Author Interviews
5:58 pm
Mon February 27, 2012

'Tinderbox': How The West Fueled The AIDS Epidemic

Originally published on Tue February 28, 2012 8:16 am

HIV is a slow-moving time bomb.

Unlike Ebola, which infects and kills people quickly — and then disappears just as quickly — the HIV epidemic has become so good at killing people in part because it moves so very slowly, says journalist Craig Timberg.

"In vaginal sex, you can have sex with hundreds of people and not transmit [HIV], it turns out," he says. "And that's part of the reason it's still with us today. It has spread very slowly. It makes people ill very slowly. ... And that's one of the reasons why it's been so difficult for the world to understand it. ... It's been hard to make sense of this epidemic because of the way it moves. It's not obvious."

Timberg, the former Johannesburg bureau chief for The Washington Post, with his co-author Daniel Halperin, an AIDS expert currently at the University of North Carolina, explores the history of the HIV virus and efforts to fight the AIDS epidemic in his book Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It.

The History Of HIV

Timberg tells Fresh Air's Dave Davies that the simian version of HIV — which is called SIV — has been around for thousands of years. It was only when colonial powers migrated across parts of Africa — where the SIV virus existed among the chimps — that the virus started to spread among humans.

"It was only with the introduction of these new transport routes, of these human movements, that HIV popped out of the chimpanzee population and starts an epidemic among the human population and became what we see today," he says.

In the past 100 years, 99 percent of all of the world's deaths from AIDS have come from a strain of the virus called HIV-1 group M, which first appeared in remote parts of Cameroon, where African porters worked a century ago cutting paths across dense brush in places where humans had never before traveled.

"The best theory is that a human caught a chimp, was butchering a chimp — which is a very bloody business — and in the process of that cut his hand, and the virus mutated as it went into the human bloodstream," says Timberg. "... [There was] human movement in areas where humans didn't live in great density before colonialism arrived — you had the arrival of the rubber trade and the ivory trade, and suddenly you had to go into these very deep parts of the forest that were not hospitable to humans before and since."

From Cameroon, strains of HIV migrated down into other parts of central Africa and then into Leopoldville, which is now called Kinshasa. Leopoldville was a Belgian territory and by 1920 had become the capital of the Belgian Congo — complete with factories, shipyards, railways and single-sex dormitories for the workers, who were thrust into urban living conditions.

"You had the kind of human movement that could really get an epidemic moving," says Timberg.

In 1960, the Belgians gave up Congo, which then became an independent country again. At that point, 1,000 to 2,000 people likely had HIV, says Timberg.

"But you have to bear in mind, when HIV progresses into AIDS, it looks like a lot of other diseases," he says. "You have diarrhea, you have fevers, you have wasting. So there's not much evidence that anybody at the time had any evidence that there was a new sickness."

The unknowingly infected inhabitants of Kinshasa mingled with U.N. aid workers who were flown over from Haiti to work as physicians and civil servants. It is almost certainly the case, says Timberg, that one of the Haitian aid workers caught HIV in Leopoldville and then flew back to Haiti.

"From Haiti, it brews up for a few years and then it makes its way into the United States, and from the United States it comes back and infects Europe through airline traffic," he says. "So every HIV virus in the United States or Europe or the Caribbean can be traced to a single ancestor, a single virus that came over from Kinshasa in the 1960s."

Fighting AIDS In Africa

In the 1980s in the United States, there was a large resistance to the idea that HIV and AIDS could spread widely among a heterosexual population — in part, says Timberg, because it didn't happen in many places. But across Africa, he says, it was a different story.

"The first researchers who began to look into the HIV epidemic in Africa found these unbelievable rates of infection that frankly horrified them and terrified them," he says. "When they began to write their papers about this, the peer-reviewed medical journals were like, 'You're crazy. You can't have HIV spreading like this.' But in Africa, it did."

Many African countries initially ignored the AIDS crisis, but some nations — like Uganda and Zimbabwe — were successful in providing public health information and slowing the spread of the disease. Timberg says when Western countries later became serious about fighting the African AIDS epidemic, international AIDS groups didn't follow Uganda's model — and overlooked some relatively simple and inexpensive approaches proven to stem the spread of HIV.

One of their errors, he says, was overlooking the effectiveness of male circumcision. Circumcised men are at a much lower risk of becoming infected with HIV through sexual transmission.

"When you look at the parts of not just Africa but the world where HIV is worse, it is almost inevitably societies that don't circumcise," he says. "The science on this began emerging in the 1980s and it became terribly politicized. People were uncomfortable with the subject, and the whole discussion became incredibly controversial. It took almost 20 years for the scientific community and the community of policymakers to really do enough science and enough research to realize how important this was."

Prevention Programs

In other places, like South Africa, prevention programs funded by Western charities focused on messages that Timberg says were "stunningly off point" and puzzled their intended audiences. One initiative, called loveLife, was designed to get South Africans to talk about sex more openly, but their billboard campaigns left many South Africans scratching their heads.

"Again and again, as the Western world took over these HIV prevention campaigns, truly frank conversation about sex drained out of these societies," says Timberg. "And fascinatingly, the places that were kind of left alone [like] Zimbabwe — which is north of South Africa, has a horrible government, political collapse — did way better on preventing HIV than South Africa did. Because Zimbabweans didn't have all of the heavy-handed Western messages [and] they watched lots of people die."

In Uganda, he says, the HIV rate went up when Western organizations began pumping money into the country.

"There was this remarkable five-year period where [Uganda] literally saved hundreds of thousands of lives by heading off the spread of HIV [themselves]," he says. "A few years later, when Uganda became this hot nation to give AIDS money to, it went in reverse. HIV started going back up. The HIV [infection rate] is higher than it was 10 years ago. ... It stopped being something that Ugandans themselves felt like they owned."


Interview Highlights

On sexual culture and epidemics

"The ability for a society to grasp the connection between sexual culture and the spread of this epidemic is just essential to reversing it. And it seems like the more the United States or other Western nations get involved, the farther societies get away from that kind of moment of reckoning."

On the legacy of colonialism

"One of the really pernicious legacies of colonialism in Africa is a bunch of rich governments come in — a bunch of European and American governments come in — and tell people what to do, and lots of people listen. Money talks. You come in with billions of dollars into societies that don't have access to those means or anything else, and you can hire the best doctors, the best thinkers, you can invite journalists out to clinics and tell them the story that you think works, and the usurping of the authentic local response can be very profound."

On the spread of HIV

"Whether it spreads quickly or slowly depends on a lot of factors: among them, whether either partner has sexually transmitted diseases, but also, the kind of society that people are living in, particularly in societies where men and women or men and men have one partner at a time or more than one partner. Those variations in sexual culture have an enormous difference in how quickly the virus spreads. And additionally, men who are circumcised are much less likely to get HIV, and that can really affect how quickly the virus spreads."

On the origins of HIV

"This remarkable biologist at the University of Arizona had found a piece of virus that had been circulating in the capital of Congo back in 1960, and he compared it to a second piece that existed from that same era. And when you look at how different those pieces of virus are, you can sort of do the math and figure out what the origin is. And by looking at the pace with which viruses evolved, you can reverse engineer your way back into a date range. His research suggests that the key year was around 1908, but the range is a bit wider — 1884 to 1924. Somewhere in there, the first HIV is loose in the world, has come out of the chimp population and is infecting humans."

On Patient Zero from And the Band Played On

"Randy Shilts talks about the CDC's fixation on this one airline steward who was Canadian, and he traveled back and to Europe, and he clearly infected plenty of people. There's no reason to minimize that, but what is now clear that wasn't clear when Randy Shilts was writing, was by the time that happened in the late '70s and early '80s, HIV is already all over parts of the United States and, increasingly, parts of Europe as well."

On why HIV spread rapidly in the gay community in the early 1980s

"One of them was that anal sex, when condoms aren't involved, is a very efficient way to spread this virus, much more so than vaginal sex or oral sex. And in addition, you had a fast-lane gay culture in some American cities, where men were having lots of partners in a given year. You had the bathhouses around. That's very consequential in how all sorts of STDs move, not just HIV, sadly."

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

DAVE DAVIES, HOST:

This is FRESH AIR. I'm Dave Davies, filling in for Terry Gross, who is off this week. When Western countries got serious about fighting the AIDS epidemic and put billions into condom distribution and HIV testing in Africa, were they committing a huge blunder? That's the provocative question raised by our guest, journalist Craig Timberg.

He reported on the AIDS epidemic when he was the Washington Post's bureau chief in Johannesburg, South Africa. His research on the HIV virus and contact with AIDS specialist Daniel Halperin convinced him that international AIDS groups had for years overlooked some relatively simple and inexpensive approaches proven to stem the spread of HIV.

Their book also details the history of the virus, how it existed for hundreds of years in a remote region of Africa before the growth of colonial economies sparked its spread to a wider population. Craig Timberg is now the Washington Post's deputy national security editor. His book with Daniel Halperin is called "Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It."

Well, Craig Timberg, welcome to FRESH AIR. Let's start with some basics. Describe the history of the virus. You say that it existed among chimpanzees in Africa for - well, for how long, do we think?

CRAIG TIMBERG: Tens of thousands of years. The simian version of this, what they call SIV, has been around for quite some time, and the scientists who study this think that it became a human virus plenty of times over the centuries. What was crucial about the birth of HIV was that you had this intrusion of colonialism into the parts of Africa where the virus existed among the chimps.

So for the first time ever, you have steamships going up these rivers. You have porters being forced through these places, some of whom were capturing and killing the chimpanzees that had the virus. And it was only with the introduction of this new - of these new transport routes, of these new - really the human movement to the rise of cities, that HIV for the first time pops out of the chimpanzee population and starts an epidemic among the human population, you know, and became what we see today.

I mean, that happened more than a century ago.

DAVIES: Right. So hundreds of years ago, you might have had a human infected by a chimp. But because there was simply far less contact, people were more isolated, it didn't spread.

TIMBERG: That's right. I mean, chimps and humans lived in different places. They - chimps are very aggressive animals. They don't kind of hang out with humans. It was only when humans and chimps were forced into close contact by the arrival of colonialism that you saw HIV begin to spread as an epidemic.

DAVIES: And how did humans get it from the chimps?

TIMBERG: The best theory is that humans caught - some human caught a chimp, was butchering the chimp, which is a very bloody business, as you might imagine, and in the process of that cut his hand, and the virus mutated as it went into the human bloodstream.

And lots of viruses do that. Many of our most diabolical illnesses come from animals and our close contact with animals, and HIV is one of those.

DAVIES: Right, and they would have caught the chimp and butchered it to eat it, right?

TIMBERG: That's right, and in parts of Africa, eating chimps is still something done routinely today. And so you have the combination of the need for food but also the human movement through areas where humans frankly didn't live in great density before colonialism arrived. And, you know, you had the arrival of the rubber trade and the ivory trade, and suddenly you had to go into these very deep parts of the forest that were not that hospitable to human communities before, or really since.

DAVIES: Right. Paint that picture just a bit, if you would, how the development of the rubber industry - and this would have been in the Belgian colony of the Congo, right? And...

TIMBERG: Yeah, there were actually a lot of different European groups there. The part of what we call the Congo River Basin that - where this happens is actually a German territory in Cameroon, and so this is a place that would have had a scattering of villages, people living in ways that were, you know, fairly similar over the centuries.

And very abruptly, you have the arrival of Germans with guns and dogs, walking into villages and demanding that the villagers stop what they're doing, go out into the forest, either collect elephant tusks or cut rubber vines and collect sap so that they can be brought back to trading stations and sold.

There's this amazing I came across as part of my research; it's an oral history of a village, and when the Germans first arrived, they were so pale that the villagers thought they were actually ghosts, that they were ancestors who had come back. And then they realized that, well, the ancestors wouldn't have brought guns with them, nor would they have brought dogs with them.

And the Germans sort of, you know, make nice, and they're friendly, and they offer salt to make their food taste better. And then they say, wouldn't you like to help us collect this stuff? Wouldn't you like to help us carry our goods over to the next village?

And one of the villagers says no, you know, we have our lives here. We don't need to do that. And so, you know, the colonial Germans come in and beat him up and strap a suitcase onto his back and force him on at the point of a gun. Even at the Germans at the time, you know, describe this as just a hurricane that blew through Cameroon. It just absolutely devastated these societies.

DAVIES: So we had these porters, often abused, often underfed, and it's believed that one of those might have butchered a chimp, gotten the infection and by now is in a situation where there were more people, more contact, and there are more of an opportunity for the virus to spread.

You said this happened about a century ago. How does anybody know that?

TIMBERG: You know, over many years now, genetic scientists have been collecting pieces of HIV from around the world and examining them to see how they're related to one another. You can trace the path of HIV, you know, from Cameroon down into other parts of Central Africa, over to Haiti, into the New World, over to Europe. And that's because when you get different pieces of HIV together, you can see the ways in which they're slightly different or identical to other ones.

And so as part of this, this remarkable biologist at the University of Arizona had found a piece of virus that had been circulating in Kinshasa, which is the capital of Congo, back in 1960. And he compared it to a second piece that existed from that same era. And when you look at how different those pieces of virus are, you can sort of do the math and figure out what the origin of that must have been. What's the grandfather or great-grandfather, great-great-grandfather of that virus?

And by looking at the pace with which viruses evolve, you can sort of reverse-engineer your way back into a date range. And so his research suggests that the key year was around 1908, but the range is a bit wider. They say 1884 to 1924. Somewhere in there, the first HIV, you know, is loose in the world, has come out of the chimp population and is infecting humans.

DAVIES: And it eventually found a colonial city, right? Tell us about that.

TIMBERG: Yes, so in the beginning of the - in the late 1800s, rather, various European countries are moving into Africa and are slicing up different areas of interest, and they're building cities to essentially extract the value from the different parts of Africa that they control.

And in this part of Africa, the key city is what was then Leopoldville and is now Kinshasa. And before the - in this case, it's the Belgians, but before the Belgians arrived, there was just a little village there. But in the course of just a couple of decades, you have factories, you have steamships, you have plantations, you have men being pulled in from the countryside and being essentially forced to work in these factories.

And so never before in that part of the world do you have major cities, do you have the kind of human movement that can really get an epidemic moving. And also with the arrival of these cities, you have a real encounter with prostitution for the first time, right?

The women are still in the countryside, the men have been pulled in, are living in single-sex dormitories. And so, you know, many, many decades before anybody knew HIV was loose in the world, colonial doctors are tracing the path of syphilis and Chlamydia and gonorrhea through this part of Africa. They literally - you can track them along the river routes, the highways, the railroads, everywhere these - this new form of trade went, sexually transmitted diseases followed.

And what we didn't know at the time is that HIV was one of them.

DAVIES: And so if you go back to the 1960s in Leopoldville, deep in the Congo, do we know how many cases of AIDS there might have been?

TIMBERG: So a key year in this chronology is 1960, which is the year that the Belgians give up their colony, and Congo becomes an independent nation again. At that point, the genetic scientists in the world will tell you that 1,000 or 2,000 people probably had HIV.

But you have to bear in mind that when HIV progresses into AIDS, it looks like a lot of other diseases, right? I mean, you have diarrhea, you have fevers, you have wasting. So there's not much evidence that anybody at the time had any idea that there was some sort of new sickness abroad in the land.

DAVIES: And how do we think it got to the Western Hemisphere?

TIMBERG: This is a - this is actually one of my favorite stories in the middle of all this. So we just mentioned 1960. The Belgians leave, there's - many of your listeners will remember the Congo crisis and the collapse of that economy and government. And so in the '60s, there's total chaos there, and the United Nations brings in a bunch of French-speaking technocrats from other countries.

And it just so happens to be the case that over in Haiti, which is a French-speaking country that had quite a large middle class. They're going through one of their periodic times of a little trouble. So quite a few hundred, probably thousands of Haitians are being flown by the United Nations to Leopoldville to work as doctors, nurses, civil servants.

It is almost certainly the case that one of those Haitians caught HIV in Leopoldville, which then became Kinshasa, and flew back to Haiti, and then from Haiti, it sort of brews up for a few years, and then it makes its way into the United States. And from the United States, it comes back and infects Europe, probably through airline traffic. And so every HIV virus in the United States or Europe or the Caribbean can be traced to a single ancestor, a single virus that came over from Kinshasa probably in the 1960s.

DAVIES: We're speaking with Craig Timberg. We'll be back after a short break. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

DAVIES: If you're just joining us, we're speaking with journalist Craig Timberg. His new book with Daniel Halperin is called "Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It."

So HIV infected humans in Africa decades ago, eventually made its way into the Western Hemisphere, but it really became known as a disease of the gay community in the United States, I guess in the, what, late '70s and '80s. How did that - how did it come to be a disease of the American gay community?

TIMBERG: Well, it comes out Haiti, as I guess everybody knows, and it's not entirely clear whether a gay American man went to Haiti on a tourist trip or a Haitian man traveled from Haiti - or a woman for that matter - traveled somewhere in the United States and transmitted it.

But once it crossed over into the American gay population, you had a combination of factors that were pretty profound. One of them was that anal sex, when condoms aren't involved, is a very efficient way to spread this virus, much more so than vaginal sex or oral sex.

And in addition, you had a fast-lane gay culture in some American cities where men were having an awful lot of sex partners in a given year. You had the bathhouses around, and, you know, that's very consequential in how all sorts of sexually transmitted infections move, not just HIV, sadly.

DAVIES: And for a long time, people saw it as a disease of the gay community. Was there resistance to accepting the notion that it affected heterosexual folks, as well?

TIMBERG: There certainly was. I mean, from a fairly early phase in all this, it was clear that, you know, hemophiliacs from blood products got HIV. It was also clear that there was some sort of nexus with Haitians having more HIV than other people. And also injecting drug users turned up with HIV at much higher rates than anyone else, which clearly was from passing the virus in hypodermic needles.

But the idea that HIV could spread widely among, you know, a sort of generalized heterosexual community was resisted for a long time in part because it didn't happen in that many places. I mean, I remember I was in high school in the 1980s, and I remember, you know, being terrified. We were all terrified. You know, if you ever had sex without a condom, you were going to get AIDS, you were going to die, and that turns out to really not be true. It's not that it's impossible.

But there's a lot of other things that are bad that are much more likely than getting HIV from heterosexual contact. But what turned out to be true is that in Africa, it was a different story. And so the first researchers who began to look into the HIV epidemic in Africa found these unbelievable rates of infection that just frankly horrified them and terrified them. And when they began to write their papers about this, you know, the journals, the peer-reviewed medical journals of the world were like you're crazy, you can't have HIV spreading like this. Well, but in Africa it did.

DAVIES: An important part of the story here, of course, is how various African governments reacted to the presence of AIDS and HIV infection in their countries. And one of the most interesting and one of the earliest was Mobutu, who was the dictator of Zaire, which was what the Belgian Congo became. Now it's Congo again. How did he respond to the infection, to HIV?

TIMBERG: Well, he, like many African leaders, reacted, I think we can say, very badly, right? The idea that an infection that in their minds was about, you know, gay American men, that that traveled widely in Africa, a place where homosexuality is very taboo, was awfully hard to take.

And when the first science came out suggesting that, you know, that it really originated somewhere in Africa, it was treated with utter scorn. And so you had really almost - pretty close to an entire generation of African leaders who tried to resist the idea that this epidemic was abroad in their land in a major way.

And that clearly set back the fight against this in meaningful ways. And you also had a whole generation of kind of well-meaning Westerners at the United Nations, the U.S. government, the various NGOs, who just felt like they were banging their heads against the table, trying to get African leaders to listen.

But for me, the more interesting counter-narrative here that has not been written about very much is that as all this was happening, Africans themselves, like ordinary people living in towns and villages and cities, were kind of putting this together, right?

It gradually became clear that people were dying. It became clear that they were dying because of, you know, sexual encounters that they had. And it also became clear that sort of what they call big men - traders, musicians, people who had lots of sex partners - were dying a lot faster than everybody else.

And so there's this kind of sort of natural reaction to that that ends up being consequential. Sexual behavior in lots of part of Africa gradually shift in ways that make it much less hospitable to HIV spread. And that has not been written about very much, but it - the science on it is pretty solid, and it's remarkably well-documented now.

DAVIES: Right. I want to get to several cases like that and how they interacted with the big policymakers on AIDS issues. But before we do, when Mobutu was condemning the notion that HIV could have been an African disease, what was he telling people, and how did it affect their perceptions?

TIMBERG: Pretty much everywhere HIV arrived in a large scale, the reaction was the same, which was to say this is a disease of outsiders. This is not our disease. This was brought by those, you know, those naughty people who are having sex with the wrong people or socializing with the wrong people.

And in parts of Congo, you know, there were Congolese who spent a lot of time with Western ex-pats, they called them Londoners, and they suggested, oh, HIV comes from them. It really just affects the ex-pats and the Londoners.

And then there's the famous Rumble in the Jungle that George Foreman and Muhammad Ali fight, and, you know, in retrospect, people said, oh, it must have been that crazy fight when all of those foreigners came here. That must have been where HIV came.

It took literally years and years before you had a sort of deep understanding that HIV was striking all sorts of people across all parts of society in these African nations and to have any kind of useful government response to that.

Right, and so Mobutu really, at least in those years, did nothing to slow the spread of the virus or alleviate its suffering...

That's right, and tragically, his own son, so far as we can tell, contracted it and died of AIDS.

DAVIES: There are a number of counter-examples that you cite, and one of the most interesting is Uganda, where the disease bore the name of Slim, colloquially, right, and this guy Yoweri Museveni, he took power, who took a completely different approach to the issue. Explain what he did.

TIMBERG: So Museveni comes to power in 1986, after a long civil war. And he, you know, he's an intellectual, a leftist, and he gets the memo that this is a big problem when he sends off a bunch of his officers to Cuba, of all places, to get trained. And the Cubans are very aggressive about monitoring HIV.

So 18 of this initial tranche of officers turn up with HIV, and at a conference in Zimbabwe, Fidel Castro turns to President Museveni of Uganda and said: Brother, you have a problem. And Museveni really takes that to heart. And he gathers together his top scientists, his doctors, and says what can we do?

And they fixed on some fairly simple facts, right? AIDS is deadly; the virus that causes it is spread by sex; and there's not much you can do about it once you have it. So they lead with religious leaders, with musicians, with other kinds of cultural figures. They lead what they called the Zero Grazing Campaign, and they make the case, you know, if we as a society move away from having more than one sexual partner at a time, which of course was deeply embedded in the culture - you know, Uganda even today still has some polygamy - then we're going to be safer.

Fewer people are going to die of HIV. And so for a very concentrated five-year period, there's billboards, there's posters. They frankly resorted very forcefully to using fear, warning people if you - you know, if you have more than one sex partner, you're going to die.

And while that may have been a little bit of an exaggeration, it's clearly the case that sexual behavior changed in Uganda and that the spread of HIV really tumbled off a cliff in a way that has not been seen anywhere in Africa before or since.

And this happened, you know, without the U.N., without the U.S. government, with very little money. They did it themselves. They figured it out, and they came up with a program that really worked.

DAVIES: Right, you said this program had the term Zero Grazing. What did that mean?

TIMBERG: Right, it's a great - Museveni is a lot of things, not all of them good, but he's brilliant with his metaphors. So imagine a rural African setting, lots of people living in villages, homesteads, everybody lives off the land to some extent. And so when a goat is tied to a stake and grazes just in the area that he can reach while he's still tied to the stake, it forms a circular pattern than looks like a zero.

And so the zero grazing immediately evoked the idea that, you know, sex is normal, we all have sex, but if you have sex within this one place, as opposed to out in the bars, you're going to live longer, and everyone around you is going to live longer.

DAVIES: Yeah. Stay home, stay safe.

TIMBERG: It's worth mentioning here that at the time, a good chunk of Uganda was still polygamous, right? Men with two wives, three wives. It wasn't illegal. It wasn't all that unusual. And so they had to kind of thread the needle a little bit, right? They couldn't say men have only one sex partner. What they said was essentially keep your sexual behavior at home.

So if you have two wives or three wives, you're only having sex with them. They're only having sex with you. That's fine, right? The virus has nowhere to go. But if you have a wife and two girlfriends, and your girlfriend has a couple of boyfriends, you end up with these networks of sexual interaction that spread the virus.

So the zero grazing was kind of brilliant when you think about it because it had a message that the Christian churches could get behind - monogamy good, right? Have sex with your wife or your husband, that's fine. It also had a message that people who were living in more traditional African households in which polygamy was alive and well, that they could embrace, too.

DAVIES: Craig Timberg's book with Daniel Halperin is called "Tinderbox." Timberg will be back in the second half of the show. I'm Dave Davies, and this is FRESH AIR.

(SOUNDBITE OF MUSIC)

DAVIES: This is FRESH AIR. I'm David Davies, filling in for Terry Gross, who is off this week.

We're speaking with journalist Craig Timberg, who reported on the AIDS epidemic when he was the Washington Post Johannesburg bureau chief. His book with epidemiologist Daniel Halperin, called "Tinderbox," argues that Western AIDS groups for years overlooked some relatively simple and inexpensive approaches to stemming the HIV epidemic.

In the first half of the show, he described a public information campaign in Uganda, which encouraged people to have fewer sexual partners - an effort which dramatically cut rates of infection in the country.

And just to let you know, the next few minutes of the show will include a brief anatomical discussion of why HIV infection is more likely among uncircumcised men.

Now, what's interesting about this, this comes, as you note in the book, after a period in which the American gay community, in response to this deadly epidemic, changed a lot of its practices, had fewer partners, you know, more protection much more often, and the result was a dramatic decline in the rate of infection.

You case here in Uganda where a specific effort to change sexual practices again, had a very dramatic impact. It would seem that this would have been a really important development that would have swept through the AIDS policy and research community. Did it?

TIMBERG: Yeah, wouldn't it be nice if things were that simple?

(SOUNDBITE OF LAUGHTER)

TIMBERG: If, you know, if developments happen and scientists looked at them in their labs and everybody agreed? But there are very few things in cultures that are more, you know, politicized than sexuality. And so a disease - a fatal disease -that's transmitted largely through sex, it was just from the very beginning it was really, really political.

You had Pat Buchanan essentially saying to gay men, you know, this is your just deserts for being gay. You had people on the other side of the debates saying, you know, we should be allowed to have as many partners as we want to. We should keep the bathhouses open. So that what you had was this amazing culture war that was really about what was going on here in the United States. And it had a way of infusing itself into every conversation about AIDS really ever said. So when the science started emerging that changes in sexual behavior could be really consequential, could save lots of lives, it was awfully difficult for that message to get absorbed for a very long time. And it remains, in its way, kind of a controversial notion now.

And when you think about it, it makes some sense, right? The money to fight AIDS comes predominantly from the West. A lot of the policy initiatives come predominantly from the West. And so were we to go over to Uganda or Zimbabwe and say, you know, if you want to live through this epidemic, if you want society to thrive, you really need to alter your lives in some way that involves having sex with fewer people. That's a hard message to deliver and people were very self-conscious about it. And so it became in a way a taboo subject about a taboo subject. And so the ability of the decision-makers on this subject to deal straightforwardly and rationally about the impact of sexual behavior on the spread of this epidemic was truly profound and really distracting. And that's - it's been a tragedy. I mean it really has been a tragedy.

DAVIES: All right. Now the other factor which, in retrospect, had enormous impact on the rate of spread of the virus was circumcision among men. So talk about why that matters and how we came to understand that.

TIMBERG: So since this is a daytime show, I'll try not to get, I'll try not to get any more graphic than I need to. But the essential fact is that a man's foreskin is a different kind of tissue than the other parts of his penis. It's a little softer. It's a little thinner. And it's more easily penetrated by the virus. And so a man who doesn't have a foreskin is much less likely - 70 percent or so less likely - to get HIV and crucially, the man who doesn't get HIV is much like, you know, who can't give it to anybody else, who can't give it to anybody else, who can't give it to anybody else, right? There's a chain of consequence when you block one infection. And so when you look at the parts of not just Africa, but the world where HIV is worse, it is almost inevitably societies that don't circumcise - that don't circumcise their men, rather.

And that, you know, the science on this began emerging in the 1980s and it really became terribly politicized. People were uncomfortable with the subject. The whole discussion became incredibly controversial. And, so, it took almost 20 years for the scientific community and the community of policymakers to really do enough science, enough research, to accept how important this was.

DAVIES: Well, you know, we've talked about how a couple of factors that clearly had enormous effect on the extent to which HIV would spread through a community. One was to the extent to which people had multiple sexual partners at one time. The other was the extent to which men are circumcised. Those who were circumcised were far less at risk.

Now in the '80s and '90s, I mean the world really began to take on the AIDS epidemic and devote billions of dollars to the effort. You had a whole new effort organized through the United Nations. And you write that there was sort of a fundamental divide among policymakers on the most effective approach. Do you want to describe that debate?

TIMBERG: Yeah. There was - the instinct of a lot of folks this back here was if you could get enough condoms to enough people that HIV would stop and that, you know, it's very plausible, right? And, again, I can remember in my own life during the period when the panic over AIDS was so intense that condoms were seen as something of a panacea, and what turns out to be the case, though it's very hard to have people to use condoms in every sexual encounter for their entire lives. And so what happened in practice was that people used to condoms in bars, with hookups. They used condoms with prostitutes. What they didn't use is they didn't use condoms with their regular sex partners - their husbands and wives, their girlfriends and boyfriends who they have over a long period of time. But given that HIV is this is much more likely to spread with someone you have sex with many times, as opposed to just once, the inability to get people to use condoms routinely over time with regular partners ended up being a limiting factor in its ability to become like the key factor in stopping the spread of HIV.

And, of course, the other big idea that got a lot of conversation for a long time was the idea of abstinence programs. If you could - if the problem is sex the solution is not sex, or getting people to delay sex until marriage. And that was very popular among certain conservative Christian policymakers for some time. It was a key element of the Bush administration's approach to HIV. But again, when this policy gets to the real world, you can probably convince people to delay the beginning of their sexual lives by a few months, maybe even a couple of years. But, you know, once people become sexually active adults they tend to stay that way. It's very hard to kind of go in reverse on that. So that ended up not being terribly consequential either, so you have this, you know, amazing political fight over condoms and abstinence, as much as anything ends up being a real distraction.

DAVIES: We're speaking with journalists Craig Timberg. His new book about the history of AIDS is called "Tinderbox." We'll talk more after a short break. This is FRESH AIR.

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DAVIES: If you're just joining us, we're speaking with writer Craig Timberg. His new book with Daniel Halperin is called "Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It."

South Africa itself is a fascinating case and much of it is centered around Thabo Mbeki, the, you know, the president who succeeded Mandela who had well, what? What would you say, an idiosyncratic approach to this issue?

TIMBERG: Right.

DAVIES: Describe his approach.

TIMBERG: So Thabo Mbeki, who was the president after Mandela left, and was Mandela's deputy president, is incredibly smart and really shrewd about all sorts of things, except for the AIDS epidemic, which he frankly completely botched. And he fell under the sway of a group of Americans who were trying to convince him that the AIDS epidemic wasn't really an HIV-caused problem. That it was essentially problems of poverty expressed through other means. That when the people were dying, that, yes they were dying, but it wasn't really from HIV.

And this line of conversation really spoke to Mbeki, who was an economist, who had, who used to be a Marxist, who really believed that the biggest problem in Africa was poverty and, you know, he frankly has a point there. And so he fell under the sway of this group of thinkers who believe that anti-retro viral drugs, which were among the most amazing medicine in the world, that they were essentially poison.

And, so South Africa, which is the, you know, richest most powerful country in that part of the world had a relatively advanced medical system, for years resisted giving the drugs to sick people, resisted giving the drugs to pregnant women who were infected, which allows you to keep the baby from getting infected. So you could be sitting in Johannesburg in South Africa and dying of AIDS. But if you were a four-hour drive north in Botswana, you'd get free medicine, because that country hadn't fallen for this denialist line, and you'd live 10 more years, 20 more years, 30 more years, who really knows? And that - it is one of the most painful tragedies of the whole thing.

DAVIES: And, you know, you describe some fairly heavily-funded public information campaigns, you know, funded by nonprofits from the West that, you know, in South Africa and elsewhere that seem well, remarkable. You want to describe a couple of these?

TIMBERG: Well, there is - the most famous of these is called Love Life, which is funded, you know, mainly by some American charities and their basic idea was that if you made people feel better about their lives they'd be less likely to engage in risky behavior. And, you know, on the face of it, that's not hardly a dumb idea, right? I mean the one I first noticed, I remember fairly shortly after I got South Africa, I was driving in from the airport and there's this giant billboard of a woman who's naked but posed in a way that was at least modestly tasteful. And next to the woman hovering above her are the words: gender. And so you think OK, you know, what exactly do I do with that message?

And, you know, you talk to South Africans about this and they would just scratch their heads and roll their eyes. And frankly, nobody wanted to talk about sex. Here's an epidemic that's spread predominantly by sexual contact and yet again and again, as the Western world sort of took over these HIV prevention campaigns, truly frank conversation about sex, you know, drained out of the societies. And fascinatingly, the places that were kind of left alone, for whatever reason, and the most famous example that we chronicle in the book is Zimbabwe, which is just to the north of South Africa, has a horrible government, you know, political collapse, everything bad you can imagine, and yet they did way better on preventing HIV than South Africa or even some of these other nations did. Because Zimbabweans, they didn't have all of the heavy-handed Western messages, they watched lots of people die. And a very famous Zimbabwean singer, the most famous of all of the Zimbabwean singer, is a guy named Oliver Mutukudzi, he sang about it. He sang this famous, incredibly moving song that the English translation is "What Shall We Do?

And, you know, Zimbabweans talk to each other. I remember interviewing a bar owner, you know, outside of Harare, the capital, and he was oh yeah, you know, 10 years ago if I was here there'd be, you know, those cleaning women, they'd be here offering the sex and I go out back and for a dollar or whatever, I'd have sex with them. Now I look at them and I think, you know, they're going to kill me. There's death there. The ability to, for a society to grasp the connection between sexual culture and the spread of this epidemic is just essential to reversing it. And it seems like the more the United States or other Western nations get involved the farther societies get away from that kind of moment of reckoning.

DAVIES: Explain that. Why would that be? I mean it's one thing if a misguided public information campaign from the West gives information that is not helpful, why is it counterproductive? Why does it keep people from having the kind of the conversations that would matter?

TIMBERG: You know, one of the really pernicious legacies of colonialism in Africa is that when, you know, a bunch of rich governments come in, a bunch of Americans or Europeans come in and tell people what to do, lots of people listen. And money talks, right? You come in with billions of dollars in societies that don't have - don't have access to that kind of means or really anything else, and you can hire the best doctors, you can hire up the best thinkers, you can invite journalists out to clinics and tell them the story that you think works. And the usurping of the kind of authentic local responses can be very profound.

And sadly, we talked earlier about Uganda and about this remarkable five-year period, where they had Zero Grazing, where they did a great job of really, you know, they saved literally hundreds of thousands of lives by heading off the spread of HIV. A few years later, when Uganda became the sort of like hot nation to give AIDS money to, actually it went in reverse. HIV started going back up. It's higher today than it was, you know, the HIV is higher than it was 10 years ago, and I think that's part of the reason why.

DAVIES: Because people started focusing on condoms and testing rather than safer sexual conduct?

TIMBERG: Yeah. Exactly. I mean the people - it stopped being something that Ugandans themselves felt like they owned. You know, I can recall being in the Health Ministry in Kampala talking to one of these policymakers who had helped put the Zero Grazing campaign together and he would, you know, his shelf was now lined with his gigantic books that the UN kept sending him about what they're supposed to do, pulled one of them out and he held it and he said, you know, the whole thing has become too heavy now. And he said, you know, we had our thing back - it was years ago and it was controversial, but you know, it really worked.

And just to give you an example of the kind of things they did back in the late '80s, every morning on the radio at 6:00 a.m. there were these war drums that would play, because they were invoking a state of war to fight this epidemic.

And immediately after the war drums you'd hear the voice of a young girl, of an eight-year-old, say: Daddy, Daddy, please don't have other sex partners. Come home. I need you to stay alive for your family. And you know, that has a way of cutting through the clutter, doesn't it?

DAVIES: Those who are shaping the battle against AIDS, you know, have relied heavily on condom use and condom distribution, and the example which is often cited of its success is Thailand. It does appear that widespread condom distribution in Thailand made an enormous difference relatively quickly. Why isn't that an example that could be replicated?

TIMBERG: Boy, that's a great question and it's one of the more confusing pieces of the puzzle. So the AIDS epidemic is different in different places, based on the culture and all sorts of other things, and in Thailand, HIV was spread predominantly through brothels, right, prostitutes having sex with men as the main vector of disease.

And so if you could get those prostitutes to insist, and they did, that the men wear condoms all the time, you actually can stop the epidemic. They've made remarkable strides there. It's an amazing success story. HIV spreads in Africa in a fundamentally different way because it's not fundamentally about prostitution there.

It's about men and women having more than one partner in the ordinary course of their lives, right? It's a guy who has a wife and a girlfriend on the side, or sometimes two, and that girlfriend may be having a guy or two on the side. I can remember sitting outside of a dormitory of a university in Kampala in Uganda and watching young women come down and get into the cars of these middle-aged men.

I was sitting there with a student there and she said: you know, all those men, they all have wives but this is their Friday night. And all those girls you're seeing there? They all have college boyfriends. This is the night they go off and they go out with their sort of big man boyfriends, the guys who pay their tuition, buy them clothes, buy their refrigerators.

Now, you may sort of, you know, cynically think of that as prostitution but it's really not. It's a different - it's a kind of sexual behavior that's much more kind of broad based. It's much less, you know, it's happening kind of everywhere all the time as opposed to in single interactions in a place like a brothel.

DAVIES: And people are less likely to use condoms for that kind of sex.

TIMBERG: Yeah. I mean, condom usage rates in parts of Africa are much higher than they are in the United States and much higher than they are in, really, anywhere else in the world, but that refers really to casual encounters, right, prostitutes, people you meet in a bar.

That message has succeeded amazingly. What hasn't succeeded is getting people to use condoms with people they have sex with on a regular basis - their wives or husbands, their boyfriends, their girlfriends. Over time, people really see it as a barrier to intimacy and they don't see it as part of what a long-term kind of romantic relationship is about.

DAVIES: So where are we in the fight against AIDS today, in Africa and elsewhere? Have we learned from these mistakes?

TIMBERG: To some extent, yeah, but I guess not really. We're so much better at treating people, as I said, and that is - it's just miraculous. When you see someone come back from the edge of their graves and go back to their families or go back to work, it's just the most amazing and moving thing.

So that's a great thing. And the circumcision services, that's going quite well in lots of places. We're very good now at keeping women who are infected with HIV from giving it to their children when they're - during birth. That's going really well. But the single most consequential factor in why HIV spreads fast in some societies and slowly in other societies are these matters of sexual behavior and culture.

And the conversation around that remains really unsophisticated. The people who have the most money and power around these things are either scared or disinclined to talk about it directly. And so I have to say, in some ways I'm kind of discouraged, which is a place I hate to be because the book attempts to be hopeful, right?

I mean, when you realize that HIV doesn't just exist, that it was born, that this epidemic came out of a place at a certain time at a certain - for certain reasons, you think, oh, you can end this. You could really stop this epidemic. If it wasn't there 200 years ago, it doesn't have to be here 50 years from now.

But if we're going to get to that place, if we're going to get to the place where we don't have an AIDS epidemic anymore, it's going to be because consequential changes are made in sexual behavior, and that's not going to happen, I fear, just on its own necessarily. There have to be decent programs.

There has to be real conversation about multiple partners, about how much safer it is to be monogamous, at least for periods of time.

DAVIES: Well, Craig Timberg, it's been really interesting. Thanks so much for speaking with us.

TIMBERG: Oh, it's been great. I really appreciate it.

DAVIES: Craig Timberg's book with Daniel Halperin is called "Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It." Coming up, Maureen Corrigan reviews Jim Yardley's new book "Brave Dragons." This is FRESH AIR. Transcript provided by NPR, Copyright NPR.