIV.

Now, Swedes have serial monogamy, which is one partner after another but no overlap. And then there is polygamy. Concurrent partners does not mean polygamy. These are as different as snow and sand. I want to carefully explain this, because this area is so heavy with moral judgment.

Having concurrent partners means that during a one month period, on a regular basis, you have sex with more than one person. There is not one main partner and then little affairs, either. In these societies, sex is linked to the social transaction. Sex has a different social role. There’s not as much jealousy with regard to sex. Now, it sounds as if I am defending concurrent partners. But with the Swedish way, serial monogamy, you just drop partners. It’s not very nice.

There is another model as well. In the Middle East, you marry when you are between 17 and 21 and you only have sex with the person you marry. And, actually these people probably have more intercourse, with their spouse, than anyone else. Many of these couples have a great sex life, too.

Also, as I said in the talk, HIV doesn’t have the same risk of transmission at all times. From the time of infection, the virus’ levels grow and peak in the blood in the first six weeks. With no other STD present, the risk of transmission is actually very low at other times. So with serial monogamy, even if a person is infected, they continue to have sex only with the person that infected them until their viral levels have fallen. Whereas, if you have sex with two other people just after infection, the virus is more likely to spread.

Promiscuous parts of the gay community in the United States, and in Sweden, also have concurrent partners. Note that I said promiscuous. For heroin abusers, this concurrency pattern is also the same as they reuse needles from many different people. This is also significant as blood is more contagious than any other bodily fluid.

There is no research consensus on concurrency, but it is the most probable hypothesis.

This brings me back to a question I was going to ask on why the rate of AIDS is higher in Southeast Africa than in West Africa. So, clearly it’s not related to viral mutations but to culture, right?

No, no, no. Don’t say “clearly.” There is no research on this, as I said. Researchers haven’t done this yet, probably because it’s a very controversial topic. There’s lots of research on mother to child transmission, but they haven’t done the main method of transmission, you see. This is because this topic of sex is so delicate and also so methodologically difficult.

After 25 years of this virus, now UNAIDS is discussing funding someone to do this research. Peter Piot finally heard of it. But, I’m not complaining because this is how it is with these big diseases. It has taken 25 years, but we’ve finally gotten the big specialists.

So, I can’t completely defend everything in this theory scientifically. But, I can provoke research. I showed the differences between income groups. That was not what we thought it would be. There’s no war-torn country with more than three percent infection. That’s not what we thought it would be. The hypotheses don’t hold with the statistics. High literacy rates correspond with the highest infection rates. Going to school actually increases your risk of contracting HIV.


Reality is like that.

When a new disease arises we want to use it for our old fights. And we are not really addressing HIV, we are using it to fight our old battles.

So we get stuck in ideological ruts?

Yes. And at the local community and neighborhood levels, and even city and state levels, our understanding of issues tends to be evidence-based. But at the global level, we tend to think on the only on the ideological level.

When Nathan (Wolfe) showed a photograph of a man who had killed a monkey and then defended him, that was my best moment at TED. The audience was silent. This went completely against the accepted idea of preserving and conservation of monkeys. But this man had to kill the monkey to feed his family.

I showed a powerpoint in 2007 that demonstrated the difference between the means of progress and the goals of progress. People mix up means and goals. Goals, like human rights and gender equity, are often used as means. These are very nice goals, but they are not means.

You see, it is very easy to be an evidence-based professor lecturing about global theory because many people get stuck in wrong ideas.

Speaking of ideological shifts, you mentioned circumcision earlier and I’ve read a few studies about it lowering AIDS transmission within populations. At the time these findings were considered controversial — are they still?

This is proven beyond a doubt. It was tested in randomized controlled trials, the strongest study design we have. It’s very well proven.

The problem is that it’s linked to religion and ethnicity, so that it also can become this anti-Semitic upheaval. Where you are, in New York, this sort of thing is more relaxed. Circumcision is the norm. In Sweden you can talk about condoms as much as you want, give them to all the teenagers. But circumcision — no. In many countries, it is socially, politically and culturally impossible to promote.

The only problem with circumcision is that more safety measures mean more risk-taking. You know, using a bike helmet means you ride more recklessly and seat belts mean you drive faster. A lot of the positive effects you get from safety measures, you lose in risk-taking. So this is a double-edged sword.

It’s difficult to understand how we can reduce transmission in countries with concurrency. But we must, because we can’t provide treatment to everyone at the poorest levels. It’s impossible. Of those that have received care from PEPFAR, 60 percent are alive after five years. In Sweden, we’ve got 98 percent of patients alive after 10 years. It may not seem like a nice thing to say, but perhaps the money could have been used more effectively. Diabetes, cervical cancer and heart disease are all without international support. Oh, and tuberculosis! Did you see my video on swine flu and tuberculosis?

Yes! We loved it at the TED office.

I’m a little afraid that it gets misinterpreted. I defended all disease control agencies. That should be done. Their work is very important. It’s the media hype! The story is too easy for them. It’s like putting a child in a candy shop. It’s like the first job for an intern — so simple.

The people in disease control have to be very serious and give proper warnings but I don’t think that the media supports them well. They give them attention for a short time and then they leave them. So people were just not aware of 60,000 deaths from TB in 13 days .

When I released this video, the Swedish media got very offended and started to defend themselves on their webpages. It’s a small place, like Vermont. They thought I was directly criticizing them, but it was global media. One of the heads of news in Sweden told me, “The thing about news is that it’s about things that are not continuous.” So I told him, “You’re right. You should never report about domestic abuse. But when one Swedish man is killed by one bear, that’s what you should report about.”

Actually, in North Sweden a man was killed by a bear in the same county where a man killed his wife two days before. The bear story made the news for weeks, but the other was featured once on the inside pages of the newspaper. There was a huge backlash. There were big protests of the media by women’s organizations.

The media misses a lot of things that change slowly. They have to use the annual report of the WHO on TB and explain those things. When I did my presentations at TED, no-one knew that Vietnam had become so healthy. Al Gore whispered to me, “I had no idea about what you said about Vietnam.” Steady change, they don’t report. The media is simply a bad source of knowledge and understanding.

What about your website, Gapminder.org? This is one way of informing the public. Is there anything new we can look for there?

Yes. It will be better! I’m going to do more videos and I will be developing an Obama-meter. I will plot his days in office against the number of African-American kids who die in D.C. You see, the infant mortality rate amongst African-Americans in Washington, D.C. is more than three times as much as that of African immigrants in Sweden. It’s also much higher than in the white population of D.C. You know, he said it himself, in one of his best speeches — D.C. has the highest income per person in the country yet the child mortality rate is higher than that of some African countries.

I’ll be creating the Obama-meter per 100 days. And people can put it on to their facebook accounts!

This is not just to pull him down. It’s also recognizing him. I could also put up a graph for George Bush showing no change when he was in office. But that’s unnecessary. We already knew that, huh?

To be continued tomorrow …