An African Solution
It takes a great deal of confidence to name a book about this disease The Invisible Cure. Luckily, Helen Epstein has a compelling thesis, and she explains it in lucid, sometimes extraordinary, prose. She has clearly benefited from a literary upbringing: Her parents, Barbara and Jason Epstein, were co-founders of The New York Review of Books, and several of her chapters first appeared as essays in that magazine. But she is also a molecular biologist, though seemingly a disillusioned one. With unstinting self-awareness, Epstein describes how, in the early 1990s, she went to Uganda to search for a "magic bullet," a scientific answer to the disease: an HIV vaccine. She was so enthusiastic that she paid her own way on the trip. "I felt like a pioneer," she writes. "The hour of the lone scientist following his or her imagination into the unlit corners of nature is passing." In the end, Epstein's imagination didn't lead her to a breakthrough, and her faith in scientific solutions waned. (In fact, HIV mutates so quickly that some experts now doubt whether it is even possible to engineer an effective vaccine.) But she did acquire a healthy skepticism for the pieties of humanitarian work as she toiled in labs alongside better-funded colleagues. "I was just a hitchhiker, and as hitchhikers sometimes do, I became a little arrogant," she writes. "Hitchhikers live cynical, parasitic existences, but sometimes they see the landscape more clearly than drivers."
The landscape of Uganda in the early 1990s was far different from the one I encountered a decade later. At the time Epstein arrived there, the country was recovering from two decades of tyranny and civil war, and people were dying of AIDS in numbers far greater than today. Uganda was the first country in Africa to feel the full force of the epidemic, which first emerged in the fishing villages ringing Lake Victoria in the late 1970s. (The origin of the virus, which probably crossed the species barrier from monkeys to humans less than a century ago, is another great mystery. Epstein speculates that it might have been inadvertently spread by colonial-era vaccination campaigns.) By the early 1990s, it was estimated that one-third of all adults in Kampala were HIV positive. The disease seemed to strike the very people a rebuilding society could least afford to lose: university students, their professors, lawyers, journalists and especially doctors.
"Then something remarkable occurred," Epstein writes. In the early '90s, unbeknownst to anyone else in Uganda at the time, the rate of HIV prevalence began to fall. At first, it seemed like a fluke. But Uganda's prevalence rate kept plummeting, from 30 percent to 20 percent to less than 10 percent, where it remains today. People called it a "miracle," and wondered what Ugandans were doing right, because elsewhere in Africa the virus was still spreading exponentially. Epstein had an idea, but she didn't yet recognize its significance. "Back then I was still subject to magic bullet thinking--the idea that serious public health problems could be addressed without considering their social and political causes," she writes. "The Ugandans seemed to know better, but their message was lost on me."
What was Uganda's secret? In public health circles, the argument continues to this day. There are basically three theories. One says the secret was in the statistics. The early estimates that 30 percent of the population had HIV may have been overstated, and the subsequent drop might be explained by the cold fact that infected people were dying. A second theory says the secret was on the billboards. In the 1990s, advertisements promoting condom brands called Lifeguard and Protector appeared all over the country, with the support of Uganda's youthful president, Yoweri Museveni, who urged his people to set aside the traditional value placed on having large families. The third theory says the secret was in the bedroom. It's commonly believed that Africans, many of whom come from cultures that practice polygamy, are relaxed about sexual mores and promiscuity, at least of the heterosexual variety. But the fear of AIDS, this theory suggests, forced them to change their behavior.
Epstein finds each of these explanations wanting. If the prevalence of HIV in Uganda was dropping just because deaths from AIDS were outpacing new infections, why hasn't this pattern repeated itself elsewhere in Africa? It's hard to measure condom use--in the average sexual encounter, only two people really know what happened--but anyway, Epstein writes, it appears Uganda's infection rate was falling before the marketing campaigns began. (And even with all the AIDS deaths, the country's population has almost doubled since 1990, which suggests that birth control has not exactly caught on.) As for the notion that Africans are more promiscuous, studies indicate that the average Ugandan has sex with fewer people over the course of a lifetime than the average American.
So something else was going on. "Because HIV prevalence in Africa is highest among heterosexual men and women, most people suspected it must have something to do with sex," Epstein writes. "But what were Africans doing differently?"
When it comes to African culture, there may be no word more charged than "polygamy." It brings to mind those titillated travelogues by Victorian explorers, with their descriptions of bare-breasted women and chiefs in leopard skins. But this is how polygamy usually works in contemporary Africa. I have a Ugandan friend--I'll call him David--whose father is a well-off merchant. When David was a young man, his father was often away from home on business trips. When he got a little older, David discovered that there was another reason for his father's absences: He'd taken up with a younger woman. David's mother knew, and she was furious, but there wasn't much she could do. Ugandan divorce laws are skewed against women, and she and her children depended on her husband's income. David's parents stayed together, and his father's second wife, and second life, was never mentioned around the house. When David reached adulthood, he decided he wanted to meet his half-siblings, and they cautiously got to know one another. But some tension remains between the two sides of the family over David's father's money and favor. It's a messy, emotionally difficult arrangement--one that might not seem entirely unfamiliar to many "blended" American families.
There is an important difference, though, and Epstein believes it explains Africa's exceptional susceptibility to AIDS. Americans tend to leave one relationship for the next. Ugandans--or, rather, Ugandan men--don't have to choose. Another way of describing this phenomenon is to say that Europeans and Americans typically have lovers consecutively, while Africans--men and women alike--are commonly involved in several overlapping relationships. Studies have found that such "concurrent or simultaneous sexual partnerships are far more dangerous than serial monogamy," Epstein writes, "because they link people up in a giant web of sexual relationships that creates ideal conditions for the rapid spread of HIV." In any given sexual encounter, an HIV-positive person has around a 1-in-100 chance of passing on the virus. That's a long shot in the context of a one-off tryst with a prostitute, but extended over the course of an enduring relationship, the chance of infection rises to near-certainty. Also, in many African cultures, men are not circumcised, which considerably increases their vulnerability. (Recent studies suggest this simple procedure cuts in half a man's risk of infection.) Epstein produces a series of charts that the reader can view like a flip book, showing how a single case of HIV can spread through a network of concurrent relationships in just a few months.
In the early years of the epidemic in Africa, much of the medical community's response was geared toward intervening with so-called high-risk groups: truckers who crisscrossed the continent; migrants who toiled in South African mines; the bar girls and prostitutes who serviced them. As the role of concurrency came to be understood, the true perversity of the epidemic revealed itself. In Africa, the biggest risk factor is trust.
Whatever the "invisible cure" might have been--and Epstein has an interesting hypothesis--it's fairly certain that Ugandans came up with it themselves. "It seemed to me that what mattered most was something for which public-health experts had no name," Epstein writes. "It is best described as a social movement characterized by a shared sense of humanity, collective action, and mutual aid that is impossible to quantify or measure." That sounds a bit nebulous, and the fuzziness points to a weakness in her book: It's better at analyzing societies than describing individuals. In a way, she's made an understandable authorial choice: The world doesn't need another book that caricatures helpless African victims. But social movements are made of people, of millions of solitary commitments born of personal experience and tragedy.