Book Review: ‘Tinderbox’ by Craig Timberg and Daniel Halperin

Tinderbox: How the West Sparked the AIDS Epidemic and the How the World Can Finally Overcome It
By Craig Timberg and Daniel Halperin
Penguin Press, 421 pp., $29.95

Few diseases have been the subject of more books than the HIV/AIDS pandemic, with such notable works as Randy Shilts’ 1987 volume “And the Band Played On: People, Politics and the AIDS Epidemic” and Laurie Garrett’s 1995 “The Coming Plague: Newly Emerging Disease in a World Out of Balance.” Not surprisingly, writers have been able to paint a more complete picture of the emergence of this deadly disease as new genetic research and other insights have revealed how the plague began and how it spread. Also not surprising, the tone of these tomes has become gloomier as the difficulties of fighting this scourge have become clearer and the prospects of defeating it seemingly bleaker.

Onto this stage now comes “Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It,” by Craig Timberg and Daniel Halperin. Timberg, a former Johannesburg bureau chief for the Washington Post, witnessed much of the AIDS pandemic firsthand, and the book is filled with the stories of individuals who suffered from the disease and battled against it. But the overall tenor of the book reflects the personal views of Halperin, a medical anthropologist and epidemiologist at the Harvard School of Public Health’s AIDS Prevention Research Project.

Genetic evidence strongly indicates that the AIDS pandemic originated in southeastern Cameroon sometime between 1880 and 1920, most likely when a hunter butchering a chimpanzee infected with simian immunodeficiency virus (SIV), the precursor of HIV, became infected through a cut on his body. That event had probably happened hundreds of times in the past, perhaps even more. But Halperin argues that European efforts to exploit Africa’s vast resources of rubber, ivory and other materials provided a unique push to the virus. Porters toting their loads of precious cargo carried it across the previously uncharted jungles, allowing it to spread much more widely than before. Steamships plying the region’s rivers and the newly developed railroads allowed the virus to travel much faster than had ever been possible. European exploitation thus allowed the virus to escape its natural habitat.

But Africans themselves shared much of the blame for the virus taking root, Halperin argues. Cultural norms in the region allowed men to have several wives, as well as multiple sexual partners outside of marriage. Those concurrent sexual relationships provided the tinderbox that allowed the spark of HIV to take full flame. Repeated analyses have shown, the authors argue, that AIDS became epidemic only in regions where the number of each person’s sexual partners was high, either in African villages or in the gay enclaves of San Francisco and other western cities. The primary exception to that is its spread among drug abusers, who use contaminated needles to inject themselves.

Timberg and Halperin thus conclude that AIDS will never be a major threat to heterosexual communities throughout the world where monogamy is prevalent.

The final ingredient of the tinderbox, they argue, is the issue of circumcision. A variety of studies have shown that the prevalence of HIV infections is much higher — as much as five times higher in some cases — in African regions where circumcision has never been adopted or has fallen out of favor. Halperin, who served as an advisor on AIDS during in the George W. Bush presidency, has argued for more than a decade that widespread circumcision was the cheapest, most effective way to blunt the AIDS epidemic, but his views received little attention in an administration that was focused primarily on condoms and drug cocktails. Only within the last few years have clinical trials demonstrated that circumcision is an effective tool in fighting HIV spread – primarily because the virus much more readily enters the body through the foreskin than the rest of the penis.

So what can be done? Condoms, they argue, have had minimal impact, primarily because so few use them regularly. Anti-HIV drugs can control AIDS and give longer lives, but at a tremendous financial cost. Early treatment of the newly infected can also help stop HIV’s spread, but studies have shown that patients are reluctant to take the toxic drugs until symptoms develop. Circumcision can provide major benefits at a relatively low price, they say, and most men in Africa should undergo the procedure. That alone would save millions of lives.

Ultimately, however, the best solution is a change in sexual mores. Timberg and Halperin cite the case of Uganda, where the biggest inroads against the disease were made in the 1980s and 1990s. They attribute the success to the efforts of dictator Yoweri Museveni, who initiated the “Stop Grazing” program when it became clear that many of his top soldiers were infected. Stop grazing meant limiting sex outside of marriage or other stable relationships, and the campaign emphasized the lethal consequences from such encounters. “Fear works,” one African official noted. The highly public deaths of popular singers Franco, Fela Kuti and Philly Lutaaya from the disease reinforced that fear, and HIV transmission rates in Uganda fell markedly — at least until the fear wore off. Whether similar results can be obtained elsewhere remains highly questionable

Maugh is a former Times medical and science writer.