American Scientist

The Invisible Cure: Africa, the West, and the Fight Against AIDS. Helen Epstein. xxv + 326 pp. Farrar, Straus and Giroux, 2007. $26.

The development of effective antiretrovirals has transformed AIDS into two diseases—one for the rich and quite a different one for the poor. In the developed world, people infected with HIV who have access to health care can now think of their illness as a chronic condition with which they may live for decades, and the incidence (the number of new cases diagnosed each year) has declined significantly. By contrast, in much of the developing world HIV infection is still largely a near-term death sentence, and the far greater incidence is only just beginning to level off.

Why have we not yet prevailed over HIV? Part of the answer is to be found in the biology of the virus, which evolves quickly, hijacks and eventually destroys the host's immune system, and depends on the most powerful of human urges—sex—for its transmission.

But the AIDS pandemic has been a formidable adversary for other reasons as well. As Helen Epstein makes clear in The Invisible Cure, the fight against AIDS in Africa, where nearly 70 percent of the world's HIV patients live, has been a chronicle of missed opportunities, well-intentioned fiascos, greed and folly.

Epstein, a trained scientist who is now a journalist eager to make a difference in the lives of others, has spent many years in the AIDS trenches. With clarity and precision, she describes the human dimensions of the crisis in Africa, casting a cool and analytical eye on the way the world has responded. The book makes a major contribution to our understanding of the pandemic by focusing on the many ways in which foreign aid, foreign experts and unresponsive Western governments have collided with long-standing traditions and emerging dysfunctions of the African continent.

Because Africa is such a complex mosaic of nations, peoples and histories, no single pattern of disease is found throughout the continent. Eastern and Southern Africa, for example, themselves heterogeneous regions, have suffered far greater ravages from AIDS than have North or West African nations. Certain countries, such as Uganda, have achieved remarkable decreases in the incidence of HIV infection, whereas others, such as Botswana and South Africa, continue to labor under an increasing burden. Having spent considerable time working in and reporting from various parts of Africa, Epstein understands that no single explanation accounts for the ferocity of the unfolding pandemic. The power of the book lies in Epstein's ability to derive compelling conclusions without ignoring country-specific idiosyncrasies. The Invisible Cure is not just a disjointed collection of dispatches from the AIDS front.

Epstein notes that potential aid givers realized, correctly, that the per capita health budgets and the poor medical infrastructure of many African countries made a vigorous local response to this emerging disease unlikely. So when the dimensions of the pandemic first began to come into focus in the late 1980s, international organizations, public and private charities and donor nations all earmarked billions of dollars to address prevention and treatment in Africa. But tangible successes have been hard to come by. How could so much money end up making so little difference?

Part of the problem is that the response to AIDS, both inside and outside Africa, was conditioned by events in the early history of the epidemic. For instance, the initial reports of deaths among gay men due to an unknown illness that caused the immune system to collapse appeared in June of 1981, irreversibly branding HIV as a gay disease. And yet, only a few months later, similar reports appeared of deaths among hemophiliacs receiving blood transfusions and of deaths among infants born to mothers using intravenous drugs. One can only imagine how differently forces would have been marshaled had HIV initially been seen as a disease afflicting newborns. Similarly, the linking of the HIV epidemic with patterns of sexual behavior that prevailed in parts of the urban gay subculture of the 1980s provided ammunition for branding HIV infection as a disease of promiscuity. This stigmatization resulted in needless suffering and facilitated the illusion that AIDS was exclusively a disease of homosexuals, prostitutes and drug users.

In a series of dispassionately narrated but profoundly affecting vignettes, The Invisible Cure chronicles how the social construction of the pandemic continues to haunt efforts to address AIDS in Africa. A number of governments there wasted valuable time before acknowledging the reality of the pandemic, in part because of the perception (conveyed by narratives in the developed world) that the disease was associated with homosexual behavior. In the 1990s, however, it became clear that HIV transmission in Africa was occurring primarily as a result of heterosexual contact.

A new explanation for the high prevalence of HIV infection there subsequently emerged, one that, as Epstein makes clear, bought into an old racist stereotype about African promiscuity and hypersexuality. The focus was now on this supposed promiscuity which, in conjunction with purported high rates of prostitution, was thought to account for the spread of HIV. As a result, many foreign aid initiatives either preached abstinence or targeted high-risk populations: sex workers and their migrant-labor clients.

Epstein compellingly argues that we cannot understand AIDS in Africa without understanding the arrangements that frequently underlie sexual relations there.

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These aid programs, in effect, had been constructed around Western narratives at odds with the realities of African culture. A number of surveys, including some conducted prior to the onset of the epidemic, revealed that in Africa the average number of sexual partners over a lifetime for both men and women was at or below the norm in the developed world. How then to account for the fact that no more than 1 percent of the population of the United States was infected with HIV, whereas prevalences of 20 to 25 percent or even higher could be found in certain countries of Eastern and Southern Africa? The answer is embedded in the details of social relations.

Certainly the introduction of the disease had been facilitated by the movement of individuals and populations across the continent. The colonial enterprise displaced people from their ancestral agricultural lands. In the absence of jobs near their homes, laborers left their villages in search of wages and lived for months or years at a time as migrant workers in camps and hostels near mines and factories. All of this, in combination with increased urbanization, created opportunities for the migration of the HIV virus across the continent and the world.

However, none of these factors alone could account for the startling incidence of HIV in countries such as South Africa, Botswana, Uganda, Kenya and Lesotho. Epstein compellingly argues that we cannot understand AIDS in Africa without understanding the arrangements that frequently underlie sexual relations there. For instance, she points out that transactional sex—engaging in longer-term sexual relationships with an expectation of receiving cash or gifts—is common in many parts of Southern Africa and should not be conflated with prostitution. Also, coerced sex occurs with alarming frequency in certain parts of Africa and has not, until recently, been treated as a serious crime of violence. Perhaps most important, in many of these countries men (and to some extent, women) engage in simultaneous long-term relationships with two, three or more partners. These relationships are not casual and might last months, years or even a lifetime. But their concurrent nature provides a web of transmission opportunities for the virus. In contrast, in the United States, men and women might, on average, have many more partners over their lifetimes, but social norms dictate that these relationships be sequential.

Epstein emphasizes that many social factors affect the dynamics of HIV on the African continent. Some arise from the disruptions that have gripped the continent in recent decades: wars, displacements and the pathological violence—particularly against women—that emerges in times of social upheaval. As the role and status of women in traditional agrarian and pastoralist societies gives way to a more egalitarian conception of women's lives, the control of women's sexuality becomes contested territory.

Epstein also provides a nuanced and evidence-driven critique of foreign aid programs. She turns the spotlight on this multibillion-dollar enterprise to reveal the gulf that often separates good intentions from desirable outcomes. Furthermore, she has the courage to expose the mixed motives and deplorable behaviors that inhabit the shadows of virtually all foreign aid undertakings.

Although no single factor can explain why large-scale foreign aid projects so often fail, the history of efforts to combat AIDS in Africa reveals how such programs satisfy not just the needs of the recipient but also the needs of the donor. Early in the history of the pandemic, aid projects relied heavily on consumables (testing kits, antiretrovirals) available only from the donor country. Such programs in effect diverted tax dollars  into the coffers of companies in the donor country. Foreign aid undertakings often provided significant employment opportunities for professionals from the donor nation while generating only a few transient low-wage jobs in the recipient country. Most perniciously, recipient countries became dependent on the vast streams of capital being funneled through the project—streams that would inevitably dry up.

Western countries are learning from their mistakes, and the massive involvement of nongovernmental organizations and private foundations has dramatically altered the landscape of the fight against AIDS in Africa. Nonetheless, a certain Western gigantism still afflicts many of these programs: The sheer scale of the pandemic compels the creation of multimillion-dollar initiatives. But the sudden infusion of vast sums of cash into the economies of most African countries is in itself disruptive, igniting corruption and highlighting inefficiency.

Here again, Epstein's analysis is subtle and informed by her time in Africa. She unflinchingly details the acts of petty and grotesque corruption that have taken place, but she does not succumb to the conventional narrative that blames African greed. As the number of U.S. public servants serving time in prison attests, greed in combination with a shortage of civic morals is not solely an African phenomenon. But in the absence of an independent judiciary and an infrastructure that can audit expenditures, the concentration of power in the hands of only a few people sets the stage for flagrant acts of personal and institutional corruption.

The gigantism Epstein notes also results in the chronic underfunding of small-scale projects, particularly those for which effects cannot be readily quantified in the short term. The book describes a succession of immense aid ventures foundering under the weight of their own complexity and ambition—for instance, the $20-million-per-year loveLife project in South Africa, which sought to reduce HIV infection by enhancing the self-esteem of participating teens. But loveLife would not mention AIDS directly and did not, in the end, significantly reduce the risk of contracting HIV.

Epstein also details the rise of abstinence programs, driven by political considerations in the United States and the spread of evangelical churches throughout the African continent. These efforts, usually well intentioned and always well funded (by a $1 billion allocation from the U.S. Congress), have yet to demonstrate any effect on the behavior or the HIV risk of teenagers.

This book is sobering, but it is not demoralizing. For among the many tales of cultural blindness, venality and mismanagement in the fight against AIDS in Africa, there are some successes. Most notable perhaps is the case of Uganda, where HIV prevalence has fallen from about 18 percent in 1993 to just under 7 percent in 2005. Some of this progress may well depend on factors unique to Uganda—the country's fertile soils, natural wealth and relatively small population. In addition, colonial behavior in Uganda was comparatively benign, leaving behind a cadre of qualified professionals and one of Africa's premier universities. As a result, Uganda has been able to withstand years of political turmoil and violence without the uprooting of the population and the disruption of traditional social networks one might have expected.

But perhaps most important has been the willingness of Uganda's citizens and their government to talk openly about HIV and AIDS. Diversified programs distributed condoms and also warned people about the dangers inherent in partner networks. Ugandan men and women were encouraged to practice "zero grazing," a cheeky allusion to the risks of concurrency in sexual relationships. More recently, Uganda has incorporated an extensive array of home services for individuals and families afflicted with AIDS, ranging from meal preparation to the delivery and monitoring of antiretroviral drug therapy. As a result, access to and compliance with antiretroviral regimes has increased markedly. From the outset, Uganda treated HIV as a disease that could infect any of its citizens. The resulting "social cohesion" meant that individuals and institutions viewed combating the pandemic and caring for the afflicted as a shared responsibility.

Infectious diseases, as The Invisible Cure reminds us, are the truth serum of social relations. Regardless of what people claim, admit, deny or fear, HIV transmission simultaneously reflects and illuminates the complex reality of sexual contacts. The HIV virus has caused the African continent immense suffering. Its effects—demographic, economic and social—will be felt for many generations. But Africa is a resilient continent. If the economic and scientific resources of the developed world can be joined with the courage and resourcefulness of the people of Africa, the cure for AIDS need not remain invisible.