Don’t look away

ONE death is a tragedy. A million are a statistic.

Most of us live the truth of this awful adage, a buffer that enables us to go about our business. We all have our own problems, challenges, sick relatives. Who needs the burden of others’ suffering?

Now come two new authors whose books about the disaster of AIDS in Africa try to break through our unresponsiveness. Helen Epstein writes often for the New York Review of Books, where parts of “The Invisible Cure” first appeared. Her book is intelligent and judicious. Stephanie Nolen, a journalist for the Toronto Globe and Mail, gives us 28 moving stories of daily life in AIDS-devastated Africa -- one for every million Africans who are HIV-positive. These stories offer astonishing glimpses of the people of a continent brought to its knees. We meet a household headed by a 14-year-old and families with grandparents who have lost most of their children and grandchildren. Cities have become ghost towns. In 2005, Nolen reports, the public health service for Malawi did not have a single pathologist. Forty children an hour die from AIDS, most of them in Africa, but a simple course of drugs at birth would save them. “AIDS is not an event, or a series of them; it’s a mirror held up to the cultures and societies we build,” Nolen writes.

Nolen is a pro; in the dankest wattle hut, you sense the notepad at the ready. Epstein, although her narrative is less emotional, made a personal decision to enter the drama. Before becoming interested in AIDS, she was a molecular biologist at UC Berkeley, studying a tiny aphid-like bug’s even tinier sex organs. In 1992, she had a conversion moment at a lecture by a researcher who was running an AIDS vaccine trial in Africa. She came away aware of what very few Americans paid attention to: that a holocaust was going on there.

Epstein promptly left her job to work for a nonprofit doing strain testing of HIV-positive blood samples in Uganda. A Porsche repurposed as a tractor, she entered a world where nothing worked. She notes that the large amounts of nongovernmental money flowing into the country were creating two classes: fat AIDS people and thin AIDS people. Thin AIDS people were the ones who had the disease; fat AIDS people were the ones profiting from it. “The refrigerator that arrived at the lab ... was half the size of the one we had bought in the shop,” she writes, adding that in Uganda, “if you said you were working on HIV, people thought you were a thief.”

Epstein’s strain-typing was meant to find out whether AIDS in Africa was vulnerable to a particular vaccine. Unfortunately, as has happened again and again with this sneaky virus, the answer was no: AIDS was too complex to yield to a magic bullet. After this setback, instead of returning to the cocoon of postdoc life, Epstein stayed on to investigate how the AIDS disaster in Africa happened. What she found is informative. She takes the reader through Lesotho, Swaziland, Botswana, Mozambique, South Africa, Zambia and back to Uganda as she looks into the geographic, demographic and cultural causes of the African AIDS epidemic.

How did a disease that arose primarily among gay Americans and Europeans become a huge killer of heterosexuals in Africa? Epstein makes several interesting points. First, the lethality of AIDS in Africa is related not to greater African promiscuity or the prevalence of sexually transmitted diseases there, as was once thought, but to a tradition of informal polygamy. “What may have helped spare the West a heterosexual AIDS epidemic on the scale of Africa’s,” Epstein notes wryly, “is the romantic belief that there is a ‘perfect partner,’ a ‘soul mate,’ to be cherished ... if not for life, then for a long time.”

Nor is AIDS exclusively a disease of the poor in Africa, as most Westerners think; on the contrary, it chiefly affects the elite, who have the money and the mobility to acquire multiple partners. AIDS is also closely tied to the history of colonialism, in that it flourishes where traditional tribal loyalties have been undone.

Epstein’s main point is that a solution to the tragedy of AIDS in Africa must come from the Africans, not from the “global archipelago of governmental and nongovernmental agencies [that] has emerged to channel money.” She learns this lesson years after her first visit to Uganda to set up her lab. Uganda is one of the few African countries to have experienced a significant decrease in the rate of HIV infection: From 1992 to 2003, it fell by two-thirds. Uganda achieved this coup through a government-sponsored program known as Zero Grazing. In schools, churches and tribal gatherings, Zero Grazing warned of the dangers of concurrent relationships; beyond that, it encouraged Ugandans to break through their shame and talk frankly about what was going on.

In public and private, in the press and in the councils of government, Ugandans made a connection between AIDS and the economic domination that men had over women so that sex was often exchanged for cash or small gifts. Ugandans first changed their consciousness, then their laws, finally their behavior. They promoted women’s rights, because they knew that working, independent women could better defend themselves against exploitative sex and that this defense would also protect them (and their spouses) against AIDS. “We told women, if your husband is unfaithful and is going to kill you with AIDS, you divorce him,” one female activist tells the author. Epstein writes: “I came to understand that when it comes to saving lives, intangible things -- the solidarity of ordinary people facing up to a shared calamity; the anger of activists, especially women; and new scientific ideas -- can be just as important as medicine and technology.”

Epstein does not hold out much hope for the antiretroviral drugs that have transformed the disease here and finally gotten to Africa. “Those who do receive treatment can expect to gain, on average, only an extra four or five years of life,” she writes, “because the virus eventually develops resistance, necessitating second- and third-line treatment, presently all but unavailable in Africa.” For Nolen, though, antiretrovirals are the central player in the drama of AIDS in Africa.

This is partly a narrative artifact. Nolen knows that readers crave hope, and her graceful, often memorable portraits are chosen from among the lucky few who came back from the dead. There is Cynthia Leshomo, Miss HIV Stigma-Free of Botswana, who, before she began taking antiretrovirals, had a CD4 count (a measure of the body’s ability to fight infection) of 8, when a count of between 500 and 1,500 is normal. There is Alice Kadzanja, an HIV-positive nurse in Malawi, a country so devastated by AIDS that in 2005 it had “just a hundred doctors working in all its public hospitals.” We leave Kadzanja handing out antiretrovirals to other HIV-positive Malawians. “One by one,” Nolen writes, “she plans to save them all.”

And there is Mfanimpela Thlabatse, a farmer in Swaziland who has just buried his wife and two children when Nolen, accompanying an HIV-positive AIDS activist named Siphiwe Hlophe, encounters him. Antiretroviral drugs have recently become widely available in Swaziland, and Hlophe pulls out her cellphone and puts Thlabatse on the waiting list. At 34, Nolen notes pointedly, “a few months older than I ... he had outlived his entire family.”

Each of these books somewhat overstates its case: “The Invisible Cure” is mostly a highly reliable primer on the African epidemic. As beneficial as Uganda’s Zero Grazing program is, if AIDS could be defeated by the continental equivalent of a rap session, it wouldn’t be the worst plague to hit humanity since the Black Death. With regard to “28,” one cannot help but feel that drugs are not the real answer in Africa; breaking the cycle of infection is. But together, they provide an excellent education in the most appalling and overlooked tragedy of our day. Please read them.