It is hard to remember when AIDS was just a simple epidemic disease. Long ago it exploded into a global rallying cry for ideologues of every stripe, politicizing the science and the social science alike. A small army of academics and consultants now stake careers - and millions of international aid dollars - on specific and often conflicting theories of how to reduce behavioral risks for acquiring and transmitting HIV.
Amid the partisan babble, Helen Epstein has for years generated some of the most sensible commentary around, posting dispatches from AIDS-afflicted countries in Africa to The New York Review of Books and other publications. As a scientist morphed into a journalist, Epstein combines an understanding of the biology of AIDS with a coolly impartial view of the political and social landscape of Africa. She has assembled more than a decade's worth of reporting into an enlightening and troubling book.
It is a testament to the book's strength that the one scientific goof she makes actually matters relatively little. AIDS drugs, Epstein says, will never prove the salvation of infected Africans, as they have Westerners, because "HIV mutates and soon becomes resistant to one or all of the cocktail drugs. Therefore, patients must eventually switch to a new cocktail" - and the second-line drugs for this purpose are likely to be unavailable in Africa for years.
Her statement about drug resistance is incorrect. Although resistance does occur and may turn out to be a particular problem in Africa, it is by no means an inevitable outcome of treatment. Studies indicate that antiretroviral drug combinations, used correctly, work about as well in Africa as anywhere else and are just as likely to induce a permanent remission.
That said, however, Epstein's basic point is quite true: the drugs alone will never save Africa. Prevalence and transmission rates are too high, the health care infrastructure is too weak, there are too many other threatening diseases, and the costs are impossible. Instead, experts agree that hope lies in a still-distant vaccine, and in the "invisible cure" of Epstein's title: dramatic behavioral changes to prevent new infections.
But the problem lies in achieving those changes in cities where almost half the adult population is infected, where rampant poverty turns sex into a form of currency, and children orphaned by AIDS grow up in a chaos that may render them particularly vulnerable to becoming infected as adults.
Interrupting this perfect storm requires a clear understanding of its origins, and we still cannot fully explain why heterosexually transmitted HIV exploded in Africa while remaining confined to very specific communities in the West. Theories abound, and Epstein does a nice job of reviewing them.
The fiction that Africans are more "promiscuous" than Westerners has been disproved; studies have found that Africans often have fewer sexual partners during their lifetime than Westerners do.
But accepted patterns of sexual activity seem to have ignited the tinderbox in Africa. Sex there crosses social boundaries more often than in the West, and the habit of having concurrent partners - simultaneous long-term relationships in which friendship and trust may thwart routine condom use - means a single person's infection may spread rapidly through a group.
Unfortunately, understanding these patterns makes it no easier to interrupt them. Enter the ideologies: should the catchword of anti-HIV campaigns be "abstinence" or "condoms"? If both, should they be invoked in parallel or in sequence? How vigorously should Western AIDS experts exert their wisdom and dollars to change indigenous African values? And what about religion, fertility, and the fact that, for the destitute, today's food and shelter are invariably more important than tomorrow's health?
Something of a natural experiment addressing these questions took place in the AIDS-devastated countries of East and Southern Africa in the epidemic's early years, as each country embarked on its own independent anti-AIDS campaign.
In the end, there was one clear winner: Uganda. From 1992 to 2003, the HIV rate there fell by two-thirds, Epstein writes, "a success that saved perhaps a million lives."
Needless to say, scholars vehemently dispute the cause of Uganda's success. Some credit various religious or bureaucratic initiatives, while others cite the country's relatively stable politics, relative economic health and relatively strong women's movement.
Epstein makes a good case for the efficacy of a pervasive grass-roots effort, with ordinary people talking openly about AIDS and caring for the sick and orphaned in hundreds of small community initiatives in a "spirit of collective action and mutual aid." Radio spots on AIDS were accompanied by the beating of a traditional warning drum: "When I was young, I'd lie awake all night if I heard a drum beating that way," a Ugandan man tells Epstein.
In stark contrast stands the disaster of present-day South Africa. AIDS was a taboo topic there for years. When it could no longer be ignored, the country's president decided to question all basic assumptions about the disease, undermining progress and delaying treatment and prevention programs for still longer. Even now, South Africa's prevention programs seem to Epstein to lack the simplicity and practicality of the Ugandan efforts, favoring a far less direct, heavily Westernized approach instead.
Throughout the book, Epstein paints an unforgettably nuanced portrait of Western efforts in Africa: Well-meaning, vitally necessary and yet often so misguided. Well-financed Western research projects seduce health care workers from other important work. Western bureaucracy lurches and stalls. And Western money sometimes bypasses the people who need it most, nourishing consultants and middlemen rather than patients.
To describe a rather lackadaisical group of American researchers whose projects in Kampala go nowhere, Epstein borrows pseudonyms from the children's Babar books. There they are - Celeste, Arthur and Cornelius - pleasant, ineffectual, two-dimensional cutouts pasted into a complex and dangerous landscape they will never quite fathom. It is a sadly inspired touch.
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