The Invisible Cure: Africa, the West, and the Fight Against AIDS

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"AIDS has come to haunt a world that thought it was incomplete. Some wanted children, some wanted money, some wanted property, some wanted power, but all we have ended up with is AIDS."

-- Bernadette Nabatanzi, traditional healer, Kampala, Uganda, 1994.

The occurrence of AIDS in East and southern Africa is uniquely severe: even though less than 3 percent of the world's population lives here, this region is home to more than 40 percent of all those people with HIV infections. Throughout much of the world, HIV is mainly limited to gay men, intravenous drug users, sex workers and their customers, but things are very different in Africa. In Africa, AIDS is widespread throughout the general heterosexual population, even among those who have never engaged in risky sexual behavior. Why? And what can we do to help those in need? In this insightful and compassionate book, The Invisible Cure: Africa, the West, and the Fight Against AIDS (NYC: Farrar, Straus and Giroux; 2007), molecular biologist and writer, Helen Epstein, explores these questions in great depth and provides some surprising answers.

The story begins in 1993, after Epstein heard a scientific talk that discussed research problems involved with developing a vaccine against HIV/AIDS in Africa. Inspired by this presentation and by her confidence in her laboratory skills, the author decided to leave her postdoctoral work in San Francisco to join a biotech company's ongoing research project in Uganda to help develop an HIV vaccine. But after she's there, she is confronted with numerous problems, ranging from undelivered research materials and samples to a severe lack of lab space, combined with sudden power outages lasting as long as one week, and even having to invest weeks into simply obtaining a few liters of distilled water -- all these challenges eat up her time and energy, eventually causing her own research project (and its funding) to derail.

While tackling these obstacles, Epstein spends a fair amount of time interacting with and learning from the people of Uganda and from the medical personnel who work there. She travels to clinics all over the country and talks with the people there and along the way, often finds herself involved in very detailed discussions about her research with taxi drivers, construction workers, high school students, hair dressers and janitors -- all of whom are surprisingly well-informed about HIV, possessing a commanding knowledge of the virus and the intricacies of its biology that is comparable to that of her colleagues.

As the result of all her conversations, Epstein later realizes that Uganda represents a unique social experiment among sub-Saharan African nations because this country, and this country alone, managed to reduce its own staggering rates of AIDS using methods that were misunderstood by Western nations. In short, the message was "Abstain, Be Faithful, and Use Condoms," combined with instilling a healthy fear of AIDS into the populace through "ordinary, but frank, conversations people had with their family, friends, and neighbors -- not about sex -- but about the frightening, calamitous effects of AIDS itself."

The author's quest to understand how Ugandans accomplished this dramatic reduction in HIV/AIDS provided the impetus for this book, and she discusses both the successes and failures along the way, beginning with her own failed research project. Epstein writes in the preface; "Much of this book is concerned with donor-funded AIDS programs that failed in some way, beginning with my own vaccine project. I tell these stories not with a sense of satisfaction. I could not have done better myself at the time. But in science, failures are often as important as successes, because they tell us where the limits are. Only by looking honestly at our mistakes can we hope to overcome them." [p. xvii].

Numerous interviews throughout the eleven nations of sub-Saharan Africa convinces Epstein that there are two main factors that underly the tremendous spread of HIV in this region. First; boys are not circumcized, even though this practice remains a vital weapon in combating the HIV infection. For example, one 2006 study revealed that circumcision can reduce the risk of HIV transmission by roughly 50%.

The other factor that underlies the runaway HIV infection rate is the widespread social practice of concurrent sexual partners. This is not to say that concurrent partners constitute rampant promiscuity or prostitution, nor that Africans have more sexual partners than in other places in the world, nor do they have anywhere near as many as do gay men in America (who have much lower HIV rates). Instead of one-night-stands, Africans maintain a complex web of intimate relationships that sustain them when familes are torn apart by the demands of having to work jobs that are located hundreds or even a thousand miles away from their families for many years at a time.

Concurrent sexual relationships are more dangerous for spreading HIV than promoscuity or prostitution because the probability of one sex act infecting a partner is very low. However, those who have HIV are most contagious shortly after they themselves have become infected, thus, the complex web of sexual relationships in sub-Saharan Africa allows this virus to spread throughout the network rather than remaining trapped in a monogamous relationship, as seen in the West. Epstein includes a series of graphics that nicely illustrate her point.

The social context that supports the lack of circumcision and concurrent sexual partners -- crushing poverty, the socially-sanctioned abuse of women, civil war and political upheaval -- is complex and difficult to address. Worse, when Western aid agencies, such as the UN and various faith-based organizations enter the picture, they arrive with their own pre-ordained agendas instead of trying to understand and work within the social framework that has already been established in countries such as Uganda. The author wryly observes that "[w]hen it comes to fighting AIDS, our greatest mistake may have been to overlook the fact that, in spite of everything, African people often know best how to solve their own problems."

Epstein's own view of these aid organizations is quite cynical. AIDS is a multibillion-dollar industry in Africa, and many of the officials and experts engaged in this battle are not altruists at all, but rather, they are making a wise career move that proves both lucrative and politically expedient. Sadly, political agendas, misdirected priorities, ignorance, and incompetence among these agencies are commonplace. Worse, this fact is not lost on the very people whom they presume to help: a Ugandan doctor whom Epstein interviews repeats his countrymens' harsh words specifically about these aid agencies;

[T]hey talk about two kinds of AIDS in Uganda: slim AIDS and fat AIDS. People with slim AIDS get slimmer and slimmer and slimmer until they finally disappear. Fat AIDS afflicts doctors, bureaucrats, and foreign-aid consultants with enormous grants and salaries; they fly around the world to exotic places and get fatter and fatter and fatter. Fat AIDS had become so prevalent in Uganda that .. if you were working on HIV, people thought you were a thief. [p. 27]

Despite the overall high quality of the writing and research supporting this book, I was surprised to discover one mistake. Epstein states that the HIV strains that infect Africans can develop resistance to antiretroviral drugs. However, there is no evidence that I am aware of indicating that these "African" varieties of HIV are more likely to become resistant to the multi-drug cocktails than those "Western" forms of HIV that AIDS patients are treated with in the Western world. Further, there is overlap between HIV varieties found throughout the world.

This 326 page book reads like a memoir, a scientific mystery, and a social and political commentary. It is carefully researched and well-documented, and passionately written. This is a readable true account of a terrible tragedy that is happening right now, that we can prevent, if only we knew what to do. Anyone involved with AIDS/HIV funding programs, medicine and public health in Africa must read this book, and those who are seeking to develop a vaccine against HIV would be wise to read this book to get a clearer understanding of the problems they face. Even though Epstein's own pursuit of an HIV vaccine was short-lived, her positive contribution to the fight against HIV/AIDS in sub-Saharan Africa is both important and ongoing. Highly recommended.

Read the first chapter online.

Helen Epstein is a molecular biologist by training, but she currently is an independent consultant and writer specializing in public health in developing countries. In the early 1990s she worked at Makerere University in Uganda. She was until recently visiting scholar at the Center for Health and Wellbeing at Princeton University and is currently working for Human Rights Watch. Her papers and articles have been published in both academic journals and in popular magazines such as Discover, New Scientist, The New York Times Magazine, Granta, and she has written frequently on AIDS for the New York Review of Books. Helen earned her PhD from Cambridge University, UK, and her MSc from the London School of Hygiene and Tropical Medicine.


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I know I'll get shot for saying this, but one method of reducing the risk of catching AIDs is monogamy.

I realise that with migrant workers (such as I) this can be a problem but it would work as long as both partners are faithful.

We seem to want our cake and to eat it as well.

Does she mention how Uganda reduced AIDs so much?

By Chris' Wills (not verified) on 20 Feb 2008 #permalink

the Ugandan program that brought such a dramatic decline in HIV/AIDS was a "Zero Grazing" campaign ("grazing" being the colloquial term for formation of several concurrent sexual relationships, which was especially prevalent among married men), which was also supplemented with this message; "Abstain, Be Faithful, and Use Condoms."

Also crucial in this effort was developing a healthy fear of HIV/AIDS through "ordinary, but frank, conversations people had with their family, friends, and neighbors -- not about sex -- but about the frightening, calamitous effects of AIDS itself."

(i went back and rewrote the review a little bit since i neglected to include those into the review).

Throughout much of the world, HIV is mainly limited to gay men, intravenous drug users, sex workers and their customers, but things are very different in Africa.

Do you have a citation for this? It was my understanding that the idea of AIDS being a gay disease was outdated, but I haven't kept up with the literature.

"It was my understanding that the idea of AIDS being a gay disease was outdated,"

Not quite, but getting there. The difference incidence of HIV in the heterosexual and homosexual populations has been steadily shrinking in both the US and UK, but its not equal yet.

I really think the rules for blood donations should be revised... with the testing and screening in place now, its a rediculous overkill to exclude any man who has ever had 'anal or oral sex, even with a condom, with another man.' Just excluding those who have had male-male sex in the last few years (I dont have the statistics to find the optimal time, I would estimate fiveish) wouldn't compromise safety in the slightest and would give a small increase in the donor pool size.

the information cited in this review is from the book itself, so yes, the book is the citation, but the precise original paper .. ? it's in the bibliography of the book, but i don't have time to dig it up since there are so many others in there, too.

Uganda may be the only sub-saharan african success, but Brazil did very impressively in South America. Interestingly, using a quite different approach - they placed a high emphesis on prostitution control, distributing condoms and education to prostitutes and providing them with HIV testing, and conducting a wide condom education campaign dispite the objections of the strict catholics who make up a substantial part of the population. The results were quite spectacular - so great was their improvement that Brazil was forced to turn down a $40m US anti-AIDS grant because some of the moralising strings attached to all US AIDS grants require, among other things, that recipients refrain from any activities which could support, encourage or legitimise prostitution even if they arn't using US money for such activities.

I find it interesting that Brazil and Uganda both achieved impressive results, dispite taking opposing ways to achieve them - Uganda's emphesis on less sex and fewer relationships with a vague mention of condoms, and Brazil's aggressive promotion of condoms and close cooperation with sex workers.