Epidemiologists social scientists and the structure of medical research on AIDS in Africa. Comment.

This commentary on the Packard and Epstein critique of AIDS research in Africa reiterates some of the important points of the discussion. It is noteworthy that the paper challenges a dominant epidemiologic paradigm and makes some accurate albeit uncomfortable historical comments. Although the argument is strident it is also a familiar clash between a successful biomedical paradigm and a weaker social science perspective. It is pointed out that AIDS prevention efforts were medicalized and emphasized individual behavior change. The argument is persuasive in depicting the interpretation and explanation of AIDS as based on promiscuity and exotic risk-taking customs in stipulating this behavior as inherent in African character and culture (not multiple and complex situations of current political social and economic life) and lacking in social science input in a multidisciplinary effort. Mechanistic explanations replaced multicausal explanations. The strengths and limitations of the paradigm are sharply outlined. While the biomedical paradigm gives the reality of the HIV virus and the epidemiological one maps the distribution of disease and seropositivity these are insufficient to help in changing the pattern of distribution. A noncontroversial multidisciplinary approach should be pursued as well as social policy or behavioral research. Political strife migration urbanization and other changes are an important context to consider in terms of research policy options. The question is posed as to the whereabouts of social science researchers on urbanization social change and the spread of new diseases. Anthropologists are identified as focusing on exotic customs to demonstrate the importance and relevance of the discipline. The practices reported out of context were mapped against reported HIV prevalence and represent the worst sort of correlation fishing expedition. It is pointed out that the readiness of authorities to accept African immortality is offset with a counterproposal that alternative explanations (needles sticks in urban and traditional medical procedures) were important. However there is strong evidence in support of the sexual pathway as a primary mode of transmission. But the point is well made that behavioral social political and economic factors have not been addressed by current research efforts. Research agendas which illuminate the complex interactions are important in light of the failure of African AIDS prevention programs.