Book Review

Frontline of a pandemic

28: stories of Aids in Africa

It is fortunate that these two excellent books, 28 and The Invisible Cure, were published recently within a few weeks of each other. They give complementary insights into the Aids pandemic in Africa and, read in parallel, they will educate those of us who struggle to comprehend the extent, the impact and the significance of the pandemic there, and the successes and failures of the varied responses to it.

Stephanie Nolen is a Canadian journalist who has been reporting on HIV/Aids since 2000 and now lives in Johannesburg. She wrote the book to alter the sense people in North America and Europe feel that experiences such as "an orphaned 15 year-old thrust into caring for four ... siblings, or a teacher thrown out of her house after she tells her husband she is infected", are somehow less terrifying or strange for a person in Zambia or Mozambique. Her 28 introduces us to 28 people, most, but not all, living with HIV, one for each of the estimated 28 million people living with HIV in sub-Saharan Africa. They come from 13 countries, and among them are a long-distance truck driver, a former migrant miner in South Africa, a 14-year-old caring for a younger sibling, the deputy director of the Ugandan Virus Research Institute, a grandmother bringing up orphaned grandchildren, Miss HIV Stigma-Free from Botswana, activists, doctors and Nelson Mandela. She tells us about each one, we look at their photograph and we have a sense of listening in on the conversations; something of their personalities and experiences comes through to the reader. It is difficult to read more than two or three at a sitting because of the lasting impact each has on one's mind and heart. 

She usefully includes a section on "How You Can Help", not by volunteering to work in Africa, but by advocacy here for improved political and financial responses, and by donations to appropriate organisations. There is also background information; for example, about the history of the pandemic, the efforts to develop a vaccine, and the different governmental responses, particularly in Uganda and South Africa. Nolen also gives examples of the role of support groups and the responses of the Churches, and the knock-on effects of decisions by international financial institutions on countries' ability to cope with the pandemic. However, it is not always easy to identify a lead to further information on a particular topic in her short bibliography. In a future edition, an extended bibliography could perhaps be annotated or related to particular stories.

Helen Epstein is a molecular biologist who started work on an (unsuccessful) Aids vaccine project in Uganda in 1993 and, after further training in epidemiology, went on to visit Africa repeatedly over the next 12 years as a reporter and researcher, to try to find out why the epidemic is so severe in East and Southern Africa, why it has been so difficult to control, and what accounts for the decline in the infection rate in Uganda, which fell by 60 per cent during the 1990s. (About 40 per cent of all those infected with HIV world-wide live in 11 countries in the region, accounting for only 3 per cent of the world population; in several countries about one third of adults are infected, a rate 10 times higher than in any country outside Africa.) She talked with activists and carers, scientists and politicians, aid workers and ordinary citizens and "read everything I could about the epidemic" (there are 40 pages of notes). The book is based on her reports on the pandemic, many in The New York Review of Books. She explores in particular the different responses in Uganda and South Africa, the political and social reasons for the difference, the mistakes that were made and what can be learned from them.

The section "Aids Research for Beginners" is a lucid introduction, informative and interesting. In it Epstein explains the evidence that a critically important reason for the rapid spread of HIV throughout the population in Africa is that many people, both men and women, have long-term concurrent sexual relationships. This links people into a network of relationships, and if one person becomes infected the infection will spread rapidly. (In Europe and North America, long-term sexual relationships tend to be sequential, not concurrent and if one partner becomes infected it will not extend to others until the relationship breaks down.) In addition, male circumcision is not common in the region, and it has very recently become clear that circumcision greatly reduces a man's risk of becoming infected and, if he is himself infected, it reduces the risk of spreading it to his partner. The combination of the practice of concurrency and absence of circumcision goes far to account for the form of the pandemic in the region.

In the 1990s, in the experts' view the best way to halt HIV transmission in Africa was to concentrate on what was thought to be the main route: sex workers and their male clients, truckers and migrant workers, by promoting condoms and treating their sexually transmitted diseases. Despite this action, HIV spread rapidly  through the general population. Only in Uganda was there a sustained decline in new infections. Here from the late 1980s, there was widespread recognition that every sexually active person was at risk, open discussion about Aids, many community and church-based groups to care for and support the sick and orphans, and a vigorous government campaign promoting "Zero Grazing" (supported by the Churches), and "Love Carefully". The statistics show a marked reduction in concurrency. Epstein points out that the key to the success was "something for which the public health field has no name or programme. It is best described as a sense of solidarity, compassion, and mutual aid that brings people together to solve a common problem ..."; this is "not something that can be packaged and paid for and then shipped around the world".

Reading both these books is unsettling; they inform heart and mind and challenge preconceptions. You have been warned.

In Reflecting Theologically on AIDS, Robin Gill has brought together articles by Catholic and non-Catholic theologians, some of whom took part in 2003 in a UNAIDS-sponsored workshop in Namibia to produce a framework for theological reflection on the subject; the final report, focusing on the stigma of Aids, is included.

It is an illustration of the lack of attention to the pandemic from the theologians in the northern hemisphere that they have produced so very few books and articles addressing this challenge. Reading these three books will help to do so.

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