April 16, 2012
Tinderbox Author Hopes to Ignite Dialogue About HIV Prevention
by Reed Vreeland
Tinderbox, a new book coauthored by journalist Craig Timberg and Daniel Halperin, PhD, compares colonialism’s role in the early spread of HIV in Africa with today’s international efforts to combat the virus. In a provocative move, Halperin and Timberg juxtapose present-day international HIV experts with cutthroat, profit-driven colonials.
Tinderbox, published by Penguin Press in March 2012, incorporates archival material, interviews and recent genetic discoveries to piece together a historical collage that details the emergence and spread of HIV in Africa. As a jumping-off point, the authors use recent DNA evidence obtained by biologists Michael Worobey and William D. Hamilton to offer a rough location and date for the crossover of the virus from chimpanzees to humans—a hunter likely came in contact with an infected chimp’s blood roughly 100 years ago in remote southeastern Cameroon and contracted a common ancestor of today’s dominant genotypes of HIV. Based on the new time line, Halperin and Timberg argue that colonialism, particularly in central Africa, introduced the conditions of urbanization, prostitution and increased mobility that enabled HIV to become a major epidemic in the region, and then spread across the globe.
The authors also chronicle several local grassroots responses to the continent’s epidemic, including the impact of individuals, such as Philly Lutaaya, a popular Ugandan singer who incorporated lyrics about AIDS into his songs. He continued to publicly sing and educate, even as he was dying. Lutaaya, as well as other African figures named by Halperin and Timberg, helped curb the spread of HIV in their countries and will likely emerge as globally recognized heroes in the fight against AIDS on the same level with Ryan White, Larry Kramer and Magic Johnson. One of the book’s central messages is that HIV prevention works best when the people affected get involved.
Tinderbox also has to be read as a critique of recent international interventions to curb the spread of HIV in Africa. The book notes several occasions when HIV experts, sometimes arrogantly, undertook well-intentioned programs that had disastrous consequences. Much of the book’s critical insight comes from Daniel Halperin, who served as a top adviser to the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and has taught research in epidemiology and medical anthropology at Harvard and the University of North Carolina at Chapel Hill. Halperin questions the impact of condoms-only HIV prevention programs in Africa; he’s suspicious of the hype around treatment-as-prevention; and he has long challenged experts who do not recognize the scientific evidence that male circumcision significantly reduces female-to-male HIV transmission. Of course, it’s necessary to read the book in its entirety to digest the critique that Halperin and Timberg have presented. What’s certain is that Tinderbox was created to engender debate and spawn new ideas and approaches to HIV prevention; it is not a history book made to sit dustily on the shelf.
What inspired you to team up with journalist Craig Timberg to write a history of HIV/AIDS?
We loved the book And the Band Played On, and in some ways Tinderbox is an update. Our book explains what has happened since then, both in terms of the scientific developments and in terms of the early history of the virus and its origins—information Randy Shilts just didn’t have access to. Of course, our book is much more about Africa; his is mostly about the United States.
What’s the main piece of information you’d like to convey to readers?
It’s quite likely that colonialism in Africa was complicit in the spread of HIV early on, and although the response to HIV/AIDS has been well meaning since then, there’ve been mistakes made and unintended negative consequences of the West’s involvement in more recent years.
Before we get to the present day, can you explain some of the recent discoveries about the origins of HIV?
Two main points: In the last seven years, recent discoveries have shown that the epidemic likely is around 100 years old—between 85 and 125 years old. The second concordant piece of information that has come through in the scientific literature is the location of where HIV started, and that’s been nailed down to a very remote part of southeastern Cameroon.
How does this new information implicate colonialism in the early spread of HIV?
Well, that remote part of Cameroon—where this one chimpanzee somehow was able to transmit the virus to one human being about 100 years ago—up until about 120 years ago very few human beings even lived there, and the few that did were very sparsely populated. It was not at all an environment where a major epidemic could take off because there were too few people. But starting about 120 years ago, the colonial powers, particularly Germany, built that area up, and they brought in thousands of African porters who were almost like slaves, tromping through that rain forest. [Colonial powers, including Germany, France and Belgium,] had traffic going up and down the river there, eventually making it down to Leopoldville, which is today Kinshasa. All that movement that hadn’t existed before, it created an environment in which an epidemic could take off through all the movement, urbanization and prostitution—and changes in the [region’s] sexual culture were also a result of colonialism’s influence.
So you use the metaphor of a tinderbox to say: Once colonialism had introduced mobility, urbanization and prostitution, and once HIV struck that colonial network, it was inevitable that HIV would spread through Africa and globally like a fire. Is that right?
Right. Once HIV was established in that part of Africa, it would only be a matter of time until it would spread internationally, given sea and air traffic and other forms of transportation.
Maybe partly because of the book’s title, you seem to imply that someone or some group was to blame for sparking the AIDS epidemic. So should the West take responsibility?
I think part of the motivation of the book was to start that conversation, not necessarily to give the answer to that question. Personally, I wouldn’t be that happy if the take-home was that we in the West are responsible, and now we have to solve it. That could just lead to more problems if we feel like it was our fault and it’s our responsibility to come marching in with all of our ideas about how to end it. That may be well meaning, but it could backfire.
Based on the new timeline, should we abandon the “30 years of AIDS” language?
That definitely is one of the take-homes of our book. When people say, “30 years of HIV,” it not only ignores all of the deaths that happened before 1982, but it further “Americanizes” AIDS in the popular mind. Even internationally, the image is that AIDS started with gay men in San Francisco, in the United States, when it was actually going on for a long time before that, especially in Africa. So I think for various reasons it’s important to talk about HIV as it is, as disease that started in Africa about 100 years ago.
In the book you also write about some of the homegrown African responses to AIDS prevention that helped dramatically decrease new HIV infections. You describe the “Zero Grazing” campaign in Uganda aimed at decreasing the number of people’s sexual partners.
We talk about three different examples: Congo, Uganda and Zimbabwe. In each case, even though there are lots of differences between those three, it’s interesting that each of those places where sexual behavior change occurred, a pivotal moment was when the most popular entertainer and singer in the country composed a song about AIDS in a very kind of in-your-face direct way. These were not donor funded prevention programs. These were grassroots, cultural responses that had a big impact.
Something similar happened in the early 1980s [in the United States], during the Reagan years, when HIV incidence plummeted among gay men. In 1982, as soon as the gay community learned that there was this disease that was spreading rapidly, that it was sexually transmitted, that there was no cure and that it would kill you; once that information got out, there was a big change in behavior that happened almost spontaneously. It didn’t happen because of any kind of prevention program or funding; it was just the community’s own response.
So one message from the book is to pay more attention to these types of grassroots responses and to encourage them and help them along when possible?
Exactly. At the very least, don’t get in the way of them. When it comes to the issue of behavior change, there’s now a lot of pushback from American and European HIV experts. I’ve seen several examples of experts telling people in Africa, “Oh, don’t waste your time on behavior changes. That doesn’t work; that’s unproven.” That’s an example of getting in the way. At least we shouldn’t be doing that. But ideally, we could do even better than that. Ideally, we could be scientifically validating how important these approaches are, and that would help as well.
Can you explain the misconception about the link between poverty and HIV in Africa?
There have been a lot of myths and assumptions about the epidemic—it’s probably one of the least understood epidemics ever, and one of the most politicized epidemics. It’s easy to see that Africa’s the hardest hit continent and Africa is also the poorest continent—[therefore] poverty must be part of the explanation. Of course, it’s politically correct to say that poverty is part of the explanation. But we show that when you actually look inside the continent, it’s a lot more complicated. Very often the most affected places in Africa have been the wealthiest parts of the continent and a lot of the poorest parts of Africa haven’t been that affected. Even within countries, the most affected groups are often the wealthiest and most educated groups. So again, it’s one of those things that when you look at it from 10,000 miles away you get a certain impression, but when you look closer on the ground you see something else.
You are also a proponent of male circumcision as an HIV prevention tool, and you’ve gotten a lot of criticism from prominent HIV experts on the topic.
For decades really, circumcision was ignored by policy makers, even though the scientific evidence was strong. For example, in 1999 we published a review paper in The Lancet, and even back then there were already dozens of studies indicating that circumcision had a strong protective effect. In the last couple years, people’s positions have changed because of the success of randomized trials showing that circumcision provides 60 to 75 percent reduction in HIV risk for heterosexual men, and consequently also lowers risk for women and the entire community, over time. Suddenly, almost all of the scientific leaders have embraced circumcision, and they say how important it is.
But I would imagine that it’s very difficult as a Western researcher to come in and say, “You need to change your country’s sexual culture, or more men in your country should get circumcised.” Do you think that explains some of the resistance to these approaches?
I’m glad you asked that, because I think there have been a lot of problems over the years with Western experts coming in to places like Africa and saying: You all need to use a condom. You all need to get tested for HIV. You all need to do this or do that. It’s a well-meaning thing to say, but it can backfire and cause problems. So the last thing in the world that our book wants to propose is that we should then go in and tell people to change their behavior. Tell them to have fewer partners. Or tell them to get circumcised, because that definitely also would create other kinds of unintended problems that would not necessarily be productive.
It’s really about presenting the scientific evidence. I don’t think we should heavily promote circumcision for HIV prevention, but I think we should make the service available, especially in the high HIV prevalence parts of Africa, because I think lots of men would just go for it anyway if you just made it available. In over a dozen studies in many parts of Africa we’ve interviewed men and women and found in almost all these surveys and qualitative studies most men and women in these places favor circumcision. Even though they don’t practice it, for the most part, they think it’s a really good thing. They think it’s cleaner and the sex is better. It’s easier to use a condom if you’re circumcised—things like that.
Since you start with colonialism and end with the international AIDS response today, it seems the structure of the book draws a comparison between colonialism and the present-day AIDS response. You mention the term the “AIDS-industrial complex.”
It’s difficult, because on the one hand Americans and others who are involved in HIV work these days are not doing it primarily for some profit motive. They’re not in Africa to get rich. In a way, they’re completely different from the colonials 100 years ago. But there’s something that unfortunately has carried over, and there is sometimes a sense of hubris, of “we know what’s best,” and that’s troubling.
Then, as you mentioned, there’s the growth of this big industry, this AIDS-industrial-complex, it’s been called. It’s not actually an industry in the sense that there’s this profit motive. It’s not like people are selling condoms and getting rich off of selling condoms. But all of the billions of dollars that now goes into aid every year for HIV, that’s a lot of money, and most of it doesn’t even go to Africans directly. I wouldn’t blame anybody personally, but if you look at the defense industry, or you look at any area of government that gets a lot of funding, it’s going to inevitably develop these kind of industrial complex kind of issues. And that’s what’s happened with HIV.
Are you critical of the idea of treatment-as-prevention?
I think if people read the whole book carefully, it’s really obvious that we’re totally for treatment. ARVs [antiretrovirals] have kept a lot of people from dying. At the end of the book we talk about treatment-as-prevention and we’re calling into question some of the hype around this idea that if all we do is make ARVs available, then we’ll wipe out the epidemic—we consider that hype.
I’m originally from San Francisco, and in the mid-1990s ARVs came in and at first it was this incredible thing, just amazing. So many people were able to stay alive because of the medications, and it was an incredible godsend. But then, many years later I think some people began realizing that they were accidentally having a negative effect on prevention, which is a really depressing thought. But we’re not at all against treatment for people that need it. In fact, the majority of HIV funding should go toward treatment. But I think we have to do a better job on how we spend the minority of funding that goes to prevention.
It seems like you’re not opposed to saying things that are controversial.
In some ways, it would be easier to write a book that was just about the orphans and the wailing grandmothers, or one that said that if everybody just bought a red ribbon latté, it would solve the problem—that would have been an easier book to write. But we’re trying to tell it the way we see it.
Search: Halperin, Daniel Halperin, PhD, Craig Timberg, Tinderbox, history, HIV history, AIDS history, colonialism, Africa, African, Cameroon, Origins of AIDS, Worobey, Hamilton, Lutaaya, Uganda, Ugandan, HIV prevention, prevention, PEPFAR, Harvard, University of North Carolina, circumcision, condoms, epidemiology, treatment-as-prevention
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