Helen Epstein's book The invisible cure: Africa, the West, and the fight against AIDS seeks to explain AIDS in Africa to the lay public, focusing on the common but loaded question: why is the AIDS epidemic so severe in Africa? A journalist with a PhD in molecular biology, Epstein writes in a clear and engaging style, making the book a quick and accessible read. Its popular appeal and focus on the failures of AIDS policy in Africa make it somewhat akin to Randy Shilts' And the band played on (1987) for the global epidemic. As such, Epstein's book will likely reach a much wider audience than any of the other books review in this Forum, which are targeted at academic audiences. This role as the public face of ‘AIDS in Africa’ brings with it particular responsibilities. As a medical anthropologist who researches and teaches on global HIV/AIDS, I approached the book with the following question in mind: if someone were only going to read one book about AIDS in Africa, would I want it to be this one?

Answering this question is complicated by the fact that much of The invisible cure is based on pieces Epstein published earlier in the New York Times Magazine and the New York Review of Books, making the book essentially a collection of (at times) loosely related essays rather than a single narrative. This unevenness makes it difficult to review, as it has both strengths and deeply problematic aspects. For example, at times Epstein demonstrates a complex understanding of the social, political and economic forces behind the epidemic (such as when she chronicles the Sisyphean efforts of Mozambican women widowed by AIDS to obtain their husbands' pensions from the South African mining companies that—through their system of migrant labor—played a key role laying the groundwork for the spread of HIV in southern Africa). Unfortunately, this kind of nuanced attention to history and political economy is undermined by the book's consistent focus on a cultural/behavioral explanation for the epidemic—‘concurrent’ or overlapping sexual relationships—and Epstein's insistence that partner reduction is the disease's ‘invisible cure’. In focusing so much attention on a single explanation for ‘AIDS in Africa’, Epstein dismisses other non-sexual factors behind the spread of the virus and fails to account for the social, epidemiological and biological diversity of the epidemic across the continent.

Epstein's preferred explanation for the African epidemic is what she calls the ‘concurrency theory’—an epidemiological model based on the idea that long-term overlapping heterosexual relationships are not uncommon in Africa. Such relationships can take the form of a long-term partner outside of marriage, or formalized polygyny, in which one man has two or more wives. In contrast, she argues, relationships in the West are likely to be of a serial and more-or-less monogamous nature, one following the other with little or no overlap (though this does not rule out short-term infidelities). Given the stigma surrounding polygamy in the West (and perhaps the US in particular), this is loaded territory, and Epstein takes pains to note that concurrency does not mean that Africans are more ‘promiscuous’ than Westerners—a stereotype that pervaded early explanations of the severity of the epidemic in Africa (and elsewhere). In fact, she notes, research has shown that ‘the average Ugandan had fewer sexual partners over a lifetime than the average American, but America's higher rates of promiscuity did not result in a higher rate of infection’ (p. 56).

Why is this so? Epstein argues that a sexual structure of concurrent relationships facilitates the spread of the virus because an HIV-positive individual is most infectious shortly after contracting the virus. This initial phase, called ‘acute infection’, is characterized by a spike in viral load (the amount of virus carried in the blood) followed by flu-like symptoms as the body's immune system struggles to fight off the virus. The acute phase usually occurs within the first few weeks of contracting HIV, after which the viral load drops to much lower (and less infectious) levels and the disease enters its asymptomatic ‘latent’ stage, which may last for 10 years or more. Due to their high viral load, people in the acute phase of HIV infection are most likely to pass on the virus to others, and this, Epstein argues, is what makes a sexual network based on concurrent relationships conducive to rapid spread of the virus. To give a hypothetical example: a man with two wives becomes infected with HIV through a contaminated needle, an outside sexual encounter, or an unsafe transfusion. Shortly thereafter, during the acute phase of infection, he has sex with each wife. According to the concurrency theory both wives are likely to become infected within a short period of time due to his high viral load and they, in turn, are more likely to pass on the virus to any outside partners they might have during their own acute infection. In this way, the virus could spread rapidly within a matter of months—a point Epstein emphasizes in diagrams that show the virus saturating a concurrent sexual network of 16 people over the course of eight months. (Her diagram of ‘serial monogamy’ depicts two infections over five months.)

In later sections, Epstein discusses the relative success or failure of prevention efforts in Africa in light of the concurrency theory. In southern Africa, and South Africa in particular, Epstein argues, leaders largely avoided confronting the epidemic head on. When they did, they targeted prevention messages at so-called ‘high-risk groups’ such as sex workers and their clients. She argues that the result was ineffective, as it failed to reach average people and ignored the risks posed by concurrency. This failure, she claims, contributed to the explosive growth of the southern African epidemic in the 1990s.

Epstein contrasts South Africa with the case of Uganda, which has been repeatedly lauded in public health circles as the only African country to have witnessed a decline in its infection rate (currently estimated at about 7 percent, down from estimates ranging from 15–30 percent in the late 1980s and early 1990s). Epstein attributes Uganda's early success to its national ‘Zero Grazing’ prevention campaign, which entreated Ugandans to ‘love carefully’ and ‘avoid indiscriminate and free-ranging sexual relations’ (p. 162). By targeting the general public and encouraging people to curtail their sexual contacts, she argues that Zero Grazing successfully reduced numbers of sexual partners and reduced the number of concurrent relationships.

In and of itself, the concurrency theory is not a bad one and may indeed explain at least part of the virus's extensive spread in some African countries. And Epstein is likely right that partner reduction played an important role in reducing Uganda's infection rates early on. What is problematic is Epstein's framing of concurrency theory. Despite her best efforts to write against the negative stereotyping of African sexualities that has plagued the AIDS literature, her attempts to portray polygamy as simply a normative cultural preference are stymied by her elision of concurrency with domestic abuse, ‘infidelity’ and danger. For example, when Epstein first introduces the idea of concurrency, she is careful to present long-term concurrent relationships (whether they be plural marriages or long-term extramarital relationships) in relatively value-neutral terms. She writes:

This culturally relativist approach is important given the taboo nature of polygamy and extra-marital relationships in the United States. However, it is an approach that Epstein is unable to sustain in later chapters, where her depiction of concurrency becomes increasingly judgmental. For example, in Chapter 4 she compares a conversation she has with Masai nomads in Kenya to one she has with young women in rural South Africa, writing: ‘The pattern of relationships—men with multiple partners, women acquiescing to the sexual demands of abusive men—resembled the polygamous ways of the Masai’ (p. 75). Such a comparison is problematic on a number of levels, but for the purposes of my argument at present I am concerned with how it equates polygamy with abuse. This implication appears again in inverse form later in the book, where Epstein argues that ‘encouraging partner reduction may even improve gender relations, since so much domestic violence involves infidelity’ (p. 179). Here concurrency is equated not only with abuse, but also with ‘infidelity’—an elision that collapses sanctioned polygamy and unsanctioned ‘affairs’ into a single category and undermines Epstein's earlier efforts to present concurrency in value-neutral terms.Footnote 1 Later on, she describes polygamy simply as ‘dangerous’ (p. 197).

Equally troubling is Epstein's argument that what relationships in Africa need is romantic love, which she views as the foundation for Western monogamous norms:

Though she acknowledges that this romantic ideal ‘may not exist’ in reality, she implies that its pursuit is somehow protective against AIDS and would thus be beneficial to African societies, though it ‘may take some getting used to’ (p. 85).

All of this is not to say that concurrency isn't worth talking about. Sexual networks based on long-term concurrent relationships likely do facilitate the spread of HIV in some societies. And Uganda's reduction in infection rates probably did come in part from the alteration of these networks—either through partner reduction, as Epstein claims, and/or by keeping sexual contacts more geographically restricted, as Robert Thornton argues in Unimagined communities (Reference Thornton2008). In addition, as Epstein and others argue, the success of Uganda's AIDS policy lay not simply in the Zero Grazing campaign's entreaties to ‘love carefully’, but more so in the mobilization of multiple levels of Ugandan society to confront the epidemic early on—a factor that Epstein names ‘collective efficacy’ (and Thornton, in his more historical approach, describes as ‘nation building’).

Interestingly, despite its name, ‘Zero Grazing’ was not a monogamy campaign, but simply urged Ugandans to be more cautious and discriminatory in their sexual relations. As such, it differs from the government's more recent ‘ABC’ campaign where ‘A’ stands for ‘abstinence’, ‘B’ for ‘be faithful’, and ‘C’ for ‘condoms’. In attributing the Ugandan success story primarily to partner reduction, Epstein is stepping into an ongoing and contentious debate. Despite the differences between the partner-reduction emphasis of ‘Zero Grazing’ and the monogamy-focused ‘ABC’ message, Uganda's success has been upheld by the Bush administration and pro-abstinence groups as validating an ABC model, in which A and B are emphasized and condoms are promoted primarily as a last resort. At the same time, others have argued that condom use is responsible for Uganda's reduced infection rate, and see the current popularity of the A and B messages as a right-wing ploy to undermine the promotion of safe sex as a valid prevention tactic. (Still others argue that the early decline in infections was due mainly to ‘D’ or death). Epstein gives a compelling account of the polarization around this debate in her chapter ‘God and the fight against AIDS’. Here she describes the message of partner reduction as getting lost in a stand-off between pro-abstinence evangelicals (both American and Ugandan) and aid organizations invested in proving the utility of their condom social marketing campaigns. Unfortunately, while she is able to see the appeal of ABC as both contested and historically constituted, she is not able to do the same with concurrency theory.

Epstein's allegiance to the idea of concurrency makes her dismissive of any skepticism regarding its causative power. As a result, valid alternative explanations are treated as forms of denial about the ‘real’ cause of the epidemic. Instead, Epstein presents concurrency as the problem and partner reduction as the solution. Doubts about concurrency as the main factor driving the epidemic are treated either as denial (when espoused by Africans), or as a cover-up of the scientific truth (when voiced by epidemiologists). International health experts who entertain other explanations for Uganda's success are portrayed as ‘shroud[ing] the history of the Uganda HIV decline in a fog of uncertainty’ (p. 183). In turn, African interviewees who greet Epstein's concurrency explanation with silence are dismissed as ‘bureaucrats’ who must have been ‘thinking about their own behavior and wondering if they themselves might have been infected by a concurrency network. Perhaps for the first time they were seeing the AIDS crisis for the tragedy it was’ (p. 65). (Whether or not the African bureaucrats Epstein spoke with were involved in concurrent relationships, it seems equally likely that their silence was an effort to be polite to yet another white foreigner endeavoring to explain the ‘truth’ of their country and their culture to them.)

In fact, both the role of concurrency in spreading the epidemic in Uganda and the impact of partner reduction in slowing it are subjects of a valid ongoing debate that Epstein too readily dismisses. There are many interesting explanations for why parts of Africa have been hit so hard by the epidemic, and for why Uganda's infection rates have declined. In focusing so intently on concurrency, Epstein gives short shrift to non-sexual elements that likely contributed to shaping the epidemic in Uganda and elsewhere, such as the widespread use of injectable medications and the re-use of needles in the home, pharmacies and healthcare settings. The popularity of treatment by injection hails back to colonial-era successes in treating infections with injectable antibiotics. Susan Reynolds Whyte, Harriet Burungi and others have described how this historical legacy—combined with the collapse of health services under Amin and Obote in the 1970s and early 1980s—contributed to the privatization of medicine in Uganda and the flourishing of both lay ‘injectionists’ and injection in the home (Whyte et al., Reference Whyte, Van der Geest and Hardon2002). Likewise, Tim Allen has pointed to data suggesting that only 30 percent of infections in Africa are explained by sexual transmission—findings that were rejected by international health agencies but which he argues have yet to be scientifically ‘rebutted in detail’ (Allen, Reference Allen2005). Epstein also ignores the historical argument made by John Iliffe in his recent history of the African AIDS epidemic, which attributes the severity of AIDS on the continent primarily to the simple factor of time—in other words, ‘Africa had the worst epidemic because it had the first epidemic established in the general population before anyone knew the disease existed’ (Iliffe, Reference Iliffe2006:1).

Lastly, her search for ‘the invisible cure’ that will explain and successfully mitigate the epidemic in Africa causes Epstein to over-generalize about both the continent and its diverse citizens. First, by presenting concurrency as an ‘African’ problem and partner reduction as the ‘cure’ to AIDS on the continent, Epstein implies that the Ugandan prevention model is exportable—an implication that erases the very specific social and historical circumstances that made Uganda's success possible. As Thornton describes in his book, the ‘Zero Grazing’ campaign and other AIDS awareness efforts came as Uganda was transitioning out of a period of protracted violence and despotism into a more peaceful and prosperous era under President Yoweri Museveni, who came to power in 1986. The new government was able to successfully mobilize multiple sectors of society against the epidemic in part because the fight against AIDS was part of a larger project of nation-building (Thornton, Reference Thornton2008). The specificity of this historical context makes it clear that Uganda's success story is based on politics just as much on behavior, and raises the question as to whether it could be duplicated elsewhere. (It also provides a very interesting contrast to the story of South Africa, where post-apartheid nation-building was tied to HIV denialism rather than pro-active prevention efforts, with disastrous results.)

Despite her own efforts to compare and contrast ‘what happened in southern Africa’ with ‘what happened in Uganda’, Epstein too often lapses into generalities about ‘Africa’ and ‘AIDS in Africa’ that obscure the fact that culture, history and infection rates vary considerably across the continent. Statements such as ‘AIDS is common in Africa not because African people have so many sexual partners, but because they are more likely than people in other world regions to have a small number of concurrent long-term partners’ (p. 144) render the epidemic in Africa homogeneous, when in fact there is great diversity in infection rates, epidemiology and sexual networks across the continent. For example, as I mentioned earlier, in discussing concurrency theory, Epstein implies that the gender and sexual norms of the Masai in Kenya are comparable to those South Africa's Eastern Cape region. Though some form of concurrent sexual networks may exist in both places, this comparison seems an odd one given the significant geographic, historical and cultural differences between these two groups. Is it really wise or useful to extrapolate from a cattle-raising nomadic tribe in the Rift Valley of East Africa to a rural village sustained by government pensions and migrant work in post-apartheid South Africa? Moreover, the Masai hardly serve Epstein's purpose of pinning the African epidemic on concurrency, as their infection rates are ‘relatively low’—a fact that she relegates to a footnote. Those looking for a thorough and nuanced overview of the epidemic in Africa would be better served by Iliffe's The African AIDS epidemic: A history (Reference Iliffe2006), which uses history and epidemiology to explain how the disease spread through different regions of the continent and why, for example, it reached devastating levels in Uganda, South Africa and Cote d'Ivoire but not in Congo, Nigeria or Senegal. (To answer the question I posed myself at the beginning of this review, it is Iliffe's book, and not Epstein's, that I would rather have readers choose were they to select a single book about AIDS in Africa.)

Epstein's tendency to homogenize AIDS in Africa is further exacerbated by her occasional invocation of colonial tropes in her descriptive prose: rural Mozambique is a ‘drowsy world’ of ‘sultry villages’ (p. 89) and seemingly contradictory cultural beliefs in Uganda are explained away by the assertion that ‘Africa's masks and secrets are often impenetrable to outsiders’ (p. 190). Even more troublesome is her suggestion that in South Africa ‘contemporary gang rape may be a violent reprise’ of pre-colonial wife-sharing practices among the Sotho people (p. 234). Such language is surprising because Epstein is clearly aware of the racism that haunts discussions of AIDS in Africa and makes an effort to dispel Western myths surrounding sexuality in Africa. As I stated earlier, her description of concurrency theory is quite explicit in its dismissal of Western stereotypes about African ‘promiscuity’. In addition, in ‘Wartime’, her chapter on sexual violence, she takes the American press to task for sensationalistic stories reporting that African men were seeking out virgins to rape in the belief that it would cure them of AIDS, writing: ‘The idea that virgin-rape myths are a significant cause of either child abuse or the spread of AIDS in Africa is itself a myth, perpetrated by stigmatizing attitudes toward people with HIV and racist fears of black sexuality’ (p. 229). Her simultaneous perpetuation of some of the stereotypes about Africa and Africans that she argues against is one of the book's major disappointments.

Perhaps it is the ambitious scope of Epstein's book that is ultimately weakens it. In striving to cover the broad topic of ‘Africa, the West, and the fight against AIDS’ (or, as subtitle of the paperback edition reads, ‘Why we are losing the fight against AIDS’) she loses the complexity and diversity of what are actually multiple AIDS epidemics, each with their own history and their own road towards a ‘cure’.