Sunday, July 22, 2007

Q&A Helen Epstein

First appeared in the Boston Globe.

THE JULY ISSUE of Vanity Fair, dedicated to Africa and guest-edited with much fanfare by U2's Bono, trumpets the "lifesaving" impact of anti-retroviral drugs (ARVs) on AIDS patients in Rwanda, where the drugs are distributed for free by clinics. But when I spoke to public health activist and writer Helen Epstein last week, she said the magazine's version of events fails to acknowledge that the "HIV infection rate in Rwanda began to decline dramatically in the mid-1990s, well before ARVs, which only started arriving in the last four years."

Epstein, who gave up a career in molecular biology in 1993 to focus on Africa's mounting AIDS crisis, feels this sort of omission crops up often in Western ideas about Africa. In her new book, "The Invisible Cure: Africa, the West, and the Fight Against AIDS," she writes that though Westerners tend to conceive of Africans as helpless in the face of war, poverty, and now AIDS, sometimes "helplessness is in the eye of the beholder." She points to the existence of "another Africa, characterized by a striking degree of reciprocity, solidarity, and ingenuity." These qualities, along with the African capacity for "compassion and mutual aid," make up what Epstein calls "the invisible cure."

But for these qualities to be activated in the fight against AIDS, the shame and denial that surround the illness in southern and eastern Africa, where HIV rages at epidemic levels in the population at large, has to be overcome. Epstein told me she has devised "a sort of litmus test" to see if that is happening. "I talk to kids in school," she said, "and ask if they know anyone with AIDS. In southern African countries, like Botswana and South Africa, where the virus is spreading like wildfire, everybody says no. But kids in Uganda or Rwanda all tell deeply personal stories."

Uganda and Rwanda are countries that have had success fighting AIDS. In Rwanda, Epstein told me when I called her at her home in Brooklyn, the rate of HIV infection went into steepest decline after the genocide of 1994, and, as she explained it, partly because of it.

IDEAS: How could the genocide possibly have helped Rwandans fight AIDS?

EPSTEIN: In the aftermath of the genocide people were talking about reconciliation, about who they were, about what they had done -- and about AIDS. People began to attribute the infection of women to their having been raped during the genocide, which destigmatized the issue. It was no longer as though a woman with AIDS had to have been a prostitute. The genocide changed everything, even the way AIDS spread, and let people be open about it.

IDEAS: How did the virus infect the general population in places like South Africa and Uganda?

EPSTEIN: It spread through concurrent long-term sexual relationships. It's not that people have so many sexual partners. They have fewer, on average, than people in the United States. But they have more than one long-term partner at a time.

So a man may have two wives. One of those wives may have a secret boyfriend somewhere, and that boyfriend may have two other wives, and one of those wives might be sleeping around. All these people are sleeping regularly with each other, which is highly conducive to the spread of HIV. It's like a superhighway for the virus.

IDEAS: Was concurrency the way AIDS became rife in America's gay community?

EPSTEIN: No. The first 100 men diagnosed with AIDS were interviewed about their sexual behavior. They had an average of 1,000 lifetime partners. People were changing partners at an enormously high rate because of the bath houses, for example.

IDEAS: So that gay experience is really the opposite of concurrency?

EPSTEIN: Right. And because gay people were already burdened with other sexually transmitted diseases, they knew pretty early on how HIV was spreading through their community. That made it easier for them to respond -- to argue about condoms and bathhouses, for example. They were able to come together around this as they had around other things, such as the fight for their rights.

IDEAS: Who first figured out that concurrency was the way AIDS was spreading in Africa?

EPSTEIN: Ugandan doctors, in the late 1980s. The computer modeling and epidemiology was done later by Western scientists, but the idea that you had to look at long-term concurrency came from Ugandans themselves. They saw that the virus wasn't just going through prostitutes and truck drivers, as had been supposed, but was also going through ordinary families and people in relatively ordinary relationships.

And they themselves designed a campaign to address this particular behavior. The campaign had two basic messages. One was sometimes called, "zero grazing": Try to stick to one partner, avoid casual relationships, and try to reduce the number of concurrent partnerships. The other message was: Don't point fingers.

IDEAS: You write that the campaign worked, and that, "In 2003, the only African country that had seen a nationwide decline in HIV prevalence was Uganda." So is it now generally accepted that to deal with the epidemic of AIDS in Africa you have to deal with concurrency?

EPSTEIN: I was gratified because the UN's 2006 report on AIDS paid quite a bit of attention to it, saying that where the virus is widespread not just in high-risk groups but in the general population, concurrency plays a very important role.

That's an important breakthrough. For a long time concurrency wasn't part of the picture the UNAIDS group had of the epidemic.

IDEAS: The great news in the book is about the intelligence and sophistication of the AIDS campaign in Uganda. But you strike a pessimistic note when you add that now, with a huge amount of donor money going to Uganda to fight AIDS, people barely remember that earlier campaign.

EPSTEIN: That's why I wrote the book. I think that history is terribly important for people to know.

IDEAS: Do you think there's a danger of romanticizing African culture?

EPSTEIN: I do. But it's hard to address these things coldly. I think the approach to Africa has been far too cold for far too long. Our development policy and health policy have not been sensitive enough to conditions there. And when the policies don't work, we blame them for not being enough like us.

So there has to be a greater effort to be sensitive even if it risks sentimentalizing. It may be time.

And I think the most powerful weapon we have is each other, our collective social will. Maybe not in every case. There may be public health problems you can deal with using technology.

IDEAS: Such as?

EPSTEIN: I was going to say the measles vaccine, but I stopped myself. To get measles vaccination programs to work, you needed collective action, too. You needed people willing to make the programs work at the local level. You needed people to care. For everything you need that. But especially for AIDS.

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