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How, and How Not, to Stop AIDS in Africa

One of the classic works of journalism of the last couple of decades was Randy Shilts’s And the Band Played On1 about the sluggish response to AIDS in the 1980s in the United States, which indicted both the Reagan administration and the leaders of the gay community. I still remember the sense of outrage I felt when reading Shilts’s book; it struck just the right note, leaving one both horrified about the tragic incompetence of so many and yet also hopeful that someone, somewhere could do things better next time.

Yet after reading Helen Epstein’s masterful new book, the response to AIDS in America now looks in retrospect like a model of courage, speed, and efficiency by comparison with the response in Africa. In the US, the government publicized the threat and funded research, the gay community reduced its infection rates by encouraging less risky sexual behavior, the dreaded breakout into the heterosexual population never happened, and AIDS receded to become a disease that, while still tragic, could in most cases be kept under control with expensive new antiretroviral drugs (ARVs).

The opposite is true in every respect of AIDS in Africa, which was anticipated as a looming crisis already in the 1980s, yet governments, foreign aid agencies, and even activists reacted with denials and evasion. The disease rampaged through the heterosexual population and is still rampaging, ARVs were too late, too costly, and available to too few, and Africa is still in the midst of an epic disaster without a solution in sight. As of the latest figures in 2006, 25 million Africans are HIV-positive, 2.1 million die from AIDS every year, and 2.8 million are newly infected each year.2

Epstein’s book lays all this out in courageous and thought-provoking detail, describing the maddening complexity of the AIDS crisis in Africa, and the reprehensible and simplistic evasions of nearly everyone involved. It is not only a book that should be required reading for people concerned in the least with AIDS or with Africa; it is also compulsively readable.

It is not without some flaws. Epstein’s discussion of the economics of African poverty is overly simple—it sometimes sounds more like flat statements about corporate and official power than deep analysis. More seriously, for some of her key points, the evidence base—the numbers of studies and of people and the different groups whose experience she draws on—seems a little thin, although I found her points plausible and largely convincing. Perhaps the fact that there is insufficient evidence about so many aspects of AIDS in Africa is itself a symptom of the skewed priorities that the book describes as afflicting the international AIDS effort.

The history of the response to African AIDS can be divided into two phases: (1) fiddling while Rome burns, and then (2) trying to use the fiddles to put out the fire.

Phase I began long ago, undermining any claims of any of those involved to ignorance of the problem. An article published in the London Times on October 27, 1986, said:

A catastrophic epidemic of AIDS is sweeping across Africa…. The disease has already infected several millions of Africans, posing colossal health problems to more than 20 countries…. “Aids has become a major health threat to all Africans and prevention and control of infection…must become an immediate public health priority for all African countries,” says a report published in a leading American scientific journal.

Signs of the coming epidemic had appeared even earlier. A sample of prostitutes in Butare, Rwanda, in 1983 found that 75 percent were infected with HIV. A later study reporting this statistic dated the general awareness that Central Africa was at risk for the spread of AIDS back to 1983 as well.3 An article in 1991 in the World Bank/ International Monetary Fund quarterly magazine predicted that 30 million people would be infected worldwide by the year 2000 if nothing were done.4 This was not far off the actual outcome in 2000, so sixteen years ago many knew that a catastrophic epidemic was underway.

One of the lead organizations for fighting the African epidemic was the World Bank, which says today on its AIDS Web site that it is “the largest long-term investor in prevention and mitigation of HIV/AIDS in developing countries.” In its first AIDS strategy report in 1988, the World Bank said the crisis was urgent. It presciently detected “an environment highly conducive to the spread of HIV” in many African countries. It noted that the epidemic was far from reaching its full potential and that “the AIDS epidemic in Africa is an emergency situation and appropriate action must be undertaken now.”5

Yet the World Bank’s effort at the time was pitiful: it made a grant of $1 million to the World Health Organization (WHO) in the 1988–1989 fiscal year to fight AIDS. The World Bank sponsored only one project dedicated to AIDS before 1993 (an $8 million loan to President Mobutu of Zaire in 1988). Over the entire period between 1988 and 1999, it spent $15 million a year on all AIDS projects in Africa. In 1992, another World Bank report noted that it “has done little to initiate prevention in countries in which the risk of spread is high.” Yet the 1992 report closed with the inexplicable admonition that “AIDS should not be allowed to dominate the Bank’s agenda on population, health, and nutrition issues in Africa.”

Other aid organizations did little better. What explains such fateful inaction? There was a failure of courage on the part of both Western aid agencies and African leaders, and misinformation that made both parties reluctant to press the issue. As Epstein explains, Western scientists had identified the continent as the source of the worldwide epidemic, and pinpointed a virus in monkeys that had somehow jumped to humans as having initiated it. There were still plenty of mysteries: How had the jump happened? When did it happen and why? Why did the virus not spread before the 1980s and then why did it spread so rapidly in Africa afterward? Epstein discusses what is known and unknown about these questions, which makes fascinating reading. Perhaps what is even more relevant than the right answers to the questions, however, is the way that the wrong answers inhibited the response to the epidemic.

Western scientists flew into Africa, collected blood samples, and flew out, seemingly much more interested in getting recognition in the Western press than in communicating useful and sensitive knowledge to African leaders and the public. Scientists carelessly put forward hypotheses about African promiscuity without considering how important it was to avoid any unnecessary stigma that would provide an excuse for denial by African leaders. The press and television portrayed (and still does portray) Africans as being almost universally HIV-positive. Would African AIDS become less of a tragedy if the press reported accurately that HIV-positive individuals make up just 3 percent of the population of sub-Saharan Africa? Of course, being accused of promiscuity and having Africans labeled as the equivalents of Typhoid Mary did not make their leaders or the general population all that receptive to messages from Western scientists on how to confront the epidemic.

Many Africans reacted with a mixture of denial and conspiracy theories. Maybe the CIA had targeted Africans during the cold war with a scientifically engineered virus, perhaps spread through vaccination campaigns. In South Africa, there was a claim that the apartheid government had targeted black South Africans for decimation through the HIV virus (a conspiracy theory that may not have seemed so far-fetched in view of the evil deeds of the South African secret service under apartheid). As Epstein chronicles, South African President Thabo Mbeki and Health Minister Dr. M.E. Tshabalala-Msimang also consorted with AIDS quacks who doubted that HIV caused AIDS. Few in Africa or the aid agencies lending to Africa wanted to talk about AIDS with these ideas in the air.

A more mainstream but also damaging view of the Western AIDS experts was that the spread of AIDS in Africa was driven by “core transmitters,” such as prostitutes and the truck drivers and migrant workers who patronized them. This was a theory favored by the World Health Organization and World Bank, as set out in the bank’s 1997 AIDS report. This new theory added yet more layers of stigma and denial. If AIDS victims were prostitutes or patrons of prostitutes, who was going to admit being HIV-positive? Or that their late relatives died of AIDS? This could explain some of the astonishing wall of silence surrounding AIDS that Epstein documents and that still prevails among both the African public and politicians.

Of course, such theories may well have been true—maybe AIDS was the result of the sex trade and promiscuity. So some Westerners advised Africans: just try to overcome the stigma as best you can. Treat the problem at its source by getting prostitutes to force condoms on their customers. The rest of the population could breathe easy as long as they did not use prostitutes or sleep promiscuously with men who did.

Epstein’s contribution is to say loudly that this conventional wisdom is wrong. The stigma attached to the HIV-positive, and the implied general stigma for Africa, were tragically misguided. According to survey evidence Epstein provides, Africans are no more promiscuous than most other people, as measured by numbers of sexual partners in a lifetime, casual sexual encounters, and visits to prostitutes. As she says, sexual behavior in Africa is governed by strict rules; they are just different rules from those prevailing elsewhere. She argues that in many African countries the large numbers of people willing to follow those rules have a great deal to fear from AIDS; and they must know they cannot dismiss the problem of infection as one of a whoring minority. The international aid agencies and Western governments are only now belatedly coming around to Epstein’s perspective (which is based on the findings of a number of independent researchers), over two decades after the start of the epidemic, and they still don’t know quite how to handle it.

Epstein’s view is that the cause of the AIDS crisis in Africa is what has now become known in AIDS jargon as “concurrent” relationships. Africans have about the same number of sexual partners as anyone else; they are just more likely to have more than one long-term partner at a time. Crucially, both men and women have multiple partners, in contrast to other poor societies where men may often stray but women’s monogamy is jealously guarded. Western men and women are more likely to practice serial monogamy or engage in one-night stands. To oversimplify a little, Africa’s AIDS tragedy is that it combines greater Western-style sexual equality for women with social norms that permit simultaneous long-term sexual relationships for both partners.

Multiple long-term relationships are prevalent in Africa for many reasons. In southern Africa (where the epidemic is concentrated), one of the few opportunities for gainful work open to men is to become long-distance migrants to the mines. Both husbands and wives may have other long-term partners during the months when they are separated. The African tradition of polygamy (described by historians like John Iliffe as a cultural response to maximize fertility in what used to be a lightly settled continent) has given way to modern relationships between older, well-to-do, gift-bestowing men and multiple young girlfriends. This is not so different from the successive trophy wives of American fat cats, but much more widespread since Africa’s poverty often makes it a matter of survival for African young women to have a rich (older) boyfriend. The desire of young women for young boyfriends can be accommodated on the side.

  1. 1

    And the Band Played On: Politics, People, and the AIDS Epidemic (St. Martins, 1987).

  2. 2

    UNAIDS report, December 2006.

  3. 3

    Bekki J. Johnson and Robert S. Pond, AIDS in Africa: A Review of Medical, Public Health, Social Science and Popular Literature (Aachen: MISEORE, Campaign Against Hunger and Disease in the World, 1988).

  4. 4

    Jill Armstrong, “Socioeconomic Implications of AIDS in Developing Countries,” Finance and Development, Vol. 28, No. 4 (December 1991), pp. 14–17.

  5. 5

    World Bank, Africa Technical Department, “Acquired Immunodeficiency Syndrome (AIDS): The Bank’s Agenda for Action in Africa,” October 24, 1988.

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