The EconomistJune 27th 2020 Books & arts 732
1the sickness and death of others, knowing that you too
could be next, even as you feel fine.” In “How to Survive
a Plague”, the American author David France recounts
trips to the doctor at the merest hint of a skin blemish.
Some revelled in the terror. Most people catch hiv
through heterosexual sex, but in many rich countries
the majority of cases were among gay men. “The poor
homosexuals—they have declared war upon nature,
and now nature is exacting an awful retribution,” said
Pat Buchanan, an adviser to Ronald Reagan, who was
elected president of the United States in 1980. Venom
was coupled with hysteria. Just one undertaker in New
York City would embalm aidsvictims.
It did not help that the Reagan administration was
neglectful. The federal government shortchanged and
slowed efforts to prevent, treat and research hiv/aids.
The president did not mention the disease in public
until 1985. Similarly Margaret Thatcher, then prime
minister of Britain, was squeamish about safe-sex
campaigns and had to be overruled by Norman Fowler,
her health secretary, who launched the “Don’t Die of Ig-
norance” campaign in 1986.Today it’s me, tomorrow someone else
Ultimately it was people with aidswho did much to
turn the tide of the disease. Safe-sex campaigners pop-
ularised the use of condoms, while activists pressed
the Food and Drug Administration, which approves
medicines, to accelerate clinical trials. In America Dr
Fauci, then as now the head of the National Institute of
Allergy and Infectious Diseases, went from being a tar-
get of activists to becoming an ally. Larry Kramer, the
irascible founding father of aidsactivism, who died
aged 84 on May 27th, considered Dr Fauci “the only true
and great hero” in officialdom (Kramer originally
thought he was “an incompetent idiot”).
The first evidence that combination antiretroviral
therapy (art), a cocktail of hiv-suppressing drugs,
could radically change the course of the disease arrived
in 1996. artled to dramatic reductions in mortality
rates. Patients spoke of a “Lazarus effect”. It was a turn-
ing point in rich countries. Histories of the American
epidemic often end here—with a coda on how thehiv/
aidsepidemic helped human rights and probably ac-
celerated public acceptance of same-sex marriage.
But in developing countries the situation remained
grim. Most hiv-positive people have always lived in
Africa, where the virus is overwhelmingly spread via
heterosexual sex. By 1996 aidswas the most common
cause of death in sub-Saharan Africa. In Zimbabwe life
expectancy fell to 43 in 2003.
There is no single reason for the severity of the pan-
demic in Africa. There are biological reasons to consid-
er, from the amplifying role of tuberculosis, high rates
of other sexually transmitted diseases, the potential
role of African genomes, and the viral subtypes com-
mon in Africa. Then there is the swish of Occam’s razor
by John Iliffe in “The African aidsEpidemic”, in which
he writes that: “Africa had the worst epidemic because
it had the first epidemic.”
Multiple theories have been put forward, most con-
taining some truth. Poverty, for example, matters.
When artcost at least $10,000 per person per year, as it
did in 1996, only elites could be treated. But poverty
does not explain why prevalence was already so high.
More than a fifth of adult residents of capitals such as
Kampala and Lusaka were hiv-positive by 1990. Other
poor parts of the world, including central America,South Asia and the Caribbean were less affected. Bo-
tswana and South Africa, two of the richest African
countries, are two of the hardest hit.
Patterns of commerce and migration are important.
Across Africa goods are moved by long and slow truck
journeys. Studies have highlighted the high rates of
hivamong truck drivers and prostitutes at stops. An-
other arrangement that encouraged the spread of hiv,
especially in southern Africa, was the migratory labour
system that began in colonial times and persists to this
day. Miners would spend many months away from
their families. Often they lived in single-sex dormito-
ries, surrounded by prostitutes attracted by the min-
ers’ steady wages. Studies of mining towns found ex-
tremely high rates of hiv.
It was once suggested, with a large degree of preju-
dice, that African “promiscuity” was to blame. Subse-
quent research in various countries suggests that Afri-
cans have no more partners over a lifetime than
anyone else. What is key is the detail. Studies by Mar-
tina Morris of the University of Washington suggest
that in some African countries it is relatively common
to have concurrent partners, which raises the infection
risk. In Uganda, which successfully reduced infection
rates, a “zero grazing” campaign is cited as a cause, in
which men were encouraged to reduce the number of
their sexual encounters.
Sex is wrapped up with power dynamics. It is im-
possible to understand aidsin Africa without a grasp
of sexual inequality. A survey of rural women who mi-
grated to Kinshasa, Congo’s capital, revealed that many
contracted hivafter entering into transactional sexual
relationships, often with older, richer men. To this day,
across the region, the rates of hivinfection among
young women are far higher than among young men.
In some cases women either do not feel a need to insist
on condom use or are not able to insist.
Another amplifying factor was the responses of Af-
rican leaders. Some, such as Uganda’s Yoweri Muse-
veni, talked openly about the disease (even if he was
sceptical about condoms). Others saw hiv/aidsas a
Western plot or denied that it existed because Africa
did not have homosexuals.
Worst was Thabo Mbeki, who succeeded Nelson
Mandela as president of South Africa in 1999. While
surfing the internet, he encountered the ideas of hiv
denialists, or “dissidents”, who claimed that the virus
was not the cause of the disease. He prevented poor
South Africans from getting state-funded arts, while
backing a scheme to develop a local alternative that
turned out to be an industrial solvent. Activists and
judges eventually brought about a more rational set of
hivpolicies. But not before 340,000 needless deaths,
estimates Nicoli Nattrass, an economist.
Religion also played a role; sometimes for good, but
often for ill. Data from Afrobarometer, a pollster, sug-
gest that religious figures are more respected than oth-
er pillars of society. As in America, many saw hiv/aids
as punishment for sin, with some churches opposing
condoms and refusing to bury aidsvictims. Tradition-
al religions could be unhelpful, too. In Malawi hun-
dreds of thousands flocked to one healer who claimed
ancestral spirits had instructed him in the use of a tree
bark to cleanse people of the disease.
Blame, stigma and denial discouraged open conver-
sations about hiv/aids. In Congo, sida, the French ini-
tials for aids, was said to stand for syndrome imaginaire
pour décourager les amoureux, or “imaginary syndromeIt is impossible
to understand
AIDS in Africa
without a grasp
of sexual
inequalityNew HIV infections
Global, mSource:UNAIDS43210
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