The Invisible Cure: Africa, the West, and the Fight Against AIDS
by Helen Epstein
Epstein's view is that the cause of the AIDS crisis in Africa is what has now become known in AIDS jargon as "concurrent" relationships. Africans have about the same number of sexual partners as anyone else; they are just more likely to have more than one long-term partner at a time. Crucially, both men and women have multiple partners, in contrast to other poor societies where men may often stray but women's monogamy is jealously guarded. Western men and women are more likely to practice serial monogamy or engage in one-night stands. To oversimplify a little, Africa's AIDS tragedy is that it combines greater Western-style sexual equality for women with social norms that permit simultaneous long-term sexual relationships for both partners.
Multiple long-term relationships are prevalent in Africa for many reasons. In southern Africa (where the epidemic is concentrated), one of the few opportunities for gainful work open to men is to become long-distance migrants to the mines. Both husbands and wives may have other long-term partners during the months when they are separated. The African tradition of polygamy (described by historians like John Iliffe as a cultural response to maximize fertility in what used to be a lightly settled continent) has given way to modern relationships between older, well-to-do, gift-bestowing men and multiple young girlfriends. This is not so different from the successive trophy wives of American fat cats, but much more widespread since Africa's poverty often makes it a matter of survival for African young women to have a rich (older) boyfriend. The desire of young women for young boyfriends can be accommodated on the side.
For many reasons, concurrent, long-term sexual relationships are much more dangerous for the spread of AIDS than serial monogamy. When both men and women have concurrent relationships, they are part of a huge web of sexual partners by which the HIV virus moves through the population. Long-term relationships are much more likely to spread AIDS than one-night stands because of the low probability of a single sex act spreading the virus. Since the HIV-positive are most contagious soon after they themselves become infected, a long-term partner who has just become infected in another relationship poses much more risk than a prostitute who has been infected for a long time. Serial monogamy in the West kept the virus largely trapped within single relationships, a fact Epstein nicely illustrates with some clever graphs. Her explanation based on concurrent relationships has gained broad acceptance and has been confirmed by mathematical modeling and by surveys of sexual habits in various countries; but one still wishes the evidence was a little more extensive for such a critical issue. At this point, however, it looks like much stigma, denial, and inaction took place simply because of lack of understanding of African sexual behavior. ...
To illustrate the role of political agendas, Epstein discusses the famous success story by which AIDS infection rates in Uganda decreased as a result of the ABC campaign—"Abstain, Be Faithful, and Use Condoms." Epstein damns both the Western right and left for their misuse of the lessons of Uganda. The religious right played up the "Abstain" part because it happened to fit their particular moral preferences. People on the left, who had different sexual morals, said just use condoms. The "Be Faithful" message, precisely the one in Epstein's story that was critical in Uganda (led by Ugandan President Yoweri Museveni, who called for "Zero Grazing"), was a political orphan, disdained by both left and right. ...
When well-conceived efforts to improve prevention do exist, they often run afoul of the aid industry. Epstein observes that there was already a huge international bureaucracy devoted to combating population growth by distributing condoms. When suddenly condoms became marketable for preventing AIDS as well as pregnancy, this presented a huge new growth opportunity for family-planning organizations (which had been losing foreign aid market share as people realized that population growth was not as scary as originally thought). The condom bureaucracy did what it does best, which is flood countries with condoms. Alas, supply does not create its own demand. Condom-saturated countries like Botswana have made little progress in reducing new AIDS infections, since people there don't like to use condoms and are not yet convinced that they are at risk of HIV infection if they don't. Meanwhile, the "Be Faithful" message was neglected because it was not of interest to the bureaucracy concerned with AIDS. As Epstein muses acidly: "Zero Grazing" had "no multimillion-dollar bureaucracy to support it." ...
Epstein argues that it violates both common sense and the evidence to put much faith in vague, happy-sounding messages about self-esteem and safe sex. During visits to Africa I have often seen the ubiquitous donor-funded "AIDS prevention" billboards, featuring beautiful young couples who are meant to convey—well, what exactly? Epstein (backed up by an epidemiological study of the Uganda prevention success story) argues that the prevention campaigns could use less sexiness and more fearfulness. What worked in Uganda, she writes, was the "ordinary, but frank, conversations people had with their family, friends, and neighbors—not about sex—but about the frightening, calamitous effects of AIDS itself."
This is Epstein's "Invisible Cure." ... One still wishes that the evidence for what works was a little more substantial than one Ugandan success story that lasted a few years, but Epstein is such a persuasive storyteller that she earns a serious hearing. To illustrate what's needed, Epstein draws an analogy to the medical activism of women's groups in nineteenth-century America. Once they understood the germ theory of disease, they were able to spread habits of hand washing, covering your mouth while coughing, not spitting in public, etc. This successfully reduced disease even before the invention of antibiotics.
October 15, 2007
From the New York Review of Books: