Local Knowledge

Recently, Africa has become a continent of great concern to much of the American public, riveting the attention of both philanthropists and political activists. Indeed, one of the covers of the July edition of Vanity Fair (there were several) pictured Nobel laureate Archbishop Desmond Tutu embracing Hollywood celebrity Brad Pitt. The entire issue was dedicated to Africa and edited by rock-star-turned-activist Bono. Why this renewed interest in the problems of Africa? Is the West’s fascination—and America’s in particular—just a colonialist reflex? Or is it a positive consequence of globalization?

Helen Epstein’s The Invisible Cure: Africa, the West, and the Fight against AIDS is an excellent primer on the complicated relationship between American medical science and philanthropy, and the public-health crisis in Africa.

Everyone seems to know what Africa needs, but sometimes I think our minds are not really on it. Most of us see only Africa’s contours, and we use them to map out problems of our own. Africa is a career move, an adventure, an experiment. It fades into an idea.

Indeed, for Epstein herself, Africa began as a career: she first went to Uganda to do research as a scientist for a biotech firm working on an AIDS vaccine. At the center of Epstein’s argument is a detailed discussion of how and why Western philanthropists and scientists initially misunderstood the African context for AIDS. So prominent in the Western imagination was the continent’s history of war, tyranny, corruption, famine, and natural disaster that many overlooked what Epstein calls “the other Africa”—an Africa characterized by “a striking degree of reciprocity, solidarity, and ingenuity.” Epstein’s book provides a detailed inquiry into the way certain Western presumptions obscured the medical realities of AIDS in Africa.

Why, asks Epstein, has the AIDS epidemic been so severe in Africa? And why have some prevention programs, particularly those in Uganda, been remarkably successful while others, especially those in South Africa, have been miserable failures? As Epstein explains, the scientific community initially misunderstood how the HIV virus was being transmitted in African communities. In contrast to the United States, most HIV cases in Africa were among heterosexual men and women; it took a while for some Westerners to recognize and respond to this difference. Other differences were exaggerated, misunderstood, or even invented: for example, demographers initially argued that the virus was spreading rapidly in Africa because people there had a unique “sexual system” characterized by higher rates of casual and premarital sex. Such theories seemed to confirm racist stereotypes of African sexuality, but ongoing studies have revealed that heterosexual Africans do not have more sexual partners over the course of a lifetime than heterosexuals in other parts of the world. Other theories proposed that Africa was home to a “killer strain” of HIV that spread especially rapidly, or that Africans were particularly vulnerable to HIV because their immune systems had been weakened by malnutrition and parasite infections common among the poor.

Then, in the 1990s, sociologists began to recognize that a relatively high proportion of African men and women had ongoing relationships with a small number of people—perhaps two or three—at the same time. These relationships might overlap for months or years, or even, in the case of polygamous marriages, a lifetime. Such sexual practices are far more dangerous than serial monogamy, because, as Epstein explains, “they link people up in a giant web of sexual relationships that creates ideal conditions for the rapid spread of HIV.”

This discovery had a profound impact on Uganda’s prevention strategy. While other African countries continued to focus on what were considered high-risk segments of their populations, the Ugandan prevention programs made HIV everyone’s concern. By 2003, Uganda was the only African country that had seen a nationwide decline in HIV infections. Epstein explores in considerable detail the many possible reasons for this improvement. Epidemiologists point to the powerful role played by the ordinary but frank conversations Ugandans had with family, friends, and neighbors—not about sex, but about the calamitous effects of AIDS itself. Because most Ugandans still live in tightly knit rural communities, personal testimonies resonated in ways that billboards and more formal education programs could not.

The story of AIDS in South Africa furnishes a sad contrast to Uganda’s success. Among the most disturbing parts of Epstein’s book is her account of South African President Thabo Mbeki’s denial of the scientific evidence about the HIV virus. Epstein is very critical of Mbeki’s disastrous policies, but she also describes how Western presumption aggravated the crisis in South Africa. Aggressive condom campaigns, funded by Western governments and aid groups, reinforced the social stigma attached to AIDS by associating it with “bad behavior.” Such heavy-handed efforts seemed to fuel Mbeki’s fury. He insisted that “the HIV/AIDS thesis is informed by deeply entrenched and centuries-old white-racist beliefs about Africans and black people.” He railed against the idea that Africans were “natural-born promiscuous carriers of germs unique in the world.” For Mbeki, the battle against the scientific consensus on AIDS was part of a larger war against colonialism. There were signs of this sort of backlash even in Uganda, whose first lady, Janet Museveni, described condoms as “un-African” and recommended programs that promoted abstinence instead.

This reaction against Western interference, at once unanticipated and predictable, has complicated efforts to combat the epidemic in Africa. The Invisible Cure reminds American readers that while good intentions are necessary, they’re rarely enough. As Epstein’s balanced account shows, ignorant good will can be as harmful as neglect. It will take more than money and medical knowledge to stop AIDS in Africa; it will take knowledge about the people we intend to help. And also, perhaps, a measure of humility.

Related: The Church & AIDS in Africa, by Marcella Alsan, MD
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