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| From the September 2003
Anthropology News, p 7
AIDS: A Biosocial Problem Paul Farmer Edward Green’s important piece raises two major questions about AIDS prevention paradigms. Why are they ineffective? And what can be done to make them less so? Green begins his overview of the problem by noting, “Evidence is mounting that the global model of AIDS prevention, designed by Western experts, has been largely ineffective in Africa.” It would be hard to argue with him on this score as thousands of new infections accrue each week. With millions of new infections occurring each year, AIDS prevention is by and large a failure, especially on the world’s most heavily burdened continent, which is also, not coincidentally, the globe’s poorest. Quibbling over terminology (the specialty of the seminar-room warrior) is not all that important, but permit me to object to the term “Western.” I could do so by saying that “Western” prevention paradigms are to some extent ineffective in Haiti, too—and that country is, as Alfred Metraux and others have noted, about as Western a nation as one could imagine: Haiti is a creation of European expansionism. Africa, too, is a vast and heterogeneous continent where many “traditional healers” (as I learned from Green’s previous work on this topic, which is extensive) are as likely to use ampicillin as they are the wisdom of elders. However, this is not the only way in which the term “Western” is misleading. “Western,” in development-speak, means wealthy countries, whether the US or Japan. The “global north” is a bit more accurate but the truly apposite term is “the haves.” Those who have—and we have now taken to calling ourselves, somewhat self-righteously, “the donor nations”—are those who are currently deciding the fates of hundreds of millions. So it’s crucial that we understand why HIV prevention hasn’t been more effective and Green is to be lauded for sticking with this topic for many years. Green is also to be applauded for taking on some of the sanctimonious sloganeering rife in AIDS prevention work. He summarizes such softheaded thinking: “Let’s not single out particular risk groups. That will stigmatize them—blame the victims—and make the general public feel that they are not at risk. So our message should be, ‘We are all at risk of AIDS.’ This has a nice, egalitarian ring; we are all in this thing together. Nevertheless, differences in epidemiological patterns and cultural settings are real, calling for—among other things—different approaches to prevention.” All good, but Green should push this further. Why is HIV concentrated so heavily in the poorest parts of the world? Why do social inequalities, including gender inequality and racism, seem to fuel the AIDS pandemic whether in Africa or in the cities of the US? Why do economic policies foisted on poor countries tend to heighten HIV risk? Part of the answer to each question: because risk for HIV goes hand in hand with not having. The have-nots constitute the global risk group, if there is such a thing. Thus a behavioral model of HIV prevention such as that advanced by Green needs to be embedded in a much broader social analysis especially if one is as concerned with the prevention of new infections as with contributing to the scholarly literature. Green also takes on other prevention pieties, including those regarding condoms. Condom promotion and social marketing are not “the” solution to the problem. But are there other solutions out there? I hope he’s right in lifting up Uganda as a model for other African nations. “The genius of Uganda’s ABC program (Abstain, Be faithful, or use Condoms),” Green argues, “is that it focuses on what individuals themselves can do to change (or maintain) behavior, and thereby avoid or reduce risk of infection.” But what Green refers to as Uganda’s “home-grown approach” doesn’t strike me as all that indigenous to Uganda. Quibbling over the origins of customs or behaviors is tiresome within anthropology, and hardly the primary issue. The real issue is to ask what really happened in Uganda and what is happening now. What worries me is that Uganda-as-an-AIDS-success story has already taken on a paradigmatic quality. There are skeptics out there—I am one—who think that what has happened in Uganda is complex and has as much to do with war, dying off, migration, and many other events and processes (including, in Kampala and beyond, increased access to better HIV care) not readily classed under the rubric “ABC campaign.” All this will one day be hashed out in the pages of journals, but time is short. We know that a proper accounting of what has happened in Uganda needs to be profoundly biosocial. In addition to behaviorist approaches, we will need to understand political economy, troop movements, trade, structural adjustment policies from above and abroad and of course the cultural arcana so beloved by our own tribe. To return to the second burning question, what’s to be done, Ted Green argues that AIDS is a “behavioral problem with behavioral solutions.” Perhaps. But AIDS is also, surely, a social problem with social solutions. Some of these can certainly be classed as behavioral (there’s nothing wrong with the ABC campaign in my book), others as properly clinical (improved HIV care will lessen death, increase uptake of voluntary counseling and testing and also destigmatize AIDS and lessen provider burn-out). And isn’t a vaccine an important part of the solution? It’s hard to class vaccines as “behavioral.” What about repealing laws that penalize women who lose a partner to AIDS? Gender discrimination against poor girls? Prohibitively high school fees? The list goes on, and it does not seem to be a very “behavioral” list—unless of course we talk about the behavior of the truly powerful. I would ask Green to make his analysis and his prescriptions more social. Hard to sum up concisely what needs to underpin behavioral models but it could go something like this: current AIDS prevention tools work least well precisely where individual agency is most constrained, usually by poverty and gender inequality. Because what the have-nots lack is agency. The only way to rehabilitate behavioral models honestly, in my view, is to scrutinize the behavior of the powerful: those who set economic policies for countries like Uganda or Haiti or Mozambique. Those who write laws. Those who decide who will have access to care and who will not. And a lot of these folks, whose agency is decidedly unconstrained, are not to be found on the continent of Africa. Finally, I’d ask Green to consider the thorny issue of treatment for advanced HIV disease as part of the prevention agenda, especially for Africa. We can formulate a rather long list of the ways in which improving HIV care can enhance prevention and have done so. Mostly, these lists have been ignored by “prevention people” since prevention and care have been divorced, absurdly enough, by the “Western” experts who run much of the world. We need anthropologists like Ted Green to help the experts, with their varying agendas, resocialize the worst epidemic the world has ever known. Paul Farmer, MD, PhD, is a medical anthropologist whose work draws primarily on active clinical practice and focuses on diseases disproportionately afflicting the poor. He is the author of AIDS and Accusation, Infections and Inequalities and Pathologies of Power. |
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