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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