PHA-Exchange> AIDS Policy Critique (excerpts)

[Claudio]

From: "Dr Debabar Banerji" <nhpp at bol.net.in>
>
> WORLD AIDS DAY: THE CLOCK IS STILL TICKING
> Hein Marais
>   AIDS. It killed roughly 3 million people last year, most of them poor,
> and most of them in Africa. Between 34 and 42 million people are living
> with HIV. Absent antiretroviral therapies, AIDS will have killed the
> vast majority of them by 2015.
>
>   In such a world, time can seem a luxury, and the rigours of critical
> enquiry an indulgence. We need things done now, yesterday, last year.
> Indeed, an overdue sense of urgency has taken hold in the past five
> years - much of it thanks to relentless AIDS advocacy efforts. All this
> has helped put and keep AIDS in the spotlight. It has popularized
> knowledge of the epidemic, helped marshal billions of dollars in funding
and goad dozens of foot-dragging countries into action. It has worked
wonders.
>
>   But alongside these achievements are some troubling trends. There has
> emerged a  misleading  sense of certitude steering institutional
> responses in ineffectual directions. Awkward gaps are cleaving
> the AIDS world - gaps that detach advocacy  from epidemiological and
social research.
>
>   Strong advocacy tends to convey unequivocal information.
> But in achieving this, vital complexity and ambivalence is often
> snipped and siphoned out. At times, research findings are casually
> interpreted or contradictory evidence is ignored. Sometimes intuitive
> reasoning is made into empirical evidence.
>
>   All this occurs in good faith - and with the pressures of time and the
 need to spur countries into action. But it shouldn't stand in the way of
doing the right things and doing them properly. And that's the danger we're
flirting with at the moment.
>
>   Effective advocacy is not simply a neutral catalyst - all the more so
when
> the advocacy carries the imprint of key donors and multilateral agencies.
This has very practical consequences.
> Big-gun advocacy often prefigures key elements of AIDS programming around
the world. We are seeing AIDS advocacy (and  policy) 'interpreting'  AIDS
research and analysis.
>
>   Some examples. By the early 2000s the view that conflict
> led to rising HIV rates was in wide circulation. Evidence for this
assertion was scant. It now appears that chronic conflicts might actually
have curbed the spread of  HIV by limiting mobility. It might be that the
threat of a
> surging epidemic is greater as peace is recuperated and as normality
> returns in post-conflict settings. The lesson? Assumptions, no matter
> how logical they seem, should be tested before they're paraded as
> facts.
>
It is becoming increasingly evident how multifaceted and
> complex the responses of people and systems are to the epidemic.
>
>   One example is the understandable temptation to distil generalized and
> ubiquitous "truths" from highly localized  research findings  to
extrapolate them  to all of a country or continent. From this there
> might emerge a claim that, says, "AIDS is cutting agricultural
> productivity by one-third in Africa". In advocacy terms, of course,
> this has great currency. But it matters that the statement is inaccurate.
>
> Neither the epidemic's effects nor the responses they elicit necessarily
adhere to a predictable, homogenous, linear paths. This has important
bearing on the kinds of policies and interventions. Reality is rendered
mechanistic
as a predictable sequence of events.
>
>   Another example.  There is ample evidence
> showing that the effects of AIDS in rural households, particularly
> those engaged in agricultural production, are pernicious.  But then came a
grand leap of logic. With little but anecdotal evidence, a causal and
> definitive link was asserted between the AIDS epidemic and the food
> shortages.  The reasoning hinged mainly on reduced labour inputs (due to
> illness and death of working-age adults). But these inputs
> figure among a wide range of variables needed to achieve food security
> - including marketing systems, food reserve stores, rain patterns, soil
> quality, food prices, income levels,  etc. It is difficult, perhaps even
impossible to unscramble the effects of AIDS on rural communities and food
security from economic, climatic, environmental and governance developments.
>
>   Singling AIDS out as a primary factor is a lot easier than
> tackling the other, more prickly factors - many of them
> tied to formidable interests and forces - that are at play. But it can
> be misleading and tempt short-sighted policy responses.
Policy responses are more likely to make a difference if AIDS is made to
take its place alongside the other micro and macro culprits. The
over-privileging of AIDS lets decision-makers off the hook by endorsing
fashionable courses of action that can fail to go to the heart of the
matter.
>
>   The ground zero of this epidemic is where community and household life
> is built.  There's the danger, though, that unless these mechanisms are
buttressed with other structural support, we may end up fencing off much of
> the AIDS burden within already-strained households and communities.
> Yet, such forms of structural support have been systematically
> neglected in many of the hardest-hit countries. Indeed, much of social
> life has been subordinated to the reign of the market and the state
> shorn of its ability to fulfil societal duties.
>
   Overall, a potentially treacherous distance is opening between the
> imperatives of advocacy and outlines of big-league programming, on the
> one hand, and rigorous epidemiological and social research and
> analysis, on the other.  Part of it is inflected
> with institutional "cultures" and ideologies. Part of it is
> panic-induced; it's 2004, and we can count the national "success
> stories" against the epidemic on one hand.
>
>   But part of the problem also lies in a failure to reconcile  AIDS - as a
short-term emergency and a long-term crisis. It's become second-nature to
hitch the word "AIDS" to "development". Google that phrase and the search en
gine will fling 5 million hits back at you. AIDS advocacy  has
> assimilated very little of the critical knowledge built in development
> theory and practice over the past quarter century.
> There is precious little genuine, multidisciplinary rigour evident in the
> AIDS discourse. It is as if, once declarative truisms are
> achieved, serious reflection becomes a luxury.
>
>   All this is unfortunate and, ultimately, counter-productive. Because
> AIDS advocacy is not just about sharing vital knowledge, it
> is aimed also at promoting specific types of practice and forms of
> policy. If that knowledge is stunted, we run a real risk of embarking on
> inappropriate action. And all the while, that clock would
> still be ticking.
>
>   * World Aids Day is on 1 December.
>
>   * Hein Marais is a South African writer and journalist. A former chief
> writer for the Joint United Nations Programme on HIV/AIDS (UNAIDS), his
work is focused largely on AIDS and on political-economic issues.