AIDS Quartet

Claire Panosian Dunavan
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Not long ago, I e-mailed Donald McNeil, Jr. I wanted to know how many HIV/AIDS articles the New York Times reporter had written over the years.

“Fiddling with the Times' website and internal library … produces 201 to 495,” McNeil replied. “I think it's safe to say I've written 400 stories about AIDS.”

At the end of this piece I'll share McNeil's favorite, but for now I'll state the obvious. No infectious disease has yielded more inches of newsprint or popular book pages. So what makes for a fresh, inspiring read—and might even inform policy–in this HIV-AIDS info-laden era?

I set out to answer that question by reading several recent books about HIV/AIDS.

Pointing fingers?

“Tinderbox—How the West Sparked the AIDS Epidemic and the World Can Finally Overcome It” was first on my list. I also assigned it to this year's crop of undergrads enrolled in my global health seminar. Although I didn't love its sensational sub-title, the joint effort of a former Johannesburg bureau chief (the Washington Post's Craig Timberg) and HIV/AIDS epidemiologist Daniel Halperin promised rich background plus frank analysis of the good, the bad, and the deadly–so to speak–of HIV-AIDS global policy.

Did the book live up to my hopes? Yes and no. On the one hand, it's rich in history and human vignettes. In particular, “Tinderbox” focuses on these milestones: 1) the initial movement, circa 1900, of chimpanzee simian immunodeficiency virus (SIV) into a “cut” human hunter in Cameroon; 2) HIV's further enabling by 20th century Europeans' frenzy to exploit Africa's vast resources; and 3) with respect to control, the modern era's late-dawning recognition that sexual concurrency and a (partly) Western-influenced decline in male circumcision were dangerous allies in the tragic infection of millions upon millions of African heterosexuals.

Let's return, for now, to item 2. Linking human and microbial opportunism is nothing new. In his 1997 book, “Epidemics and History—Disease, Power, and Imperialism,” historian Sheldon Watts even asserts that plague, leprosy, smallpox, syphilis, cholera, and the dual mosquito-borne menaces (malaria and yellow fever) imported to the New World by African slaves were serendipitous if not purposeful instruments of European domination until the early 20th century.

For the record, Timberg and Halperin are never this dark. However, the following passage from “Tinderbox” carries a whiff of Watt's disquieting thesis:

“It is now clear that the AIDS epidemic's birth and crucial early growth happened amid the massive intrusion of new people and technology into a land where ancient ways still prevailed. European powers engaged in a feverish race for wealth and glory blazed routes up muddy rivers and into dense forests traveled only sporadically by humans before. The most disruptive of these intruders were the thousands of African porters forced to cut paths through the exact areas that researchers have now identified as the birthplace of the AIDS epidemic. It was here, in a single moment of transmission from chimp to human, that a strain of virus called HIV-1 group M first appeared. In the century since it has been responsible for 99% of the world's deaths from AIDS—not just in Africa but in Moscow, Bangkok, Rio de Janeiro, San Francisco, and New York. All that began when the West forced its will on an unfamiliar land, causing the essential ingredients of the AIDS epidemic to combine. It was here, by accident but with motives by no means pure, that we built a tinderbox and tossed in a spark.”

One element largely missing from Timberg's and Halperin's landscape is the contribution of unsafe, albeit well-intentioned, healthcare to HIV's early spread. (More about that later.)

Where “Tinderbox” excels is in parsing HIV/AIDS prevention strategies many governments and global public health leaders were slow to embrace. Here, Halperin shines, having co-authored with anthropologist Robert Bailey a prophetic 1999 essay, which cited already-decade-old data linking male circumcision with regional rates of HIV in Africa. The Lancet Viewpoint also bluntly states: “the association between lack of male circumcision and HIV transmission has [thus far] met with fierce resistance, cautious skepticism, or more, typically utter silence.”

(By coincidence, I once treated Bob Bailey for a mild case of onchocerciasis. In a recent conversation, he reminded me of something interesting, namely, that several key decision makers who remained staunch circumcision cynics until late in the game hailed from countries that largely eschew the practice.)

Failed efforts to curb sexual concurrency also draw angry sparks in “Tinderbox,” echoing a screed published four years earlier by former UNAIDS epidemiologist Elizabeth Pisani, quoted here:

“Africa is a giant, in-your-face failure for the HIV prevention industry. It might be even worse without prevention efforts though it is hard to see how it could be. On the prevention balance sheet, we're in the red to the tune of 4.5 millions infections … [Why?] Because most African politicians found it easier to watch hundreds of thousands of young adults die rather than to say what everyone was secretly thinking: HIV is spread by sex. Most HIV is in Africa. Ergo, Africans must have a lot of sex. There, I've said it.”

For HIV rookies, “Tinderbox” unpacks the original “A (abstinence)-B (be faithful)-C (condom)” strategy designed to reduce sexual transmission. It worked in Uganda–for a while. Timberg's and Halperin's cavil?

“The debate quickly became polarized, with conservatives rallying for A and liberals for C as each disparaged the other side's preferred strategies. The intensity of the debate sucked the oxygen away from almost everything else, including the part of the slogan that Halperin and a small but growing number of colleagues believed offered the best chance to curb HIV—the “B” for be faithful, a shorthand for the broad concept of partner reduction. They started calling it the neglected middle child of ABC.”

South Africa's “loveLife” program that ended up glamorizing sex and confusing its target audience also draws fire, as does the suspension of Swaziland's “secret lover” campaign. Timberg and Halperin believe such edgy messages as “I'm dying to have you!” and “Why destroy your family? Your secret lover can kill you” might well have deterred many now-infected Swazis from HIV-imperiling sexual nets.

In sum, there's a fair amount of moralizing in “Tinderbox.” Does it deflect from the book's power? Not for me. Tinderbox is a trove of lessons-learned that can and should continue to impact HIV prevention well into the future.

Unintended medical consequences

The next work has already earned near-classic status. How often does a relatively short, esoteric medical text rate 2,200 words in a major newspaper? That's what the New York Times allotted to its review of Jacques Pepin's seminal “The Origin of AIDS” published last year by Cambridge University Press.

At first I thought of titling this section “Of trypanosomes, treponemes, hep C, and HIV-2” in recognition of Pepin's connecting-of-dots between HIV and other tropical pathogens. However, the infectious shorthand doesn't do justice to the mass of original evidence leading to Pepin's core conclusion, namely, that inadequately sterilized medical equipment used to treat other diseases significantly amplified HIV's human reservoir in Africa well before transactional sex, gay tourism, and unregulated blood trade transformed it into a global pandemic.

Pepin's thesis draws on his experience as a young MD in a bush hospital in the former Belgian Congo (where, he admits, he paid little attention to the boiling and autoclaving of needles and syringes, especially during prolonged power outages) and, more recently, as a researcher. Forty years after his debut stint in Africa, Pepin found that elderly Guinea Bissauans treated long ago for sleeping sickness or TB were more likely than non-injected counterparts to carry HIV-2. The finding suggests remote iatrogenic exposure to the indolent HIV-1 relative.

How ironic, in retrospect, that early disease control campaigns employing not just parenteral tryparsamide and pentamidine for sleeping sickness and streptomycin for tuberculosis but arsenic, bismuth, mercury, and penicillin for syphilis and yaws; chaulmoogra extracts for leprosy; tartar emetic for schistosomiasis; and quinimax for malaria may have simultaneously spread HIV.

Pepin is hardly naive about campaign motives, of course. After first establishing that sleeping sickness mushroomed after colonization forced major human displacements, he says

“… indeed, the aim of many of the disease control initiatives implemented during the early colonial era was to protect the Europeans by decreasing the reservoir of the pathogen in the African population around them.”

Pepin also explores the conflation of urban migration, gender imbalance, changing female sex roles (in some cases, from rural polygamous wives to financially independent “femmes libres” and “menageres” to high-volume prostitutes) and accelerated transmission of sexually transmitted infections once checked by colonial “sanitary programs.” Sadly, political independence—which brought with it even more urban refugees and rocketing unemployment—had a profound impact on sex trade in many new African states. “Poverty among young women [grew] so much,” he states, “that some had no option but to accept those few pennies, which, multiplied by the number of clients … allowed them to satisfy their basic needs.”

As we now know, high-volume prostitution set the stage for HIV's rapid spread in the 1980s and 1990s among sex workers and clients in whom ulcerative STIs provided ideal portals of infection and genital HIV shed during primary viremia led to unnervingly efficient transmission.

Pepin is the only hands-on clinician among the authors featured in this essay. Perhaps that explains why his text has subtle emotional undertones along with data and reasoned arguments—as if the early tropical healer is still coming to terms with the silent plague he may have inadvertently helped to spread in 1960s Zaire. The same reflective tone laces his discussion of the loosening political oppression that ironically accompanied the birth of HIV/AIDS and final musings about its modern-day lessons for humanity.

“The Origin of AIDS” is not for medical neophytes, but it is a beautifully researched and thought-provoking examination of African culture, European colonization, 20th century social change, and infectious disease.

Sex, drugs, and TED talks

Elizabeth Pisani rocks— even if you disagree with her. The woman is smart, funny, and fearless. In the words of one book reviewer, she also excels at “skewering everyone who allows ideology to overrule science.” No doubt, these qualities inspired the 2009 Technology, Entertainment and Design (TED) organizers to invite her to speak. As most people know, TED is all about (intellectual) rock stars.

On the TED stage, Pisani focused on aligning politics with rational public health policy (read universal clean needle exchange and condoms, condoms, condoms) for drug injectors, gay men, and sex workers. She also reminded her audience that the first “bleeding heart liberal” to institute needle exchange was Maggie Thatcher.

Pisani's personal journey is chronicled in “The Wisdom of Whores: Bureaucrats, Brothels and the Business of AIDS.” We first meet the former journalist slash greenhorn epidemiologist at the London School of Hygiene and Tropical Medicine. From there she moves to Geneva at the same time UNAIDS leaders decide that “beating up” the virus's threat to global security (i.e., fanning fear over its imminent infiltration of India, Russia, China, and other parts of Asia) is a great way to attract major donors. Pisani helps craft reports that make the case.

Soon, Pisani lands in Indonesia and tries to synch implausibly-low national HIV estimates with reality on the ground, discovering genuine pockets of risk. Here are some fragments from her reporter's notebook:

“ … despite the colorful parade of high heels and short skirts, bright lipstick, and dark looks, none of them was actually a girl. They were ‘waria,’ and no one had bothered to measure HIV infection in waria since 1997. No data equals no problem.”

“A waria is a smush-up of ‘woman’ (WAnita) and ‘man’ (pRIA). We tend to translate this as ‘transgender sex worker’ but the term seems flaccid in the face of this throbbing subculture of biological males who live as women and sell sex to men … in fact, a waria is between ten and twenty times more likely to be infected with HIV than a female sex worker in Jakarta, and the discrepancy is even greater in other cities.”

“As we saw during gay liberation of the 1970s in the US and Britain, an active gay scene concentrates risk … [and] drugs make you temporarily stupid. Many also make you horny or lazy or careless or all of the above. There is no shortage of recreational drugs in Asia … two blocks from the US ambassador's house in Jakarta, they came for fried rice, the best in Jakarta, but they came also for the panoply of drugs on offer, cannabis or shabu shabu, ecstasy or smack. Increasingly smack.”

Pisani's willingness to blurt uncomfortable truths is disarming—and powerful. Her honesty extends to herself. She doesn't pretend she has never tried drugs (although she never injected). For a while, her war correspondent spouse was an addict. She meets junkies, wins trust, and “gets” them. She brings similar insight to prostitution, stating:

“The fact is most women sell sex for the same reason that people flip burgers in McDonalds, clean other people's toilets, hack coal out of a mine, or do any number of other poorly paid, unpleasant and sometimes dangerous jobs. …Lots of women (and men and trans-genders too) sell sex because it is the best gig they can get.”

As for the “business of AIDS”? Pisani's disillusionment is as keen as her compassion for some of the epidemic's most reviled sufferers. Here's her verdict on the yearly “kumbaya” of the International AIDS Society: “Once upon a time, these conferences were about science. Nowadays, they are about institutional posturing, theatrical activism, and money. Lots of money.”

According to her website, Pisani is currently taking a year off from working as an international HIV/AIDS consultant to spend more time in Indonesia. But I trust we'll hear from her again. Her voice is needed.

Faith-based boots on the ground

In June 2012, global health journalist John Donnelly was the opening speaker at a USAID/Kaiser Family Foundation-sponsored briefing on HIV-AIDS orphaned and vulnerable children. Days later, Beacon Press published “A Twist of Faith: An American Christian's Quest to Help Orphans in Africa.” In it, Donnelly profiles David Nixon, a North Carolina carpenter who battles personal demons and emerges with a passion to help children on a far-off continent. Mark Dybul, the former U.S. Global AIDS coordinator who saw the need “to look at the practices of some tens of thousands of small projects linked to faith-based missions, school projects and NGOs for orphans in Africa” was among those who encouraged Donnelly to write his book.

“A Twist of Faith” is an engrossing account of one man's spiritual and cross-cultural journey. At one point, NOAH (the name Nixon chose for his organization stands for ‘Nlira-Wanga’ –translated from Chihewa: “I am crying for my own”–Orphan Aid Homes) is teaching and feeding 350 Malawian youngsters. Dramatic plot-points include the firing of a corrupt senior manager and the death of a 10 year-old, 29-pound boy who has already lost both of his parents to AIDS. Nixon helps nurse Sautso through his final battle with cryptococcal meningitis, then tenderly places coloring book and pencils, a toy car, and new clothes in the boy's coffin (all are quickly repossessed by the boy's grandmother). Then comes Nixon's unexpected call to solo-parent his own grandson followed by the 2008 economic downturn and major setbacks in funding. After much soul-searching, Nixon surrenders his big vision. He continues, however, to underwrite schooling and health care for five HIV-positive Malawian orphans.

Donnelly interweaves Nixon's saga with portrayals of other privately-funded African schools, from Oprah Winfrey's no-expense-spared Leadership Academy for Girls to Uganda's Watoto, an upscale boarding school for HIV/AIDS orphans established by North American Pentecostals. At Watoto, the annual per-student cost is $4,000. Donnelly contrasts Watoto with the crowded, public “Golden Age Community School” down the road that amounted, in his words, “to a small grouping of tiny, open-air buildings with dirt floors and worn wooden benches” plus scrabbling chickens, lazing dogs, and leaking roofs. Golden Age operates on a budget of $27 per student per year.

Heeding the wisdom of local leaders and, whenever possible, allowing orphans to remain in their communities are big themes running through “A Twist of Faith.” Another message? The danger of outsiders—however well-intentioned–giving too much money, too quickly, with unrealistic expectations. Madonna's “Raising Malawi” charity, for example, channeled $1.8 million over two years to ten organizations, several of which had previous annual budgets under $25,000. According to Donnelly's sources, some of the checks produced more jealousy and infighting than services for those in need.

Modern-day David Nixons and celebrity philanthropists—like old-style missionaries—often have mixed agendas. One of Madonna's programs offers “kabbalah” (Jewish mysticism) as a means of empowering kids. “Was it any different than what Christian missionaries had done for generations,” Donnelly asks himself, “basically imposing their beliefs on a vulnerable population?” In a later chapter, Donnelly repeats similar questions posed by a long-time Catholic expat in Malawi: “What was the purpose of coming to Africa? Was it ultimately to convert Africans to Christianity? Or was it to follow the example of Jesus Christ and help relieve others' suffering? Or was it something else entirely? Was it more about the person who went, rather than about the people in Africa?”

Motives aside, the final message of “A Twist of Faith” is the enormous, albeit poorly measured and monitored work of faith-based groups. According to Donnelly, U.S. churches currently give more to Africa than USAID. The question is: how can American believers' big hearts, deep pockets, and desire to help be most effectively focused and integrated with other efforts on the ground.

Next book, anyone?

“I think the most important stories I've written were part of a series about why drugs were unavailable or impossibly expensive in Africa,” mused Donald McNeil in response to my second question. Things have certainly improved since 2000, when McNeil's reporting helped prick then-prevailing myths about treating the world's poorest HIV/AIDS sufferers. On the other hand, despite recent cheery political forecasts of an “AIDS-free generation,” the continued scale-up of effective, affordable HIV/AIDS healthcare in developing countries remains a daunting challenge. Will someone someday write a book on how this was accomplished? One can only hope.

Work Cited

Donnelly J, 2012. A Twist of Faith: An American Christian's Quest to Help Orphans in Africa. Boston, MA: Beacon Press.

Halperin DT, Bailey RC, 1999. Male circumcision and HIV infection: 10 years and counting. Lancet 354: 1813–1815.

McNeil DJ Jr, 2011. Chimp to Man to History Books: The Path of AIDS. The New York Times, October 17, 2011.

Pepin J, Plamondon M, Alves AC, Beaudet M, Labbe AC, 2006. Parenteral transmission during excision and treatment of tuberculosis and trypanosomiasis may be responsible for the HIV-2 epidemic in Guinea-Bissau. AIDS 20: 2003–2011.

Pepin J, 2011. The Origins of AIDS. New York: Cambridge University Press.

Pisani E, 2008. The Wisdom of Whores: Bureaucrats, Brothels and the Business of AIDS. New York: W.W. Norton.

Timberg C, Halperin D, 2012. Tinderbox: How the West Sparked the AIDS Epidemic and the World Can Finally Overcome It. New York: The Penguin Press.

Watts S, 1995. Epidemics and History: Disease, Power, and Imperialism. New Haven: Yale University Press.

Author Notes

Claire Panosian Dunavan is a past-president of the American Society of Tropical Medicine and Hygiene.
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