Tinderbox by Daniel Halperin & Craig Timberg

Reviewers: Roxana Rogers, Director, Office of HIV/AIDS; Paul Mahanna, Deputy Director, Office of HIV/AIDS; David Stanton, chief of Technical Leadership & Research Division, Office of HIV/AIDS

Synopsis:

Daniel Halperin, a medical anthropologist with a peripatetic background, including work with USAID, and Craig Timberg, a Washington Post journalist, combined impressive talent in this book, which details the unintended consequences of colonialization as it created the ideal situation for an explosive AIDS epidemic.

For centuries, or even millennia, SIV (simian immunodeficiency virus) had been carried by monkeys, and probably jumped from monkey to man many times as men killed and cut up monkeys to eat as bush meat. But, until the time of colonial ransacking, the virus fell on wet moss, infecting households occasionally but travelling no further. The brutal intrusion of colonial Europeans seeking fast wealth and power destroyed ancient social norms, tore apart families and created a “tinderbox” ignited by the spark that turned into a raging epidemic.

The authors provocatively argue that Westerners, and even USAID, have failed to appreciate the unique risk factors in this tinderbox. HIV spreads in very different ways in different parts of the world, yet we used (and still tend to use) the same approach to fighting the epidemic everywhere. While acknowledging the importance of treatment and other interventions, the book argues that in Africa the major intervention for HIV should be prevention aimed directly at the main cause of its spread: sexual behavior. They also argue that local solutions work best.

Review:

We found this a fascinating, very readable book that draws on science, social history, anthropology and personal stories to tell the evolution of the disease and recommend solutions.

The book traces HIV’s spread over the last century, starting from chimpanzees in isolated West African rainforests to the boomtown, Leopoldville, and from there to the rest of Africa and the world. It tells the unlikely story of how an American Rhodes scholar who had bicycled across Africa, paired up with a venerable evolutionary British biologist and traced the genetic history of the virus by analyzing samples of blood and tissues that had remarkably been preserved for 40 or 50 years. And, how Californian scientists studied monkey feces in remote sections of Cameroon to determine the exact area where the virus leaped from monkey to man.

It tells compelling stories about Africans infected early, before drugs were available, struggling to warn people to change behavior despite the stigma associated with AIDS; people like the famous Zairian singer Franco, who died in 1989; and, the popular Ugandan singer Philly Lutaaya who spent his last days singing messages of prevention and hope. And, how President Museveni in the earlier days of his presidency, recognized the threat posed by HIV and preached "zero grazing."  Under the influence of this early leadership, behavior changed dramatically in Uganda and prevalence fell rapidly.

The authors also take aim with certain aspects of the U.S. Government’s President’s Emergency Plan for AIDS Relief (PEPFAR), which they say has taken an approach to fighting HIV that is expensive, not adapted or locally designed, and too dependent on technology. In its initial days, they say PEPFAR was too focused on A, for ‘abstinence’ when the focus should have been on B, for ‘be faithful’ - also known as partner reduction. They point out that condoms have a role to play where key populations - such as gay populations and sex workers - drive the epidemic, but not where the epidemic is generalized and affects all populations indiscriminately. USAID promoted condoms as one key strategy to fighting AIDS because they played a significant role in driving down the epidemic in the U.S., and because they were easy to count and report as indicators, claim the authors. Dr. Halperin, who was an outspoken advocate of circumcision to prevent HIV long before the World Health Organization (WHO) had endorsed it based on the outcome of three clinical trials, laments that had we promoted circumcision years earlier, much transmission would have been prevented.

Today, the United States is looking to eliminate AIDS as a disease of consequence. The tipping point, when the infection rate falls below the rate of new people on treatment, is in sight. In November, one year ago, Secretary of State Hillary Clinton announced that the U.S. Government is on the road to an AIDS-Free generation; then on World AIDS Day last year, President Obama announced that the United States, through PEFPAR, would scale up treatment, circumcision and prevention of mother to child transmission interventions, with the dual goal of saving lives and preventing new infections.

The contributions of the United States to fighting HIV & AIDS and improving health in Africa have been outstanding. Indeed, it is now hard to remember what Southern and Eastern Africa looked in 2003. AIDS affected every aspect of life. Hospitals were overwhelmed. I remember visiting a hospital where two people shared the same bed and a third laid on the floor. Coffin-making was a growing business and funerals were almost a daily event. This has turned around dramatically, with much credit to PEPFAR and USAID. Almost 8 million in the world are receiving treatment, and more than half of those receive some support from PEPFAR.

Indeed through PEPFAR, USAID has changed the world. Some coffin makers are going out of business. Yet, it would be a mistake to ignore the lessons from this book. We know that sustaining the response will be challenging over the long term. The findings of many studies confirm what we already know -- that adherence is a challenge. Risk perception is low. Uganda, the early success story, is now experiencing an increase in prevalence as the commitment of local leadership has waned. Unless there is fundamental behavior change that accompanies the scaled up efforts around treatment, our remarkable success to date may be short lived.

Discussion Questions

1. The authors present some unorthodox views on the long-term approaches to ending the AIDS epidemic. To what extent do you agree or disagree with their case for "how the world can finally overcome AIDS"?
2. A number of countries are now experiencing declines in HIV prevalence. What, if any, are the roles of interventions that address changes in behavior as other more aggressive interventions, such as treatment for prevention and circumcision, are rapidly being scaled up in Africa?
3. The AIDS epidemic in Africa is a tragic example of the negative consequences of both colonialization of Africa and the increased mobility and inequity that accompanied economic development. But, was it inevitable? What are the lessons learned from the history of HIV in Africa and around the world?
4. The book outlines the importance of local leadership in affecting social change. If this is true, what is the role of an international development agency in affecting sustainable long-term change?
5. What most surprised you in the book? Has your view of the HIV epidemic changed after reading this book and how?

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