The AIDS epidemic in Africa has killed more than 13 million people. But most of the literature on it produced so far has either focused on narrow medical and epidemiological issues or taken an ethnographic view of the disease; the sociological and political implications of the disease have been surprisingly shortchanged, even if observers have routinely predicted dramatic consequences for the continent. These three fine books go a long way toward demystifying the epidemic by carefully deconstructing its internal dynamics and effects.
Iliffe, a professor of history at the University of Cambridge, has written a splendid social history that is both comprehensive and authoritative; it should be widely read. He traces the disease back to several mysterious deaths in central Africa in the early 1950s that retroactively can be diagnosed as AIDS-related; the epidemic's virulence in sub-Saharan Africa, he argues, can be linked to this early start in the region, which allowed AIDS to progress unchecked longer than in other regions. Iliffe shows how the virus' impact has been exacerbated by the fact that HIV is "mildly infectious, slow acting, incurable, fatal." In particular, the unusually long incubation period between infection with HIV and the onset of AIDS has helped spread the virus, and complicated its containment, not least because treatment seemed useless. In analyzing the public-policy responses and the societal and individual attempts to palliate the epidemic, Iliffe castigates incompetence and hypocrisy when he comes across them. But his narrative focuses more on the courage and altruism he encounters from individuals caring for the sick and from the organizations leading the mostly quixotic struggle against the epidemic. Indeed, the plethora of both foreign and domestic nongovernmental organizations that have emerged to deal with AIDS in Africa over the course of the last two decades is staggering. For Iliffe, this newfound activism is a cause for optimism. He ends his study by presenting the view that by 2005 human agency had contained the disease, which, although not yet eradicated, had stopped progressing. He is particularly hopeful that the emergence of antiretroviral drugs in the last decade will encourage more comprehensive public health efforts.
De Waal's short book is less optimistic. His primary goal is to answer the question posed by his title. Why, indeed, has such a devastating epidemic not had more of a political impact? De Waal, too, argues that the nature of the disease itself has facilitated denial by African governments and citizens. Governments have typically lacked both the public health capability and the political will to engage in a resolute anti-AIDS campaign. But citizens' denial also has ensured that AIDS issues have not featured prominently in the many elections that a democratizing Africa has held since the onset of the epidemic. As a result, African governments have simply not been held accountable for the deplorable state of their countries' public health systems. As de Waal notes, African governments are masters in the art of political survival, even deriving some advantage, notably in the form of foreign aid, for their failures. As de Waal puts it in his always lively prose, "AIDS has been politically domesticated."
Patterson's monograph comes to a similar conclusion, but at the end of a more conventional academic narrative. The best chapters of her book are the ones that explain why democratization has not led to more effective public responses to the epidemic. Patterson makes much of political leadership, arguing that the biggest difference between countries is often the willingness of the president to talk frankly about the disease. Such leadership is not easily explained by the structural characteristics of a country. South Africa, with its comparatively strong institutions, free press, and big middle class, has suffered from particularly obtuse presidential leadership; poor, authoritarian Uganda, still brutalized by civil war, has produced one of the more effective AIDS campaigns on the continent. Patterson also emphasizes the gendered nature of the epidemic, an important dimension perhaps inadequately emphasized by the two other books under review. The fact that poor women have, over the course of the epidemic, become the population disproportionately infected may help account for the uneven public response.