Culpa y coraje: Historia de las politicas sobre el VIH/Sida en el Peru (review)

Historians may face writing about contemporary questions with a mixture of excitement and apprehension—excitement at reaching a broad policy world beyond the typically small audience of fellow-historians, apprehension at the possible simplification of historical arguments in the name of brevity, summary statistics, and facile lessons. In his analysis of AIDS/HIV policies in Peru (evocatively titled Blame and Bravery), Marcos Cueto has faced this challenge with panache. Given the burden of AIDS in developing countries—where more than 32 million people are estimated to have been infected with HIV, as compared to some 1.5 million in developed countries¹ —and the paucity of related historical work (an inverse relationship between disease burden and historical monographs), this is an important story to tell.

Cueto documents three stages in the official Peruvian response to HIV/AIDS: beginning in the mid-1980s with an official distancing, followed by an "illusion of control" (p. 74) from the late 1980s until the mid-1990s, and the more recent attempts at institutionalization of policies around HIV/AIDS. In Peru, unlike the United States, the appearance of AIDS did not rapidly mobilize public health officials, nongovernmental organizations (NGOs), or even medical researchers. Indeed, the immunologist who diagnosed the first AIDS case in Lima in 1983 waited several years to publish his finding—in part because this highly trained researcher was under less pressure to publish, and in part because he and his colleagues (as well as Ministry of Health officials) believed it prudent to await further developments from overseas to mitigate panic, sensationalism, and prejudice. But Cueto makes it clear that this position must also be understood in terms of the country's political and economic situation—hyperinflation, governmental chaos, political violence, and extreme poverty—which paradoxically both made HIV/AIDS seem less pressing and exacerbated its spread. To this day, some countries facing severe problems of infant and child mortality from preventable infectious diseases view AIDS control as a secondary priority, or even a luxury.

In the late 1980s Peruvian policymakers pointed to a relatively low incidence of HIV compared to other Latin American countries, which they explained in terms of less sexual tourism from the United States and Europe and lower intravenous drug use than in countries such as Brazil and Mexico. Into this official inaction stepped the U.S. Navy Medical Research Institute Detachment, which, in the name of U.S. national security, set up a large-scale HIV prevalence study in conjunction with Peru's Ministry of Health, hospitals, and leading university. For several years this study operated as the Ministry's HIV laboratory, testing almost 80,000 people by the end of 1988 at a cost of more than one million dollars. Though the study found only 351 cases of HIV infection at that time, it uncovered severe problems with the country's blood banks. It also revealed a largely hidden and apparently widespread phenomenon of male bisexuality that made the U.S.-developed disease-control categories of "risk groups"—and even the less-stigmatizing replacement, "risk behaviors"—of little use in the Peruvian context.

Cueto is careful to note the capacity of Peruvian researchers and policymakers to mold the Navy program to local needs, but he also points to the persistent local perception that AIDS control in Peru was and remains generously funded and guided by foreign donors, with insufficient participation by the growing number of NGOs, patients, and...