Plagues in World History (32 page)

Aside from the sheer scale of its epidemic, Africa’s AIDS crisis also differs from the West’s in terms of how the disease is thought to be transmitted—primarily through heterosexual intercourse in Africa as opposed to homosexual intercourse and drug use in Pattern I countries—although some would argue that anal sex is vastly underestimated in Africa largely due to homophobia, underreported incidence among heterosexual couples, or cultural misunderstandings as to what constitutes such an act.26 Yet, this bare, banal fact alone, that AIDS in Africa is a widespread disease among the general population spread by a common and, one might almost say, biologically necessitated behavior among humans, namely, (unprotected) heterosexual intercourse, is precisely what makes the African AIDS

epidemic so different from that in the West and comprises perhaps the most controversial statement in the AIDS discourse today. For it naturally implies that, in order for both epidemiological models in Pattern I and II countries to be valid, heterosexual sex must be of a radically different sort in sub-Saharan Africa as opposed to what is practiced in the United States or Europe, and indeed this is ex-AIDS y 157

actly what we get in much of the early literature on the African AIDS epidemic, such as that published by the Australian researchers John and Pat Caldwell and which continues to be repeated in some form among certain publications. But all too often assumptions about sexual promiscuity in Africa are based on outdated or strictly anecdotal evidence that play into centuries-old racial stereotypes about the exotic, hypersexed African.27 However, some recent observers of the African AIDS crisis continue to insist, on the basis of focused surveys and mathematical models, that African sexual behaviors do differ in significant ways from those in the West and other countries around the world, particularly in terms of maintaining multiple concurrent partners (as opposed to serial relationships) that in turn make Africans substantially more susceptible to HIV infection.28 And yet to make broad-based generalizations and comparisons about intensely personal behaviors is difficult and dangerous. If African culture does sanction sex outside marriage, early teenage sexual initiation, and sexual predation of younger females by older males, then very similar observations are also general y made of Western culture.

This does not mean, of course, that, as in the West, sexual behaviors among certain “high-risk” groups in Africa—such as commercial sex workers, migrant populations, and urban dwellers displaced from their traditional rural environments—have not historical y contributed to Africa’s AIDS epidemic and continue to do so.29 For example, the transient mining community in Carletonville, South Africa, some 65 percent of whom were found to be HIV-positive in 1999, the highest seroprevalence rate at that time anywhere in the world, undoubtedly played an incubating role in the spread of AIDS within their familial and social networks that was akin to what the bathhouses did for the gay community in San Francisco in the United States, among whom HIV infection rates likewise reached 65 percent by 1984.30 Anecdotal reports of exotic sexual activities in Africa contributing to AIDS—such as “dry sex” (inserting drying agents into the vagina in order to increase male sexual pleasure), genital mutilation, and “widow inheritance” (a sexual “cleansing” ritual in which a widow must have sex with her husband’s nearest male relative)—all might have some basis in reality within select groups in certain regions. These groups include commercial sex workers in South Africa, Muslim communities in east Africa, and tribal communities in the Rakai district of Uganda and in southern Zambia, but these can hardly be extrapolated to the general population throughout the entire continent.31 In the end, it is important to keep in mind that heterosexual intercourse is no longer sufficient as the
sole
explanation of Africa’s unprecedented and atypical AIDS epidemic; it is certainly a factor, and a very important one, but it is stil just one among many that cannot be so easily disentangled from each other.

More recent studies of the African AIDS epidemic are now placing greater emphasis on poverty, famine and malnutrition, and opportunistic or coexisting 158 y Chapter 6

diseases with AIDS, namely, tuberculosis; STDs such as syphilis, gonorrhea, chlamydia, and chancroid; and a host of parasitic illnesses that include malaria, leishmaniasis, schistosomiasis or bilharzia, filariasis, typanosomiasis or sleeping sickness, and helminth infections. Some of these diseases, such as malaria, schistosomiasis, and typanosomiasis, are well known to have a long, endemic history on the African continent, and their prevalence there, alongside extensive poverty and malnutrition, could be said to be an important distinguishing feature that makes Africa’s situation different from the West’s. What is more, all these cofactors have a synergistic relationship with HIV and AIDS. The link between STDs and HIV infection is a rather obvious and well-established article of faith, since both are sexually transmitted and the former produce inflammation or lesions in the genital area that facilitate (by as much as five times the norm) transmission of HIV. STDs also concentrate CD4 immune cells—the target of the AIDS virus—in the genital area and increase viral shedding in seminal fluids. There is also much evidence from prenatal clinics that STDs are quite common in Africa even as they go untreated or undiagnosed, particularly in female patients. What is not so well known, however, is that other diseases as well as malnutrition that are not normally associated with AIDS can likewise contribute in a direct,
biological
way to HIV transmission, just like STDs. For example, schistosomiasis, a parasitic worm disease carried by snails living in natural and artificial bodies of water, infects the genital tract and causes the same lesions and immune cell concentrations that facilitate HIV transmission in STDs; moreover, it is highly endemic to Africa, which hosts the vast majority of the world’s second-most common tropical disease, and its prevalence has only become worse in recent decades with new dam construction and other projects that create surface water sites and that have spread the disease from rural to urban areas. Other parasitic diseases that are especially prevalent and acute in equatorial Africa, such as malaria, can greatly increase HIV viral loads in AIDS patients or trigger latent viruses into replication by stimulating the immune system. Malnutrition and vitamin deficiencies can also promote viral replication, weaken epithelial barriers to the virus, and increase the likelihood of MTCT. Tuberculosis, the leading cause of death of people with AIDS in Africa, may in turn increase susceptibility to the disease in HIV-negative populations due to its impact upon the immune system; most of the widely prevalent cases of TB in Africa in fact exist independently of AIDS

and are especially rampant among young people. While both TB and AIDS are latent diseases, either can easily be reactivated by coinfection with the other. In addition to TB, AIDS can likewise make patients more vulnerable to all the above diseases. Like AIDS and TB, some of these diseases are asymptomatic, and their presence has been equally overlooked by researchers searching for more typical behavioral risk factors of HIV.32

AIDS y 159

Poverty also has a synergistic relationship with AIDS but in a more indirect way, by forcing people to engage in risky behaviors such as commercial sex work or migrancy (where a “survival strategy” becomes a “death strategy”), and in turn AIDS can amplify poverty or malnutrition by diverting scarce resources to health care or funerals and by incapacitating or removing wage earners and care givers.33

Even though the scale of Africa’s poverty dwarfs that of the West, poverty’s connection with AIDS is nonetheless something that both Africa and the United States share, for one of the highest risk groups for AIDS in America today are poor minorities. Instead of AIDS being primarily a behavioral problem for Africans, therefore, poverty, climactic-related famines, and contingent diseases all make it more of an ecological or environmental one, with far less of the moral-istic and cultural complications and judgmental comparisons that go with the former. On these grounds, there are now calls for a complete rethinking of international AIDS policy, particularly in Africa, as coordinated (since 1996) by the United Nations agency, UNAIDS. Since, it is argued, poverty all too often removes individual autonomy in choosing risky social behaviors, which are of course also impacted by cultural expectations, especially in terms of male-female relationships, intervention efforts should instead focus on the root cause of such behaviors (namely, poverty) or on biological cofactors such as malnutrition and other diseases besides AIDS—especially when, provided distribution mechanisms and political stability are adequate, these are more easily addressed through food aid or existing antibiotics (except for MDRTB). In this scenario, a whole decade or more has been lost to inappropriate and largely ineffective AIDS prevention strategies, which are now also being superseded by more effective antiretroviral (ARV) treatment programs. In response, some will point to the success of behavioral modification programs in places like Uganda (where it was famously called “ABC”—abstinence, be careful, use condoms) and Zimbabwe in reducing HIV prevalence rates, or that education and counseling programs have at least been proven effective in reducing risk behaviors and increasing condom use in countries like Tanzania, Kenya, Trinidad, and South Africa.34 However, considerable debate still exists as to whether behavioral modifications are due to government programs or rather to simple fear and community awareness of AIDS, while others question how much of the decline in HIV prevalence is due to changes in behavior or instead to an inevitable maturing of the epidemic? But an even more apropos concern with an overly narrow or exclusive focus on poverty and malnutrition in AIDS strategy is the fact that these factors alone will not explain the unique severity of Africa’s AIDS epidemic. Within Africa, for example, how do we account for a high HIV prevalence rate in the richest country on the continent, South Africa, but an exceptionally low one in a poor country like Senegal (where a third of the population lives on less than a dollar a day); 160 y Chapter 6

how do we explain why in other regions of the world that are just as poor as Africa, such as India or parts of Southeast Asia, AIDS infections and deaths have yet to reach the levels seen in Pattern II countries?35 We also have to be mindful of the fact that some, such as former South African president Mbeki, have used poverty as a cover for denying the existence of AIDS or for abrogating their re-sponsibilities in providing all possible treatments for the disease. In actuality, most historians are quick to point out that they are arguing for poverty having an intimate, synergistic relationship with HIV and AIDS, rather than that there is no relation or that poverty is an independent cause altogether.36

Despite all the attention being paid to poverty or sexual behaviors as the cause of AIDS in Africa, comparatively little notice has been taken of the actual history of the epidemic on the continent, for a third, and perhaps decisive, contributory factor to why Africa has the worst AIDS epidemic in the world is the simple reason that “it had the first AIDS epidemic.”37 This rather obvious fact has been somewhat obscured, however, by the controversy surrounding the origins of HIV in Africa, where some scholars have accused the theory of having an underlying racial prejudice that would naturally associate black Africans with monkeys, even though there is a sound scientific basis for doing so in terms of the specific disease of AIDS.38 Granted there may really be some discrimination in this regard that is part of human nature and has always been a part of the history of disease, but this still doesn’t obviate the necessity of arriving at a true understanding of the history of AIDS in Africa, if only to better understand how to draw up the right policy in treating the disease on the continent. Africa’s early history with AIDS was largely determined by the latent, asymptomatic, and slow-to-progress qualities of the disease, which made it difficult to identify and target on a continent whose medical technology and health care system remain far behind those of the West; oftentimes AIDS’ silent insidiousness was aided and abetted by attitudes of studied ignorance or outright denial, at both a local or individual level (reflected in a widespread reluctance to get an AIDS test) and even at the level of official government policy in some countries, such as the Democratic Republic of Congo and Zimbabwe. Whereas AIDS was confined fairly quickly in the United States to certain high-risk groups such as homosexuals and intravenous drug users, the epidemic in Africa was allowed to fester for a decade or more and was not fully addressed in most places on the continent until the late 1980s and 1990s. Thus, AIDS managed to insinuate itself deeply and broadly into African society, afflicting many more sectors of the population than just one or two “high-risk” groups, as in the United States. And just like its synergistic relationship with poverty and other diseases, AIDS also has a mutual, two-way dynamic with African history: at the same time that AIDS is having a unique impact upon the continent by virtue of the kind of disease it is, so mod-AIDS y 161

ern trends in Africa during the twentieth century have paved the way for AIDS

to make a tenacious home there, which include the political and socioeconomic legacies of colonialism; soaring populations after successful eradication of some deadly diseases, such as smallpox; rampant urbanization and displacement facilitated by new, transnational highway networks; ecological infringement upon previously isolated animal habitats; and widespread medicalization, including greater use of blood transfusions and injections, all of which contributed to the spread of AIDS in both direct and indirect ways. Rather like the Black Death, the current pandemic of AIDS in Africa seems destined to endure for quite some time, though what the end will be and how it will ultimately affect the history of the continent is still a mystery.39