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…

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