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LGD 2004 (1) - Celine Tan

Who Cares? AIDS in Africa

by Susan Hunter

Palgrave MacMillan (2003), New York and Basingstoke,
ISBN: 1 4038 3615 3

Reviewed by:
Celine Tan
Research Fellow
School of Law,
University of Warwick, UK

1. Introduction

The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that there are now 34 – 46 million people living with HIV/AIDS worldwide, out of which 2.5 million are children under the age of 15 years (UNAIDS/WHO, 2003, pp 2 - 3). Five million people contracted the disease worldwide in 2003 and three million people have died from AIDS-related illnesses in the same year (UNAIDS/WHO, 2003, pp 2 – 3).

Sub-Saharan Africa has been the most severely affected region with 26.6 million people living with HIV/AIDS (UNAIDS/WHO, 2003, p 7). The scale of the HIV/AIDS epidemic in Africa is incomparable to any other region with similar population ratio. UNAIDS estimates that almost 40 percent of the populations of Botswana and Swaziland are infected with the virus (p 7) with southern Africa being the home of 30 percent of HIV/AIDS sufferers although the region has less than two percent of the world’s population (p 8). Women in sub-Saharan Africa are 1.2 times as likely to contract the virus as men and one in five pregnant women are infected with HIV/AIDS in most southern African countries (p 7).

It is against this backdrop that makes AIDS researcher and anthropologist demographer Susan Hunter’s book, Who Cares ? AIDS in Africa (published in the US as Black Death: AIDS in Africa) compelling reading for the sheer polemical power it possesses and the sweeping narratives it uses to engage the reader. Hunter’s novel method of using literary scholarship to debate one of the most pressing political health policy issues of today – containment of the devastating HIV/AIDS epidemic and solutions to the widespread human suffering it entails - is both effective in conveying the sheer urgency for the need for action in this area and yet close to becoming ineffectual at best and dangerously counter-productive at worst, in the outcome of its arguments.

Hunter herself admits in the Preface that many of her ‘preliminary readers’ found the book engaging, that ‘they couldn’t put this book down, that it reads like a novel …’ (p v). Herein lies the problem with the book: it reads too much like a novel than a work of researched scholarship on a very pertinent issue, and, as a result, detracts both from the well-intentioned objective of the author – ‘that [the book] opens your heart to their struggle’ [1] (p v) – and the fundamental tenets of her argument - that the issue of HIV/AIDS in Africa cannot be considered in absence of the social, economic and political upheavals that have been visited upon the continent by outside forces over the centuries.

But more disturbingly, is Hunter’s controversial suggestion that the neglect of the west towards the HIV/AIDS epidemic in Africa has roots in the biological determinism of evolution. Her attempt to posit a biological explanation for the endemic racism that has led to the west’s exploitative political and economic interventions in the African continent over centuries and the corresponding failure to redress the consequences of this exploitation is worrying for the possibility that it justifies an abdication of responsibility for a problem that has roots in social and cultural factors rather than biology.

 2. Interspersing Fact with Fiction

In many respects, Who Cares ? AIDS in Africa reads like a text version of a made-for-television documentary-drama. Hunter takes poetic licence both in her narration of Charles’ Darwin’s life story and development of the fictional characters of ‘Molly’, ‘Pauline’ and ‘Robina’, loosely based on the collective experiences of their real-life counterparts Hunter met during her work in Africa from 1989 to 2001 (pp 17 – 18; n 2, p 229).

Weaving the political and epidemiological story of HIV/AIDS through a creative recounting of Darwin’s life and vignettes from the fictitious lives of three Ugandan women, Hunter creates a complex, interdependent web of historical and contemporary events that have contributed to the sub-Sahara housing three-quarters of the world’s HIV/AIDS burden and which explain the reasons behind the complacency of the global community in the face of such devastating statistics. Using Darwin’s life story as a spring board, Hunter traces the history of epidemiology and the epidemiological impact of colonial conquest and resource exploitation in Africa and using the fictional narratives of ‘Molly, ‘Pauline’ and ‘Robina’, she describes how the legacy of this and the impact it has on HIV/AIDS policy in Africa.

In doing so, Hunter attempts two things: (1) to broaden the debate of HIV/AIDS policy outside the realm of science and public health sociology, into the realm of global economics and political power in order to seek explanations from historical antecedents that may inform present and future solutions; and (2) to highlight the suffering of individuals afflicted by the disease, both personally and vicariously, to initiate a visceral response to the magnitude of the HIV/AIDS epidemic in order to galvanise support for action.

However, while Hunter’s narrative is engaging, her approach remains questionable with regards to the arguments she attempts to forward (I say ‘attempt’ because it is unclear from the book whether Hunter has reached discernable conclusions to her hypotheses). It is slightly problematic when an author of a book on a subject as important HIV/AIDS chooses to use fictionalised accounts of her collective field experiences to illustrate the human suffering that the epidemic has wrought on a continent rather than enabling the subjects of her book to speak for themselves.

In discarding empirical narratives and individual stories for a collective set of invented dialogue [2] , Hunter not only does a disservice to the people who she wishes to speak for, but also, more importantly, objectifies the subjects of her study. In doing so, Hunter unwittingly implies that the experiences of millions of people afflicted with the virus and affected by the epidemic in Africa, even in a work of academic scholarship, can only be filtered through a generic fictionalised narrative of a western researcher.

3. Colonialism, Racism, Militarism and Globalism

Who Cares ? AIDS in Africa does indeed raise critical arguments that cover much more interdisciplinary ground than most current literature on the HIV/AIDS crisis [3] , a perspective she holds because ‘[t]he question of what to do about HIV/AIDS in Africa will not be resolved by science’ (p 11). While she does not belittle the role of science, nor the biological factors that contribute to the spread of the HIV/AIDS epidemic in Africa, Hunter sees the need to examine the socio-economic factors that hasten the infection rates in the continent: ‘In the history of epidemic disease, there are many examples of the disastrous results that occur when all of the conditioning factors intersect and contact with new disease agents occurs’ (p 87).

In the case of the HIV/AIDS epidemic in sub-Saharan Africa, Hunter argues that these ‘conditioning factors’ include the centuries of natural and human resource exploitation and the resultant social and economic impoverishment of African societies caused by the slave trade, colonialism, armed conflict and unfettered economic liberalisation.

She argues that ‘[t]he emergence of HIV/AIDS in Africa is a result of the convergence of long-developing trends in human history, technology, philosophy, and evolution’ and that ‘[t]he global HIV/AIDS pandemic has come at a time when new findings in human biological and social evolution are converging, causing us to question and expand traditional views of disease and its agents, forcing us to restate our understanding of the relationship of human and natural agency in shaping epidemics’ (pp 10 -11).

As a result, conventional approaches to health policy will not stem the tide of this infectious disease that has outpaced the two next most important infectious diseases, tuberculosis and malaria by two to one (p 21) and, especially in Africa, a continent that has been ravaged by the devastating consequences of colonial exploitation and oppression, and which is still suffering the debilitating effects of postcolonial structural adjustment imposed by western governments and international financial institutions, namely the World Bank and the International Monetary Fund (IMF) (ch 3, pp 50 – 75).

Poverty, Hunter argues is the root cause of the spread of the disease that has reached epidemic proportions in Africa. Not only is the capacity of the African state to provide health services eroding with the crippling effects of neoliberal structural adjustment and debt service – ‘[p]oor countries devoted huge portions of their budget to debt service and have little left over to invest even in basic healthcare’ (p 34) – but poverty has created the social conditions which contribute to widespread HIV/AIDS infections. Migration and recourse to sex work resulting from unemployment and impoverishment have contributed to the rise in HIV/AIDS infections worldwide (p 28 -29) so has the inability to control reproductive action (especially on the part of women) resulting from lack of education, and access to barrier contraceptives, namely condoms.

Hunter is particularly scathing of the west’s wilful ignorance of the scale of the epidemic in Africa and the reluctance of western governments to cough up the necessary financial resources to prevent the scourge, preferring instead to give into the demands of multinational pharmaceutical companies and to the moralising discourse of the religious right (pp 35 – 36; 215). Nonetheless, the legitimacy of Hunter’s arguments in this respect is undermined by a number of inconsistencies and sweeping generalisations she makes across the book.

4. Dangerous Half-Truths

Who Cares ? AIDS in Africa makes a fair number of unsubstantiated claims which has implications for a lay reader with no background in HIV/AIDS research and which are worrying given that the author is described as ‘a global AIDS expert’ and ‘an independent consultant at the highest policy levels of world health organizations’ (back cover).

Hunter’s reactionary conclusions drawn from expert studies would probably make scary reading for biologists and virologists, including, most probably, the authors of her unreferenced studies.

A prime example of this being her conclusion on the issue of male circumcision and rates of HIV/AIDS infection in Chapter Two. Here, she cites (but does not reference) a study conducted by Australian demographers Jack and Pat Caldwell and Nigerian demographer I O Orubuloye that first suggested the coincidence of male circumcision and lower HIV prevalence based on studies in eastern and southern Africa, and another ‘UN study of HIV transmission in four African cities’ that ‘found that uncircumcised males where more likely to have AIDS and other curable sexually transmitted diseases’. Based on this research and the other 40-plus studies which ‘show that uncircumcised men gave two to eight times the risk of contracting HIV’, Hunter concludes: ‘The reason is simple: male circumcision fosters improved personal hygiene’ (p 31, emphasis added).

Hunter does not clarify nor qualify her remarks except to discuss the possibility of introducing male circumcision as a possible HIV/AIDS prevention measure (pp 31 – 32). Neither does she reference any of the sources which she uses to support her argument, not even the Caldwell-Orubuloyle study to which she alludes to. The only footnote to this subject is a hyperlink to a website on circumcision (p 32, fn 18; p 231, fn 18).

Hunter’s conclusion on this matter is disturbing as it is clearly incorrect. While studies have indicated the correlation between male circumcision and lower HIV/AIDS infection rates, it is inaccurate to suggest that this is a result of ‘better hygiene’ as AIDS virologists would maintain that infection has very little to do with hygiene practices (reproductive health measures are not considered ‘hygiene’ practices for this purpose). In fact, according to UNAIDS, the possible reasons behind lower HIV infection rates amongst circumcised men as to do with the physiology of the male reproductive organ:

The tissue of the internal foreskin absorbs HIV up to nine times more efficiently than female cervical tissue, mainly because it contains Langerhans and other HIV ‘target cells’ in much greater quantities than the cervix or other genital tissue (including other parts of the penis). In addition, the internal foreskin has a mucosal surface, as opposed to the more hardened skinlike surface of the external foreskin. This mucosal surface is particularly susceptible to tears and abrasions, and, consequently, infection by STDs and HIV (UNAIDS, 2003).

In spite of the strong ‘epidemiological, geographical and biological findings’, the UN agency is careful to say that research so far remains inconclusive and that further studies are being carried to identify the role of male circumcision in the prevention of the virus (UNAIDS, 2003). This approach is adopted by bilateral aid agencies, such as USAID [4] , and nowhere is ‘hygiene’ given as a potential reason for the hypotheses that links male circumcision with lower HIV/AIDS infection rates.

In a subject area where myths prevail and unsubstantiated half-truths carry dangerous consequences, it is irresponsible for an author to forward such clearly erroneous arguments in a book that is supposedly meant to help rather than hinder progress towards eradicating the epidemic.

5. Inconsistencies and Theoretical Concerns

One of the recurring inconsistencies in the book is Hunter’s reproach of social Darwinism and the role played by pernicious racism in the study of epidemiology and her maintenance of an uncharacteristic modernist approach to public health policy. Hunter appears to have faith in orthodox medicine and conventional public health approaches in stemming the tide of epidemics. The problem with the shift away from ‘modern’ medical and public health interventions, both in the days of colonial conquest and today, is, in Hunter’s view, a problem with those with the power of implementation and the perceived biological superiority of these executors of medical and public health policy - the colonial masters in the days of imperialism and the industrialised nations of today – rather than the inherent contradictions that exist in ‘modern’ medical practice and the Eurocentrism that characterises ‘modern’ public health practice both historically and contemporarily.

She argues in Chapter Five, quoting in part, tropical disease expert Megan Vaughn:

Responsibility for all of Africa’s disease problems were systematically deflected away from colonial powers onto the ‘backwardness’ and ‘cultural practices’ of the natives themselves and medicine helped create Africa ‘as a repository of death, disease and degeneration,’ says Vaughn. Since most medical interventions had failed, social and cultural explanations for disease patterns were sought and formed the basis of wider ‘knowledge of the African’, a dynamic that still features strong in constructing strategies to deal with HIV/AIDS. Africans were portrayed as beyond understanding and beyond help … (p 145).

Hunter is sympathetic to the unfair portrayal of the African ‘other’ but maintains an unconscious objectification of the subjects of her book, which could explain why she chose to fictionalise accounts of her Ugandan experience rather than provide empirical narratives. Her inconsistency is clear from this passage:

The inability of colonial medicine to repair the ravages of colonialization in Africa, its subsequent cynicism, manipulation of African reality, and readiness to blame the victim was part of a vast exercise in Social Darwinism that harmed people like Molly, Pauline and Robina and their communities as much as it helped them. The drama being played out now with the HIV/AIDS epidemic in sub-Saharan (sic), but political and economic motivations have been brought to a conscious level …

But our willingness to help still depends on on whether we feel threatened. History shows that the more distant a disease threat seems and the less likely it is to infect us, the less likely we are to respond. Deliberately encouraging the deaths of the world’s poor, or a lack of compassion for them, as was the czase with New World native Americans, Oceanic islanders, or Australian aborigines at the time of colonial contact is no longer acceptable … (p 146)

From this premise, Hunter also forwards an argument about the evolutionary forces of HIV/AIDS epidemic that comes dangerously close to the pseudo-science that informed proponents of eugenics, the very racism in research that she seeks to eradicate. She questions whether biological determinism has a role to play in contributing to the lack of a global, in particular, a northern, response to the HIV/AIDS crisis in Africa. Hunter argues:

The growing body of evidence that human behaviour is conditioned by our evolutionary past has relevance for HIV/AIDS in four ways: First, although our sexual behaviour is determined by our genes, how can we change it ? Second, can human behaviour really be explained by presuming that humans are driven by the desire to maximize the presence of their genes in the next generations, or is it possible that human behaviour has become a good deal more subtle than that ? Third, if genetic analysis of the world’s populations has revealed two major clusters, ‘Africans’ and ‘non-Africans’, are the centuries of exploitation by Africa by the developed world and the current disinterest in its fate (as measured by the amounts of aid being pledged to the Global AIDS fund and other relief measures) a reflection of this ? Finally, how long does it take for human behaviour and genetic composition to change in relation to disease ? (pp 215 – 216)

Hunter deliberates the suggestion that the HIV/AIDS virus is an evolutionary screening mechanism to ensure the development of a healthier gene pool, contributing to the idea that ‘evolution is favoring people who have been and are able to practice caution in their sexual relationships’ and that ‘AIDS is suggesting that it is prudent to develop new ways to screen desirable mates. At the same time, the author suggests that the lack of political will of western countries to help stem the scourge of the virus in African countries is due to an evolutionary characteristic that separates Africans from non-Africans.

She asks:

‘If the rest of the human species is more related to one another than they are related to Africans, is it simply the case that human genetics determines that we suffer less guilt in leaving Africa to fall to ruins ? Is this intraspecies rivalry, which, as we learned from Darwin, is the most ruthless of nature’s competitions ? If we help Africa, are we helping the ‘less fit’ to survive ?’ (p219).

While the author does not come to a conclusion, the suggestion of evolutionary forces at work with regards to the world’s wilful ignorance of the African epidemic is a dangerous path to tread, particularly at this point in time when the need for a comprehensive, objective analysis of the epidemic is sorely lacking. Hunter implies that there is some basis in the notion that non-Africans are biologically predetermined to ignore the suffering of Africans although she qualifies this by acknowledging the role played by the manipulation of discourse: ‘While our attitudes toward Africa may have a genetic basis, we also have been systematically misled in understanding a number of things about Africa critical for us to make clear decisions about right action and social justice’ (p 219, emphasis added).

This suggestion that there is a biological reason behind the global community’s apathy, complacency and sometimes wilful reluctance, to help Africa overcome its HIV/AIDS crisis is extremely unhelpful and severely undermines Hunter’s aim to broaden the debate on the HIV/AIDS crisis in Africa and galvanise action.

It also creates an easy abdication of responsibility by negating the role of individual consciousness in public health policy – if our public health policy and international development strategies are biologically predetermined, can policymakers (and by extension all who have the capacity to effect change) be held accountable for acts of omission ? In looking for a biological reason for the racism that Hunter believes underpins the west’s exploitation of the African continent, Hunter ignores the important role played by social and cultural factors in the construction of Africa and the rest of the developing world, in particular the role played by negative discursive representations of the south.

6. Conclusion

Who Cares ? AIDS in Africa has been described as ‘one of the most important books on AIDS’ by Stephen Lewis, the United Special Envoy for AIDS, one that is ‘chilling and fascinating in equal measure’ (back cover). The author herself acknowledges that ‘[n]ot everyone will agree with what I say’ but that she aims to ‘fill a gap in the knowledge base’ and ‘provoke controversy, study, counter arguments and action’ (Preface). It is undoubtedly a controversial book and one that is no doubt well-intentioned.

However, much of the controversy generated by Who Cares ? AIDS in Africa is not well-reasoned and often unsubstantiated, with a heavy reliance on the author’s own interpretation of Darwin’s theory of evolution, and the author’s own anecdotal field experiences supported only through the dialogue of fictional characters. This book is a troubling read for those who are calling more comprehensive, cross-disciplinary approaches to the study of the HIV/AIDS epidemic in Africa today, and also for those who struggle everyday to dispel the mythmaking and the quasi-scientific theorising that have grave implications for public health policy in this area.

The book forwards dangerous arguments about the causes and nature of the HIV/AIDS epidemic in Africa alongside very sound and critically pertinent analysis on the same subject in a half-whimsical, half-missionary fashion that excludes the voices of those in the continent who are directly affected by the epidemic. In doing so, the book undermines not only its own goal but that of the millions worldwide who are fighting the epidemic and who are fighting for legitimacy and voice in their struggles.


[1] ‘Their’ referring to the people of Africa living with HIV/AIDS, those looking after family and friends afflicted by the virus, and those doing their best both to mitigate the devastating effects of the virus and to find solutions to the problem at large (p v).

[2] Hunter explains that the stories of ‘Molly’, ‘Pauline’ and ‘Robina’ were ‘fictionalized from real community activities in Uganda’s Rakai district in 1989,combined with community stories from other countries’ the author visited in Africa during from 1989 – 2001. She acknowledges that ‘[w]hile a few of the characters are based on real people, many of events and all of the dialogue have been invented. None of the opinions expressed can be attributed to actual people’ (p 227, fn 2).

[3] Although the author does acknowledge that the nature of the HIV/AIDS epidemic in itself calls for the need for such wide-ranging study: ‘The HIV/AIDS epidemic has finally broken the illusion of medicine’s control of epidemics and infections, cultivated in public policy thinking since the 1950s. Scientists are now developing a new view of epidemics and of the microbes with which we interact’ (p 213).

[4] United States Agency for International Development (USAID) (2003). ‘Research: Male Circumcision and HIV Prevention’


UNAIDS (2003). UNAIDS Questions and Answers, November 2003. (Geneva: UNAIDS).

UNAIDS and WHO (2003) AIDS Epidemic Update 2003. December 2003. (Geneva: UNAIDS).

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This is a book review published on 4 June 2004.

Citation: Tan, C, 'Who Cares ? AIDS in Africa' by Susan Hunter , Book Review, Law, Social Justice & Global Development Journal (LGD) 2004 (1) <>. New citation as at 15/07/04: <>.