Danit Kaya
The Invisible Cure – Why We are Losing the Fight Against AIDS in Africa. Helen
Epstein. New York: Picador, 2007. First Edition, 324 pp. $16.00, ISBN 0312427726.
As a molecular biologist with a keen eye for social maladies, Helen Epstein has documented her work and discoveries on HIV/AIDS in Uganda since the early 1990s.
Epstein aims to add to the existing literature on the HIV/AIDS epidemic, by identifying not only why the epidemic seems most severe in eastern and southern Africa but also what can be done to decrease this tendency. Through meticulous research, Epstein uses the case of the Ugandan response to identify an alternative cure to HIV/AIDS transmission. Researchers and academics before her have offered various scientific and political theories for the noticeable downturn in Ugandan HIV rates in the 1990s.
These theories included the mass dissemination of condoms, large scale education campaigns and wider access to medical services. Epstein, however, argues that the decrease in Ugandan HIV rates during this time period was due to something much simpler to explain and much more difficult to produce: community.
As Epstein illustrates, “the key to their success resided in something for which the public health field currently has no name or program….a sense of solidarity, compassion, and mutual aid that brings people together to solve a common problem.” The capacity of communities in Uganda to understand the behavioral cause of HIV transmission led to a steep decline in HIV transmission, which also enabled them to speak openly about HIV. This additionally eliminated the grave social stigmas and prejudice which currently surround HIV in many developed nations. Through her field-based experiences and often spine-chilling anecdotes about the global response to AIDS, Epstein manages to unwrap the complex factors involved in the transmission and eradication of HIV.
Concurrency, or having multiple sexual partners at once, is a phenomenon to which Epstein devotes a large portion of her book. The Invisible Cure documents cultural folktales surrounding the opposing models of monogamy and concurrency through computer generated illustrations and simple narratives. Epstein explains the model of concurrency, wherein one man or woman may have multiple, simultaneous long-term sexual partners. Since these tend to be committed relationships, partners are less likely to use condoms or other forms of protection and are made increasingly vulnerable if one person within the network contracts HIV. This system has served as an expressway for HIV transmission in that it links people in a large web of sexual relations.
By contrast, Epstein argues the prevalent Western notion of monogamy, seeking one sexual partner, explains the noticeably smaller effect of the AIDS epidemic in Western countries. Since this model only connects two people at a time, even serial relationships which occur consecutively, disconnect people from the larger sexual community. Monogamy, Epstein suggests, is partly responsible for sparing the West from the staggering number of AIDS-related mortality present in southern and eastern African nations. The reader may find piercing irony in Epstein’s commentary about these two models. While the common stigma facing HIV-positive individuals is that of promiscuity, it becomes clear that Westerners tend to have far more sexual partners over the course of a lifetime than their eastern and southern African peers. This shatters the stigma of promiscuity faced by HIV-positive individuals globally.
Little can be found about the notion of concurrency nor its counterpart, partner reduction, on the websites of prominent international health agencies. Just last year UNAIDS developed OneLove, its first program in southern African centered around the notion of partner reduction. Most other agency-supported literature has remained silent on this issue. The notable lack of attention that partner reduction has received in a context of concurrent relationships highlights the impotency which Epstein argues is inherent in multilateral agencies. Rather than addressing the sociological sources of the AIDS epidemic, agencies too often direct global aid to exclusively technical solutions.
Yet the reader may find that even partner reduction is a brand of technical solution. It was only successful in Uganda because of the tenacious presence of social mobilization. Epstein argues that communities throughout Uganda responded to the HIV/AIDS epidemic through the notion of collective efficacy or ubuntu which states that “a person is a person through other people.” In the late 1990s, state sanctioned slogans such as ‘Zero Grazing’ and ‘Love Carefully’ were common in government speeches, radio broadcasts and public buildings. Teams of AIDS educators, trained by the Ministry of Health, fanned out across the country to inform people about curbing HIV infections. National debate ensued over the use of condoms, and what was once a taboo subject soon became the center of routine conversation. Gossip also became a significant tool in the struggle with concurrency, as many women began to publicly reprimand men for having multiple concurrent sexual partners. These domestically led actions, Epstein argues, created an environment in which the people mobilized themselves and worked in the collective fight against AIDS. Unlike most of other nations in the world, AIDS was not viewed as the punishment for high risk populations, but was rather understood as a risk to all.
Epstein’s work in Uganda sheds light on both the intricacies of the HIV/AIDS epidemic and the simplicities that may prove more effective in eliminating AIDS than medical relief alone. Although Epstein offers a consistent view of the insufficient global response to HIV infection in southern and eastern Africa, she leaves little room for an analysis of positive action. The reader may become frustrated by Epstein’s one-sided presentation of multilateral agencies. Throughout the work, she tends to describe only their failed global health responses and characterizes them as most effective in creating bureaucracies which at best serve as temporary crutches and perpetuate disease at worst. She does not offer much to rectify her distaste for the design of foreign aid.
Epstein clearly argues that the invisible cure for HIV eradication lies within the power of communities to care for one another and take control of their sexual lives through behavioral change. Though this seems to leave little room for a global partnership, a wider reading of this case study implies that the current global aid model cannot be successful on its own. It must actively hold in high regard those campaigns which originate from the local community and stem from local practices if HIV transmission and AIDS related mortality is to be effectively addressed. At times, she focuses too often on the shortcomings of other nations’ responses to HIV and romanticizes the Ugandan response. Nevertheless, Epstein’s work serves as a noteworthy contribution to the field of HIV/AIDS eradication theory and is accessible to novice and experienced health proponents alike. Though the reader might prefer for Epstein to provide a fuller framework from which public health practitioners may guide their future actions, this was not the stated goal of her work. Rather, Epstein offers insightful commentary on the successes of the Ugandan AIDS response while acknowledging the frustrations that workers in this field are sure to encounter.
