Where to begin? When we tell stories about Africa we can’t speak without an imported frame of reference, carving up the years into the pre-colonial, the post-colonial era: once upon a time in the golden age, once upon a time in the dark ages that followed. But in South Africa over the last two decades, story itself has been shortened, shrinking to the time-span of a truncated life – thirty years perhaps, enough time to have children of your own and leave them a memory box when you die. Puleng, from Alexandra township, aged 29, weight about 35 kilos, tells her story ‘in one breath’ and pro forma, as if she were part of the government’s initiative to tackle the disease biographically; storytelling has become an organised activity, intended to stem denial and ease stigma, with an exhibition of storyboard biographies travelling among the stricken. Puleng’s is a township story from the apartheid years: family breakdown, alcoholic mother, vanished father; her good looks and talent squandered; ambitions thwarted; a house burned down, a brother killed by the police; then the arrival of the virus, contracted from a man who tells lies. And now, the need to plan one’s funeral.
Didier Fassin, who recorded Puleng’s words, is a Paris-based sociologist, anthropologist and doctor of medicine, with extensive fieldwork experience in South Africa. Many writers have referred to the ‘mystery’ of Aids in Africa; the chief puzzle is why rates of heterosexual transmission are so high. Why, Fassin asks, should the mystery yield readily to outside investigation? South Africa in particular is not a transparent society. But, he says, ‘my purpose and hope here is to affirm the principle of intelligibility.’ He reads the epidemic not so much through medical facts, statistics and case histories as through a history of how we think about Aids and why we think as we do. He wants to understand the epidemic phenomenologically, and not merely through the experience of individuals but of communities, not just in the light of the present but of the past; above all, to understand it as an experience of the body, the site where the past has made its mark as surely as it has made its mark on the landscape.
Helen Epstein is an American molecular biologist who became involved in Aids studies when she went to Uganda in 1993 to work on a vaccine, her role being to determine which sub-types of HIV were prevalent there. Since then, she has visited, studied and written about the other countries in sub-Saharan Africa affected by the crisis. None of these countries can act as a case study. Each has a different experience of colonialism, a different narrative of independence, a different self-image; accordingly, the epidemic has been viewed differently, tackled differently. Her well-organised book is practical, concrete and full of hard information, but it lacks nothing in subtlety; she is conscious of the ambivalence and complexity that hedge all discussion of Aids. She extends many of Fassin’s observations and shows that they are not unique to the society that suffered under apartheid; her wider focus helps us to see the influence, economic and social, that South Africa has exerted over the whole region. Epstein’s book began life as series of articles published in the American press. Occasionally, the text shows this by some overlap, though with such complex material a reprise is often welcome. Fassin, who has read some of Epstein’s earlier work, casts doubt on her credentials, but her scientific background, lucidity of expression and habit of wide-ranging inquiry lend her book authority and accessibility.
Taken together, the books present a desolating account of pain and loss, hypocrisy and cant, corruption and incompetence, suffering which is almost – but not quite – unspeakable. Epstein’s book is the kind in which acronyms proliferate; it has charts showing the transmission networks of HIV, ‘arranged so that readers may thumb through them, as with a “flip-book”’. Fassin’s is a self-doubting text, fascinating and difficult, in which a shack is an ‘ephemeral construction’. In the end, their conclusions draw closer than the reader could have foreseen. Neither allows one to dwell for long on the problem in the abstract. The body is always present, in its unfathomable singularity, and repulsion as well as compassion finds its place in the story. Epstein says: ‘Aids can be a lonely disease. You die slowly, in great pain, and many people are frightened of you.’ Fassin relates the words of a young woman volunteer in Alexandra township; asked what was most distressing about her work with Aids patients, she replied with a directness he found devastating: ‘The hardest in this work is when you find maggots in the bedsores.’
Fassin credits Desmond Tutu with the phrase: ‘Aids is our new apartheid.’ The West pities South Africa as a stricken country, and sees a kind of cosmic unfairness at work: sees a country hit by the terrible tragedy of Aids at a time of national regeneration. But there are problems with this view. For one thing, it splits off South African experience from that of the countries around. And also, it assumes that apartheid had some kind of final curtain. If we look at it as a system for running a country, we can say, ‘it is over’; but we can’t delimit its effects. What many in the West see as distinct stories – the beginning of reconstruction, the devastation of Aids – are intimately linked in the bodies of those who have lived through an era of South African history. Fassin hopes to show how the past interpenetrates the present, how deeply it is knitted into the experience of disease, death and survival. Should South Africa dwell on its past, or not? Perhaps it seems extraordinary that any society would entertain a project of national forgetting. But it has recognised that certain erasures may be politic, if a whole society is not to collapse into eternal recrimination and demands for reparation. At the end of apartheid, the national mood was to look forward. For the activist, the future was what counted. Now the happy horizon has shifted, the virus has collapsed the nation into a dense, curtailed present.
Thabo Mbeki has asked, what is a just society? His answer: a society that remembers. Yet South Africa might be said to have no collective past, no shared history. Fassin says that the republic’s history is not to be found at the Voortrekker Monument or even at the Apartheid Museum, but in ‘words and gestures, silences and attitudes that expose the grim realities experienced by those who have been on the wrong side of history’. You could not grow up under apartheid and be blind to the experience of the body; rights depended on the colour of the skin, on measurable biological attributes inseparable from identity. Long before the virus came, biology was destiny. Life was so fractured, so dehumanising and precarious, that the state’s ideology impacted on the most personal and intimate negotiations; the catastrophe of Aids has imported the old inequities into a new situation. Now as then, the body has no frontiers where politics stops.
One of Fassin’s chief intentions is to shed light on the scientific dissidence of Mbeki, which to Western observers has seemed so peculiar and destructive. Epstein explains succinctly:
He publicly questioned the relationship between HIV and Aids, claiming the disease was not caused by a virus, but by a mysterious syndrome resulting from poverty and malnutrition; it was more common in Africa because African people had been physically weakened by centuries of humiliation and oppression. It was no wonder they were more susceptible to tuberculosis, wasting and other symptoms that looked like Aids. To Mbeki, HIV tests were meaningless and Aids drugs were toxic poison, foisted on Africa by a venal pharmaceutical industry bent on exploiting the poor.
Epstein describes his dissent as ‘a public health disaster’. It alienated the South African government from the international scientific and medical establishment, and antagonised Aids campaigners within his own country. The government failed to roll out an antenatal programme to stem mother-baby transmission, which would have been well within the budget of the health ministry. It also refused to back an antiretroviral programme, Mbeki angrily questioning the use of giving sophisticated drugs to people who didn’t have enough to eat. Such a programme certainly has drawbacks. The drugs have side-effects, sometimes severe. The task of administering them and following up patients diverts health workers from the treatment of diseases that are cheaper and simpler to treat, but which are potentially fatal. Furthermore, antiretrovirals serve only to hold the disease at bay; the virus mutates, so that in time more sophisticated drug cocktails are required, and these are expensive, largely unavailable in Africa, and test health workers’ expertise and patient compliance. And yet it seems clear that if they had been used early in South Africa, antiretrovirals might have preserved thousands of lives.
The decision was reversed in 2004, but the government’s attitude is still equivocal. Last month, Mbeki sacked his popular deputy health minister, who has been active in treatment promotion and has built bridges to the orthodox medical community; the five-year plan she formulated, which had won widespread backing, is now left in the hands of the health minister, Manto Tshabalala-Msimang, known as ‘Dr Beetroot’ for her promotion of vegetables as a cure. If this is an African disease, the dissidents say, there must be an African treatment. There have been several would-be miracle cures, Fassin says, developed by local researchers and announced without proper testing: ‘Each announced discovery appears to serve as revenge for the colonial and post-colonial past; and, at the same time, any reservations expressed by representatives of official science are attributed to ulterior motives with racist overtones.’
In the years since Mbeki declared himself a dissident, the debate has been conducted in the most bitter and personal terms, each side flinging accusations of racism and bad faith and murderous intent. In 2001, a newspaper headline asked: ‘Has Mbeki heard of Nuremberg?’ Orthodox believers have denounced his position as irrational, marginal and paranoid. The West sees it as a product of local incompetence and error, an opportunistic alliance between a coterie of corrupt politicians and quack scientists. Mbeki has been urged to ‘leave science to the scientists,’ as if scientists possess a purer form of knowledge, which is value-free and can be abstracted from the body politic. Such was the derision to which Mbeki’s view was exposed that it became very difficult to question statistics, interrogate doctors’ assumptions, or question the ethics and protocol of drug testing without being accused of ‘denialism’. Fassin’s own position on the science is orthodox, but he doesn’t think it is enough to denounce Mbeki’s view as irrational. ‘Saying that poverty causes Aids is inexact, especially if such a statement serves to exclude its viral aetiology.’ Yet he believes that ‘there is a profound truth behind the factual error.’ Much of his book is an attempt to illuminate that truth, and to link the ideological structure of the controversies – controversies that have made politics into necropolitics – to the ideological structure of South African society.
To make that link we need to explore the frontiers of history and memory. Fassin speaks of the past as existing in two dimensions. On the one hand, there is the past of the historians: objectified, distanced, depending on documents, archives, artefacts. On the other hand, memories of individuals, which are subjective, and in which what is repressed and unsaid is also significant. These two overlapping representations can sometimes compete, for they are founded on different schemes of truth-telling. Like a psychoanalyst, the ethnographer is in dialogue with the living, yet he has no access to their interiority: his job is to objectify, like a historian. He is shot through with the terror of interpretation, and he is alive to all the unconscious prejudices that shape what can be heard; yet if he does not interpret, his material becomes simply exotica, to be placed in a cabinet of curiosities.
These scruples may seem academic, this unease indulgent, when faced with the facts of the epidemic. But consider what the Truth and Reconciliation Commission has been trying to do: to legitimate the memory of individuals, and at the same time to produce an official version of the past, one that everybody can sign up to. In its hearings, different realities collide. ‘Reconciliation’ is a project poised between remembering and forgetting, and the problem (or so it seems to me) is that in the case of South Africa memory, personal or collective, is often accompanied by crippling shame; whether you have been victim or victimiser – or cannot agree which role you occupy – you are ashamed to have lived under apartheid, to be the relict of such a system. Shame is what makes forgetting most urgent, and also what makes it impossible. And the virus has arrived to intensify stigma; South Africa, for so long a political untouchable, so far off the moral map, is ravaged by a disease which from its inception has been identified with sexual shame. Fassin says: ‘The South African government and maybe society as a whole push away the intolerable,’ and try to select an alternative truth; and what is intolerable is not only the disease itself, but its stigmatising representations. Mbeki has accused the West in these terms: ‘Convinced that we are but natural-born, promiscuous carriers of germs, unique in the world, they proclaim that our continent is doomed to an inevitable mortal end because of our unconquerable devotion to the sin of lust.’
The first Dutch colonisers who arrived in the Cape read the new land through Christian myth, taking African women as a reminder of Man’s fall, as examples of unselfconscious, unmediated animal sensuality. If from among the legions of the dead there is one single ghost that haunts the Aids narratives, it is the ghost of Saartjie Baartman, taken to Europe in 1810 and exhibited as ‘the Hottentot Venus’. After her death, her dissected remains were presented to a Paris museum, pitiful remnants used to furnish a pseudo-scientific discourse on racial difference and inferiority. In South Africa’s history it has been meaningless to say that one human life has the same value as another. Mbeki’s dissent on Aids becomes comprehensible if you understand how public health projects have always – not just in South Africa – been closely linked to political projects: projects designed to put the poor at a safe distance from their masters, and to guarantee a pool of physically strong workers. This is not to deny the existence of humanitarian concern, but to point out how often it goes hand in hand with a stigmatising process: the poor are unclean, they are not like us, they are more like animals. In South African history, health and hygiene considerations offered a rationale for physical segregation, which then became ideological; you put the others beyond the city wall, and then make up a theory about why they ought to be there. The ‘mystery’ of the incidence of tuberculosis in the African population was solved by deciding that the native was weakened by his contact with civilisation. City habits exposed him to infection; in crowded conditions his precarious morals would break down, and syphilis would spread. His body – closer to nature, for better or worse, than the bodies of whites – was actively harmed by inclusion in the polis. It became a thing to be defined, counted, regulated and excluded, or admitted under strict conditions when it was necessary to have it work in the factories and mines. It became a thing to be cast aside in sickness: sent home, exiled from the city, placed out of sight.
It also became a thing to be feared. A Johannesburg newspaper of 1893 reports the attempted rape of a white woman by a black servant: ‘Beware of your houseboy, for under his innocent front may be lurking and lying latent the passions of a panther, or worse.’ That word ‘latent’ is interesting, suggesting as it does what is hidden perhaps even from the possessor of the power; suggesting arrested development which ultimately you cannot arrest, for though you may call your servant a ‘boy’, you will learn in the worst possible way that he is a man.
The most odious document Fassin finds to quote is an 1894 article published, presumably in all seriousness, in the South African Medical Journal. ‘Why has the white master got syphilis?’ is the problem posed. We must look for the focus of infection. ‘This in nine cases out of ten is the servant,’ who is ‘generally a church-native’, and ‘wears stockings’. She has kissed the baby; the baby gets syphilis; papa treats his offspring to ‘a chaste and paternal kiss’ and next thing ‘gets a hard sore on his glands and prepuce’.
There is no need to multiply examples. Both Fassin and Epstein are alive to the sorry history of cholera, TB and sexually transmitted diseases in the mines and wherever population is concentrated without adequate public health facilities. Once you understand this history you begin to see why a common reading of the epidemic among black South Africans is that it is a genocide project, planned by the whites to kill off the blacks and have the land to themselves. When you look at how medical resources were distributed under apartheid, this reading becomes intelligible. Fassin says that in the 1980s, after the creation of the ‘homelands’, half the country’s population shared 3 per cent of the doctors.
Wherever the virus spreads, rapidly mutating misinformation spreads in its wake, and multiple fables tyrannise the imagination. Aids is caused by antiretrovirals, by witchcraft, by the CIA. It’s the freemasons, it’s extraterrestrials. If you hang up a certain brand of condom in the sun you can see the HIV virus squirming around inside it. Rumours may be culturally intelligible, or they may take novel forms. A male patient told Fassin that the virus had been spread through injections of Depo-Provera, a long-acting contraceptive; an interesting rumour, this one, since it places the blame on both the whites and the women, and exonerates the African male. Like many of the rumours, it is not incomprehensible; Depo-Provera has long been a controversial drug because of the extent of the testing that was carried out in the developing world and on poor women, and there is one clinical study that suggests an increased HIV risk in users, though the relationship is unlikely to be causal. Sometimes you can guess how the more baffling rumours start. In Alexandra township, Fassin was told that the virus had been injected into oranges; it was citrus fruit that was spreading the plague. Medical staff learning to give injections often practise on oranges before they are let loose on people; one understands that it’s not the job of an anthropologist to judge between stories, but perhaps in not telling the reader this, Fassin is guilty of what he calls ‘opacity’. Rumours need not be natural growths; they can be planted. Epstein details a story spread as far back as 1986, that HIV was developed by the Americans in a military laboratory and introduced into Africa by British and American doctors; the authors of the rumour, ‘assumed to be Soviet propagandists’, were careful to tailor it to every district, putting in the names of local white doctors.
Yet there may be a grain of truth in the notion that Aids was spread by doctors: reused needles, blood transfusion, old techniques of smallpox vaccination – all these may have been implicated in the untraceable beginnings of the epidemic. We know from court cases brought since the end of apartheid and from the proceedings of the Truth and Reconciliation Commission that the government up to the 1990s supported research into germ-warfare agents which could be used, selectively, on opponents or on sections of the civil population. Very recently, the law and order minister under the old regime was given a ten-year suspended sentence for trying to kill the then secretary-general of the South African Council of Churches; the method chosen by the policemen helping him was to put a nerve agent in the priest’s underwear.
Now that a black government is running South Africa, rumours of high-level malfeasance have not ceased. A township dweller tells Fassin: ‘The ANC wants us to die. Most people with HIV are unskilled, uneducated, unemployed . . . How will the government benefit from us?’ It is natural that apartheid – indeed, colonialism itself – should leave a legacy of resentment and mistrust of authority. Perhaps paranoia is simply a concomitant of civilisation. Whenever there is government there is an ‘us’ and a ‘them’, and whenever that division arises the next question is ‘what are they up to? What are they keeping from us?’ (One day, when the story of the triple-vaccine/autism panic is written, it will not be a story just about medicine, but about society.) In more comfortable times and places, you can hope that rumour and fear will give way to rational persuasion, that consensus will soothe the unease of minorities. But in South Africa, it is the majority who have been ill-used, who are traumatised and embittered. They cannot be expected to read a situation objectively; to do so they would need to obliterate both their own history and their bodies’ experience. And if it is difficult for everyone, in the South African context, to disentangle truth from falsehood, it may be that South Africa’s style, cut off as the country was from the rest of the world, has long been a paranoid style; those who favoured the cultural boycott forget that, though it may have acted as an expression of disgust, it also meant a lamentable absence of reality checks. Towards the end of the 1980s, the far right came up with a theory that Aids had been imported by the ANC, who were planting HIV-positive terrorists in the townships to have sex with prostitutes and so spread the epidemic. Whether they originate with sick, scared and disempowered black people, or with Afrikaners on the run from the future, the rumours mirror each other, and all the reflections are ugly, the distortions of an ugly history.
The epidemic progressed, as both authors show, from a minority concern in the mid-1980s to mass panic by the late 1990s. In South Africa, inequalities in diagnosis and treatment echoed the old inequalities. In 1987, the then health minister put sexual behaviour at the heart of the matter. ‘Promiscuity is the greatest danger, whether one likes it or not. We have to say that. It is a fact.’ So what to do? Preach at people? Give out condoms? With an admirably straight face, Epstein reports on National Condom Week, ‘during which free condoms that had unfortunately been stapled to cards were distributed’. And what she has to tell us about transmission of the virus goes some way to vindicate Mbeki’s angry assertion that it makes no sense to superimpose Western explanations on African reality. Epstein says that it is not promiscuity but concurrency that poses the greatest risk of transmission. Concurrent relationships may be long-term. A man may have a wife and a steady girlfriend, a woman may have two boyfriends who, between them, give her enough money to feed herself and her children. The men in these relationships are not necessarily promiscuous. The women are not prostitutes. Such arrangements are accepted as normal in many present-day African countries, and they derive from a notion of social responsibility as well as from economic need; if you have a child by a woman, although you are married, it is better to maintain a relationship with her, even a part-time one, than to treat her and your child as a mistake. Men and women in Africa, it seems, have no more sexual partners in the course of a lifetime than people in the West. But the effect of concurrency is to create sexual networks which are ideal for spreading the virus. If any one person has a casual relationship, and imports the virus into the network, it spreads fast, being most easily transmitted in the early weeks of infection.
If this is true – and it is very persuasive – then Mbeki was right to say that the problem of Aids has a specifically African dimension; his social assumptions were right, even if his science was wrong. And Fassin is right to protest against the historic assumptions about African sexuality which have driven the notion that promiscuity is the key to transmission.
Yet changing the individual’s behaviour may still be the key to containing infection. ‘Zero Grazing’ was the slogan of the successful Ugandan campaign to combat the virus. It asked people to do something realistic: not to eschew pleasure and overturn their way of life, but to cut down on concurrent partners and limit sexual contacts – if you can’t be good, be careful. Epstein explains that Uganda was the only nation which saw a decline in the prevalence of HIV by 2003. She looks at how this country, devastated by civil war, its health infrastructure collapsed, tackled the crisis not only with drugs but by plain speaking, community cohesion and a vigorous women’s movement. Botswana, peaceful, democratic and with a universal healthcare system, was less successful. Denial does not exist only at government level, Epstein shows. Both these African governments acknowledged the problem and tackled it energetically. But the outcome was different. In Uganda, the virus was seen as everybody’s problem, but in Botswana, entangled in stigma and shame, Aids was something that happened to other people, to bad people, to people in ‘risk groups’. Epstein suggests that Uganda’s grassroots activism and home-based care was more effective than Botswana’s hospital-based services and mass media campaigns.
Unfortunately, in Uganda the gains are becoming losses. HIV rates are now rising again. The ‘Zero Grazing’ campaign has been phased out in favour of the abstinence and virginity campaigns influenced by the American right. Some funding agencies do not like the idea of asking people to limit their sexuality. Others, it seems, do not like the idea of sex at all. It is African self-determination they are quarrelling over, African bodies, which are again being counted and controlled by someone else’s agenda. As research progresses, ironies multiply. Circumcision – a practice to which Fassin makes one slighting reference – seems to cut a man’s risk of contracting the virus by at least 50 per cent. It is also protective of his sexual partners. It is probably the reason HIV rates in West Africa, where circumcision is widely practised, are so much lower than in southern Africa. One can readily imagine the difficulties of introducing the practice where it is not culturally accepted. And yet the Zulu and the Tswana – two of the peoples hardest hit by Aids – practised circumcision in pre-colonial times.
Because of Fassin’s sensitivity to the injustice of white construction of black African sexuality, it is hard for him to speak on a topic where silence is not an option: the topic of sexual violence in South Africa. ‘When history has not been on one’s side, at least its telling should be,’ he writes. Gender politics are not central to his book, but that is not to say he ignores them; he produces some startlingly nasty examples of what happens when sex is not about love or lust but about survival. Astrid, a young woman he meets in Alexandra, tells how she contracted the virus after having been raped by her father. She told her mother, who appealed to the economic facts of life: ‘Because he’s the only one who is working, let’s not put him to jail.’ When it became evident that she was HIV positive, both parents told her she was going to die and washed their hands of her. She ran away from home after reporting her father to the police; he was sentenced to eight years.
Fassin is keen to emphasise that sexual violence in South Africa is not something new – though you would have to be very ill-informed to think that it was. It is its acknowledgment that is new. The West, still fearful, is ready to believe that new and unique forms of wickedness come out of Africa. Instances of the rape of babies and young children – crimes which are hardly specific to that society – have been linked by the Western media to reports of a folk-belief that sex with virgins can cure Aids. But does anyone really believe this? Has anyone believed it, at any time? It’s rather that everybody has heard, or read, that there are stupid people somewhere else who believe it. It is Epstein who nails the ‘myth about a myth’, and finds its antecedents: in America in the 19th century, the same allegations were made about newly arrived immigrants from southern and eastern Europe, who were said to be raping virgins to cure themselves of syphilis.
Epstein is unequivocal about the extent of sexual violence. South Africa, she says, has the highest rate of reported rape in the world; and we must assume that many more are not reported. She explores the ‘scripts of male domination’ that have created this situation. Rape has become an instrument by which men control women – they may target the woman herself, or her children. Concurrent relationships are also, very often, transactional, arising from an unemployed woman’s need to keep a household together. A man who has nothing material to offer a woman is useless, socially adrift and liable to be coercive. Economic empowerment – not just of women – seems vital to the social transformation that must occur if sexual violence is to be stemmed; and these writers agree that, whatever its origins, whatever its route of transmission, Aids is a disease born in poverty and inequality, which brings in its train of disasters further poverty, the breakdown of family and social structures. Wherever she went, Epstein said, ‘when I came to talk to them about HIV, they told me about money instead.’ Her belief is that the crisis is best tackled by modest community-based initiatives run by knowledgable local people who have influence with their neighbours, rather than by multi-million pound projects devised in Geneva or Washington. On her first visit to Africa she was told that there are two kinds of Aids: slim, which afflicts infected people, and fat, which causes bloated bureaucracy, and makes doctors, managers and consultants grow sleek. The inflow of funds has become what Epstein calls an ‘all-you-can-eat buffet’ for corrupt politicians. She is asking one of the big questions of our time: does aid to Africa do anything, except make the donors feel good?
Both authors quote from Mbeki’s overblown ‘African Renaissance’ rhetoric: ‘I owe my being to the Khoi and the San, whose desolate souls haunt the great expanses of the beautiful Cape . . . I am formed of the migrants who left Europe . . . In my veins courses the blood of the Malay slaves.’ It sounds less like renaissance than the last gasp of pan-African romanticism, and is about as convincing as Margaret Thatcher sounded when she took to public prayer. Fassin would not agree. He sees it as a ‘refutation of the morbid ideology that is crushing Africa’.
He requires us to suspend judgment, think more deeply, learn more, reflect critically, be sparing with denunciation. Anthropology is long-term work, which goes against ‘the imperious necessity to act in the world’. He worries that his discipline, attacked from without and vulnerable to its own self-questioning, has missed its way as a ‘form of moral commitment to the world’, losing touch with the Enlightenment project of working out what human beings have in common, and devoting itself to the discernment of difference. He recommends that we set ourselves in an attitude of inquiétude, which he distinguishes from anxiety: the latter paralysing us, the former provoking us to constructive action.
At best – if indeed any good is to be found in Africa’s catastrophe – he believes that the virus offers ‘a resource for the reconstruction of the self’. He sees those who are carrying it campaigning with born-again vigour, and caring for those who are sick; making themselves into cautionary tales, making themselves examples, drawing some meaning from their approaching death. They are turning the brute fact of biological survival into something active, something ethical, moving from an individual experience of pain into a collective experience. He quotes Wittgenstein: ‘I am the only one to know if I really suffer; another person will merely suspect it.’ Philosophically speaking, we may be doomed to that solipsism, but to try to break out of it is a political act. Fassin convicts the West not so much of hardness of heart towards Africa, as of a sort of acedia, an indolence: ‘There is no inequality more disturbing than that by which we decide what is interesting and what is not.’ Epstein says: ‘Everyone seems to know what Africa needs, but sometimes I think our minds are not really on it. Most of us see only Africa’s contours, and we use them to map out problems of our own. Africa is a career move, an adventure, an experiment. It fades into an idea.’ Fassin hears overhead the creaking wings of Benjamin’s Angel of History, surely no longer surprised at the corpses piling up at his feet as he flies backwards towards the future. Epstein hears the beating of the ‘Drums of Affliction’, an alarm signal which says that life and culture are threatened, but also a signal of cohesion, of union in the face of disaster: perhaps, one day, a signal of regeneration, of a healing process beginning its work.