million AIDS deaths already in the worst affected countries. Without
care and treatment, there will be 68 million more between now and
2020.” The global figures on AIDS are terrifying, but the first
reaction of a number of world experts (of other diseases) to the
above announcement at the International AIDS Conference in Barcelona,
July 2002, was indignation. They protested that Peter Piot, executive
director of UNAIDS, must be stealing some of his figures from “their
diseases.” Such is politics in the international health community.
on a grander scale has prevented a rational and effective response
to the AIDS pandemic, which is killing up to a quarter of many southern
African countries’ populations. The real scandal is not the
unseemly scrambling after donor funds, but the imperceptible impact
of international and national responses to AIDS over two decades
of intense and costly activity. In its sobering 2002 report, UNAIDS
states that prevalence is climbing higher than ever previously believed
possible. It is spreading rapidly into new populations in Africa,
Asia, the Caribbean, and Eastern Europe.
third of Zimbabwe’s population is infected and the epidemic
continues to expand even in countries that already had extremely
high HIV prevalence. In Botswana for example, the country with the
highest HIV infection rates in the world, almost 39 percent of all
adults are now living with HIV, up from less than 36 percent 2 years
we doing something wrong? Is the approach ill founded or even fatally
flawed? Neither UNAIDS nor any of its partners are even asking the
question let alone revising their strategies.
A Neo-liberal Approach
over 20 years now, the international AIDS community has persisted
in a reductionist obsession with individual behavior and an implicit
acceptance of a deeply flawed and essentially racist theory.
line with neo-liberal doctrine, it has explained the spread of AIDS—and
the extremely high prevalences in sub-Saharan Africa—in terms
of individual sexual behavior. It has exaggerated the extent to
which people control their lives and circumstances and ignored larger
macroeconomic and political factors and poverty-induced population
vulnerability in terms of seriously weakened immune systems. The
insistence on analyzing this colossal public health catastrophe
in terms of individual behavior has correspondingly restricted the
response to action at the individual level, usually promotion of
safer sex, condom use, and education for prevention.
the impact of these peripheral efforts has been insignificant, although
tired old success stories are still regularly wheeled out for display.
As long as the root causes of AIDS continue to be neglected, such
efforts will remain cosmetic, unsustainable, and exceptions. Average
HIV prevalences in the adult population of most sub-Saharan African
countries are 25 percent. The figures for Europe and most of the
industrialized world are still under 0.1 percent and, in many cases,
under 0.01 percent. Individual behavior cannot possibly account
for this enormous difference, which would imply that people in some
African countries have at least 250 and even 2,500 times more unprotected/unsafe
sex than people in Europe, the U.S., or Australia.
absurdity of this proposition, which has its origins in racist mythology,
is not confronted because assumptions about sexual behavior are
usually implicit. Myths thrive precisely because they are unstated
and therefore rarely subjected to scrutiny. Running parallel to
this dubious proposition is the perverse refusal to confront the
obvious, such as the almost perfect “coincidence” of high
prevalence of HIV/AIDS (and all the diseases of poverty) with the
poorest regions of the earth.
epidemic of gigantic proportions is taking hold in Southeast Asia,
home to an even larger number of powerless and poverty stricken
people. It will be interesting to see if any notion of structural
violence is at last invoked to advance our understanding of the
dynamics of the pandemic or if we will discover that previously
quite “well-behaved” Asians are as “promi- scuous”
fundamental public health lessons of the past 150 years are known
even to lay people. It is well understood that the overall health
status of populations and their capacity to fight off infection
is related primarily to food, water, sanitation, and housing. According
to an article by E. Stillwaggon, “HIV/AIDS in Africa: Fertile
Terrain,” published in the
Journal of Development Studies
(August 2002): “A century of clinical practice demonstrates
that people with nutritional deficiencies, parasitic diseases, generally
poor health and little access to health services or who are otherwise
economically disadvantaged have greater susceptibility to infectious
diseases whether they are transmitted sexually, by food, water,
air or other means.”
in the case of HIV/AIDS, seriously deficient immune systems have
been ignored as a factor of vulnerability and determinant of the
high levels of infection in desperately poor populations.
dictum, “the microbe is nothing, the terrain is everything,”
is still the best summary of century-old public health wisdom. The
focus on individual behavior is almost as absurd in the response
to AIDS as it would be if it were applied to the response to tuberculosis.
A sound public health approach to TB does not exhort people in high
prevalence areas not to breathe too much on each other—not
understanding that they are breathing more or less like every other
human being on earth. It addresses the sanitary, nutritional, and
housing arrangements, which determine their high vulnerability.
and having sex—though not quite in the same category—can
both reasonably be seen as everyday human behaviors. The peculiar
focus on the exotic, the unusual, the immoral, and the illegal has
obscured the simple fact that AIDS is overwhelmingly transmitted
through heterosexual, penetrative, vaginal sex. Few people know
that when AIDS hit the headlines as a “gay plague” in
California it was already a well established heterosexual epidemic
in Africa. The unimportance, in the eyes of the world, of African
people in general, and of African women in particular, may partly
explain this neglect. The common sense interpretation of the facts
is that high risk physical and economic environments, coupled with
dangerously weakened immune systems, leave people highly susceptible
to all kinds of infections including HIV.
A Racist Theory?
fight against AIDS in Africa has been dominated by long-standing
Western prejudices against African sexuality and cultural practices.
A striking example was in the early 1980s, when speculation about
the Haitian origin of AIDS and the role of bizarre voodoo practices
led to a wave of anti-Haitian discrimination. As with Jamaica, the
Dominican Republic, and Trinidad, it turned out that tourists (mainly
U.S. homosexuals) were the most likely source of virus transmission.
It has been pointed out that in the absence of penicillin, the war-ravaged
Europe of the late 1940s would have been devastated by epidemics
of syphilis and gonorrhea.
international AIDS community has pursued a singularly unsuccessful
strategy with religious conviction, rather than with good science
or even common sense. Evidence, in the rather odious academic area
known euphemistically as “sexual networking,” is flimsy.
Rates of sexual activity do not appear to vary much between populations
(though of course there are always groups within populations who
either take more risks or have more risks imposed on them). What
seems to emerge from the literature with consistency is that multiple,
mostly serial, casual, and unprotected sex is common in Africa,
Europe, the U.S., and parts of Asia, with most men everywhere having
more partners than most women (WHO 1995).
rates/types of sexual activity do not appear to have a clear relation
with prevalence of HIV infection. A major multi-site study undertaken
by UNAIDS in four sub-Saharan African cities showed that most parameters
of risky sexual behavior were not consistently more common in the
high HIV prevalence sites than in the relatively low prevalence
implicit assumption that African people have more or less “brought
it on themselves” through their “promiscuity” has
evolved through a superficial, neo-liberal gender analysis into
a much more explicit accusation of African men. If such an apolitical
gender debate has resulted in shifting the blame from all African
people to all African men, it has failed. No one disputes that women,
particularly in developing countries, are not only biologically
more vulnerable to sexually transmitted infections including HIV,
but they are also acutely vulnerable socially, culturally and economically.
Women have to exchange sex for material favors for their own and
their children’s survival in many poor countries. For as long
as they do not control when, where, with whom, with or without protection,
they have sex—they will be at risk.
women in Europe are clearly at far less risk than men in Africa.
If we take as a rough indicator of risk, the average prevalences
of less than 0.1 percent and 25 percent for Europe and Africa respectively,
it becomes clear that neither individual behavior nor gender inequality
accounts for the spread and pattern of the pandemic. Sound feminist
analysis, rooted in social justice, recognizes oppression of women
in poor countries within the context of the oppression of entire
communities of men, women, and children, none of whom have any meaningful
control over their lives.
in sub-Saharan Africa carry a risk of contracting HIV infection
at a rate 500-1,000-fold compared to women in the rest of the world.
This is quite a large difference to explain in terms of African
and European male sexual behavior.
A Disease Of Poverty
common with all sexually transmitted infections (STIs), HIV/AIDS
has a particular relationship to poverty. The poor are more vulnerable
to HIV infection than the rich—notwithstanding transient vulnerabilities
of richer men who can afford to use prostitutes—of which much
has been made. The fact remains that 95 percent of infections are
in developing countries; and more than 70 percent are in sub-Saharan
Africa where over 80 percent of the deaths have occurred. Women
are more vulnerable than men; young women are far more vulnerable
(4 to 5 times) than young men. Oppressed and marginalized “minorities”—blacks
and Hispanics in the U.S., refugees and street children everywhere—are
more vulnerable than dominant majorities.
are plausible explanations, in terms of biological vulnerability,
for the very high rates of HIV transmission among poor populations.
The major biological factors of interest are malnutrition and chronic
co-infection with other diseases of poverty, notably, parasitic
infection, tuberculosis, malaria, and other tropical diseases. These
factors are known to seriously impair and interfere with immune
function, and to be responsible for the bulk of infectious disease—whether
bacterial, viral, or parasitic.
thesis that is proposed for the huge variation in prevalence between
countries is that HIV-negative people whose immune systems are weakened
by poor nutrition and constantly challenged by co-infections are
more vulnerable to HIV infection; and that HIV-positive people,
in the same condition, are more infectious to others. The result
is high population transmission rates.
is no shortage of evidence on the adverse, even devastating effects
of malnutrition, under-nutrition, and specific nutritional deficiencies
on immune function, susceptibility to infection and capacity to
cope, once infected.
term nutritionally acquired immune deficiency syndrome (NAIDS) is
applied to immunological dysfunction associated with malnutrition
in infants and small children. Is it unreasonable to suppose that
a similar mechanism may operate in adolescents and adults and may
be worth investigating and even—as a precautionary principle—acting
on? The average African household is caught in a poverty cycle of
low food production, low income, poor health, malnutrition, poor
environmental sanitation, and infectious disease. Food security,
as primary prevention, should be a priority strategy in the fight
against AIDS in Africa. With water and sanitation, it has the huge
advantage of simultaneously reducing population vulnerability to
all the other diseases of poverty.
brings us to the second major factor, chronic co-infections, most
of which are also related to the failure to meet basic needs. There
is ample evidence that co-infections not only interfere with immune
function, but they also increase viremia—the level of HIV circulating
in the body. High viremia, unsurprisingly, is associated with increased
risk of transmission.
infections, which affect over a quarter of the world’s population,
overwhelmingly in developing countries, may play a particularly
important role in high population transmission rates of HIV and
TB. Some researchers have suggested that in order to control both
these epidemics, parasitic infections must be controlled first.
The only co-infection that has received due attention is sexually
transmitted infection (syphilis, gonorrhea, chancroid etc), which
is known to substantially increase vulnerability to HIV infection.
Prevention and control of STI has been recognized as a key strategy
in the fight against AIDS.
the fact that the modes of transmission are the same for STIs as
for HIV—both are blood borne diseases, which can be transmitted
sexually—has meant that the focus on individual behavior and
individual agency can go unchallenged. This would not be the case
if the co-infection to be prevented or controlled as a factor of
susceptibility to HIV infection were intestinal worms or enteritis.
the exception of some brave and outspoken NGOs, the mainstream international
AIDS community steadfastly refuses to address poverty, powerlessness,
and inequality. It is not that the AIDS community does not talk
about poverty. On the contrary, it is the most fashionable subject
at the moment. Poverty reduction (rather than eradication) is on
everyone’s lips in the alliance of WB/IMF/WTO/G8, the UN agencies
dealing with AIDS, government aid agencies, and “charitable”
foundations, such as Ford, Rockefeller, and Bill and Melinda Gates.
sanctimonious tones, they lament the persistence of poverty, but
in a perverse reversal of logic, they advocate for massive attacks
on a few killer diseases (malaria, TB, and AIDS) in order to “create
prosperity.” No amount of health delivered to Haitians or Tanzanians
today is going to provide them with prosperity tomorrow or the next
day. It will allow them to survive where others die in rather precarious
conditions, perhaps until the next bout of illness.
will protest that the connections with poverty have been recognized
from the start. This is true, but it has invariably been in terms
of the economic impact of AIDS on communities, in particular on
their productivity rather than poverty as the root cause of extreme
susceptibility to all infections including HIV.
when social and economic factors, such as labor migration, exchange
of sex for survival, gender power imbalances and population movements,
have been identified as contributing to vulnerability, the solutions
proposed are still focused on the residual action possible at the
level of individual behavior.
most striking example of this is the provision of condoms at the
pithead of mines in South Africa to tens of thousands of migrant
laborers slaving to bring up gold for white-owned transnational
corporations and to thousands of migrant women selling sex to feed
and clothe their children. Migrant labor and sex slavery are unhealthy—even
life threatening—socially constructed phenomena, which can
therefore be socially deconstructed. Examination of poverty and
powerlessness as root causes of AIDS would threaten these kinds
of production arrangements. They would also imply a fundamental
shift in the international economic order, massive redistribution
of the earth’s resources, and an end to the fantastically exploitative
rela- tions between North and South.
overwhelming power of vested interests confines both the research
agenda and the strategies of the international AIDS community to
the sphere of the individual in order that structural, economic,
and political inequalities neither be brought to light nor questioned.
Declaration of Alma Ata (International Conference on Primary Health
Care) in 1978 explicitly recognized structural inequalities and
macroeconomic factors as determinants of poverty and therefore of
population health status. As this approach threatened the status
quo, it was politically sanitized and reduced to a few technological
interventions. By the early 1980s, neoliberal dogma was already
being imposed in international fora and primary health care had
more or less been abandoned.
the only progress possible in public health today, and in the fight
against AIDS, is a return to the wisdom of Alma Ata—armed at
the turn of the century with 20 years’ more evidence of the
negative health effects of savage, free market neoliberalism. The
“triumph” of capitalism in the Russian Federation, for
example, has been accompanied by the collapse of health services
and spectacular increases in rates of illness and death.
Trillions Rather Than Millions?
sums made available through international aid are pitiful compared
to the sums that would be released through debt cancellation, fair
trade, and measures to end the continued pillage of developing country
resources. These amount to trillions rather than millions. It is
not hard to understand the preference for international aid. First,
it brings about one and half times more back to the donor country
than is received by the recipient country. Second, it is immediately
used to service the debt to Northern banks—far larger sums
than are available to the health and education sectors of debtor
countries. Third, even though it may increase the size of the crumbs
from the rich person’s table, it does not threaten the international
economic order. On the contrary, it deepens the dependency that
is so profitable to the developed countries and so devastating to
is the responsibility of international health authorities to identify
the determinants of health (and disease) and to advocate for policy
and action, which will contribute most effectively to the goal of
health for all, even if this lies outside the health sector. If
food, water, sanitation, basic health care, and housing are the
quickest, cheapest, most effective ways of achieving health for
all, then the international health community should be advocating
these basic needs can only be met when countries’ national
capacities are freed from the strangulation of debt and unfair terms
of trade and from the destabilizing chaos of financial flows then
they must recommend this. If national food security requires a degree
of protectionism rather than unfettered free trade, it must be strongly
advocated. There could be no clearer public health imperative. If
the obstacle to such advocacy is the hand that feeds the international
AIDS community, then the time has come to bite it. That hand is
the alliance of WB/IMF/WTO, the G8—even occasionally the UN—and
the transnational corporations influencing their policies.
beauty of a fair international economic order lies in the fact that
nations, communities, and families left to their own devices are
quite capable of meeting their own basic needs. Removing the obstacles
to self determination is the task to be accomplished.
international AIDS community needs to ally with the tremendous movement
for social and economic justice today. As a start it might wish
to make immediate debt cancellation and the introduction of a Tobin-type
tax its funding source for the first few years, followed swiftly
by the first steps towards fair trade, bringing trillions of dollars
to public health efforts within the long promised new international
A slightly different
version of this article first appeared in
of AIDS Research.
Alison Katz is a member of the People’s