An African Solution
One afternoon in the fall of 2005, I was sitting at an outdoor cafe along a pleasant tree-lined street in Kampala, the capital of Uganda, flipping through the local newspaper, when the sight of an old friend's face stopped me cold. I'd lived in Uganda for two years in the early part of the decade, but I'd been gone for a while, and I'd been wondering what had become of him, an attorney in his 50s. I'd known him as an insightful and opinionated man. When we'd last met, many months before, we'd talked about his country's contentious democracy and his hopes for a new project he'd started, a legal fund to assist the victims of Uganda's past dictators. Now I saw my friend's distinguished face at the center of a black-bordered newspaper announcement, above a quote from Thomas Paine and the legend: "Loved and Remembered By Your Entire Family."
It had just started to rain, and Ali, my regular newspaper hawker, sat down at the table to wait out the storm beneath the cover of the cafe's awning. Ali had known the lawyer too. I pointed to the death notice. "Oh, yes, it was very sad," Ali said. "He was sick."
I understood what Ali was trying to tell me. In Uganda, you heard it all the time. When the foreign minister took ill and died, the local journalists whispered, "He was sick." When my neighbor, an economics professor, started acting strangely, hiring a witch doctor to make him potions, his nephew confided, "Uncle is sick." When my former housekeeper, a shy young born-again woman, began wasting away before my eyes, anyone could tell she was sick. I helped her buy medicine, but she was dead by Christmastime. The word "sick" is a euphemism Ugandans use when they want to say "AIDS." About 91,000 Ugandans died of the disease in 2005, the last year for which data are available, and estimates say a million people there are infected with HIV, the virus that causes it. In the United States, a country with ten times the population of Uganda, AIDS kills roughly one-sixth as many people each year.
As an American who grew up in the 1980s, I remember a time when this was supposed to be our future, not just Africa's. Back then, in the first years after AIDS burst out of the bathhouses of New York and San Francisco, a sense of terror gripped this country. Rock Hudson died, the Surgeon General issued grave warnings and a generation of gym teachers were issued dildos and condoms and pressed into service as safe-sex educators. Today those fears seem quaint, like the cold war-era films where students were instructed to take cover from nuclear attacks under their desks. Predictions that the disease would spread widely among heterosexuals in the United States have so far proved mercifully wrong. Antiretroviral drugs have turned HIV into a manageable--though still incurable--condition. More than fifteen years after announcing his HIV diagnosis, Magic Johnson is developing real estate and looks a lot healthier than Larry Bird.
For all our worrying, the "HIV rate in the United States never exceeded one percent," Helen Epstein writes in her new book, The Invisible Cure. "At first, some UN officials predicted that HIV would spread rapidly in the general population of Asia and eastern Europe, but the virus has been present in these regions for decades and such extensive spread has never occurred." Sub-Saharan Africa is a different story. In some countries there, well over 30 percent of adults younger than 50 are thought to be infected with HIV. To appreciate the scale of the epidemiological disaster, consider this: Heart disease, the leading cause of death in the United States, killed some 650,000 Americans in 2004. If AIDS had hit this country as hard as it has Zimbabwe or Botswana, 3-4 million Americans would be dying of AIDS every year.
This is an immense crisis, and the developed world, to its credit, has roused its conscience. Bono, Madonna and Oprah have lent their famous monomials to initiatives meant to halt the disease's spread and soothe its consequences. Warren Buffett and Bill Gates have pledged their fortunes to the search for a vaccine and other vital research. Bill Clinton has made the continent's AIDS epidemic a focus of his post-presidential philanthropy. President Bush, not to be outdone, has promised $15 billion to fight AIDS in Africa, an initiative that for all its many weaknesses does represent "the biggest international health intervention ever attempted," journalist Stephanie Nolen writes in her book 28: Stories of AIDS in Africa. Yet for all these worthy efforts, the disease kills an estimated 5,500 Africans a day. Though Africa is the poorest continent, and certainly the least healthy one, its uncommon vulnerability to AIDS can't simply be explained by lack of wealth or access to medicine. Indeed, one lesson a reader takes away from the two books under review is that the epidemic is egalitarian: It kills the children of African farmers, businessmen and presidents alike.
In 1987, at the most panicked juncture of America's AIDS epidemic, journalist Randy Shilts published And the Band Played On, the finest piece of journalism ever written about this--and maybe any--disease. To date, no book on the African epidemic has managed to capture it so masterfully. In part, that's because most of them have been written by outsiders who can scarcely aspire to understand a foreign continent the way Shilts, one of America's first openly gay reporters, knew Castro Street. But the early AIDS epidemic also lends itself to a very traditional kind of narrative: It's a detective story in which doctors, scientists and gay rights activists scramble to identify and stop a killer. In their books on Africa, Epstein and Nolen must describe a far murkier state of affairs. Their contribution is to ask: Why is AIDS so difficult to stop in Africa, and why is our society, the richest and most technologically sophisticated in the world, unable to save Africans as we have ourselves? The story makes grim reading; it's a mystery to which there may be no solution.
Over the years, many medical researchers have tried to solve this deadly conundrum. Some point to biology, some to behavior and some to just plain bad luck. The inquiry, however, has been hindered by the nature of the disease. "AIDS is not an event, or a series of them; it's a mirror held up to the cultures and societies we build," Nolen writes in her introduction. "The pandemic, and how we respond to it, forces us to confront the tricky issues of sex and drugs and inequity." Moreover, in Africa it has required the international public health community--a group that's largely European and American, and therefore white--to address the sexuality of black people, an issue fraught with racial and colonial overtones. Some African leaders, notably South Africa's President Thabo Mbeki, are so sensitive to seeing their people stereotyped as lustful savages that they've given a platform to fringe scientists who deny that AIDS is sexually transmitted. The public health community, on the other hand, sometimes overcompensates, policing unconventional thoughts about the disease's origin and spread with the vigor of Soviet-era commissars. Writers who run afoul of this orthodoxy risk vituperative attacks. This is why I suspect the great AIDS book yet to come will be written by an African, and will probably be a novel, perhaps a satirical one.