Easterly’s review of Helen Epstein’s new book

Bill Easterly has a review of Helen Epstein’s new book in the New York Review of Books. (This follows another largely favorable review in the New York Times). The New York Review has been a frequent outlet of her work which we have written about. Her book summarizes a lot of her pathbreaking reporting on “concurrency,” the pattern in Africa of having multiple long-term sexual partners which is, unfortunately, a tremendous vehicle for the spread of HIV.

Epstein’s has mainstreamed the acceptance of concurrency as a real problem. Unfortunately, the politics of prevention has gotten hung up on unproductive arguments between idealogues on the left and right who have pet solutions–abstinence and condoms–that likely don’t work well on their own. Not enough attention has been paid to B, Being faithful. What’s more, so much attention and resources are being directed towards treatment that rich countries will never be able to pay for lifelong treatment for all the millions who become HIV positive.

Easterly’s point on this is trenchant and echoes his larger critique of the aid industry.

The response of the aid industry to AIDS has its own ABC, much less effective than its Ugandan counterpart: antiretroviral drugs, bureaucracy, and consultants. A huge part of the Western response has been concentrated on getting antiretrovirals to those in Africa with full-blown AIDS. There is nothing wrong with the urge to treat the sick, but in practice it has crowded out nearly every other response to the epidemic. ARVs are now reaching only a tiny minority of those in need and it will never be feasible to treat everyone. Even if you avoid the Scylla of insufficient money to pay for the expensive treatments, you run into the Charybdis of Africa’s dysfunctional health care systems. And even if you did treat everyone who has AIDS with ARVs, which add a few years—four or five, Epstein notes, according to current UN estimates—to the lives of people who remain terminally ill, that would still ignore the omnipotent question: How do you stop AIDS from spreading further through this generation and into the next generation?

They are both unsparing in their critique of the aid and AIDS architecture. Easterly is as cranky as ever:

The response of the aid industry to AIDS has its own ABC, much less effective than its Ugandan counterpart: antiretroviral drugs, bureaucracy, and consultants.

Of course, this critique fits his ideological view that the aid bureaucrats are a feckless, self-seeking group that is less than worthless. While he is right to fault donors for their lack of attention to prevention, I think the indictment of the treatment side of the equation goes too far. Is it not a good thing to have gotten all those people with HIV on ARV’s?

We know that we have to turn our attention to prevention, but as Easterly admits, Epstein’s solution, just encourage countries to do what Uganda did, relies on the single example of Museveni’s campaign to encourage people to have fewer sexual partners or “zero grazing.”

That may have worked in Uganda may not be a recipe for everywhere. I don’t think Easterly would disagree, but he is in danger of becoming such a fierce idealogue against international institutions that it is hard to take him seriously sometimes.

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