'The African AIDS Epidemic: A History' by John Iliffe

More than twenty years into the AIDS epidemic in Africa we continue to struggle with its scale and tragic consequences. In a continent where, according to UNAIDS and WHO in 2005, up to 28,9 million adults and children were living with HIV and AIDS, we continue to fail to prevent infection in young people, to leave many who need it without access to treatment and to rely heavily on poor households for care and support. In 2005 alone on the continent there were about 3 million people newly infected and 2,5 million adult and child deaths due to AIDS.

So what can we learn from the history of the epidemic that will help us change this unacceptable loss of life and wellbeing?

John Illife’s book claims ‘modesty’ in outlining the history of the AIDS epidemic in Africa based on accessible, published literature. He discusses the still contentious first origins of the epidemic and maps the spread of HIV across the major regions of the continent. He traces the epidemic through conditions such as Tuberculosis and Kaposi’s sarcoma, that marked the path of the virus. The book cautions against over-simplifying the conditions that lead to the spread of HIV infection. For example, he describes how areas of the Democratic Republic of Congo, affected by war and violence, had low rates of HIV infection due to isolation and reduced mobility, preventing the linking of sexual networks. At the same time economic opportunities in more stable societies led to mobility and urbanisation that provided channels for the spread of HIV infection.

His presentation of the international, national and local response to the epidemic in the 1980s and 1990s describes both the inadequacy of the international response, the burnout and collapse of morale of families and medical professionals, and the courage and focus given to the response from centres like TASO and individuals like Elly Katabira in Uganda. The book traces the maturing of the epidemic in the late 1990s, both in the falling off of HIV prevalence in some parts of Africa, and the growing pressure for access to treatment from communities on the continent.

Illife proposes that history teaches us some lessons about the epidemic and our response to it. The first new cases in Africa were early, in the late 1950s, and the disease spread through commercial and population movements before the disease was known or recognised. By the 1980s when it was recognised, after some initial resistance internationally and within the continent, it was already rooted within the population at epidemic levels. He argues that this deprived the continent of the opportunity to intervene in the earliest stages of the epidemic, and is a fundamental reason for the depth of the epidemic on the continent. Illife describes how the response to the epidemic was confounded by economic, social and gender inequities and diverse and contradictory understandings of the epidemic, from medical and scientific analyses to those drawn from religious and traditional morality and political perceptions.

The evolution of AIDS, under the intense scrutiny of medical and social science and in a period of growth of global communication, does make this epidemic unique both for the way it is understood and for the responses to it. Many of these lessons on the epidemic and the responses to it have been learned from Africa. The book by Illife adds further useful evidence to this learning and places the epidemic in a historical perspective.

And yet, despite this growing body of evidence, African households continue to take on a significant burden of the response to AIDS. Only recently have meaningful resources for treatment begun to flow to Africa and the policies and resources to prevent HIV infection remain inadequate. How can history assist to understand a global inequity of this scale? Surely this calls for a deeper political economy analysis of the historical facts that Iliffe presents?

Let’s take one example of this political economy: The book hints at the corporate economic, social and political interests that shaped responses to the epidemic. It gives less evidence on the structural adjustment policies that spread through Africa at the same time as the epidemic. In the 1980s, when countries were competing for foreign investment under liberalisation policies, public health reason was overshadowed by economic imperative. Even as AIDS was recognised and diagnosed, economic policies cut spending on the interventions and systems to prevent and treat it, with falling access to public health services, and especially primary health care outreach in low income communities. Policies that increased the economic and social determinants for HIV, such as mass retrenchment, flexible and insecure employment, inadequate housing and unsafe community environments with privatising essential services could not be questioned. The change being produced by AIDS was subject to a much more powerful change agenda: a penetration of ‘free’ market policies, efficiency driven social policies and liberalised production that left families and communities on the margins of their own national economies, producing what they did not consume, not able to afford what they did not produce, susceptible to the risk of HIV and vulnerable to the impact of AIDS.

Public health evidence on AIDS at the time was interesting, sometimes alarming, but not decisive. If in the 1980s the full devastating reality of the evidence cited in the book of 13 million AIDS related deaths and 12 million orphans due to AIDS were really given recognition, would there not have been some rethink about the scale and pace of this market reform, its associated collapse of solidarity and exposure to poverty? Perhaps it was not simply the quiet spread of the virus through our populations in the 1970s that made the epidemic in Africa so profound. It was also in the 1980s the massive block placed by dominant neoliberal free market policies to the universal, solidarity based comprehensive social protection, health and employment policies that were needed to respond to HIV and AIDS.

Iliffe is correct at the end of the book that the long incubation period of the epidemic has provided grounds for a new form of organising: that of patients for their own treatment. The actions of social movements and some states have brought back onto the agenda issues of solidarity and universal access to health care and access to treatment at a global level. Pointing to the maturing of the epidemic, Iliffe ends on a note of optimism that ‘the virus no longer holds the initiative that explained its success’. If however it is indeed our own political, economic and social institutions and policies that we must confront to take control over HIV and AIDS, then a more pertinent lesson from history may be the one captured on the front cover of the book, in the hands of a person holding a poster saying ‘Stand up for your rights’.

* Rene Loewenson is Programme Manager for Equinet, the Regional Network on Equity in Health in Southern Africa

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