The AIDS Pandemic: The Collision of Epidemiology with Political Correctness

  • James Chin
Radcliffe Publishing: 2007. 336 pp. £27.50, $39.95 1846191181 | ISBN: 1-846-19118-1

The Invisible Cure: AIDS in Africa

  • Helen Epstein
Farrar, Straus & Giroux: 2007. 336 pp. $25 0374281521 0670913561 | ISBN: 0-374-28152-1
Positive action: marchers in Cape Town campaign to prevent 2 million new HIV infections by 2010. Credit: H. BURDITT/REUTERS

Has the tide turned away from AIDS orthodoxy? Two books — strikingly different in tone and character — recount the global response to the AIDS pandemic with words of recrimination for the United Nations (UN). Helen Epstein and James Chin each raise searching questions about methods and motives, saving their most pointed barbs for UNAIDS, the body that coordinates the work of ten separate organizations within the UN system on the pandemic and tracks its spread.

There is a liberating quality to the way in which the arguments are raised and, if these authors are right, a major overhaul of the international AIDS response is overdue.

Chin, a professor of clinical epidemiology at the University of California, Berkeley, has an axe to grind. He has long felt that the work of measuring HIV/AIDS and projecting its course is in the hands of scientists who lack epidemiological know-how. The results are inflated statistics and predictions of a global Armageddon with no basis in fact.

Over several pages, Chin describes how misapplied mathematical models have churned out exaggerated numbers, all flowing from the faulty assumption that national prevalence rates can be estimated by testing women in urban prenatal clinics and extrapolating to general populations. On this score, Chin has been vindicated by the US-funded Demographic and Health Surveys — the more accurate data gathered from randomly selected households in cities and rural areas — that are forcing UNAIDS to lower its estimates of national prevalence rates dramatically in country after country. (UNAIDS simply attributes these reductions to improved surveillance and will, says Chin, “ride to glory” on the myth that further declines prove the success of its prevention programmes, particularly among the young. In fact, he says, because most AIDS epidemics peaked in the mid-1990s, rates are receding naturally.)

Having been right on prevalence, Chin has to be taken seriously when he dismisses UNAIDS' doomsday predictions for India and China. Yes, this pandemic is an unparalleled public-health emergency, he says, but the double-digit prevalence rates seen in parts of Africa will never be reached elsewhere. That's because HIV takes hold among members of high-risk groups (men who have sex with men, injecting drug users, female sex workers), but only fans out to general populations where patterns of multiple, concurrent sexual relationships are the norm. Thus in many African countries, HIV travelled from a member of a high-risk group to each of his or her regular sex partners, then to their multiple regular partners, who introduced the virus to other networks until a vast web formed. It was not the number of sex partners — people everywhere average roughly the same number over their lifetimes — but the synchronicity of the encounters. According to Chin, in most of the world outside east and southern Africa, a culture of serial rather than concurrent sex partners has so far, and will continue to, confine HIV epidemics to high-risk groups. He predicts a slow rise in prevalence rates due primarily to life-prolonging treatment and to new infections, which from here on, he says, will be confined largely to people whose regular sex partners are HIV-positive.

If Chin is right — and to the non-scientist, at any rate, his textbook-like narrative is certainly provocative — the UN has wilfully deceived. Why? Because, he contends, the larger the numbers, the greater the carnage and the more the money flows in. Because associating the continent's horrific AIDS ordeal with African sexual practices might seem like racial stereotyping. Because it's easier to conduct prevention programmes among the general public than among the high-risk groups at society's edges. But why not over-reach, spreading prevention messages to entire populations, including those at highest risk? Because, Chin argues, given limited resources, only targeted prevention programmes can protect those most likely to become infected. Yet in place of that simple piece of logic, he sees an AIDS gestalt created in the service of fundraising.

UNAIDS identifies poverty, gender inequality, discrimination and lack of access to healthcare as underlying causes of sub-Saharan Africa's plague. Chin asserts that these problems must be addressed “because they create major barriers to effective HIV prevention and treatment programs, but they are not the primary or even the major determinants of high HIV prevalence”. We're not sure that social scientists would agree (the line from poverty and gender inequality to high-risk commercial sex work seems fairly direct), but here again, it's hard to avoid the logic in the numbers.

There's much in Chin's book that Helen Epstein, author of The Invisible Cure: AIDS in Africa, would find palatable. Like Chin, she holds the bold view that the virus spreads beyond high-risk groups to the general population only through web-like networks of concurrent sex partners.

With elegant prose, a scientific background and a journalist's searching anecdotal eye, Epstein combines personal research and corroborative evidence from others to posit the view that where Africa's AIDS rates are highest, the key difference is not the numbers of sexual partners, but the timing. She then applies her theory to Uganda, the one country in Africa where a culture of concurrent sex partners was well entrenched and yet the prevalence rate of HIV/AIDS has been reduced dramatically since 1990.

Epstein describes how President Yoweri Museveni rallied his country in the 1980s with the mantra 'Zero Grazing' that cautioned Ugandans not to have more than one partner at a time. She acknowledges the application of 'ABC' — abstain, be faithful and use condoms — but asserts that an abrupt end to the practice of concurrent relationships was the decisive factor in reducing prevalence.

How was it brought about? Here we see Epstein at her best, explaining why Uganda succeeded where others failed. Above and beyond the messages from government bureaucrats, and a world away from donor-driven aid 'packages', the “personalized, informal, intimate, contingent, reciprocal nature of African society” led Ugandans to draw their own conclusions and fashion their own grassroots defence. Concludes Epstein, “the open discussions led by government field-workers in small groups of women and churchgoers, the compassionate work of the home-based care volunteers, the courage and strength of the women's-rights activists helped people see AIDS not as a disease spread by 'others' but as a shared calamity, and this made discussion of sexual behavior possible without seeming preachy, condescending or out of touch”.

Wealthier countries, such as South Africa and Botswana, looked to imported commodities and slick advertising campaigns, but in Uganda, the shocking pervasiveness of death was mellowed by the traditional African principle of ubuntu, or shared humanity, resulting in an indigenous response that stirred the collective conscience. Epstein speaks of the neighbourly exchange of caregiving as though it was a social movement, and in the mind's eye, the reader is convinced.

And then, like Chin, Epstein goes after UNAIDS. Mind you, her criticism is almost Victorian in its gentility, albeit unmistakable in its target. Where Chin uses a hatchet, Epstein wields the scalpel. She argues persuasively that the UN has long known that reduction in the number of sexual partners has been a factor wherever rates have fallen, from Uganda to San Francisco, and yet it refuses to act on it. Is it lack of respect for indigenous cultural awareness and survival instincts? She recounts how in 1993, a statistician now in the top ranks of UNAIDS misrepresented (mistakenly, it seems) findings about Uganda's success, erroneously claiming that researchers had noted an uptake in condom use and delay in sexual initiation, but no significant reduction in concurrent partners. The distortion prevailed. “It was only in 2006 that UNAIDS officials began to stress that the reduction of multiple sexual partnerships should be a key goal for AIDS prevention programmes in southern Africa,” she reports. When the organization's executive director Peter Piot was asked about the omission in a list of questions Epstein sent him in 2004, he answered every question but that one.

The issue that lurks at the back of the mind of the reader in the case of both Chin's and Epstein's arguments is, what next? If UNAIDS has been locked in a rut of culturally questionable and epidemiologically flawed approaches, can it be rehabilitated? Chin would have us look harder at the scientific facts, and then start afresh with a new set of assumptions and projections; he would eliminate conflicts of interest by segregating epidemiologists from the officials concerned with advocacy and fundraising. Epstein would add to that the plea that programme planners rediscover the indigenous wisdom of African culture, which has successfully withstood threats since the dawn of humankind. Both books are guaranteed to spark animated discussion. Together, they pose the first open challenge to the UN's role in the most eviscerating plague in human history.