Thursday, September 23, 2010

Reification of a Racist Paradigm

The President of Zimbabwe has been reported as saying that compulsory testing for HIV should be introduced on the grounds that the pandemic is a health emergency. He is right, in the sense that if it were possible to test all or most people, this would allow unprecedented progress to be made in reducing transmission. But as long as HIV is seen as the sexually transmitted infection that evil Africans spread through their selfish behaviour, I don’t see whole populations meekly lining up to be tested.

If treatment were to be guaranteed for everyone found to be in need of it, that might work as an incentive. But people might ask if the promise will be kept, especially if they look at countries where antiretroviral programs have been started but continue to miss out on or let down many people. And even the promise of some kind of treatment might not tempt some people, who are only too aware of the sort of stigma that is associated with HIV and other diseases. They will also be aware of the consequences of such stigma.

One of the most unethical aspects of the use of testing data so far has been the failure to establish how people become infected with HIV. UNAIDS and their chums in HIV related industries and academic institutions have decided that, in Africa, they don’t need to collect data on how HIV is transmitted because they, for reasons known to themselves, believe that it is already obvious; that HIV in Africa is almost always transmitted sexually.

This ‘behavioral paradigm’ is completely undermined by evidence but, being a paradigm, it is never questioned. It is frightening to think that scientific findings are judged by their possibility of supporting the paradigm, rather than the other way around. But there is something more frightening; that is when the paradigm itself becomes replaced by something far more tangible, almost a reification of the paradigm. That’s the infrastructure that has been built up around the paradigm.

This infrastructure consists of huge supplies of drugs, equipment, consultancy, programs and other paraphernalia, and a vast array of government, non-government, commercial, non-profit, religious and other institutions, which might genuinely be required for the eradication of a sexually transmitted infection. Except that some HIV transmission, how much is unclear, is not sexual. Some is undoubtedly transmitted through unsafe health care and perhaps unsafe cosmetic practices. But because the HIV infrastructure that has been built up over more than two decades is designed for sexually transmitted HIV, it has little or no effect on non-sexual transmission, perhaps even a negative effect.

Mugabe himself may well accept the behavioural paradigm. The same article says, as newspaper articles are wont to do, “United Nations agencies have for years lauded Zimbabwe's HIV and Aids intervention models, which have seen the prevalence rate declining from a high of around 25 percent a decade ago to present levels of below 14 percent.” What the article doesn’t mention is that for national prevalence to drop by this amount, an awful lot of people need to die. And that is what has happened. This is not evidence of the country’s successful ‘intervention models’, whatever form they might have taken.

The article concludes “Cuba has a system of compulsory testing that has seen the largest island in the Caribbean recording miniscule infection rates.” Testing, on its own, doesn’t reduce HIV transmission. It’s what happens as a result of testing that (possibly) reduces HIV transmission. Who is to say that in many countries, once tested, most don’t go on to infect others, or become infected or die? Much may be learned about HIV transmission by looking at Cuba’s HIV epidemic in detail, but the fact that it involved compulsory testing doesn’t tell us anything. Most countries in the world didn’t have compulsory testing and most of them also have very low infection rates.

I sympathize with the sentiment that more HIV testing would be a good thing. But the biggest problem is the prejudice of UNAIDS and others, whose insistence on a paradigm that doesn’t fit gives rise to stigma and discrimination which makes widespread testing programs unlikely ever to be realized. So if Mugabe wants to see HIV transmission reduced he should start by questioning the assumption that the people of his nation, and the people of all other African nations, have inordinate amounts of sex. Right now, this would be a hell of a lot easier and cheaper than trying to test everyone. But it could turn around the epidemic.


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