PHA-Exchange> AIDS, EMPIRE,AND PUBLIC HEALTH BEHAVIOURISM

[Claudio]

> AIDS, EMPIRE, AND PUBLIC HEALTH BEHAVIOURISM (edited)
> Sanjay Basu
>
> There is a pervasive "health belief model" that seems intuitive and
obvious:
> if people just  know how HIV is transmitted (and stop being in "denial"
> about it) --
> the rhetoric goes -- the transmission of HIV will diminish . Sounds
> credible enough; but this argument has been consistently promoted by a
group
> of public health workers and international financial institutions
> who ignore most of the available data we now have on AIDS prevention
> initiatives. While the development banks and others have promoted  the
> Ugandan case as a "model" , the Ugandan "model" appears to be promoted
> without much examination of the data.
> Certainly, prevention initiatives in Uganda have reduced HIV prevalence
in
> certain populations. But the prevalence rates have increased in some
> sections of Uganda while decreasing in others; in particular, the
> wealthier urban areas have seen a decrease in infection rates, while
> infection has rocketed upwards in the rural and poorer zones.
>  What is perhaps most problematic about the Ugandan case is that the
> so-called "model" it offers makes
> several wrong assumptions. Given that the top epidemiological predictor
for
> HIV infection around the world is not "risk behaviour" but rather a low
> income level, those most vulnerable to infection will not benefit
> from a model focused on "education" -- a model that assumes people in
> poverty have the agency to control the circumstances of their lives, even
in
> the context of gender inequality or in environments without income
> opportunities other than trading sex for money. Those most at risk for HIV
> often do  know how the virus is transmitted, and even in the highest
> prevalence  areas have sex rates lower than in many regions of the U.S.
and
> Japan  .
>
> Sex is not as much the issue as the context under which sex occurs, yet
> several social scientists studying AIDS are guilty of trying to define an
> African "system of sexuality" and render sexual behaviour the
> problem rather than examining why sex among the poor seems to lead to  HIV
> transmission so much more often than sex among the wealthy.
> "Culture" (whether a distant African one or a "culture of poverty" among
the
> poor in wealthy countries) is often described as a barrier to effective
> intervention, assumed to be a fixed, unalterable thing defined by the
> dominant groups in power, while the marginalized have no culture
themselves
> or are guilty of having a sub-culture that renders  them vulnerable to HIV
> or promotes crime and delinquency. Culture, denial, stigma and conspiracy
> theories are taken to be  the causes rather than the effects of social and
> economic problems. At other points, culture is focused upon to devise
> "culturally-competent" solutions to change the low efficacy of HIV
> prevention initiatives .  In this context, even after messages are adapted
> to "local norms" , "providing information about health risks changes the
> behaviour of, at most, one in four people -- generally those who are more
> affluent and better educated" .
>
> In response to accumulating data that the majority of education
initiatives
> are failing, the public health community is now committing another
> behaviouristic mistake; instead of examining the political and
> economic contexts of prevention, it has now returned  to a colonial
> rhetoric: claiming that the inefficacy of such
> initiatives is due to the individualistic nature of the interventions,
> ignoring the "collectivist African traditions"  The context of illness,
and
> its relationship to their position in the economic field of relations, go
> unquestioned. Now, public health behaviourism aims to solve HIV
transmission
> by holding "group rituals" for education -- so, perhaps,
> the "self-esteem" problems can be pushed aside as "traditions" solve  all
of
> the barriers to effective HIV prevention.
>
> What this rhetoric ignores and often disguises is that the background for
> increasing HIV transmission is a background of neoliberalism -- a  context
> where the movement of capital is privileged above the ability
> of persons to secure their own livelihoods. Increasing migration is
> correlated precisely to the break-up of marriages as rural farms are
> destroyed after the liberalization of markets results in sharp drops in
> primary commodity prices; (mostly male) labourers travel to urban areas
to
> work. The "rural women's epidemic" of HIV -- that is the sub-epidemics of
> women in rural zones who have been infected by their migrant male husbands
> (most of whom have already died at the time of surveys) -- is  not so
> "surprising" or "unusual" in this context .
>
> AIDS, then, is a symptom as much as it is a disease. Public health
officials
> have not strongly voiced their opposition to   focuseing on the
> "cost-effective" prevention initiatives instead. The "prevention versus
> treatment" dichotomy should have been defeated by the numerous models
> indicating that access to vital health resources like antiretroviral drugs
> is part of the process of improving livelihoods, rather than being
> dichotomously opposed to effective disease prevention. Indeed,
> effective treatment provision often helps to reduce stigma, denial and
> blame, in addition to reducing HIV transmission. Brazil has  certainly
> demonstrated this definitively, having reduced HIV prevalence  after
> providing universal access to antiretrovirals.
> Despite being threatened by the US Trade Representative for producing
> generic medicines, Brazil has allowed the use of generic medicines,saving
> the country hundreds of millions of dollars and reducing HIV  prevalence
by
> over 50% .
>
> The claim has been that such measures are not "cost-effective" in the
manner
> of education initiatives . But "cost-effectiveness" is not  based on a law
> of nature -- in its current form, the means for calculating such
> effectiveness assume that distinct health  interventions are competing
with
> one another, as if all health outcomes were pulling from the same pot of
> money, and the overall effect on
> society will be discrete, whether or not a plague is taking place. As WHO
> senior advisor Jim Yong Kim recently declared, "For years, we have assumed
> that health spending must be pulled from a fixed pot of money, without
> examining who determines how big the pot is or how ill  health plays upon
> the maintenance of the economy and general society."
> Brazil decided to counter the World Bank claims about the
> "cost-ineffectiveness" of its programs by calculating the
> "cost-effectiveness" differently; when it took into account the cost of
> hospitalizations saved by properly treating AIDS patients and thereby
> preventing them from having recurring opportunistic infections (reducing
> hospital visits by 80%), and included the costs of mass death
> to the Brazilian economy, the cost of antiretrovirals suddenly seemed
quite
> affordable .
>
>  According to the industry's own tax records (obtained from the Securities
> and Exchange Commission), Merck
> this year spent 13% of its revenue on marketing and only 5% on R&D,
Pfizer
> spent 35% n marketing and only 15% on R&D, and the industry overall spent
> 27% on marketing and 11% on R&D.
>
> Most AIDS drugs were produced under significant public funding, and 85%
of
> the research (including clinical trials) for the top five selling drugs on
> the market were produced through taxpayer funding.
> Meanwhile, all of sub-Saharan Africa constitutes only 1.3% of the
> pharmaceutical market, so as one former pharmaceutical executive put it,
> providing generics to this market would result in a profit loss equivalent
> to "about three days fluctuation in exchange rates" . But the drug
> industry's fight for this market and middle-income
> country markets is serious, as the growing inequality in poor countries
> under the context of neoliberalism manufactures a new market among the
> wealthy and a sector for industry expansion .
>
> The public health community uses varied examples  to suggest  that they
have
> no options besides meagre education-based interventions.
> What the health community ignores is that that public health must be  less
> about coercion and more about facilitation.
> When we examine within-country inequalities, we begin to see the major
> trends -- that the poor (even the relatively poor in wealthy nations)  are
> consistently those marginalized in the context of AIDS, whether
> they are located in the poor neighbourhoods of Washington D.C. or the
> mining fields just outside of Johannesburg.
> AIDS is effectively a symptom of Empire, which operates by producing
> inequalities everywhere, keeping resources inequitably distributed so that
> they may be accumulated by a few, and rendering problems like disease a
> side-effect of capital accumulation.
>  Therefore, the current anti-AIDS efforts bolster and disguise the
> mechanisms of Empire. AIDS becomes the
> product of individual irresponsibility and anonymous Third World
> destitution -- the plague captured in pictures of dying babies and  public
> health saviours desperate to convince the natives to adopt better hygiene
> practices. To expose this rhetoric's basic fallacy will require serious
> questioning of public health's behaviouristic trends,
> as well as the dominant economic and political themes that render HIV a
> plague of the poor.
>
>