HIV/AIDS has become “the most devastating disease humankind has ever faced,” according to the Joint United Nations Programme on HIV/AIDS (UNAIDS). Since the epidemic began 21 years ago, over 60 million people worldwide have contracted the virus. At the end of 2001, approximately 40 million people were living with HIV, 28.1 million of these in sub-Saharan Africa alone. HIV/AIDS is now the leading cause of death in the region and has drastically reduced life expectancy. In Botswana, one of the wealthiest countries of southern Africa, life expectancy at birth has plunged to 50 years, a drop of over 10 years since 1990. South African life expectancy is now 48 years and Zimbabwe’s is 37 years. Can this epidemic be conquered? And why have past efforts failed? AIDS and Development in Africa: A Social Science Perspective, edited by Kempe R. Hope, addresses these questions.

Throughout sub-Saharan Africa people are dying of AIDS in their productive years. Besides causing untold human misery, the pandemic is limiting economic growth and eroding social and political structures, depriving children of parents, schools of teachers, and governments of personnel. This deterioration will have global consequences. The health and prosperity of the world’s privileged cannot be insulated from the public health problems of poor countries. This point, made by Lincoln Chen in a 1987 Daedalus article, has more recently been reiterated by a January 2000 US National Intelligence Council report reviewed in the summer 2001 issue of this magazine (Jonathan B. Tucker, “Contagious Fears: Infectious Disease and National Security”), as well as by the World Health Organization’s Commission on Macroeconomics and Health (WHO-CMH) in its December 2001 report.

The WHO-CMH report proposes a new strategy for investing in healthcare for economic development and suggests a number of principles to guide the recently established Global Fund to Fight AIDS, Tuberculosis and Malaria. It calls for dramatic improvements both in treatment of people who have the virus and in programs for preventing transmission. Better prevention without better treatment would leave millions of HIV-infected adults and children without the alleviation of their suffering and prolongation of their lives made possible by modern medicine, and unless prevention efforts improve, the pandemic will continue to worsen. The report calls for increased funding for expanding existing prevention programs.

Most sub-Saharan African countries have clearly had inadequate prevention efforts, as demonstrated by the rapid spread of HIV/AIDS. This is because programs are small-scale and severely underfunded due to poverty, foreign debt, and insufficient foreign aid. But simply expanding existing programs without redesigning them would not solve the prevention problem. While increased funding is necessary, how the money is used will determine whether prevention efforts succeed or fail.

AIDS and Development in Africa is a collection of 18 papers by social scientists at universities in eight southern African countries that were written originally for a South African conference on AIDS in Africa and later revised. Although the conference took place in 1996, many of the papers cite sources published in later years. The social and economic structures and cultural practices they discuss have changed little since the papers were written. Whether and how they have changed, and why, are questions to be answered by further social scientific research on the AIDS epidemic in Africa. Until 1996, most HIV/AIDS research had been done in industrialized nations and focused on them; few reports by African physicians and researchers had been published in major scientific journals, according to Paul Farmer’s Women, Poverty and AIDS. Today this situation is largely unchanged. AIDS and Development in Africa is important for this reason, as well as because it shows that unless policymakers and program designers develop an improved understanding of the circumstances in which their policies and programs will be implemented, their efforts to contain the HIV/AIDS pandemic will fail.

Nine of the articles provide an overview of the impact of the AIDS pandemic in sub-Saharan Africa and discuss the various factors that explain its rapid spread. The other nine articles assess efforts to cope with the pandemic, which is distinctive in that the principal mode of HIV transmission (in contrast with most other regions of the world) is heterosexual sex. The inferior social and economic status of women figures prominently in nearly all of the articles as both a key causal factor and an obstacle to controlling the disease.

Most women in Africa who have become victims of HIV/AIDS were infected by their husbands. As Hope states in his preface, “Wives have very limited ability to autonomously control their personal risk of exposure to HIV/AIDS infection.” Traditions in most African societies deprive women of control over their own sexuality, rendering them “powerless and defenseless,” in Hope’s words. This collection explains the social, economic, and cultural conditions that make African women especially vulnerable to AIDS and shows that controlling the pandemic requires reducing gender inequality.

Among the most illuminating chapters are those describing psychological and cultural factors that not only impede educational efforts but also explain why even people well informed about HIV/AIDS (such as health workers in Botswana) engage in risky sexual behavior. The lesson is not that prevention programs are bound to fail because irrational behavior is widespread and irremediable, but rather that it is irrational to design prevention programs without considering how and why different subgroups of the population (males and females, members of different cultural and religious groups) might think and act differently or lack the freedom to avoid unsafe sex. Overlooking or ignoring such information leads to ineffective programs. Although more research is needed, much relevant and useful information is already available in AIDS and Development in Africa.

Among the merits of this collection is that its articles are written in plain language, free of jargon, so that non-professionals can understand them. However, the book has some shortcomings. The articles are of varying quality in terms of cogency of argument and thoroughness of research. Additionally, the index is incomplete; for example, although prevention is discussed in most of the articles, the index refers only to two of them. Moreover, there is almost no mention of Uganda or Senegal in the entire book, despite the fact that their national prevention programs are widely cited as successful examples to be followed. Given the demographic differences between these two countries and the nations of southern Africa, social scientific studies of whether such national programs would succeed in southern Africa are needed. In both Uganda and Senegal there are proportionally far more Muslims and Christians than in the countries of southern Africa, where many people practice indigenous religions.