1 March, 2007Issue 6.2AfricaPolitics & SocietyScienceSocial PolicyWorld Politics

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Making AIDS History

Rebecca Hodes

John Iliffe
The African AIDS Epidemic: A History
James Currey, 2006
214 Pages
ISBN 0821416898

In 1981, doctors living in San Francisco, New York and Los Angeles discovered a new fatal disease. Termed GRID (Gay-Related Immune Deficiency) by medical authorities, the disease—what we now know as AIDS—triggered a national panic. Fears of contamination led to gay men being evicted from jobs, houses and hospitals. Morticians refused to handle the bodies of people claimed by the mysterious new syndrome. Theories abounded as to the routes of transmission. One theory was the ‘fragile anus, rugged vagina’ hypothesis, which claimed that while gay men were at risk of contracting the disease, straights who stuck to ‘vanilla’ sex were safe.

Across the Atlantic, European doctors registered the new disease but with an additional risk group: members of the black elite who were wealthy enough to migrate to the metropoles for treatment. As AIDS-patients from Francophone Africa filled Parisian hospital beds, the ‘African connection’ was established. Stored African blood samples were tested by Western medical researchers, and one from a Congolese man taken in 1959 was seropositive, thus confirming that the virus was present in Africa before it arrived in the US and Europe. Age-old notions about black sexual brutality were revived in the popular and academic presses, while African governments closed ranks against this latest affront by expelling foreign journalists and medical researchers using public hospitals as their research sites.

The fact that a ‘history’ of the African AIDS epidemic has now been written, and by a distinguished Professor of Modern History at Cambridge rather than an angry activist or doomsayer, is a testament to how times have changed. John Iliffe’s The African AIDS Epidemic: A History does not put forward any radical new notions about the disease. Rather, it offers us a measured synthesis of the growing literature that now exists on the African epidemic. A respected scholar of African history, Iliffe brings to bear his knowledge of the continent and its medical history in this trenchant appraisal of the social and political dimensions of the epidemic.

Despite its currency, HIV remains much misunderstood, even by informed publics. There is lingering confusion, for example, about the differences between HIV (the virus) and AIDS (the syndrome that results from immunosuppression by HIV). Iliffe’s account should be required reading for anyone in need of a basic scientific overview. His description of the biological mechanisms of the virus—its branching into clades and subtypes, and the intricate ways in which antiretroviral agents stop the proliferation of the disease—is lucid and instructive. Iliffe’s explanation of the origins of the virus is equally cogent. The emergence of HIV was predicated on the improved mobility which resulted from colonial transport networks, the increasing globalisation of travel in the twentieth century, and, imperatively, the introduction of Western medical technology. Hypodermic needles and blood transfusions, the very instruments responsible for the improvements in African health standards from the sixties to the eighties, have also been crucial vectors for HIV.

In what is perhaps the most widely-read tract written on the disease, AIDS and Its Metaphors, Susan Sontag ends with a plea to cease framing AIDS within military metaphors: ‘The ill are neither unavoidable casualties nor the enemy.’ Iliffe complies with this request. In his account of the methods and meanings of HIV’s transmission, he inevitably confronts issues of responsibility. But he avoids the moralistic and militaristic overtones of so many other accounts (Countdown to Doomsday, Combating AIDS, and When Plague Strikes are among the more revealing, older titles), which blame African sexual mores and governmental incompetence for the emergence of the pandemic.

In this regard, perhaps the real value of Iliffe’s account comes in the second half of his book. There, he chronicles the responses to AIDS by activists, African governments south of the Sahara, and by international organisations such as UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Iliffe also discusses the remarkable changes resulting from the development of HAART (Highly-Active Antiretroviral Therapy), previously termed ‘Lazarus drugs’ due to their ability to restore terminal AIDS sufferers to relative good health. One of the tragedies of AIDS, as Iliffe demonstrates, has been the situation in South Africa, where President Mbeki’s desire to hit back at perceived Western charges of African sexual savagery has led him to insist that poverty, rather than HIV, is the cause of AIDS.

But in his attempt, perhaps, to avoid polemics, Iliffe remains strangely silent about the patents processes that have protected the profits of pharmaceutical corporations at the expense of the lives of HIV-positive Africans. No mention is made of either TRIPS (the World Trade Organization laws on trade-related intellectual property), nor of the Doha Declaration (2001) which ensured that countries like India and Brazil could not export their generic antiretrovirals to poor African countries unable to manufacture their own or to bulk purchase the brand-name pharmaceuticals essential for the creation of their national treatment programmes. Iliffe tiptoes around the real barriers to treatment access: political apathy combined with the enormous power of the pharmaceutical lobby.

It is an unfortunate oversight, for the book ends up glossing over some of the most influential and distressing issues about HIV. For one thing, it costs far less to produce antiretrovirals than the pharmaceutical industry would have us believe, and many of these are in fact formulated in university laboratories with tax-payer’s funding. The patents are then purchased by powerful companies, who hike up prices by over a hundred-fold. Information about the true amounts spent on research and development is closely guarded by the pharmaceutical industry, but the fact that companies like Merck and Pfizer feature in the ‘Fortune 100’ every year bespeaks of astronomical profit-mongering. And in cases where national health departments begin to consider the large-scale import of generics, such as in South Africa in 2001, companies like Glaxo and Roche quickly offer to slash the prices on brand-name antiretrovirals to avoid losing their patent monopolies. ‘Drug companies,’ as the Nobel prize-winning economist Joseph Stiglitz has written, ‘spend more on advertising and marketing than on research, more on research on lifestyle drugs than on life saving drugs, and almost nothing on diseases that affect developing countries only.’ Iliffe fails to consider the historical influence of the pharmaceutical industry, and the ways in which economic structures have shaped AIDS mortality.

Iliffe does nonetheless offer a judicious account of the responses of citizens to the HIV pandemic. He documents the various and colourful ways in which Africans have organized to halt needless and mounting deaths from AIDS, and argues that Western consumers must accelerate their actions to ensure more equitable access to essential medications. Thirteen million Africans have already died of AIDS, and we have only seen the end of the beginning of the epidemic. But although we are not yet able to cure or to vaccinate against AIDS, Iliffe notes, we are able to treat and to contain it. The African AIDS Epidemic ends on a note of cautious optimism. It might just be possible to imagine a world where the tide might be turning against the virus.

Rebecca Hodes is a DPhil student in history at Balliol College, Oxford. Her thesis is about the cultural aspects of the HIV/AIDS epidemic in South Africa, with a particular focus on film.