The African AIDS epidemic: a history
Athens, OH, Ohio University Press, 2006, ISBN: 9780821416884; 214pp.; Price: £41.00
University of Warwick (PAIS)
Date accessed: 1 June, 2023
Ten years after its publication, A History remains relevant. The epidemic continues to rage. The context of its historical and relational trajectories continues to shape both its evolution and the responses to it. Iliffe was the first to describe those contexts, and to put into perspective the epidemiological, social, economic and political histories that propelled the HIV epidemic in Africa. His insights are insightful today, too. HIV has abated, but has not been eradicated. In its wake came Ebola Virus Disease (EVD). The lessons Iliffe offers bear resonance now.
Iliffe’s intention in writing A History: The African AIDS Epidemic was pointedly not to prepare for or present new primary data. Instead, his stated aim was to make a historical contribution, to synthesize and consolidate previously collected evidence. Instead, it offers an ‘historical account,’ with four advantages (p. 1). First, Iliffe suggests an answer to the question, ‘why has Africa had a uniquely terrible HIV/Aids epidemic?’ He concludes that ‘Africa had (has) the worst epidemic because it had the first epidemic’ (p. 1). Second, such a historical account ‘highlights the evolution and role of the virus’ allowing Iliffe to put epidemiology into context (p. 1). Third, by putting HIV and AIDS into a longer context, the analysis of it illuminates how ‘it arose from the human penetration of the natural ecosystem that is the most continuous theme of the African past’ (p. 1). As the recent Ebola epidemic illustrates, this theme is not, in fact, of the past, but very much of the present. Fourth and finally, the historical review showed that the African epidemic has changed over time – and continues to change.
Iliffe shows, for the first time, the causes and consequences of the virus‘ genotype differentiations as it progressed East, South and West in Africa (and then around the world). He embeds this epidemiological knowledge within the web of intimate and personal relations – sexual and transactional (long-haul trucking and mining, in particular) – to detail the context and consequences of the epidemic in Africa.
As the epidemic has evolved, Iliffe’s book has become an invaluable contribution for those trying to understand the layers of the shifting sands caused by the virus’s epidemiological mutations and ripple effects on the fabrics of societies, economies and polities of HIV’s amorphous presence.
In doing so, he weaves together a narrative that explains as opposed to blames; that offers a tour of contours seeped in lived experience of HIV, of its mystifying mask; that elucidates the actors involved – in the grassroots and in the local, national, international and global arenas – and makes them human in their exploration of the emerging HIV and AIDS pandemic.
The HIV and AIDS epidemic is not over. Indeed, it remains not an epidemic but a series of epidemics the understanding of each of which continues to challenge and is critical to response. Iliffe’s A History: The African AIDS Epidemic is as pertinent today as it was at publication.
Iliffe’s particular insight, garnered as a historical but (unintendedly) applicable to practitioners responding to the epidemic, was the role played by time. One the one hand, the timing of the emergence of the virus and its epidemic in the course of African history; on the other hand, the time it takes from infection to illness to death. Both times influence the course of the epidemic and its impact to a determinist degree.
Attendant to time are the historical and personal relationships which both aided and abetted the epidemic. Though not formally identified as such, these form both the backdrop and the foreground to the timing of individual HIV progression and epidemic as a whole.
In the inaugural chapters, Iliffe explores the medical science and the human science of the initial spread of HIV.
‘Origins’ depicts the emergence of HIV from SIV (simian immuno-deficiency virus) in the Congo basin and its identification in the Pasteur Institut (Paris) laboratory of Luc Montagnier. Curiously, especially for a disease with such international political resonance, Iliffe completely ignores the race to identify HIV between Montagnier and the American Robert Gallo working at the US National Institutes of Health. Focusing on the biology and immunology of the virus, Iliffe does his readers a great service in succinctly explaining the evolution of HIV-1 and HIV-2 and their global migration. Furthermore, he delineates the various sub-strains of HIV-1 M, which is responsible for the global pandemic: A, B, C, D, F1, F2, G, H, J, and K. ‘At all events, there is a fundamental distinction between the great diversity of strains in western equatorial Africa and the domination of one or two subgroups (sometimes in combination) in every other region of the world: A and D in eastern Africa; a combination of A and G in West Africa; B in Europe and North America; C in southern Africa, Ethiopia, and India’ (p. 5). These differentiations still exist in 2016. They are quite significant, since the HIV genotypes are targeted by medical interventions, not all of which are equally effective against each strain.
‘Epidemic in Equatorial Africa’ describes the explosion of HIV infection, which began in the mid-1970s before anyone even suspected the emergence of a (new) infectious agent, let alone one with epidemic potential. Here he highlights the role of relationships: of time, of (post)colonialism, of intimacy.
Foreshadowing the co-epidemics of HIV and Ebola which revisited the Continent in 2014–15, ‘Blood taken from 659 villagers [at Yambuku, DR Congo] in 1976, during one of the first outbreaks of the Ebola virus, later revealed that five (0.8 per cent) were infected with HIV. Of blood samples collected across the border in southern Sudan in 1976, 0.9 per cent subsequently revealed HIV’ (p. 10). Given that the definition of a generalized epidemic is when 1 per cent of the general population are affected, already in 1976 the threshold was near. ‘When blood taken in 1980–1 from antenatal clinic attenders in Kinshasa was later tested, it showed that HIV prevalence among them had grown during the 1970s from 0.2 per cent to 3 per cent’ (p. 12).
This trajectory epitomises HIV’s relationship with time: a generalized epidemic thus existed in time before even an HIV test. This relationship of time is inextricably linked to the virus’s relationship to (post)colonialism: Project Sida, a collaboration between American, Congolese and Belgian specialists, including Jonathan Mann (later the head of the Global AIDS Program at the World Health Organisation), revealed an ‘alarming connection between HIV transmission and blood transfusion, which had become common in large African hospitals since the Second World War’ (p. 14). ‘Injections with re-used and unhygienic needles were another alarming danger, for injections had been immensely popular among African patients since the 1920s’ (p. 14). Finally, both time and (post)-colonial relations influence the intimate relationships – defined by networks as opposed to (serial) monogamy – that propelled the virus’s spread across much of Africa: ‘While the numbers of men and women in [Kinshasa] were roughly equal and nuclear families made predominated, only 70 per cent of adult women were married in 1984, while their lack of economic opportunity other than petty trade, together with a formerly polygynous culture in which young unmarried people had much sexual freedom and gifts were a normal part of love-making, led a proportion of young women to depend on sexual relationships with men either for survival or for otherwise unobtainable goods’ (p. 16). ... ‘Prevalence in Bangui‘s (Central African Republic) general population aged 15–45 rose from 2.3 per cent in 1985 to 7.8 per cent in 1987. By 1993 prevalence among antenatal women there had reached 16 percent’ (p. 15).
A harbinger of comparatively good news, years before it became a ‘best practice’, Iliffe wrote of western equatorial Africa, ‘90 per cent of men in the western equatorial region (Kinshasa, unlike Kigali) were circumcised, which probably providing some protection because the foreskin was especially liable to viral penetration, and that sexually transmitted diseases – although close associated with HIV infection – were relatively rare, including the incurable genital ulcer disease cause by herpes simplex virus 2 (HSV-2) that was spreading throughout the world in synergy with HIV’ (p. 17).
In ‘The drive to the east’, Iliffe explores the trans-African highways meant to pave the way for Africa’s prosperity, which instead became the transmission routes for HIV. He identifies three distinct groups of carriers: the military, long-distance drivers (truckers), and migrant labourers.
‘Nearly half of the adults in these areas [by Kisumu, Kenya] may have been infected by the early 2000s. Equally vulnerable were young people with casual jobs on sugar plantations and especially on the fringes of the transport industry, for Nyanza straddled the trans-African highway and had its own motor transport network. Its dense rural population, closely linked to the urban focus of infection in Kisumu, bred rural prevalence levels among adults reaching 30 or 40 percent in the early 2000s, while scarcity of land and lack of rural opportunity perpetuated migration to Kampala, Nairobi, and work placed throughout Kenya, where Nyanza people often had exceptionally high rates of HIV’ (p. 29).
The very organization of the migrant labour routes can be traced to colonial-era economies. As these transformed into carriers of death much of the post-colonial economic potential evaporated. This made HIV a symptom of a fragile state, which in turn put it onto the global security agenda.
‘The conquest of the south,’ traces the HI-virus‘s movement into southern and especially South Africa, where it would form the epicenter of the largest epidemic in the world. Here the virus met a post-colonial / post-Apartheid economic showdown which elevated its spread to an epic security concern.
Just as in central and eastern Africa, the places most affected included ‘towns on main roads close to borders .... Breitbridge, on the South African border, recorded 59 per cent prevalence in 1996’ (p. 39); trucking routes; and ‘oscillating migration between country and town made rural Zimbabwe especially vulnerable to infection’ (p. 39). In addition, ‘the position of women in society, particularly their lack of power in negotiating sexual relationships; cultural attitudes to fertility; and social migration patterns’, (p. 40), added to vulnerability of infection.
‘By 2004 the region had 2 per cent of the world’s population and nearly 30 per cent of its HIV cases, with no evidence of overall decline in any national prevalence, which in several countries exceeded 30 per cent of the sexually active population’ (p. 33). The latest statistics (2013) indicate that the region has 11 per cent of the world’s population, but 70 per cent of its new HIV infections.
As it were, in one of the most-cited passages of the book, Iliffe deduces that, ‘South Africa, by contrast, bordered a massive continental epidemic and, as will be seen, had no identifiable core group but a great diversity of cross-border contacts that can scarcely now be traced. Of course, better political leadership could have reduced the impact of HIV, but trying to prevent the extensive infection of South Africa would have been like sweeping back the ocean with a broom’ (p. 43).
While Africa’s southern tip received most of the world’s attention, HIV continued its spread into the west as well. In ‘The penetration of the west’, Iliffe sheds light on how HIV continued its expansion into the Gold Coast of Africa. Here, in contrast to eastern and southern Africa, he notes that Abidjan and Côte d’Ivoire, which became the focus of the West African HIV-1 epidemic, were: neglected during colonial period. Yet their vast areas of virgin forest and their rapid development, dependent upon lots of migrants (p. 52) rendered them as risk for HIV-s penetration.
Many young migrants had ‘adopted risky patterns of pre-marital sex in response to the commercialisation of the economy, the need to migrate for urban employment, the declining status of women consequent on the spread of Islam, the increasing difficulty of marriage, the collapse of customary sexual restrains, the spread of sexually transmitted diseases, the marginalisation of the region within independent Senegal, the destructive impact of structural adjustment policies, and their continuing anxiety to bear children at the peak of fertility’ (p. 57).
Nonetheless, the epidemic in West Africa paled in comparison to that of the east and south. ‘Senegal’s experience, like Nigeria’s, fitted closed into the wider patterns of West Africa, where the great regional variations in HIV prevalence witnessed to an epidemic that had penetrated but not conquered’ (p. 57).
Following the introductory chapters, Iliffe collates the evidence to arrive at a probable cause and for the epidemic. ‘Causation: a synthesis’, is the result. The chapter gives the succinct explanation that epidemics in Africa, with the possible exemption of North Africa, whose differing economic bases and social structures separate it from sub-Sahara,
‘are intimately related to mobility, whether the clustering together of people in drought or famine that so often caused smallpox outbreaks, the human disturbance of the natural environment that precipitated epidemic sleeping sickness, the movement of returning soldiers along shipping lanes and railway lines that spread the great influenza, or the migration routes along which southern African mineworkers carried tuberculosis to their rural homes’ (p. 59).
Each of these risks is magnified by Africa’s post-Second World War exponential demographic growth (p. 60); pervasive gender inequality and particular sexual behaviours (p. 62), for example linked sexual networks, as opposed to serial monogamy; technology fueling mobility (p. 61); and, perhaps most devastatingly, the concomitant timing of medical advances against other infectious diseases which made it possible for HIV to gain a foothold (p. 61).
Anticipating future research results, Iliffe even identifies the co-factors of high prevalence of (other) sexually transmitted diseases; lack of circumcision in parts of eastern and southern Africa (p. 62), which has indeed been correlated so much so that circumcision campaigns have sponsored since; and the frequent disparity in age between sexual partners (p. 63) as integral to the African AIDS epidemic.
Yet he concludes that fundamentally, ‘Africa did not have a more terrible epidemic than India because it was poorer but because it was infected first’ (p. 63). Extrapolating with mounds of evidence -citing nearly every medical practitioner and activist in the campaign to identify, treat, and care of HIV and AIDS infected and affected persons – Iliffe links the insight of time with that of (post)colonialism and sexual intimacy in a complex portrait of the African HIV epidemic that has no parallel in scholarship.
‘Responses from above’, focuses on the political. ‘For political leaders, moreover, HIV/Aids was a profoundly distasteful subject because they had no remedy, it threatened to raise demands for assistance that they could not afford to give, it distracted them from more pressing anxieties, it was potentially divisive, its victims had as yet no political voice, and it might damage their country’s image and tourist industry, as it had already damaged Haiti’s’ (p. 67).
‘Even Nelson Mandela, after a bold speech in 1991 had angered a rural audience, retreated into silence during his presidency, later explaining that in the 1994 election ‘I wanted to win and I didn’t talk about AIDS’ and then ‘had not time to concentrate on the issue’ while President’ (p. 67). Placing this politicking in the context of time and amidst the concurring pressure of post-Apartheid (South) Africa, Iliffe writes that as early as the early 1990s, ‘it was increasingly clear … that the response coordinated by the WHO was having little effect in checking the epidemic. Some thought, indeed, that the coordination itself was partly to blame, that national Aids plans, hatched like chickens by groups of international consultants‘, sought to impose identical structures – hierarchy, medicalisation, verticality, dependence – smothering the local initiatives emerging before the WHO intervened’ (p. 78). Those same critiques echo down the AIDS and Ebola response today. Indeed, in both cases, ‘it was true that all by the most successful programmes escaped the ownership of the communities whose energy was needed for success’ (p. 78).
‘Views from below’, corroborates this verdict. ‘The chief reasons for the failure of international Aids policies in Africa during the late twentieth century were that they came too late to check an expanding epidemic and had no effective medical remedy with which to do so, but another reason was that the medical thinking underlying international policies often conflicted with the ways in which most Africans perceived the crisis’ (p. 80).
Context matters. ‘Gabriel Rugalema, perhaps the most perceptive analyst of the rural epidemic, observed ... “What is distinctive about the local views...is the integration of the disease with wider socio-economic problems, as opposed to the prevailing scientific approach in which HIV is seen to cause AIDS and consequently adult mortality. Villagers are not reductionists. Their view is that AIDS and its effects cannot be separated from the wider social and economic environment”’ (p. 97). Successful responses to AIDS, as Ebola beyond it, depends on the integration of medical, moral, economic and political concepts and conditions.
This becomes all the more apparent in the chapters, ‘NGOS and the evolution of care’, and ‘Death and the household’. While the number of NGOs involved in HIV and AIDS response has ballooned over the years –
‘The scale and diversity of NGO action defy summary. In 1992 Uganda already had over 600 NGOs involved in Aids work; by 2003 there were about 2,000’ ... Senegal was also rich in organisations, over 700 receiving public subsidies during 2004, the same number as those affiliated to Nigeria’s Aids programme. South Africa had a vigorous NGO tradition, inherited especially from the anti-Apartheid movement, and counted over 700 bodies engaged in Aids work as early as 1993’ (p. 98).
– they have been and continue to be constrained by the limitations of the very conditions within which they work.
‘All but the smallest NGOs generally depended heavily on external funding, often to the extent of 95 per cent. The effect was seen dramatically after the establishment of majority rule in South African in 1994, when foreign money hitherto given direct to NGOs was channeled instead to the government, creating a crisis in the NGO sector’ (p. 99).
This crisis can lead to the re-creation of the very conditions which rendered populations vulnerable to HIV in the first place, amplifying the effects of the four epidemics Iliffe subsumes under the heading of the AIDS epidemic: ‘first the virus, then disease, next death, and finally social decomposition, each superimposed upon its predecessors’ (p. 112). The 2014 Ebola epidemic fits the same description, including as described by Alex de Waal and Alan Whiteside, the epidemic as the first ‘”new variant famine” shaped by young adult deaths and the "Aids-poor" households they had left behind’ (p. 122), and in the case of Ebola the collapse of agriculture and market access.
In conclusion, Iliffe presents ‘Containment’. He argues that the (non-) response to the AIDS epidemic was primarily political. With regard to South Africa, ‘the government did resist [the provision of antiretrovirals first for pregnant women] had many reasons, but probably the central one was political: an insecure regime’s anxiety to maintain control over a situation perceived as threatening. The threat was that pressure from a coalition of HIV-positive people, Aids activists, political opponents within and outside the ANC, pharmaceutical companies, and international opinion might oblige the government to undertake an antiretroviral programme that it could neither administer nor afford at current drug prices, at the expense of its authority, its health priorities, and its wider development programme’ (p. 145).
This tug-of-war over security, health and otherwise, continues. A critical component of an epidemic is that of time: time to illness, time to decide, time to intervene. It is a challenge for medicine, colored by history. It is a practical, but primarily a political struggle.
Iliffe’s book remains a cornerstone of literature in understanding the African AIDS epidemic. He provides rich contextual detail and gives voice to human experience. The book continues to illuminate the contours of epidemic history.
Bibliography (additional sources)
Tony Barnett, ‘A long-wave event. HIV/AIDS, politics, governance and ‘security’: sundering the intergenerational bond?’ International Affairs, 82, 2 (2006), 297–313.
Alex de Waal, AIDS and Power: Why there is no Politics Crisis – yet (London, 2006).
Helen Epstein, The Invisible Cure: Why we are losing the fight against AIDS in Africa (New York, NY, 2008).
Maureen Malowany, ‘Book Review: The African AIDS Epidemic: a History, by John Iliffe’, Medical History, 52, 3 (July 2008), 423–4.