Aids, Empire, And Public Health Behavioralism

In the wake of U.S. President George Bush’s trip to several African nations, and after his State of the Union speech declaring $15 billion of spending for global AIDS prevention and care, American newspapers have rallied in support of the “compassionate conservatism” represented by Bush’s “commitment” to anti-AIDS efforts. In fact, the $15 billion number has turned out to be an inflated figure, as most of the money is recycled from existing spending, with only $1.4 billion appropriated this year (and little indication of renewal in subsequent years) [1]. But while many persons have pointed out the difference between dramatic declarations and actual appropriations, the money’s final destination has been left mostly unexamined. Not only is the funding circumventing the Global Fund for AIDS, TB and Malaria, being spent almost entirely through bilateral USAID initiatives known for their inefficacy (and diversion towards abstinence-only, anti-abortion initiatives), but just as importantly the majority of funds are being spent in line with a common and fallacious public health dogma: that “information is everything”, and preventing the spread of HIV means “promoting education” [1-5].

This “health belief model” 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 [6]. Sounds credible enough. But this logic, often promoted by international financial institutions, ignores most of the available data we now have on AIDS prevention initiatives [2]. For example, while the development banks and others have promoted the Ugandan government’s education program as a “model” (at one point claiming that effective “bereavement counseling” in the country was a reason for praise, rather than preventing deaths to begin with [7]), the Ugandan “model” appears to be promoted without much examination of the country’s records. Certainly, prevention initiatives in Uganda have reduced HIV prevalence among some populations. But the prevalence rates have increased in some sections of Uganda while decreasing in others; in particular, physicians at the wealthier urban antenatal clinics have observed a decrease in prevalence among their patients, while AIDS prevalence has not been similarly affected in many of the rural and poorer zones where 87% of the population lives. What is often ignored is that even in sectors where prevalence (the number of living people with HIV infection) has reduced, the reduction has not necessarily corresponded to a decline in incidence (new cases) but rather to an increase in deaths, and in those few locales where incidence has decreased it has corresponded most frequently to the effect of changes in social demography rather than to the government’s education initiatives [8].

What is particularly problematic about the Ugandan “model” is that the political advocacy surrounding it makes several wrong assumptions. Given that the top epidemiological predictor for HIV infection around the world is not a “risk behavior” but rather a low income level, those most vulnerable to HIV infection will not significantly benefit from a model focused exclusively on education–a model that assumes people in poverty have sufficient agency to control the circumstances of their lives, even in the context of gender inequality or in locations without income opportunities other than trading sex for money [9-15]. As Dr. Paul Farmer and colleagues recently noted, “Their risk stems less from ignorance and more from the precarious situations in which hundreds of millions live” [7]. And dozens of surveys support this fact, confirming that–despite our presumptions–those most at risk for HIV often do know how the virus is transmitted, and even the highest prevalence areas have sex rates lower than in many regions of the U.S. and Japan [13, 16-20]. Sex is not as much the issue as the context under which sex occurs, yet public health workers studying AIDS are guilty of trying to define an African “system of sexuality” and render sexual behavior 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 [21-24].

In interviews, those most vulnerable regularly discuss other concerns about life (access to clean water and food, gaining financial independence, and so forth) that take precedence over preventing HIV transmission [19, 25-30]. Yet the “targeted” public health rhetoric ignores these issues and even equates the concerns of the poor with the rhetoric of politicians by labeling both “in denial” [30, 31]. In the South African mining sector, for example, a group of psychologists recently established that the norm of “masculinity” (expressed through soliciting prostitutes) in South African “culture” increases the risk of HIV transmission among miners [32]. To locate “culture” as the problem is to ignore the perspectives of the miners themselves (who, in fact, are from a variety of different locations as distinct as rural Malawi and central Soweto). As one miner put it: “Every time you go underground you have to wear a lamp on your head. Once you take on that lamp you know that you are wearing death. Where you are going you are not sure whether you will come back to the surface alive or dead. It is only with luck if you come to the surface still alive because everyday somebody gets injured or dies”[32].

In the context of a 42% injury rate, it would be natural to think that catching a disease that could kill you ten years down the road might be less pressing than trying to gain some control over life–or perhaps even enjoying life in some minor way (through alcohol or sex) before getting crushed by falling rock. But the psychologists who quoted this miner (and published their analysis in a top-ranked medical journal) labeled him “in denial,” and claimed that his “low self-esteem” was the cause of his increased risk for HIV infection [32]. A similar survey among prostitutes labeled them “liars” (in “denial” of their agency) when they attributed their prostitution to lack of education and job opportunities and to coercion [25].

“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 [20, 21, 33-38]. Denial, stigma and conspiracy theories are taken to be the “cultural” causes rather than the social effects of political and economic problems. At other points, culture is focused upon to devise “culturally-competent” solutions to change the low efficacy of HIV prevention initiatives [39, 40]. In both of these cases, “culture” is conflated with the structural violence of inequality and lack of access to resources–and when these issues are unaddressed, even the most “culturally-competent” prevention initiatives still focus on merely co-opting local culture to suit the needs of “targeted” interventions [41]. In this context, even after messages are adapted to “local norms” (ignoring the universal context of HIV-transmission, that of inequality and lack of access to resources), “providing information about health risks changes the behavior of, at most, one in four people–generally those who are more affluent and better educated” according to a recent systematic review of evidence in the British Medical Journal [42]. Even if the currently best-performing education initiatives were to cover the entire globe in just 2 years from now (a very, very big “if”), such programs would still leave a rate of transmission equivalent to 1.5 million new cases per year according to the public health community’s most advanced models [43].

In response to accumulating data that many education initiatives are failing to work in the poorest of areas (those hardest hit by AIDS), the public health community is committing another behavioristic mistake; instead of examining the political and economic contexts of prevention, it has returned (unawares, I suspect) 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” (thereby conflating all of the many social scenes in Africa into one “African system”) [39, 42]. In colonial times, “venereal” syphilis among miners (which later turned out to be non-venereal syphilis and yaws) would be explained by the loss of “African traditions,” which supposedly promoted female chastity by exerting group control over young women (paralleling the modern “revival”–and partial invention–of “traditions” like virginity testing in the context of AIDS [44]) [45, 46]. Mine workers were simultaneously taught to be individualistic and capitalistic in the mines, then returned to be collectivistic at their rural homes when they became ill (a very “cost-effective” strategy for mine owners to avoid paying for medical care) [18, 47]. The context of illness, and its relationship to miners’ position in the economic field of relations, went unquestioned. Now, public health behaviorism 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 [39, 42].

What this rhetoric ignores and often disguises is that the background for increasing HIV transmission is a background of neoliberalism–a context where the rapid movement of capital is privileged over long-term investment and the ability of persons to secure their own livelihoods. Increases in forced migration are strongly correlated with some of the most significant increases in HIV transmission across southern Africa, East Asia, Eastern Europe and Latin America (although few members of the public health community have addressed this fact), and such migration most often occurs when rural agricultural sectors are destroyed after the liberalization of markets and the subsequent drop in primary commodity prices, which leads (mostly male) laborers to find work in urban centers and leave their families behind [13, 48, 49]. In sectors of southern Africa, miners are housed in all-male barracks for months at a time, worked six days a week, and given alcohol to “keep them happy” (or keep them from rebelling) on the seventh day–when intoxication and depression lead to the solicitation of prostitutes. Similar circumstances have been documented throughout East Asia [48]. The men are returned home to die, and find that either their wives have left them to find a better source of income and support, have entered prostitution themselves to generate income, or are waiting for their husbands to return home (and infect them with HIV) [13]. 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 [48].

AIDS, then, is a symptom as much as it is a disease. In the context of the new South African Customs Union (SACU) trade agreement with the United States, it will be a most severe symptom. The SACU deal promotes rapid liberalization and the movement of capital over the securing of stable investment and employment, privileging companies who wish to setup base temporarily and shift capital at will. If similar deals in East Asia and the Caribbean are any indication, both TB and HIV will increase markedly in this context as forced migration and poverty render “monogamous marriage” a nonsensical idea and commit both women and men in poverty to constant movement to find new sources of income wherever they can [13, 48].

The SACU deal also links this neoliberal context to the distribution of resources, particularly medicines, which are often discussed through a rhetoric divorced from the context of HIV prevention. The trade deal will render generic medicines extremely difficult to procure, providing more than two-decade-long monopoly for patented medicines [50]. Public health officials have not strongly voiced their opposition to this (leaving NGOs and activists to take on the task), and have focused 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 (which should be intuitive, since there are few things as stigmatizing as a death sentence), in addition to reducing HIV transmission [51, 52]. Brazil has certainly demonstrated this definitively, having reduced HIV prevalence (and incidence) after providing universal access to antiretrovirals. Despite being threatened by the US Trade Representative for producing generic medicines, Brazil has allowed the use of generics, saving the country hundreds of millions of dollars and reducing HIV prevalence by over 50% [52].

Development banks and public health academics have claimed that such measures are not “cost-effective” in the manner of education initiatives (which themselves are declared cost-effective by predicting “high return on investments” in spite of data to the contrary). But “cost-effectiveness” is not based on a law of nature–in its current form, the means for calculating such effectiveness assumes that distinct health interventions are competing with one another, as if all health outcomes were pulling from the same pot of money, and their overall effects on society would be discrete whether or not a plague is taking place [41, 53, 54]. This logic, like the “health belief model,” seems intuitive, but it is notable that not all societies think this way; indeed, many assume instead that health is multiplicative–that healthiness among some members of society contributes to healthiness among others as the ability to work and participate in society are promoted by the lack of disease [55]. 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 and society, the prices of antiretrovirals suddenly seemed quite affordable [52].

Yet in this context, a new rhetoric against generic medicines was deployed to counter the idea that other countries could follow Brazil’s path. The US Trade Representative threatened Argentina, Thailand, South Africa and other countries when all of them attempted to regulate the prices of pharmaceuticals or introduce competition into the monopolistic patent regimes [56]. The USTR’s claim was that generic drug use would reduce innovation, but like many claims about AIDS, this one ignored all of the available data. According to the industry’s own tax records (obtained from the Securities and Exchange Commission), Merck last year spent 13% of its revenue on marketing and only 5% on R&D, Pfizer spent 35% on marketing and only 15% on R&D, and the industry overall spent 27% on marketing and 11% on R&D [57]. Most AIDS drugs were produced through public financing (even through the clinical trials stages), and 85% of the basic and applied research for the top five selling drugs on the market were produced through taxpayer funding [58]. Meanwhile, all of sub-Saharan Africa constitutes only 1.3% of the pharmaceutical market, so as one former pharmaceutical executive put it, allowing generics to enter this market would result in a profit loss to the patent-based industry equivalent to “about three days fluctuation in exchange rates” [59, 60]. 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 increases the market-share for more expensive patent-based drugs among the wealthy [61].

Realizing the problems with claims about patents and pharmaceuticals, some poor country trade ministers pushed through a deal at the November 2001 WTO trade conference in Doha, Qatar. The resulting “Doha Declaration on TRIPS and Public Health” (referring to the Trade Related Aspects of Intellectual Property Rights, or TRIPS, Agreement) would allow poor countries to import generic medicines (especially if they lacked the capacity to produce such medicines themselves) even after strong WTO patent rules were adopted in their national legislation [62]. Although it passed unanimously, the US Trade Representative managed to become the only trade official out of the WTO’s 145 member country ministers to block the implementation of the Doha accord [63]. The US often uses similar procedures to import medicines and other goods, but will not allow poor nations to do so. A deadlock still exists as the US insists upon limiting the number of poor countries eligible to import generics. The US has once again co-opted the public health rhetoric, claiming that only a few iconic, extremely-poor countries should be allowed to participate in the deal [61]. Such an exclusionary policy would not only violate the Declaration itself (which claims that the WTO will promote “access to medicines for all” [62]) and deny medicine access to the majority of people who need it, but would destroy economies of scale and other necessary economic means to build efficient and effective generic drug production facilities, and would prevent competition from challenging monopolies and introducing price checks [64, 65]. Such is the nature of “free trade”. But to blame the entire problem on the U.S. Trade Representative would be to ignore the fact that several rich country representatives from Europe have also been supporting him, and some poor country representatives are also pandering to the elites in their own nations by trading votes to the U.S. on public health measures for votes from the U.S. on agricultural export deals (again, privileging speculative capital over long-term investment) while avoiding strategies that can increase generic drug access through means that are not currently being blocked by the United States and its allies. Elites who are marginalizing the poor–wherever they may be–are the problem, and in this respect it is perverse that the world’s trade organization, built to facilitate rapid capital transfers among the wealthy, is deciding public health outcomes.

The co-opted “culture” rhetoric re-appears under this framework. U.S. presidential candidate Howard Dean, claiming to be the “Democratic wing of the Democratic party,” has argued that antiretrovirals are of humanitarian importance but should not be emphasized because they are not as “culturally appropriate” as prevention initiatives; some prominent African country ministers have made similar claims to rationalize their inaction on the issue. Culture once again becomes ammunition for elites to justify inequality. And culture is simultaneously blamed as reports are produced about the increasing prevalence of drug resistance in the U.S. and Europe. Drug resistant strains of viruses emerge when patients intake medicines irregularly, and while the reports of new resistant strains are all from Northern countries, they have been projected onto the South under the assumption that “if drug resistance emerges here, it’ll emerge there,” particularly in the “cultures of denial” (as The Boston Globe put it) [66-68]. Some public health workers have even suggested that antiretrovirals should only be accessible to those patients “most likely to comply,” yet what this denies is that those most likely to comply are those least likely to have HIV–they are the wealthy and the people with resources needed to control the circumstances of their own lives. Drug resistance can be more effectively countered by scaling-up affordable antiretroviral treatment and providing sustained and equitable distribution; resistance propagates most often because people who are denied medicine (usually because of its high cost) are desperate to get it, so a black market flourishes, allowing people to trade medicines as they become available and take improper regimens [51]. The drug resistance excuse is, like most excuses about AIDS, a vestige of past public health excuses, first deployed to suggest that persons with drug-resistant TB should not receive treatment (resulting in multi-drug resistant TB as those people–fated to die–struggled to survive and obtained pills wherever they could). Only when multi-drug resistant TB hit New York City populations did treatment for it suddenly become “cost-effective” [69].

The public health community uses examples like these to suggest that they have no options besides meager education-based interventions. As one group of health workers put it, “as ordinary citizens, we are not in a position to change the political and economic system” [70]. While such an analysis effectively loses the marathon before the race has even started, it also ignores the numerous health models (often constructed by activists rather than public health officials) that have effectively changed political and economic contexts for HIV transmission rather than subscribing to fatalism. In the context of the poorest location in the poorest country in the Western hemisphere (the central plateau of Haiti), a group of physicians has managed to provide free antiretroviral treatment without producing primary resistance, and has effectively begun to stem HIV transmission by providing new models for food provision, income generation and continuity of health care services [7, 51]. In the context of southern Africa, campaigners have forced the Coca-Cola company to change its labor policies and provide family housing, reduce migration-based networks of product distribution, and provide complete health packages including antiretroviral drugs ( Similar projects are now affecting the mining companies in South Africa. So the fatalism must be tempered by an awareness of that such models exist, and are now proliferating as those infected and affected by AIDS refuse to sick back and watch the ineffective behavioristic prevention initiatives produced by the public health community. What the health community ignores is that that public health must be less about coercing people into good behavior and more about facilitating better environments for healthiness.

To enact a new paradigm of facilitation, we must examine what the current coercive tendencies ignore. There are many campaigns now focused exclusively on inequality between countries–but these often present the idea that “Third World” starvation will be solved when “First World” people eat less ice cream. Other campaigns suggest that rich nations should help poorer nation-states because it is in their “rational self-interest,” although such projects seem to promote little more than bilateral agreements among elites. Indeed, between-country inequality is tremendously problematic. But increasingly the “First versus Third World” rhetoric produces claims that public health has competing interests–for example, between lowering prescription drug costs in wealthy countries and lowering them in poor countries (although the data indicate that the pharmaceutical industry can easily afford both [58])–instead of questioning the rhetoric of “cost-effectiveness” and the zero-sum approach to health provision. We must focus on the inequalities that take place both between and within countries, as these point us toward routes to facilitate better health and tackle political inequalities rather than attempting to coerce people whose life circumstances render the rhetoric of “personal hygiene” ineffective and often ridiculous [71-76]. When we examine within-country inequalities, we begin to see major trends: that the poor (even the relatively poor in wealthy nations) are consistently those whose access to resources and services are cut-off by domestic policies, whether they are located in the poor neighborhoods of Washington D.C. or the mining fields just outside of Johannesburg; that in both rich and poor countries, the rapid short-term accumulation and flight of capital has often promoted temporary migration for labor and threatened the health of the poor; and that AIDS is a symptom of the breakdown of stable relationships that occurs in the context of growing inequalities [12-14, 20, 25, 26, 28, 38, 41, 48, 49, 51, 54, 77-82].

AIDS is effectively a symptom of Empire (using the term in a philosophical sense to denote a decentralized network of hegemonic power relations), 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 other political priorities [83]. Empire is threatened not simply by local resistance but by resistances that occur when people in similar circumstances in different locales–people in both poor and rich countries–realize that inequality is central to this issue. Anti-AIDS efforts are funded currently to increase labor potential and prevent economic collapse by keeping workers economically productive, or by focusing so much on “behavior” and “culture” that the context in which “behavior” occurs is rendered unproblematic or unchangeable [83-85]. Therefore, the current anti-AIDS efforts bolster and disguise the mechanisms of Empire. AIDS becomes the product of “individual responsibility” and anonymous, disconnected Third World destitution–the plague captured in pictures of dying babies and public health saviors desperate to convince the natives to adopt better hygiene practices. To expose this rhetoric’s basic fallacy will require a serious criticism of public health’s behavioristic leanings, as well as a transformation of the dominant political power imbalances that render HIV a plague of the poor.

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