News & CommentaryArchive
Jul 27, 2007
An Outbreak of Truth About AIDS in Africa
It is hard to imagine that a thoroughly scorched earth history of the AIDS epidemic in Africa could result in such a hopeful perspective about what works, but Helen Epstein’s recent book The Invisible Cure: Africa, the West, and the Fight Against AIDS seems to do just that. Epstein’s work depicts the disastrous world response to the African AIDS epidemic: How it was at first ignored; then addressed using strategies designed for the West; and then hijacked by aid agencies focusing on treatment to the detriment of prevention. No one comes off clean: not the World Bank, nor UNAIDS, nor The Global Fund nor any of the nongovernmental organizations actively trying to bring antiretroviral treatments to the afflicted while ignoring the role of prevention.
Another of Epstein’s targets is how little work has been done to understand which prevention approaches work best for which types of epidemic; and even worse, how even that work has been ignored in favor of prevention efforts that match predetermined conclusions. She examines how Uganda’s successful program to reduce multiple concurrent partnerships (common not only in Uganda, but also in Southern Africa) that dramatically decreased new infections was abandoned in favor of approaches driven by donor-country lobbyists – either condom promotion or abstinence-only programs.
A series of recent articles by Craig Timberg of the Washington Post support Epstein’s positions. Timberg reports that Zimbabwe’s financial troubles of the past seven years have been matched with a drop in HIV-infections, a correlation sociologists link to the decrease in multiple partner arrangements brought about by a lack of disposable income needed by men to keep mistresses. In other articles, Timberg writes about the impact of multiple partnerships on the spread of HIV in Botswana – and how little prevention work has focused on that issue, and similar to Epstein, how Uganda’s prevention efforts have foundered.
Epstein’s book and Timberg’s reporting, as well as a recent World Bank report, indicate that a growing number of people are willing to set aside politics and predetermined conclusions about the AIDS epidemic. All of them recognize a need to better “know your epidemic,“ in the words of the World Bank’s David Wilson. In effect, medical anthropologists and sociologists are just as important to HIV prevention as medical doctors, since “knowing” means knowledge about whether a local epidemic is concentrated among prostitutes and their clients – as it is in Ghana – or within the generalized adult population – as it is in South Africa – and why. The why can then help local prevention teams concentrate efforts and funding on the interventions that will work in the local environment. This is a move away from the cut-and-paste nature of many well-intentioned but ineffective prevention programs, and it is a lot harder to do, but it is the key to success. And prevention needs more successes: Despite the monopoly of attention given to lowering the price and distribution barriers for antiretroviral treatments, there will be no way to lower the world’s death toll without stopping the virus from spreading.
The Invisible Cure: Africa, the West, and the Fight Against AIDS by Helen Epstein.
William Easterly’s thorough review of the book:
The New York Review of Books: How, and How Not, to Stop AIDS in Africa
Washington Post: In Botswana, Step to Cut AIDS Proves a Formula for Disaster
AIDSmap News: Watch Your HIV Epidemic or Risk Wasting Dollars