Contents, Prologue, Chapter 1
TABLE OF CONTENTS:
BOOK I: SILENT SPREAD
1. Francistown 13
2. Searching for the Beginning 23
3. One Tiny Speck of Truth 30
4. A Tale of Two Viruses 37
5. The Lion and Dr. Livingstone 42
6. Femmes Vivant Théoriquement Seules 53
7. The Gift 61
8. The Big Bang 67
BOOK II: AN EPIDEMIC OF POLITICS
9. Americanizing AIDS 77
10. It Can’t Be Here Already! 85
11. Attention na SIDA 92
12. You Won’t Believe 100
13. Fear Worked 109
14. Born in Africa 119
15. The Condom Code 126
16. The Beat-up 136
17. Things Just Fell Apart 152
BOOK III: THE HUMBLING
18. X-Factor 169
19. The Interests of the ANC 181
20. Poverty Trap 192
21. A, B, and C 198
22. On the Jericho Road 206
23. Gordon and Thandi 213
24. A Marshall Plan for Botswana 224
25. What Shall We Do? 234
26. Raymond the Great 243
27. Makhwapheni Uyabulala 256
28. The Flood 263
29. Mother and Son 272
30. What Shall We Do? Part II 280
Appendix: How the AIDS Epidemic Can Be Overcome 305
Appendix References 387
Additional Suggested Readings 402
This book is the product of two authors: Craig Timberg reported and wrote most of the text; Daniel Halperin developed the ideas that form its scientific backbone and also worked extensively on the manuscript. Both of us occasionally appear as observers as well as characters in the narrative. For ease of readability, Timberg speaks in the first person, as “I.” Halperin is referred to in the third person, as “Halperin.” We are a bit of an odd couple. One of us is a journalist, the other a scientist. And while we’ve faced our share of challenges in crafting a book we believe speaks to both a general audience and a scientific one, we hope you will end up agreeing that in tackling this urgent and frequently misunderstood topic, we are more than the sum of our parts. What has consistently bonded us together is a fascination with human experience, a refusal to accept easy answers, and a determination to contribute, however modestly, in the quest to defeat the AIDS epidemic.
There once was a place deep in the forest where few people dared go. Trees a dozen stories high loomed overhead, blocking out all but the faintest dapples of sunlight. Below a riot of wildlife—parrots, antelopes, chimpanzees—ranged freely. The few humans to travel routinely through this remote corner of creation were Baka “Pygmies,” who were so small and unaccustomed to the trappings of civilizations that other people regarded them as little more than animals themselves.1 Man and beast all lived together, not in harmony, but in a rough kind of stability, never having reason to take notice of the strange sickness that claimed the occasional chimpanzee. It was the course of nature, in which births and deaths were capricious, unremarkable events. And yet, in the case of some of the dying chimpanzees, there was a difference.2 Silently, invisibly, a virus with no name lurked in the blood, lymph nodes, and semen of the chimps, waiting for the chance to fulfill its fate as one of the planet’s most terrible killers. For centuries, perhaps millennia, it never did.
This uneasy peace among human, chimp, and virus broke with the pounding of exhausted feet against the ground. Those who came crashing through the jungle did not do so of their own accord. They were porters, human pack animals pressed into service by a strange new race of pale-skinned men carrying metal sticks that exploded with fire. Any Africans who resisted lost their hands, or their lives, or their wives and children to prison camps. Those who complied fared little better, as they were force-marched through unfamiliar land fifteen miles or more a day, carrying the white man’s gear, the white man’s gray gobs of rubber, the white man’s creamy tusks of ivory. Exhausted and in a place none of them wanted to be, the porters scavenged for something beyond the gruel ladled out by their masters. Among the few sources of meat were jungle animals, including, when they could be trapped, those same chimpanzees in whose bodies the virus hid.
We are unlikely ever to know all of the details of the birth of the AIDS epidemic. But a series of recent genetic discoveries point strongly toward a moment such as this, when a connection was made from chimp to human that changed the course of history. We now know where the epidemic began: a small patch of remote southeastern Cameroon. We know when: within a couple decades on either side of 1900. We have a good idea of how: somebody caught an infected chimpanzee for food, allowing the virus to pass from the chimp’s blood into the hunter’s body, probably through a cut during the butchering.3 As to the why, here is where the story gets even more fascinating, and terrible. We typically think of diseases in terms of how they threaten us personally. But they have their own stories. Diseases are born. They grow. They falter, and sometimes they die. In every case these changes happen for reasons. For decades nobody knew the reasons behind the birth of the AIDS epidemic, though theories tended to focus on growing transport links, shifting social values, and rising sexual experimentation in a world where traditions were giving way. But the new genetic discoveries have lent new precision to what were once only educated guesses.
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 same 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 percent of all of the world’s deaths from AIDS—not just in Africa but in Moscow, Bangkok, Rio de Janeiro, San Francisco, New York.4 All that began when the West forced its willon 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.
The epidemic spent the next half century following the disastrous contours of modern African history, as Westerners remained crucial, if unwitting, agents in spreading HIV around the continent and eventually the world. The virus exploited the rise of colonial cities, the growth of prostitution, and the creation of fast transport routes that linked far-flung communities together into robust new pathways for sexual transmission of disease. And when Africans finally regained their independence in the 1960s, the chaos of the years that immediately followed, with their sweltering new slums and rampant instability, only helped HIV toward its grim destiny.
But on a deeper level, the story of AIDS is not just a story of a disease and its many victims. It is a story of how greed and arrogance set the world in motion in ways that those responsible couldn’t have foreseen and those swept up in the consequences had little power to reverse. With Bibles and Gatling guns and great rivers of concrete, the West tried to remake Africa and ended up igniting a disastrous new epidemic. This is a story that has never been fully told, aside from a few references in the academic press. We all know about the abandoned orphans and suffering widows, as well as the doctors, politicians, and celebrities who are determined to help them. But who considers the outbreaks of sexually transmitted disease and infertility that followed each step of “progress” into Africa? Who recalls the disarray that followed the abrupt retreat of European power? And who would have guessed that as the West tried to look away from what it had wrought in Africa, an epidemic incubated during the colonial era would somehow escape, finding its way into our common future?
Yet the backstory of AIDS is essential, because some of the legacies of colonialism continue to undermine today’s efforts to fight the epidemic. It’s not fair to compare those fighting the disease today, motivated overwhelmingly by the desire to help, with the Europeans (and in some cases Americans) who brutally exploited Africans a century or more ago. But it’s unfortunately true that something of the relationship between the West and Africa has endured from that earlier era. Where once there were conquerors and the conquered, now the relationship too often is understood narrowly, in terms of saviors and the saved. Power, meanwhile, remains concentrated where it has always been. The result has been a war against AIDS run mainly by people who see disease through Western eyes and spend the largest sums of money on the Western biomedical tools in which they have the most faith. Similar approaches have often been successful against other global health calamities, such as polio and smallpox, but reversing the spread of HIV has proven more elusive, more entwined with cultural subtleties that outsiders have struggled to understand. Africans provide the images for the endless stacks of reports churned out by what has become a $16 billion a year industry, but the strategies emanate from the same places where the money does—from Geneva, London, Washington.
Such problems are common to even the most well-meaning foreign aid initiatives, as chronicled in William Easterly’s The White Man’s Burden and Dambisa Moyo’s Dead Aid, which show the distortions created when billions of dollars are pumped into places that lack the capacity to spend the money effectively. In the countries where HIV is most severe Westerners have overlooked some homegrown initiatives in favor of ones that better fit their own training and experiences, and often their own ideologies. Meanwhile, a handful of scientists who strive to ground their ideas in deeper understandings of the societies ravaged by AIDS often have been ignored and sometimes mocked. For years some of the very ideas now regarded as the best available tools for slowing HIV in Africa, home to at least two thirds of the world’s infected people, were mired in fractious debates driven by Western politics and sensitivities.5 This was a new kind of colonialism: rule by rich-world donor dollars.
The result has been a series of missed chances to slow the spread of HIV. Men and women in some parts of Africa are still becoming infected nearly as rapidly as they ever did. South Africans turning fifteen today have a roughly fifty-fifty chance of contracting HIV in their lifetimes.6 There have, of course, been dramatic strides in treating people once they are infected, extending the lives of millions. In this effort, each day is its own miracle, another chance for a mother to hold her children or a father to bring home grocery money from a factory. And recent studies have raised hopes that further expanding access to HIV drugs could also slow the spread of the virus. But while AIDS treatment programs have prolonged many lives, most prevention campaigns have fallen short of expectations. The fight against AIDS has become like a battle against lung cancer in which resources were devoted mainly to chemotherapy and surgery while little useful was done to curb smoking. The result is ever more infections, and ever larger demands for expensive treatment dependent on the continued largesse of foreign donors. And it is here that our failure to understand the forces that shaped the epidemic has carried such a high price: Many millions of people have been left more vulnerable to infection with an incurable virus.
I first began to sense the cracks in the Western world’s tidy portrayals of the AIDS epidemic after I moved to South Africa to become The Washington Post’s Johannesburg bureau chief in 2004. If HIV supposedly preyed on the poor and war ravaged, I couldn’t figure out why the poorest and most warravaged places I visited, such as Darfur and Sierra Leone, had high rates of many other diseases but relatively few people with AIDS.7 I also had the uneasy feeling that all the talk about condoms and “safe sex” obscured something deeper about how the epidemic spread. I remembered the terror of AIDS dating back to my high school years in the 1980s, and the resulting fixation on sexual caution. But in the most affected parts of Africa I struggled to find either the terror or the caution among people in far more peril than my friends and I had been in back home. When my warm, handsome guide to the South African township of Soweto introduced me to his steady girlfriend, then to two other women he was regularly sleeping with, I knew I was in unfamiliar territory.
My growing sense of unease led me to Daniel Halperin, an epidemiologist and medical anthropologist who was then working for the U.S. Agency for International Development in Swaziland. His job was to help that tiny nation and others in southern Africa battle their horrific HIV epidemics.8 Halperin is tall, dark haired, and lean, and his smile is disarming. This is good, because he has made a career of telling people that most of what they think they know about HIV is wrong. When I met him while working on a story in 2005, he immediately departed from the script of most experts I had met. While their conversations had focused mainly on condoms, HIV testing, or the distant hope of a breakthrough vaccine, Halperin veered quickly into the realm of the impolite. He insisted that the two most important factors in understanding the spread of AIDS through African societies were sexual behavior and male circumcision. In lands where polygamy was a common practice before Westerners began campaigning against it, substantial numbers of both men and women, whether married or single, still often had more than one sex partner at a time. This created sprawling networks that spread disease with rare efficiency. This was especially true, he said, in societies where the ancient ritual of circumcision, which removed the foreskin tissue most vulnerable to HIV, was not widely practiced. And where men were more likely to contract the virus, they were more likely to pass it on to their wives or girlfriends—and these women were more likely to pass it on to their husbands or other boyfriends.9 Most African societies had been circumcising boys as part of coming-of-age rituals for thousands of years, but in some areas the practice had either not taken hold or had gradually fallen out of fashion, often at the behest of Christian missionaries, who regarded the initiation ceremonies as heathen. It was in those places, mainly in a swath of the continent running from East Africa’s Great Lakes region down into the southern cone, where HIV now raged out of control.
As we talked, I began to sense that Halperin was an original thinker and, more important, a truth teller. In this he reminded me of people I had known on other beats I had worked. They were city planning officers, or government lawyers, or legislative staffers. They talked to me on the understanding that I wouldn’t routinely quote them directly but would draw on their unvarnished accounts of things to get stories right. As I began to incorporate Halperin’s insights into my work I had occasional pangs of doubt. I was not alone. Some of his conclusions seemed so startling, so at odds with the prevailing wisdom on AIDS, that many of those in power dismissed his ideas as eccentric, a threat to the intellectual edifi ce they had spent years building. How could condom promotion fail to reverse the spread of AIDS in Africa? Or HIV testing? Or antiretroviral drugs? Could rich people really be more vulnerable to HIV than poor ones? Should African women with HIV really breastfeed their babies? And what was all this nonsense about foreskins?
But I gradually realized that Halperin’s insights were grounded in a way of thinking about epidemics that while new to me was as old as the study of public health itself. It framed disease in terms not of individual causes but of societal ones. The potential remedies were collective as well, aimed not only at people already sick but at those who might soon be if the outbreak were not brought under control. This approach proceeded from an elementary premise: From the standpoint of a whole community it is as important to stop new cases it is to treat old ones.10 This can be as straightforward as finding a contaminated water source spreading cholera or as complex as understanding the chronic poverty that causes malnutrition. In the case of HIV, this inquiry is complicated by our nearly universal discomfort in discussing the main means of transmission: sex. Few people discuss their sex lives openly with strangers, making it difficult for scientists to study the related diseases. It is even harder to understand the consequences of billions of individual sexual decisions made by millions of people across entire societies. The other major mode of HIV transmission, injecting drug use, though relatively rare in Africa, makes the overall picture still more complex. Yet this complexity does nothing to diminish the urgency of the problem. This is, after all, not a moral investigation but a scientific one. And its goal is nothing less than
overcoming one of the world’s greatest killers.
A tinderbox is a metal container once commonly used to start fires. Steel, flint, and cloth worked together to create the initial spark and sustain the flame until it was big enough to spread. Once it got going the fire relied on a new mixture—fuel, air, and heat—to sustain itself. Take away any element, and it burned out. In the same way, the AIDS epidemic started when human actions inadvertently combined specific elements into a dangerous new mixture. And it kept going because the key ingredients became steadily more available. Had this not happened, in the time and place where it did, AIDS might have remained forever unknown.
This book relies on a range of contemporary scientific discoveries to tell the story of how AIDS grew from a small, localized outbreak into a devastating epidemic. And it shows how certain factors, especially patterns of sexual behavior and the extent of male circumcision, were decisive in whether societies had minor outbreaks, serious but confined ones, or consuming disasters that can rightly be compared to the worst plagues in history.11 The virus was virtually the same everywhere, but the impact was not, meaning that our understanding of the path of HIV across the planet must be rooted in the ways that host communities vary.12 The fast-lane gay lifestyles that arose in many American, European, and Latin American cities in the 1970s and 1980s featured sexual practices that readily transmitted disease—initially familiar ones like gonorrhea and syphilis, and eventually the virus that causes AIDS. African societies were not as freewheeling as these urban gay enclaves, but the legacies of polygamy and colonialism helped produce sexual cultures that were particularly vulnerable to the spread of HIV—especially where routine male circumcision was uncommon.13 The result, across parts of the continent, has been networks for sexual transmission of disease far more robust than in most other societies. The reluctance of the global health community to address these admittedly awkward factors has undermined the increasingly massive and well-funded eff orts to turn the tide against HIV. This is a key reason why, even as AIDS treatment has become increasingly available across the world, so many HIV-prevention campaigns have not succeeded.
But this unfortunate past need not determine the future. Tinderbox also tells the story of what might happen now if those who care most about the epidemic turned serious attention to the core factors underlying its spread. It’s the story of an epidemic that could be smaller—perhaps much smaller—if these crucial lessons could be learned.14
They are not simple, and we don’t presume to possess more intelligence or wisdom than the tens of thousands of men and women who have been valiantly fighting AIDS for many years. Compared to most people in key positions of the war against the epidemic, we are relative latecomers and, still to a substantial degree, outsiders. Halperin got immersed in HIV research in the mid-1990s, after an idiosyncratic career path that included stints as an aspiring jazz saxophonist and as one of San Francisco’s most overeducated cab drivers. And I knew little about AIDS before joining the Post’s foreign staff . Yet perhaps because we came to the battle later than some, and had the benefit of hindsight, we see in the epidemic a story of lost opportunity, of unforeseen consequences, and of (mostly) good intentions gone awry. And yet, we also share a battered but persistent hope: The epidemic has depended on human action for its birth and spread, and so too could human action finally overcome it.
I was among those who wanted the AIDS epidemic to be straightforward,
in line with our instincts about how the world worked. Clear plot lines
often make for good journalism. If poverty and strife were at the root of
the spread of HIV, and if greedy drug companies were the main barrier
to stopping it, those were stories I knew how to write. Suffering lay in almost
any direction I traveled from my home in Johannesburg. There was
dictatorship in Zimbabwe, unrest in Congo, outrageous inequality in Angola.
Even South Africa was struggling awkwardly—and often unsuccessfully—
to emerge from the long shadow of apartheid. But Halperin had helped open
my eyes to the contrary story that the science was actually telling. HIV was
bad in many places, but nowhere was it worse than in peaceful, prosperous
Botswana—bastion of good governance, haven of stability, favorite of foreign
donors. And within Botswana, nowhere was it worse than in the industrious
northern mining region whose biggest city, Francistown, was home to 85,000
people. If I wanted to understand the limits of money and good intentions
in fighting AIDS, here was the place to start. 1
After a short flight to the nation’s capital, Gaborone, I rented a car and
drove up a nearly featureless desert highway. By Botswana’s standards,
Francistown had a reputation as an unruly city, and a 2004 government survey
put the adult HIV rate at about 40 percent.2 More shocking still was the rate
among women in their early thirties; two out of every three had the virus.
The factors included, according to various experts, a bustling sex industry
and an influx of desperate migrants from nearby Zimbabwe swelling the city’s
ranks of petty criminals and prostitutes.3 As I approached the city limits, I
spotted the first sign of trouble. On a sandy rise to the left, a red billboard
had giant white block letters spelling out warning. This was a couple of years
into my posting as a foreign correspondent in Africa, and I had visited some
notorious hellholes already. So I slowed down my car in hopes of taking the
measure of the city before me, a place treacherous enough that somebody
had posted a giant alert to unwary travelers. But as I got closer, the smaller
letters below the warning came into view: “Francistown now protected by
Security Systems.” This was not a marker of the medical disaster ahead; it was
an advertising come-on straight out of Madison Avenue.
My disorientation grew as I entered Francistown and the austere desert
highway transformed into a four-lane shopping corridor that could have been
on the outskirts of any American city I knew back home. I passed gas station
minimarts, big-box retailers, a Wimpy’s fast-food joint. The city’s redbrick
downtown, meanwhile, bustled with urban energy, as people shopped and
ate and lined up for cash at ATMs posted in front of stolid bank buildings.
The Francistown Chamber of Commerce and Industry even had a fountain
out front that, unusually for such extravagances in most of Africa, apparently
had been maintained flawlessly and kept a burbling column of water spraying
steadily into the air. This was no hellhole.
But, I wondered, what was happening here? Francistown wasn’t poor. It
wasn’t war-torn. There were no signs of mass rapes or child soldiers or great
throngs of refugees sweeping back and forth across some embattled patch of
scrubland.4 There was no evidence of the squalid shantytowns that had sprung
up near most African cities. Francistown, like the rest of Botswana, even had
bounteous amounts of the world’s preferred weapons against the AIDS epidemic,
courtesy both of the nation’s treasury and an unusually heavy dose of
donations from the U.S. government, the Bill and Melinda Gates Foundation,
and the drug company Merck. HIV testing and counseling centers were widely
available, and doctors had begun ordering tests of their patients on routine
medical visits. Condoms were available in virtually every clinic, shop, and bar,
and national reported usage rates were the highest in Africa, and probably of
anywhere in the world.5 Even the expensive drugs that could usually control
the worst ravages of AIDS were free and easy to get at health centers across the
city. If the Western world’s playbook for fighting HIV in Africa was working,
Francistown should be an unquestioned success. Yet the data made clear it
Looking for answers, I turned into the nicest of the several shopping
centers built to either side of Blue Jacket Street, the main drag through
Francistown. After parking my car in a lot paved to flawless perfection, I
headed for a bar with a familiar name. The Hard Rock Cafe was not part of the
international chain, but its sensibility was decidedly First World, with posters
of British soccer stars and rows of European beers chilling in glass-fronted
refrigeration towers. The bartender was a tall, gregarious guy, Brian Khumalo,
who was twenty-five and had a ready, gap-toothed smile and plenty of tales
about what he observed each evening as he opened beers for the Hard Rock
Cafe’s many patrons. As I gently raised the subject of the epidemic raging
through his city, Khumalo nodded knowingly and gestured toward a young,
spiky-haired woman in a corner booth. “She’s new around here, so every guy
is going to talk to her,” he said. “She will be with me today. Tomorrow she
will be with my best friend. And I will be with somebody else.”
Khumalo said he had moved here the year before from Gaborone and
was startled by the accommodating sexual culture he discovered in
Francistown. His first night, Khumalo said, he slept with a woman he had just
met. He did the same the second night, and the third. Casual sex was hardly
unknown in Gaborone, where Khumalo had been a student at the University
of Botswana, but in Francistown it was at the heart of the rambunctious
He tried his best to use condoms for these casual hookups. But when an
old friend visited from out-of-town, he was disturbed to see Khumalo indulg-
ing so eagerly in risky behavior. Instead of merely giving him a lecture the
friend drove Khumalo to Nyangabgwe Hospital, on the southern side of
downtown, and pulled up near a low-slung white building. It was where
people lined up to collect supplies of the antiretroviral medicine that kept
their HIV infections at bay. The number of patients startled Khumalo, but
so did the lack of visible signs of illness. Most appeared healthy. Many were
young. He was chilled in particular at what appeared to be so many “beautiful
women going to get pills.”
The experience was enough to convince Khumalo to swear off casual
sex for a few weeks. But temptations continued to arrive almost nightly. So
Khumalo settled on a half measure he hoped would make a difference. He
began having sex only with a confined group of women he knew fairly well.
The relationships were not monogamous, but they were steadier. Even after
seeing the lines of healthy-looking young women getting medicine, Khumalo
still imagined he could spot the one who would give him HIV before it happened.
By the end of that year, Khumalo estimated, he had slept with one
hundred women in Francistown.
Discussions of sexual behavior and AIDS have been entwined since before
the disease even had a name. The first sentence of the original alert by U.S.
federal disease monitors, put out in June 1981, referred to the original cluster
of victims as “active homosexuals.” And early reports of AIDS in Africa
frequently described “promiscuity” as a key factor in how it spread. The
focus on sexual behavior has waxed and waned in the discussion about
HIV ever since, and in many quarters the subject had become controversial.
But Halperin had convinced me that to understand AIDS I needed to understand
why some places developed epidemics that were so much worse than
others. And that conversation inevitably returned to differences in sexual
cultures. Even if Brian Khumalo was an extreme case, or a braggart, or imbued
with the heedlessness of youth, something was happening that I couldn’t
ignore, no matter how impolitic it was to suggest that people here were not
merely victims of an epidemic but also helping to cause its spread. I also
began wondering: Was it a coincidence that the AIDS epidemic was especially
severe in a place whose atmospherics otherwise felt so familiar, so
Anyplace, USA? 6
Over the next couple of years Francistown became a touchstone. I interviewed
businessmen, students, teachers, shopkeepers, and office workers.
And however controversial it was to discuss sexual behavior and HIV in polite
company in the Western world, the connections were so stunningly obvious
as to be unavoidable in Francistown. One young doctor who had seen more
than her share of AIDS patients casually acknowledged that she kept up ongoing
relationships with three different men. A worker for a major company
complained about how a tendency among Botswana’s employers to routinely
transfer people to offices hundreds of miles away made long-term monogamy
seem impossible. Several of the women I interviewed at the Hard Rock
Cafe, most in their twenties or thirties, said they had all but given up on finding
men with whom they could share exclusive relationships. In a country
where only about one in six of adults were married, many had come to regard
the idea of happily-ever-after to be quaint, something from storybooks or
movies but impractical in the real world.
There were exceptions. A teacher I met at Hard Rock Cafe, Faruk Maunge,
had traveled extensively overseas and was astonished to discover that while
he was away the onslaught of AIDS had failed to change a social scene he
regarded as profoundly dangerous. “They are just a lost bunch,” Maunge said,
in a deep, smoke-cured voice filled not with condemnation but concern.
“They are very, very reckless.”
Maunge, who was in his late thirties, had long dreadlocks, a goatee,
squared-off glasses, and a yellow WWJD bracelet—for What would Jesus
do?—around his wrist. But Maunge was no angel. He had run with a fast
crowd as a younger man, and now could count at least twenty dead friends.
To drive home the toll he invited me to his concrete-block home in the outskirts
of town. When I arrived the next day Maunge ushered me into a room
that had a television, rows of shelves, and two couches. He urged me to sit
down on one while he pulled out a green plastic first-aid box filled with
photos. As he flipped through the pictures Maunge offered a tour of life and
death in Francistown in the Age of AIDS.
“This one is gone,” Maunge said, pointing to a faded picture of a woman
in a red top who was nibbling her fingernails. Moving deeper into the pile,
he continued: “This one is gone, Mooketsi. And this one is gone, Themba.
This one is gone, too, this one on the far left. This one is [HIV] positive.”
When he got to the picture of one man, frustration crept into Maunge’s
voice. “He’s sleeping around again.” He also grew irritated at a picture
showing a friend with AIDS who seemed to father a child—he was awaiting
his fourth—with every girlfriend.
“Praise God, I’ve been lucky,” he said. “It’s like you have ten bullets going
through you and none hits you.”
The story that struck me hardest in Francistown was from a grandmother
whom I will call Angela.7 She was smart and gentle, with long, lovely braids
that fell down past her slender shoulders. I had already filled several notebook
pages with her observations on how HIV spread here. Not only did she have
the virus; so did her husband, and he had come within days of death before
getting the antiretroviral drugs that revived him. Most of Angela’s friends,
who like her were in their forties, had HIV too. And Angela had a good grasp
of one of the main reasons why.
“We’ve got multiple partners here in Botswana,” Angela said simply. “A
girl who’s not working, there’s going to be a boyfriend who’s going to pay the
rent, [another] boyfriend who’s going to pay the water, buy the groceries.”
Such relationships were not strictly economic. Angela had a young boyfriend
on the side in what she called “a small house,” a slang term common
in some parts of southern Africa. She clearly enjoyed the romance, but it also
terrified her to the point that she started having nightmares. The man, who
was more than a decade younger, did not have HIV—yet. And though they
tried to use condoms for every encounter, Angela knew this required discipline
that few couples managed consistently over the long term. As a consequence,
Angela’s nights were filled with troubling dreams in which she would give the
virus to her boyfriend. Then he would transmit HIV to another woman, and
further into Francistown’s sexual networks. And then, eventually, HIV would
find its way to Angela’s own son or daughter. In this way, her unwillingness to
forego the passion of youth would deliver early death to her children, or at least
permanently alter the trajectories of their lives.
The popular image of African women with AIDS is of some combination
of poverty, victimhood, and ignorance. Angela challenged the stereotypes on
all three. She dressed well, in a button-down blouse and skirt. She may have
gotten HIV from her husband but, given the facts of her own sex life, the
transmission easily could have gone in the other direction.8 And she
understood how HIV spread, saw its terrible consequences, and yet persisted
in behavior that she knew kept the virus moving.
To add to the irony, Angela and her boyfriend had met through their
activism with an AIDS group. They were helping deliver food packages to
sick people and gradually grew closer. Angela had tried to break off the affair
but kept drifting back into it over the course of several years. Angela had no
expectation that her boyfriend was confining his affections to her.
“It’s just a natural thing,” she said, in a soft, wistful voice. “I cannot control
it. It’s such a difficult thing. I take it that it’s just human nature.” In one sense,
of course, it is. Humans are wired to want sex. And cultural and religious
expectations that we limit our intimacies to mutually monogamous
relationships do not short-circuit the desire to be with others. But it is
equally obvious that sexual cultures vary across time and place. Even within
a single community, rules get rewritten as the generations pass, as shifting
faiths, technologies, and other forces alter sensibilities about what is acceptable
and what is not. These changes have consequences, in births, in deaths,
in the lives lived in between.
Medical science has advanced to the point where those with access to its
wonders tend to view illnesses as discrete misfortunes. But pulling back the
camera, from the individual level to the societal one, reveals a picture
considerably more complex. Epidemics result from an accumulation of millions
of collective actions, rather than individual moments of poor judgment or
bad luck. Africans on average die much younger than people in richer parts
of the world and often from afflictions easily treated by modern medicine,
or prevented entirely through better diets or access to clean water. These
sturdy facts have long infused the discussions about AIDS, fueling conclusions
that this disease, like so many others in Africa, is a consequence of
poverty, of ignorance, of poor health systems. And that conclusion has
dominated thinking about how to fight HIV, framing the battle as fundamentally
one about resources, especially biomedical resources, such as drugs, condoms,
But what of Angela? With access to resources, and information far beyond
that of most Africans—and of most people in the world overall—why does
she still indulge in behavior that she knows could spread it to others, even
the ones she cares for most?
There is another axis upon which questions about HIV turn: Time.
Francistown in the early twenty-first century is an AIDS disaster, but the disease
was all but unknown there a quarter century earlier. And two centuries earlier, a
major outbreak of HIV would not merely have been unthinkable. It would
have been all but impossible.
Botswana’s sexual culture was not monogamous in the era before Christian
missionaries began traveling widely through the region in the late 1800s.
It was polygamous. The most powerful and accomplished men were supposed
to have more than one wife, and to father as many children as possible in a
harsh desert environment that killed so many of them before they reached
adulthood. In this traditional culture—remnants of which survive today—
there also was a tacit acceptance of sexual relationships outside of marriage,
so long as they were conducted discreetly.9 Ludo Margaret Mosojane, a stern
faced judge in Francistown’s customary court that adjudicates violations of
cultural norms, told me that men traveled frequently to busy trading centers,
to the remote cattle posts where they maintained herds of livestock, and then
back home to small village homesteads. It was not uncommon to have a
sexual partner in each place. Nor was it uncommon for women to have
boyfriends while their husbands were away. Mosojane explained men were not
supposed to return home directly from travels but instead to spend the first
night with a brother or cousin. Whatever the origin of the tradition, it had
the practical benefit, she said, of giving women time to send away boyfriends
and to sweep away incriminating footsteps that might have accumulated
in the sandy paths to their homes. Setswana, the main language here, even
lacked a word for “fidelity” in the sexual sense, Mosojane said. Conveying
the concept would take eight words that translated roughly as “to be with
one person and no other.”
But several other elements essential to spreading HIV were missing. There
were few highways or cities. Trade moved at the speed of cattle or donkeys
ambling on desert paths. And despite Mosojane’s account of flexibility in
marital arrangements, sex had visible consequences in this era before easy
access to birth control. Having sex with dozens of women, as Khumalo
claimed to have done in contemporary Francistown, was a path to ruin unless
a man had vast personal resources. Parenthood carried universally accepted
responsibilities in precolonial Botswana, as it did throughout most of Africa.10
This meant men and women had to be careful to avoid pregnancy outside of
traditional family structures. And so young people undergoing traditional
Setswana coming-of-age ceremonies were discreetly taught practices such as
“thigh sex” and early withdrawal.11 Such village-based rules, which could also
have helped slow the spread of HIV, began to change when Western
missionaries and adventurers began ranging widely through Africa in the
nineteenth century, and it accelerated with the development boom that
followed the discovery of Botswana’s rich diamond deposits in the 1960s. The
transformation of these places, from societies where AIDS was improbable to
ones where it was rampant, is part of a much larger tale about the forces that
shape the lives of individuals in ways they barely perceive. But telling this story
properly requires something that long has been elusive in discussions of the
AIDS epidemic: It requires that we find the beginning.
1. The term “Pygmies” is regarded by some as pejorative.
2. Scientists once thought simian immunodeficiency virus (SIV) was largely benign, but more recent research by scientists, particularly a team led by Beatrice Hahn of the University of Alabama at Birmingham, has indicated that it does kill many chimps.
3. The evidence regarding the exact nature of the initial transmission event from chimp to human remains circumstantial and open to some debate. It is possible, for example, that an infected chimp bit a human, which occasionally occurs in Central Africa. However that first infection happened, it appears unlikely that a major HIV epidemic could have emerged in Africa during this era without other key elements, including the impact of colonialism discussed in this book (see chapter 5, endnote 14).
4. Infections from HIV-1, Group M have been the cause of nearly all deaths from AIDS, but there have been some infections from other types of HIV, including HIV-2, a much less deadly virus confined mainly to parts of West Africa. There have also been some other HIV-1 types, such as Groups N and O, which are still found almost exclusively in Cameroon. In the historical recounting of this book, when we refer to the birth and global epidemic of “HIV,” we are referring specifically to the HIV-1 Group M virus.
5. According to the 2010 UNAIDS Global Report (Geneva), people living with HIV in Africa represent 70 percent of the total number of infected people worldwide. It is possible that this proportion is even greater because the estimates for HIV prevalence in other regions have tended to be less precise than those in Africa. The newer types of measurement methodologies, based upon Demographic and Health Survey–type household surveys, which are discussed in later chapters, have only been conducted in very few countries outside of sub- Saharan Africa.
6. UNAIDS, Report on the Global HIV/AIDS Epidemic (Geneva: UNAIDS, June 2000): pp. 16–19, ww.thebody.com/content/art31144.html#africa. The cumulative risk of infection for individuals over the course of their lifetimes is much higher than the prevailing HIV rate at any given moment, as the risk for contracting HIV continues over many decades of sexual activity. Simon Gregson and Geoff P. Garnett, “Contrasting Gender Differentials in HIV-1 Prevalence and Associated Mortality Increase in Eastern and Southern Africa: Artefact of Data or Natural Course of Epidemics?” AIDS 14 (2000) (Supplement 3): S85–S99; Wambura Mwita, Mark Urassa, Raphael Isingo, et al. “HIV Prevalence and Incidence in Rural Tanzania: Results from 10 Years of Follow-up in an Open Cohort Study.” J Acquir Immune Defic Syndr 46 (2007): 616–23.
7. Civil war and conflict often are cited as major causes of HIV’s spread in Africa, but careful analysis of the evidence suggests this is unlikely. Paul B. Spiegel, Anne R. Bennedsen, Johanna Claass, et al., “Prevalence of HIV Infection in Conflict-Affected and Displaced People in Seven Sub-Saharan African Countries: A Systematic Review.” Lancet 369 (2007): 2187–95. (Also see Malcolm Potts, Daniel T. Halperin, Douglas Kirby, et al., “Reassessing HIV Prevention.” Science 320 : 749–50, including the Supporting Online Supplemental Material.) Furthermore, HIV rates in Africa have tended to be higher among people with higher income: Mishra Vinod, Simona Bignami-Van Assche, Robert Greener, et al., “HIV Infection Does Not Disproportionately Affect the Poorer in Sub-Saharan Africa.” AIDS 21, suppl. 7(2007): S17–28; James D. Shelton, Michael M. Cassell, and Jacob Adetunji, “Is Poverty or Wealth at the Root of HIV?” Lancet 366 (2005): 1057–58. Daniel Halperin, “Old Ways and New Spread AIDS in Africa.” San Francisco Chronicle, Nov. 30, 2000: A31 (sfgate.com/cgi-bin/article.cgi?fi le=/chronicle/archive/2000/11/30/ED113453 .DTL). In Tanzania, for example, HIV rates among men in the highest wealth quintile were about two and a half times higher than among men in the lowest quintile, and the corresponding difference among women was about fivefold. There and in most other African countries, more educated people also have higher HIV rates. (Tanzania HIV/AIDS Indicator Survey 2003/04; Tanzania Commission for AIDS/National Bureau of Statistics, Dar es Salaam, Tanzania/ORC Macro, Calverton, MD.) However, in recent years this tendency has begun to reverse in a few countries. In Zimbabwe, for example, rates of HIV infection have become similar for poorer, less-educated people and wealthier, more-educated ones. James R. Hargreaves, Christopher P. Bonell, Tania Boler, et al., “Systematic Review Exploring Time Trends in the Association Between Educational Attainment and Risk of HIV Infection in Sub-Saharan Africa.” AIDS 22 (2008): 403–14.
8. It is common when describing the path of HIV through the world to use the term “pandemic.” As discussed in the appendix, we avoid using the term in this book because we feel this could suggest that the virus has infected relatively similar percentages of the population in much of the world. We prefer the terms “AIDS epidemic” or “HIV epidemic.” When talking about two or more communities or countries, we refer to them as “epidemics.” This better reflects, we believe, the reality that the virus has spread in particular ways through particular communities, and often at remarkably disparate rates.
9. The impact of male circumcision on the homosexual spread of HIV is more complex and less profound, mainly because most transmission among men who have sex with men occurs from being the receptive—not the insertive—partner in anal sex, in which case circumcision status is irrelevant. However, in some regions, including much of Latin America, Asia, and Africa, there are substantial numbers of men who report being exclusively the insertive partners when having sex with other men. In such instances, circumcision appears to be protective to a similar degree as it is for men having vaginal sex, based on findings from recent studies conducted in South Africa, Peru, and Australia. David J. Templeton, Fengyia Jin, Liminc Mao, Garrett P. Prestage, et al., “Circumcision and Risk of HIV Infection in Australian Homosexual Men.” AIDS 23 (2009); Charles S. Wiysonge, Eugene J. Kongnyuy, Muki Shey, et al., “Male Circumcision for Prevention of Homosexual Acquisition of HIV in Men.” Cochrane Database Syst Rev 6 (2011): CD007496; Jorge Sánchez, Victor G. Sal y Rosas, James P. Hughes, et al., “Male Circumcision and Risk of HIV Acquisition Among MSM.” AIDS 25, no. 4 (Feb. 20, 2011): 519–23; Simeon Bennett, “Circumcision Reduces HIV Risk for Some Gay Men, Research Shows.” Bloomberg News Service, July 20, 2009.
10. See the writings of Geoffrey Rose (“Sick Individuals and Sick Populations.” Int J Epid 14 : 32–38), Roy Anderson (Infectious Diseases of Humans: Dynamics and Control [New York: Oxford Univ. Press, 1991]), Douglas Weed (“A Radical Future for Public Health.” Int J Epid 30 : 440–41), and Steven Johnson (The Ghost Map: The Story of London’s Most Terrifying Epidemic—And How It Changed Science, Cities, and the Modern World [New York: Riverhead, 2006]).
11. Estimates for HIV prevalence in adults vary tremendously around the world, ranging from less than 0.1 percent in the Philippines, Bangladesh, and South Korea, to 0.2 percent in Bolivia, Belgium, and Madagascar, and up to about 25 percent in the southern African nations of Swaziland, Lesotho, and Botswana (UNAIDS Global Report, Geneva, 2010). Also, in most of the world male circumcision is not nearly as crucial a factor as it is in sub-Saharan Africa, in part because of the much larger proportion of infections in those places due to sex between men and injecting drug use.
12. Some new studies suggest that the acute infection period for the subtype C of the HIV virus, which is found predominately in southern Africa and parts of Asia, might be of longer duration. Vladimir Novitsky, Rui Wang, Hermann Bussmann, et al., “HIV-1 Subtype C-Infected Individuals Maintaining High Viral Load as Potential Targets for the ‘Test-and-Treat’ Approach to Reduce HIV Transmission.” PLoS One 5 (2010): e10148. While this may help explain the unusually high HIV rates in the southern African region, it is clear that severe epidemics can also take off in the absence of subtype C. For example, very high rates have occurred in places such as Uganda and western Kenya, where other HIV subtypes predominate.
13. In this book, for the sake of readability, we often use “Africa” when actually we mean "sub-Saharan Africa.”
14. Even if prevention efforts were to succeed—that is, if the number of people becoming newly infected fell significantly—it could still take many years for HIV prevalence rates to also decline substantially. This will increasingly be the case if many people infected with HIV are taking and adhering to ARV medications, allowing them to live longer. As that happens, the total number of people infected with HIV would tend to stay elevated because many more of them would continue to stay alive and be counted. That is why HIV rates alone are an incomplete measure of progress against the epidemic. The public health goal should be to prevent new infections while extending and improving the lives of those already living with HIV.
Chapter 1 endnotes:
1. Several elements of this chapter appeared in The Washington Post, on March 2, 2007, in an article by Timberg headlined “Speeding HIV’s Deadly Spread: Multiple, Concurrent Partners Drive Disease in Southern Africa.”
2. For the sake of simplicity we use the term “HIV rate” when technically we mean “HIV prevalence.” Prevalence is the more formal epidemiological term for describing the level of infections in a population, meaning that, if one hundred adults out of one thousand total are infected with the virus, this would translate to a prevalence “rate” of 10 percent.
3. Although many experts and others prefer the term “sex worker,” in this book we often use the colloquial term “prostitute.”
4. Please see appendix, endnote 7 for an explanation of why rape does not appear to be a major factor for HIV transmission.
5. In 1996 almost 85 percent of women ages fi teen to twenty-four in Botswana reported using a condom during their most recent sexual encounter with a non-regular partner. At the time, this percentage was much higher than similar measures reported anywhere else in Africa, or probably anywhere else globally. A similar figure was still being reported eight years later (UNAIDS/WHO Epidemiological Fact Sheets, 2000 and 2004, Geneva).
6. Municipalities such as Francistown display various similarities to some American cities or suburbs, but of course they are not completely identical, especially in areas farther from the downtown centers. In addition, it is worth noting that in countries such as Botswana the level of income inequality is much higher than in Europe or North America. (However, standard measures of inequality, including the Gini Co-Efficient, normally do not take into account the provision of free or heavily subsidized health care, education, housing, and other social services in some nations such as Botswana.)
7. We have, at Angela’s request, not used her real name.
7. We have, at Angela’s request, not used her real name.
8. Studies in Africa have found that in nearly half of all serodiscordant couples, meaning where only one person in the couple is infected, it is the woman who has HIV, not the man. Oghenowede Eyawo, Damien de Walque, Nathan Ford, Gloria Gakii, Richard T. Lester, and Edward J. Mills, “HIV Status in Discordant Couples in Sub-Saharan Africa: A Systematic Review and Meta-Analysis.” Lancet Infect Dis 10 (2010): 770–77; Damien de Walque, “Sero- Discordant Couples in Five African Countries: Implications for Prevention Strategies.” Population Devel Rev 33 (2007): 501–23; James D. Shelton, “Ten Myths and One Truth About Generalised HIV Epidemics.” Lancet 370 (2007): 1809–11; “The Not-So-Fair Sex.” The Economist, June 28, 2007, www.economist.com/science/displaystory.cfm?story_id=9401560. A number of these studies are discussed in the chapter on gender, marriage, and HIV in Edward Green and Allison Herling Ruark, AIDS, Behavior, and Culture: Understanding Evidence-Based Prevention (Walnut Creek, CA: Left Coast Press, 2011).
9. For a description of the nuances of infidelity and other aspects of sexual culture in Botswana, see Isaac Schapera, Married Life in an African Tribe (Evanston, Ill.: Northwestern University Press, 1966). For example, Schapera recounts how a groom on his wedding day was attracted to two young women attending his wedding and asked his bride if he could take them on as mistresses. She agreed, provided that he do so with discretion and that he promise to father children with her (pp. 206–7). On a 2000 visit to Botswana, Halperin interviewed the traditional leader, Kgosi Linchwe, of the same Mochudi area where Schapera conducted most of his research (Sandy Grant, People of Mochudi [Mochudi: Phuthadikobo Museum, 2001]). Chief Linchwe, now deceased, confirmed the main findings of Schapera’s work, which has occasionally been controversial. For example, he agreed that while premarital sex, including even preliminary experimentation by young children, was generally tolerated, there were also clear cultural rules regarding matters such as pregnancy outside of marriage.
10. Kenyan anthropologist Jomo Kenyatta, who later became that nation’s president, wrote that some premarital sex play traditionally was permitted among his Gikuyu ethnic group. But a man was never supposed to ejaculate inside a woman who was not his wife: “Any intercourse which may result in pregnancy before marriage is strictly forbidden. Any young man who may render a girl pregnant (kohira moiretu ihu) is severely punished by the kiama (tribal council). Th e fi ne for this is nine sheep or goats and three big, fat sheep (ndorome) as the kiama fees. Besides this, the man is made a social outcast or ‘sent to Coventry’ (kohingwo) by all the young men and girls of his own age-group. Punishment is also extended to the girl. She pays a fi ne by providing a feast to the men and the girls of her age-group. She is also liable to ridicule (kohingwo and gocambio).” Jomo Kenyatta, Facing Mt. Kenya: The Tribal Life of the Gikuyu (London: Secker and Warburg, 1938).
11. Among males, these Setswana coming-of-age ceremonies included circumcision. This too would have made HIV’s spread much less likely.