Moving Mountains: The Race to Treat Global AIDS
- Anne-Christine D'Adesky
During the past two decades, AIDS has emerged as one of the most intractable public health challenges in history. Thriving at the intersection of myriad forces—including corruption, poverty, and ignorance—AIDS has found our planet to be a fertile environment for expansion, growth and, as emerging resistant strains reflect, evolution. Evading muscular new efforts—financial, scientific and political—to mount attacks on the virus, HIV is like a viral terrorist, moving into unprotected zones and rapidly establishing dominion. The pandemic has spawned a new category of journalism and writing, to which Anne-Christine D'Adesky has added the voluminous and informative Moving Mountains: The Race to Treat Global AIDS. The title is reminiscent of Tracy Kidder's superb biography of Paul Farmer, Mountains Beyond Mountains. Unfortunately, where Kidder provides both a sophisticated working model and a convincing historical roadmap of the AIDS epidemic, woven together with the threads of Farmer's fascinating life, D'Adesky's copious pages (plus additional pages of appendices) present neither a coherent account of the disease, nor a persuasive conceptual framework for assessing the state of our fight against it.
D'Adesky is a journalist and activist by trade and her book presents sketches of the epidemic in a variety of countries: Brazil, India, Cuba, Haiti, Mexico, Uganda, Morocco, South Africa and Russia. At first glance, it seems that each chapter could serve as a free-standing journal article. D'Adesky informs her plethora of topics with research and interviews with activists, politicians and people living with HIV/AIDS. However, each chapter has about ten mini-sections which are not necessarily tied chronologically or thematically to the rest of the chapter and which lack adequate coverage. The chapter on Russia, for example, begins with a typical first-person view of her travels, and is rapidly followed by sections on epidemiological estimates, economic “shock therapy,” the growth of the epidemic, orphans, financial concerns, treatment issues and activists. Although each section's facts are presented well, the glue to hold them together is lacking. Even a reader with experience in development, health systems and HIV/AIDS might struggle to grasp the meaning of the details presented or understand how they fit into her broader agenda for rapid expansion of treatment. In D'Adesky's defense, some might argue that the pandemic is, by its nature, incoherent, but that is why we turn to books: for more thoughtful and persuasive perspectives and tools for cutting through the reports we read daily.
D'Adesky's central focus on treatment includes first-person reportage, which immediately identifies her perspective as for activistism and against the pharmaceutical industry. It is a popular perspective to embrace based on the first decades of the pandemic and the heartbreaking and unmet need of millions of people for antiretroviral drugs. However, this lens, although important and powerful, provides a one-sided view of the mountains to be moved. It condemns rich nations, but fails to show how poor countries themselves are daily making budget and programming choices that hamstring efforts to fight the epidemic. It would be unfair to suggest that D'Adesky is unaware of this often overlooked perspective on the pandemic, but none of her country studies investigates the failures of national and local governments to adequately address HIV/AIDS. In her final pages, she sharply criticizes the US response to the epidemic, the territoriality of various international agencies and the debt poor nations still owe to the rich before turning a single paragraph to the poor nations themselves, writing, “While so much attention focuses on the US and G-8 leaders, it's important to consider the money that does exist in the national budgets of developing countries.” It would have been a welcome balance to see this critique investigated and pursued in the detailed country illustrations.
Although the book is exceedingly well documented, on a few occasions the facts themselves appear to be out of place, or misleading. For example, The Global Fund to Fight AIDS Tuberculosis and Malaria—perhaps the greatest initiative to address the pandemic—is alluded to frequently but is not described in detail until the end of the book. Further, perhaps unintentionally, D'Adesky implies that the efforts of Brazil are proof that any poor country can rapidly mount an effective response. This misreading of the situation overlooks the fundamental differences between Brazil and the poorest nations. Brazil is a middle-income nation and possesses an impressive, though imperfect, public health infrastructure, systems and management. As counterpoint, she presents the enormous efforts of Haiti, which is as poor and perhaps more desperate than many African nations. Although Haiti's serious response to the epidemic is showing impressive results, enormous hurdles remain. In many cases, these are the same obstacles faced in the world's poorest and most AIDS-afflicted nations.
By exploring so many elements of the pandemic, D'Adesky misses an opportunity to emphasize the emerging impediments to expansion of HIV/AIDS treatment such as human and financial resources and transparency of finance and management. On the other hand, she does a fine job highlighting the potential for grass roots efforts and its critical role in the fight. For readers unexposed to the spectrum of issues tangled up in HIV/AIDS, D'Adesky provides an array of descriptions which reflect well the challenges faced today. Around the world, activists, researchers and advocates are searching for a set of principles and strategic actions to unify the disparate actions of humanity. For them the book reads much like their daily inbox—exciting breakthroughs, heartbreak, protest and small successes—without any hope or plan for saving the lives of the tens of millions of poor people currently infected nor for preventing the millions of new infections anticipated in the years to come. Given D'Adesky's familiarity with the issues and her intense commitment to the issue, there is time yet to translate this wealth of knowledge into action.
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Ruxin, J. Combating HIV. Nat Med 11, 114 (2005). https://doi.org/10.1038/nm0205-114