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.
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.
Stephanie Nolen's book shows how AIDS is affecting Africans in their everyday lives, and gives us some idea of the form Epstein's social movement might take. Nolen presents brief profiles of twenty-eight people, a number she chose because 28 million Africans are estimated to be living with HIV. A South Africa-based correspondent for the Toronto Globe and Mail, Nolen has traveled widely around the continent, interviewing everyone from Nelson Mandela to shantytown prostitutes. She is an evocative and empathetic writer, and her journalism doesn't succumb to the affliction of so much other writing about Africa, the tendency to reduce people to categories that fit the reader's, and the author's, preconceptions: corrupt or honest, victim or killer, sinner or saint. When Nolen rides shotgun with an HIV-positive long-haul trucker who claims to have bedded 100,000 women, she doesn't condemn him to her readers; she just lets him tell his tale.
The people introduced here give one a sense of the breadth of the epidemic. They're not exactly representative, though; a more descriptive title for Nolen's book might have been The Exceptions. All of the people she interviews meet two conditions: First, they're alive, and second, they're willing to talk frankly about AIDS, which in Africa is unusual. "Stigma is one of the most used words in the AIDS pandemic, a two-syllable shorthand for the shame and fear that cling to this disease," Nolen writes. There is "a particular distaste saved for those diseases where the sick are viewed as the authors of their own misfortune, and a particular shame that comes with a disease most often transmitted by sex."
Consequently, Nolen's profile subjects are largely a self-selected group. Many are HIV-positive people who have started advocacy groups, or who work for Western nongovernmental organizations. You get the feeling you might run into a couple of them crossing the lobby of the Nairobi Hilton the next time the UN holds an AIDS conference there. But Nolen is such a gifted writer that her book transcends its limitations. To read the stories of Malawi's Alice Kadzanja, a nurse who contracted HIV from her husband, a philandering college administrator; or Zimbabwe's Prisca Mhlolo, who lost her husband and her daughter and was shunned by her family because AIDS "was a disease for prostitutes"; or Uganda's Gideon Byamugisha, an Anglican priest who admits he "did some good things...and failed in some" in relating how he passed HIV on to his late wife, is to see Helen Epstein's thesis about concurrency brought to life. The book's finest moments, however, are the ones that take Nolen by surprise: An AIDS counselor she knows in Zambia tests positive; a little girl she met in Johannesburg dies. When her dreadlocked artist friend Thokozani, who's told her he always uses condoms, finds out he has the virus, she reflects:
At first I used to marvel at it--at why people have gone on making such choices in defiance of what might seem like the most basic survival instinct. But in talking to [Thokozani], I realized that it's not, in the end, so hard to understand. Infection rates are much higher here than in, say, Canada and France, but the variables that go into decisions about love and sex and intimacy, those are no different here. People have sex without condoms because it feels good to say you trust someone that much--or because there is a particular pleasure that comes in taking risks. Or, my friend points out, just because it feels nice. We all do things we know we shouldn't--especially when we're in love, or filled with lust, or lonely.
As it happens, Epstein believes that recognizing human nature was the key to Uganda's early success in bringing the HIV infection rate under control. She contrasts contemporary South Africa, with its culture of denial that extends up to the president, with Uganda in the early 1990s. Back then, every Ugandan was talking about AIDS: the president, newspaper columnists, taxicab drivers. People started support organizations, and churches got involved. The most successful program, Epstein argues, was a local initiative called Zero Grazing (Ugandans favor cattle metaphors). "Zero Grazing was a compromise," she writes, "and its real message was this: 'Try to stick to one partner, but if you have to keep your long-term mistresses, concubines and extra wives, at least avoid short-term casual encounters with bar girls and prostitutes.'"
At the same time, the AIDS crisis also galvanized Uganda's women's rights movement. In Africa, many women are stuck in "transactional" relationships with men, relying on their money and lacking power to demand faithfulness. In the early 1990s, "women were being urged to keep their daughters in school, start small businesses, and challenge laws and practices that discriminated against women," Epstein writes. The activists also used the Zero Grazing campaign as ammunition to confront men about their behavior: "In bars and discos that were once mobbed with men and single women, men now sat drinking among themselves." The number of people reporting casual sexual partners dropped. This "partner reduction" strategy worked, Epstein says, because such casual encounters served as "on-ramps" through which HIV entered concurrent-relationship networks.
If Zero Grazing was as successful as Epstein says, you'd think international organizations would have paid to reproduce the campaign all over the continent. But they didn't--for reasons that are once again more about our preconceptions than Africa's needs. On the one hand, Western conservatives couldn't stomach a program that countenanced polygamy. On the other--and Epstein doesn't explicitly make this connection--the early 1990s coincided with a huge homegrown evangelical revival in Uganda, and many of the loudest women's rights activists were also born-again Christians. This association made many Western liberals--the type who work for organizations like the UN--quite uncomfortable. "There was a sense that promoting fidelity must be totally wrong if it was a message favored by the Christian Right," the former head of one humanitarian group told Epstein.
Near the end of her book, Epstein notes with some sadness that Zero Grazing is now a museum piece. These days, Uganda's approach to AIDS is ruled by pieties--both religious and secular. The locally devised programs of fifteen years ago have been replaced by a bland package of somewhat conflicting strategies known by the acronym ABC: abstain, be faithful, use a condom. The Bush Administration and the evangelicals push A, the public health community stresses C and no one pays much attention to B, because there's no money in nuance. Meanwhile, on the strength of its "miracle," Uganda has become an AIDS pilgrimage spot. "The big hotels in the capital play host to a perpetual round of AIDS-related conferences and workshops, and the streets are jammed with the vehicles of AIDS NGOs," Epstein writes.
The influx of money has brought profiteers, both white and black. A recent investigation revealed massive corruption in the Ugandan Health Ministry's administration of grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria. That's just the beginning of the graft. And yet for all the many millions flowing in, HIV prevalence rates have not fallen much since the year 2000. Men aren't sitting alone at bars anymore, and statistics suggest that casual sex may once again be on the rise. For a fleeting moment, in a time of unimaginable tragedy, Ugandans found it within themselves to fight this epidemic. But AIDS has a way outlasting vigilance. It's a disease of human fallibility, and for that there is no cure.