Anton A. Van Niekerk, Loretta M. Kopelman, eds. Ethics and AIDS in Africa: The Challenge to Our Thinking. Walnut Creek: Left Coast Press, 2006. xvii + 222 pp. $24.95 (paper), ISBN 978-1-59874-071-4.

Reviewed by Jeremy Youde (Department of Political Science, Grinnell College)
Published on H-SAfrica (December, 2006)

Our Obligations to Others

AIDS is more than a medical phenomenon. The devastation wreaked by the pandemic potentially threatens economic development, social stability, and democratic governance. In their edited volume, Anton Van Niekerk and Loretta Kopelman bring together thirteen chapters, many of which were previously published in Journal of Medicine and Philosophy or other sources, to add another dimension to Africa's unfolding AIDS pandemic--the ethical dimension. In light of the numerous challenges that AIDS poses to sub-Saharan Africa, the contributors to this volume attempt to describe the nature of the international community's obligations to HIV-positive persons and to the continent in general.

Drawing on the expertise of scholars in the United States, Europe, and Africa, and from a variety of disciplines, this volume probes the complexities inherent to an epidemic that calls into question many assumptions about the international economic system, the provision of health care, and the proper conduct of medical research. By focusing on the ethical dimensions of the AIDS epidemic in Africa, the volume's contributors call attention to broader issues of economics and politics. Questions about access to AIDS medications, for example, surely concern economic arrangements and international trade. This volume forces the reader (and, by extension, the international community) to consider the nature of these economic arrangements themselves. Instead of arguing about cost, the contributors want to call attention to our responsibility to take care of each other simply by virtue of being human--even though that may be "costly" or upset existing arrangements.

If we want to understand the nature of the AIDS epidemic, then we must understand how the structural arrangements within the international system have led us to this point. In essence, these collected writings take a step back from immediate questions of policy and examine the under-girding of these policies in the first place. They want us to question the relationship between the so-called First and Third Worlds. As the editors emphasize in their introduction, "It is becoming increasingly clear that the phenomenon of HIV/AIDS reveals dramatic problems in the global interactions between countries and institutions in the developed and developing world" (p. x).

The editors seek to bring a global bioethics perspective to an issue whose debates have largely been dominated by medical doctors, politicians, and economists. To begin this pursuit, the volume highlights questions of epistemology in the first two chapters. Uncertainty persists as to the true extent of infection on the continent and the reliability of published statistics, and some have used this uncertainty to justify inaction. Alan Whiteside, director of the University of KwaZulu-Natal's renowned Health Economics and HIV/AIDS Research Division (HEARD), provides the stark realities of the extent of the AIDS pandemic in Africa. Whiteside shows that, regardless of how one collects the statistics, AIDS infection rates in Africa continue to increase. He augments his statistics with a careful analysis of the disease's impact, noting that AIDS will take a dramatic toll on the continent even if there were no further infections. The second chapter more directly addresses the reliability and validity of these statistics. Acknowledging that the current statistics may not be completely accurate, the authors lambaste leaders who hide behind such uncertainty to justify inaction. Trends clearly demonstrate that the AIDS pandemic is getting worse throughout the continent, and this fact should be more important than exact infection rates. This opening section provides a rousing call to arms, clearly demonstrating the nature of the problem and setting aside the squabbles over exact numbers.

Having established the pandemic's extent, the second section (chapters 3 through 6) places AIDS within a broader ethical context. The authors seek to engage philosophical questions about distributive justice, the structure of the international system, and issues of poverty, illiteracy, and the status of women with the spread of AIDS throughout Africa. Without understanding these questions of international ethics, this section posits that we cannot truly comprehend how and why AIDS has had such an impact in sub-Saharan Africa. Echoing the previous section, the authors assert that we cannot allow the complex interdependence between AIDS in Africa and the international system to justify inaction. Waiting until we completely understand the nature of these relationships will condemn millions to die, so the authors encourage us to think about what can be done now to ameliorate the problem. Unfortunately, the question of how to respond is left unexplored. Should we take action for the sake of taking action, and how much information do we need before we can craft effective, beneficial responses? While waiting for complete information before taking any action is obviously wrong, could taking action for the sake of taking action not cause just as many problems or encourage inappropriate responses? The difficulty is determining how to take appropriate action in the face of incomplete information, and it is not clear how (or if) we can resolve this concern. In a discussion of ethics and obligations, though, it seems important to at least tease out this balance. It is not ethical for the international community to ignore its obligations to those with AIDS, but neither is it ethical to rush to implement programs that may inadvertently cause more harm.

The final section, and the bulk of the book (chapters 7 through 13), focuses on specific ethical issues on AIDS care in Africa. How should we prevent mother-to-child transmission of HIV? How do we ensure access to life-prolonging antiretroviral drugs? Can we develop an effective AIDS vaccine while still respecting the dignity and rights of test subjects? These chapters provide concrete, in-depth, and nuanced explorations of some of the most pressing issues for stemming the spread of the AIDS epidemic in Africa. This section also demonstrates the complexities of these issues, as the authors do not all agree with one another. David Resnik, for example, argues in chapter 7 that international pharmaceutical companies have a moral obligation to develop and provide AIDS drugs for developing countries, but that intellectual property rights still have an important and beneficial role to play in the international community. Udo Schüklenk and Richard Ashcroft, in contrast, present a consequentialist argument to assert that public health emergencies like AIDS justify compulsory licensing of pharmaceutical patents. Later chapters seek to tease out the relationship between the need to develop and test an AIDS vaccine that will work for adults and children and the use of Africa as a testing ground for pharmaceutical research sponsored by Western companies. This section highlights many important issues without providing easy answers but grapples with important issues and shows how applying ethical understandings can contribute to our responses to Africa's AIDS pandemic.

Lurking in this section, though, is an essentialized notion of "the African" that may actually work against the very changes to the international system the authors hope to provoke. Many of the authors rightfully note that racism and stereotyped images of Africa encourage a lackadaisical response by the international community. However, making appeals to "traditional African values," as Godfrey Tangwa does in his chapter, paints all of sub-Saharan Africa with the same broad brush. This is not to argue against the importance of considering and valuing local knowledge (Tangwa's larger point), but rather calls attention to the tensions in speaking about sub-Saharan Africa as a unified whole. If we ignore the diversity of understandings and contours of, and responses to, the AIDS pandemic throughout sub-Saharan Africa, our generalizations will work against integrating an ethical perspective into our policy responses.

Van Niekerk and Kopelman's volume is a welcome addition to the burgeoning literature on AIDS, Africa, and the international community. With all the debates about whether AIDS represents a threat to national and international security, the contributors to this book provide a needed reminder that we are fundamentally talking about peoples' lives when we talk about the AIDS pandemic. With luck, this book will help spur a needed reconceptualization of the scope and nature of the AIDS pandemic.

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Citation: Jeremy Youde. Review of Niekerk, Anton A. Van; Kopelman, Loretta M., eds., Ethics and AIDS in Africa: The Challenge to Our Thinking. H-SAfrica, H-Net Reviews. December, 2006.
URL: http://www.h-net.org/reviews/showrev.php?id=12623

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