First appeared in the Boston Globe.
http://www.boston.com/news/globe/ideas/articles/2007/07/22/qa_helen_epstein
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."
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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