The Invisible Cure
Africa, the West and the Fight Against AIDS
by Helen Epstein
Farrar, Straus & Giroux; 352 pp., $26
Last year, the chief United Nations researchers on AIDS publicly admitted that the U.N. has consistently over-estimated the size of the AIDS epidemic. UNAIDS revised their estimates of the numbers of HIV cases worldwide downward from 40 million to 33 million, and cut the number of annual new HIV infections by more than 40 percent from previous estimates.
Skeptics wondered whether the history of consistent U.N. overstatement of the HIV problem was a deliberate ploy to raise more funds. Helen Epstein, author of The Invisible Cure, was not surprised: Her work shows beyond any doubt that the politics of AIDS often dominates the science of AIDS.
Trained in biology, Helen Epstein began her interest in HIV and AIDS with a postdoctoral project at the Uganda Cancer Institute in 1993, and her new book, based on a series of articles she wrote for the New York Review of Books between 1995 and 2006, is invaluable for anyone interested in the politics of AIDS in America. She argues that Western aid agencies are gravely culpable in their handling of the AIDS epidemic because they allowed their preconceived notions to interfere with their objective interpretation of the data. The Lifestyle Left comes off much worse than the Religious Right.
Epstein criticizes some Bush administration African initiatives, but not because their message was wrong. Their error was to transfer American abstinence-only programs into the African context, where they did not realistically apply. Abstinence Only is a fine concept if you are trying to reduce teen pregnancy; it isn't so great in a culture where adults have multiple concurrent partners, as in societies that permit polygamy or concubinage. Epstein suggests that the ABC strategy--Abstain, Be Faithful, Use Condoms--was only imperfectly applied. The right emphasized the Abstain while the left emphasized the Condoms; the Be Faithful part of the strategy did not get sufficient attention, except in Uganda.
The Ugandans themselves, not Western experts, developed a messaging strategy uniquely adapted to the local situation. The slogans "Love Carefully" and "Zero Grazing"--meaning, in the words of the head of Uganda's AIDS Control Program, "avoid indiscriminate and free-ranging sexual relations"--were posted on public buildings, broadcast on radio, and bellowed in speeches by government officials.
According to Epstein, "The genius of the Zero Grazing campaign was that it recognized both the universal power of sexuality and the specific sexual culture of this part of Africa, and it gave people advice they could realistically follow."
By far the lion's share of the blame for the African AIDS debacle lies with the Lifestyle Left. They pride themselves on being scientific, yet these are the very people who were most beguiled by their preconceived notions that condom promotion would control the spread of HIV. They clung to this superstition, even in the face of hard data to the contrary.
Condom promotion strategies take sexual behavior as a given, and attempt to reduce the risk associated with that behavior. Partner reduction strategies, by contrast, focus directly on changing sexual behavior. Here is Helen Epstein's even-handed assessment of the data:
Partner reduction has played a key role wherever HIV rates have fallen--from the market towns of East Africa to the red-light districts of Asia to the gay enclaves of the United States. . . . Part of this decline was attributable to the increased use of condoms, but partner reduction was even more important. In San Francisco, the proportion of gay men with multiple anal sex partners fell by 60% between 1984 and 1988, and similar changes were recorded in New York, Chicago and other cities. In Zimbabwe and Kenya, the HIV rate began to decline in the late 1990's. Rates of condom use had been increasing throughout the decade, but it was not until rates of multiple partnerships began to decline that HIV rate in these countries also fell.
This means that the Religious Right was much closer to the mark than the Lifestyle Left. Abstinence Only is a special case of partner reduction. The flaw of the right was that it did not sufficiently adapt its partner reduction strategies to the local situations.
