Amid reports that the United Nations has been grossly overestimating the scope of the global AIDS pandemic, a new book points to what may be an even greater miscalculation: AIDS relief efforts have failed to understand the crucial role of family and community networks in controlling the disease.
International aid agencies assumed that reducing the spread of AIDS was primarily a matter of hygiene and health care. UNAIDS, the Joint United Nations Programme on HIV/AIDS, estimates that total spending on AIDS programs will increase 12 percent this year to $10 billion. Yet, relief organizations have overlooked actual social behavior and sexual practices.
This is the message of Helen Epstein's important new book, The Invisible Cure: Africa, the West and the Fight Against Aids. Her book is one long testimony to the necessity of at least some social structures operating on a human scale. Although Epstein doesn't cite the principle of subsidiarity from Catholic social teaching, or the corresponding principle of sphere sovereignty from the Dutch Reformed tradition, the importance of intensely local communities as "first responders" is clearly highlighted. Her book shows that the few noteworthy successes in slowing the spread of AIDS and comforting the sick have not come from sophisticated international organizations, but from local communities.
In Africa, HIV spread among ordinary people who were nowhere near as promiscuous as high-risk Western groups such as prostitutes or gay men. By contrast, about 40 percent of Ugandan men and 30 percent of women have ongoing relationships with a small number of people — perhaps two or three — at a time. These 'concurrent' relationships might overlap for months or years, or even, in the case of polygamous marriages, a lifetime.
As Epstein explains, these concurrent relationships are at higher risk for spreading HIV for two reasons. First, a person recently infected with HIV may be a hundred times more likely to transmit the virus than someone who has been infected for a few months or years. Most Westerners tend to practice "serial monogamy," having only one partner at a time, and will usually only infect a current partner. By contrast, a polygamous man who becomes infected with HIV is likely to infect all his concurrent partners.
Concurrent relationships are also at higher risk for spreading HIV because the degree of intimacy and trust in these relationships means that people don't think they need to use condoms. Many faithful African women became infected with HIV because of their husbands' behavior. Few health officials from international aid organizations were aware of any of this.
Many western AIDS researchers believe that promoting condom use among high risk groups, such as prostitutes and their clients, is the best way to slow the spread of HIV. But HIV continued to spread throughout eastern and southern Africa, even when condom use soared. Epstein argues that some of the condom campaigns backfired. "By associating AIDS with beer drinking, premarital sex, prostitution … womanizing and rape, the lusty condom ads … clashed disastrously with local sensibility concerning decency and self-respect," Epstein writes. One of her African sources stated bluntly, "The campaigns were totally wrong. The message was you had to be a prostitute or truck driver to get AIDS."
A Ugandan prevention campaign focused specifically on issues of concurrent relationships. It developed the slogans "Love Carefully" and "Zero Grazing" — meaning, in the words of the head of Uganda's AIDS Control Program, "avoid indiscriminate and free-ranging sexual relations." These slogans were posted on public buildings, broadcast on radio, and bellowed in speeches by government officials. The Ugandan Association of Co-Wives and Concubines — hardly something any Western aid organization would have instituted — got involved, too. These women policed the behavior of polygamous men, encouraging them to avoid the casual affairs that could endanger all their wives and future children. One of their messages was: "If your husband is unfaithful and is going to kill you with AIDS, you divorce him."
The result of all this was a steep decline in the number of sexual partners, a basic step in controlling any sexually transmitted disease.
As Ugandans were becoming aware that even respectable people could contract HIV, they began taking personal care of the sick, through small-scale service programs. By 1991, there were hundreds of community and church-based AIDS care and support groups in Uganda. Medically, there wasn't much that could be done for people with AIDS. But Ugandans pioneered the concept of home-based care, which is now a central activity of AIDS organizations throughout Africa.
"There was a lot of stigma and fear at first," said Sister Ursula Sharp, the Catholic nun who founded Kitovu Mobile, a home-based care program. "It was hard to get nurses to work with me. There was fear of contamination and also fear of witchcraft. Some of our volunteers' huts were burned down because there was a rumor that we were poisoning people in the community. But we kept going back and going back and going back. We'd never miss an appointment with a patient. They knew we'd be there if we promised to come, rain or shine."
The contrast between the common sense of the Ugandans and the blindness of the international aid organizations demonstrates the abiding good sense of the principle of subsidiarity. Groups such as UNAIDS and the World Health Organization seek to organize the response to AIDS at the international level, the highest possible level of social organization. Although there are functions that only these large scale agencies can perform, leaving out the local level, which operates on the truly human scale, is a recipe for disaster. Helen Epstein's fine book is a testament to this fact.