Helen Epstein
THE INVISIBLE CURE
Africa, the West and the fight against AIDS
326pp. Viking. £16.99.
978 0 670 91356 5

On one of her many trips to Africa in recent years to investigate the state of the AIDS epidemic, Helen Epstein (no relation) visited the main hospital in a district known for its tea plantations, about 200 miles from Uganda’s capital, Kampala. There was one doctor at the facility, and on occasion some nurses. The X-ray machine could be powered up for an hour a day at best. Those patients not sleeping on the floor were sharing beds. The bathrooms had been gutted and served “as aviaries for the finches that made their nests in the porcelain scraps on the floor”. Some patients had AIDS; others, suffering from onchocerciasis, or “river blindness”, had long parasitic worms that formed wriggly lumps beneath the skin.

To write about AIDS in Africa for a Western audience is to confront a sharp narrative dilemma. How do you tell stories – often painful, sometimes overwhelming – without re-inforcing a sense of awful inevitability about Africa’s many problems? How do you convey the startlingly different logic by which life operates there, without trafficking in myths and stereotypes, and without solidifying a perception of Africa as radically “other”, and thus unknowable and unreachable? Epstein, a scientist turned essayist, has been piecing this account together for more than a decade in a series of lucid articles published in the New York Review of Books. Collecting that material between the covers of a single volume is a tremendous service – even if, as so often is the case for books with such origins, she has failed to eliminate distracting repetition across chapters or solve some basic problems of exposition. (Why are elementary facts about AIDS treatment and testing in Africa relegated to an appendix?) But her keen eye for detail, suspicion of conventional wisdom, and compelling prose carry the reader along. She does not shy away from telling horror stories about East and Southern Africa, home to about 40 per cent of the world’s cases of HIV infection. There are stories not just of deplorable conditions, tragic missteps and profound institutional failures, and sometimes of the hideous things that people do to one another – like the case of the South African teenage boys who stoned to death their neighbour, an HIV-positive AIDS counsellor, because she had brought “shame on the community”. But Epstein also juxtaposes failures with impressive accomplishments. Though her portraits are vividly painted, her desire is not to describe but to explain. And if she succeeds better than most in avoiding the standard portrayal of Africa as unfathomable and unchangeable, it is because she interweaves her storytelling with careful analysis. She shows how human efforts to control disease often fail but sometimes succeed, and by placing outcomes and actions squarely in their historical and cultural context – including, not incidentally, the long historical ripple effects of Western colonialism that continue to promote the spread of disease while hindering its containment – she shows us why people believe what they believe or do what they do. Finally, by linking what happens in Kampala and Pretoria to what goes on in Geneva, Washington, DC, and elsewhere, Epstein shows how the intractable dilemmas that come to seem quintessentially “African” are often caused, or compounded, by forces and agendas that originate elsewhere and over which Africans themselves exercise limited control.

Epstein’s analysis of AIDS in Africa centres on two vital questions. The first one concerns the epidemiology of transmission: why is the AIDS epidemic so much worse in sub-Saharan Africa than anywhere else in the world? More than 35 per cent of all adults in certain African countries are HIV-positive, while in the United States, Russia and India, the figures have never gone higher than 1 or 2 per cent, and the expert prediction that Asia would go the way of Africa has, thankfully, not yet come to pass. The second question concerns the sociology and politics of disease prevention as practised on the ground in different African countries: why have certain countries, such as Uganda, seen sharp declines in rates of infection with HIV, while others, such as Botswana and South Africa, continue to fare so poorly?

Although these questions prove difficult to answer, Epstein has interesting things to say about them, and draws thoughtfully on an eclectic mix of theories and findings from the natural and social sciences. To explain the devastating spread of HIV in Africa, Epstein begins by casting doubt on a range of popular hypotheses, from the plausible (weakened immune systems from malnutrition and parasitic infections) to the dubious and frankly racist (exotic tribal rituals involving blood). She points in particular to the frequency of so-called concurrent sexual relationships – that is, sustained relationships with more than one partner at a time, as opposed to either serial monogamy or monogamy punctuated by one-night stands – describing one study in which 40 per cent of Ugandan men and 30 per cent of women reported that at least two of their most recent relationships overlapped for several months or years. Mathematical models show how a sexually transmitted infection can blaze through such a population at an astonishing rate, much faster than when individuals have many sexual partners over the years but only one at a time. While those engaging in one-night stands with strangers or prostitutes may be more likely to use condoms when doing so, participants in concurrent relationships, who know, love and trust their various partners, may be far more inclined to dispense with protection altogether.

This is an ingenious explanation, but Epstein lacks the detailed comparative data that would clinch her case. Although she rightly points to the regulative effect exerted by the Western cultural ideal of true love, she doesn’t tell us much about what people outside Africa actually do sexually. Consider the findings from the National Health and Social Life Survey (published in 1994 as The Social Organization of Sexuality), which stands as the most rigorous statistical study to date about sexual practices in the US. While the researchers found low numbers of sexual partners among those respondents who were married, nearly a quarter of those who were unmarried but living together reported multiple sexual partners in the previous year. Moreover, of all those respondents who had two partners in the preceding year, half reported a period of overlap between partners, but only a quarter reported having a one-night stand. These data suggest that sexual concurrency, as Epstein defines it, may not be so exclusively an African phenomenon, and that her contrast between Africa and countries such as the US may be overdrawn.

On the crucial question of responses to the epidemic, Epstein finds no simple answer, but many suggestive hints of great potential significance. In Uganda, where the HIV rate fell by two-thirds between 1992 and 2003, AIDS became an urgent topic of collective conversation and an opportunity for social cohesion: “Kampala taxi drivers talked as passionately about AIDS as taxi drivers elsewhere discuss politics or football. And they talked about it in a way that would seem foreign to many in South Africa because it was so personal: ‘my sister’, ‘my father’, ‘my neighbor’, ‘my friend’”. Moreover, the Ugandan fight against AIDS, taken up by hundreds of small, community-based organizations, became closely connected with the campaign for women’s rights, to the mutual benefit of both struggles. South Africa, by contrast, has been the chief site of official denial of the realities of AIDS, from the office of the presidency on down. And the emphasis there on reaching those deemed at highest risk, such as prostitutes and truck drivers, left grave misunderstandings about how much the disease had penetrated the population, and who was really at risk of infection, while doing nothing to reduce the stigma associated with the condition.

In the end, Epstein tells us, there can be no single answer to the problem of HIV/AIDS – neither antiretroviral drugs (no cure-all, even when available) nor an AIDS vaccine (which remains elusive) nor any particular behavioural model of prevention and education. She is refreshingly sceptical of the AIDS prevention campaigns brought in by the global public-health establishment, not only because of their often narrow presuppositions about what motivates human behaviour, but also because of the assumption that solutions are portable – that an AIDS campaign designed in Geneva can, with modest tinkering, do the trick in Botswana. In the end, she suggests that “African people often know best how to solve their own problems”, and the kind of heartfelt social mobilization that appears to have made such a difference in Uganda is something that no public-health “social marketing” campaign can engineer or foment. African nations cannot do it alone, she suggests, but neither can Western scientists, missionaries, or consultants impose solutions in countries they have not begun to understand. Indeed, outsiders have often made things predictably worse, including the “helicopter scientists” who “parachuted in, took data, and didn’t work with local African experts”, and the pharmaceutical companies who found in Africa a place where drug trials could be conducted on the cheap, without the inconvenience of having to respect the rights of the participants.

Perhaps the most frightening stories that Epstein tells about the impact of outsiders concern the practices of the current administration in the US. President George W. Bush has expanded the funding for AIDS prevention in Africa, while promoting abstinence and fidelity. Yet this emphasis has little basis in scientific data. In Uganda, for example, Epstein reports that during the years when the national HIV rate fell by about 70 per cent, the teen pregnancy rate remained essentially unchanged – suggesting that abstinence had little to do with the remarkable reduction in new infections. What such programmes do support, however, is the promotion of God’s work, as understood by Bush’s conservative Christian backers. “AIDS has created an evangelism opportunity for the body of Christ unlike any in history”, according to Ken Isaacs, a spokesperson for the Christian charity Samaritan’s Purse. And while US law supposedly stands in the way of using Federal funds for evangelizing, Epstein reports that “every abstinence event I attended involved much praying and discussion of Jesus”. Sadly, it is precisely in Uganda, Epstein’s success story, where the tide appears to have turned in recent years, and where Epstein now encounters condom burnings in the name of Jesus. Reversing this alarming trend is now among the most crucial steps in supporting the work of Africans who struggle to solve the wrenching problem of AIDS.

Steven Epstein is Professor of Sociology and Director of the Science Studies Program at the University of California, San Diego. He is the author of Impure Science: AIDS, activism, and the politics of knowledge, 1996, and Inclusion: The politics of difference in medical research, 2007.

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