HIV/AIDS in sub-Saharan Africa: politics, aid and globalization, by Adrian Flint, Basingstoke, Palgrave Macmillan, 2011, xiv + 211 pp., £57.50 (hardback), ISBN 9780230221420
Sub-Saharan Africa has been affected significantly more than any other region of the world in terms of HIV prevalence and deaths from AIDS-related illnesses. Although estimating the numbers is notoriously difficult, the figures in sub-Saharan Africa are likely to be in the tens of millions. The impact of the disease however is not simply in terms of lives lost, nor its effect on the lifestyles and life chances of an additional tens of millions of Africans. Rather, as Flint correctly states, diseases historically have shaped societies more than almost any other factor, and HIV in Africa already appears to be fitting this pattern.
Why sub-Saharan Africa has suffered disproportionately provides the focus for this generally excellent book. Underpinning Adrian Flint's analysis is that this is a tragedy: that is, an avoidable catastrophe. Ascribing the prevalence of the disease to widespread poverty is for Flint overly simplistic as other impoverished areas of the world do not possess anything like the same prevalence rates. Nor can it be explained by the ‘otherness’ of Africa, including different sexual mores and the prevalence of traditional medicine. Like most catastrophes – avoidable or otherwise, its causes are complex and multifaceted, but for Flint the key issue is politics. HIV/AIDS is presented here as being more than a development problem or a public health problem; rather the causes of the pandemic and the means of controlling it are political and ultimately bound up with issues of governance. Put simply, Flint's thesis is that HIV/AIDS is worse in Africa because its leaders chose to do nothing about it until it was generally too late.
Flint presents his case well. It is clear, coherent and well put together. It is an argument many political scientists have been sympathetic to for some time, and Flint presents one of the best and most accessible accounts of this argument that there is. This is not to say the book is without its faults: data tend to be piled on data somewhat unproblematically; the chapters feel like a series of discrete but related seminar topics rather than a tightly controlled argument. Perhaps the two greatest problems however concern the core of the book. The first, Flint is open about: he treats sub-Saharan Africa as a single coherent region rather than one which is culturally, politically and epidemiologically diverse. He does this to provide a macro-level analysis, but in so doing risks losing much of the complexity of the situation he attempts to explain. For over a decade UNAIDS has argued that we face not a pandemic, but a series of epidemics with different political and social causes and consequences in sub-Saharan Africa. I strongly suspect Flint understands and sympathises with this. What he is trying to do is to provide a grand view and the sort of ‘big argument’ which many political scientists understand and approve of; but in so doing he risks losing some essential parts of the picture he is trying to explain. This is an argument which cannot be won: if he focused on a series of case studies he could equally be criticised for not attempting the big picture. I would have preferred he spent more time discussing the limits of the big picture approach, but to his credit he is open about this as a problem for his analysis. Second, it is increasingly difficult to argue that poor governance is either a necessary or sufficient condition for the spread of HIV. Some states with good governance and political leadership have nevertheless experienced high prevalence, while others with poor governance/leadership have not. Governance increasingly looks like one of a number of factors in the spread of the disease, perhaps the most important one, rather than the determining factor. These reservations aside, I would strongly recommend this as one of the best books to be published recently on the disease.