Tuesday, July 6, 2010

Individual Behavior Threatens National Security?

One often hears the term 'national security' being used in discussions about HIV/Aids. The epidemic is said to be threatening in a way that other epidemics are not, despite affecting fewer people than a lot of other diseases and health conditions. HIV/Aids is sometimes talked and written about as if it could topple governments or as if people from high prevalence countries could commit acts of aggression against low prevalence countries that would threaten security. There's a particularly interesting discussion of this phenomenon of the 'securitization' of HIV/Aids in relation to photo-journalism.

But I don't accept that HIV/Aids is an issue of national security. At least, I don't believe it is a threat to US national security, which is what most instances of the phrase seem to refer to. The argument is rarely that HIV/Aids is a threat to South African, Swazi, Kenyan or Botswanan national security, though it sometimes is. Even other rich countries don't seem to obsess so much about a specific national security threat from HIV/Aids. But use of the term seems to equivocate between referring to national and global security, almost as if they are the same thing.

It seems possible that the HIV/Aids pandemic, commonly framed as a threat that needs to be 'fought', becomes confused with the metaphor as used of diseases. Many diseases are said to threaten to attack us, that we need to defend ourselves, to fight back. People with a disease are said to fight it off, sometimes winning, sometimes not. Such metaphors are ubiquitous in talk about diseases of all kinds, whether infectious or not. The metaphor is fine until it starts to be taken a bit too literally.

But another thing that could be going on is that 'national security' is a convenient label, like 'terrorist', that you can slap on anything to support your claim that it is your business and that you have a right to interfere. Much of the funding for HIV/Aids over the past couple of decades seems to have been politically motivated and the fact that much of it was squandered on appeasing political and religious interests doesn't seem to bother the big donors. Health and disease don't seem to have been on the agenda, in reality.

I could understand if health, as a whole, were thought to be a potential matter of national security. But countries with high disease burdens and low standards of health care don't appear to have people fighting on the streets or invading other countries calling for these things to change. If the issue were denial of human rights, health being a human right, this might make it a matter of national security. But the big HIV/Aids donors have not shown much interest in health or in any other human rights. Some of the worst damage that the HIV/Aids pandemic has done has been to other areas of health, which have been almost completely ignored for over two decades. And the association of HIV with sex, sexuality, sex work and illicit drug use have done a lot of harm to decades of sexual, gender and racial equality movements.

If the pandemic were really an issue of national security, why is HIV prevention allocated such a small amount of money compared to HIV treatment and care? And why is HIV transmission seen as a matter of individual behavior, to be influenced, if at all, by an appeal to people to change their sexual habits, to avoid 'unsafe' sex or perhaps to avoid sex altogether? If HIV/Aids were really an issue of national security, surely reducing transmission would go beyond an appeal to individuals to modify their sexual behavior?

I recently mentioned a new fund called the Global Health Initiative, which is unusual in that it is specifically aimed at strengthening health systems in developing countries. Previous funds, such as PEPFAR (President's Emergency Fund for Aids Relief) and the World Bank's Global Fund, took the individual behavior change approach and even claimed that health systems were benefiting as a result of the work they were funding. Few critics believed this, but nor do those behind the Global Health Initiative, apparently.

Whereas the individual behavior change approach to HIV transmission seemed inimical to the 'national security' label, the perceived need to strengthen health systems could signal a renewed focus on HIV/Aids as a potential security threat. But that leaves me at a loss to know what to make of the Global Health Initiative. I think it's a good thing to see HIV transmission as going beyond the sexual behavior of individual people and to develop health systems. Health systems have been ignored for too long and this has clearly contributed to continued high levels of HIV transmission in many countries.

I just don't accept that HIV/Aids is a national security issue, or even a global security issue. I think the determinants of HIV, denial of human rights in the form of widespread poverty, poor living conditions, low levels of education and health care and crumbling infrastructures, could constitute issues of global security.

I don't think the Global Health Initiative is an admission, inadvertent or otherwise, that we have failed in our attempts to reverse the HIV pandemic. But if it reduces dependence on the individual sexual behavior theories of HIV transmission it may get us closer to working out exactly why some countries and some parts of some countries have such high levels of HIV. That should have been the first question that UNAIDS asked. But even if it's not the first, and even if UNAIDS are not asking it, it would still be good if it were taken seriously.



claire said...

Interesting. Is the ghi new and funded well? Imo the endenmic phase of the epidemic, I.e. where rates may well increase but they do not do so exponentially, or they may stabilise or slightly decrease, has been going on for 10 years and we have needed a healthcare approach for this long. At the outset of a disease outbreak, like the start of a fire, I think its probably fair enough to use any and all ammunition against it, including exhorting people to change their individual behaviour assuming that will work on anyone. But at this smouldering phase, targeting health care for improvement instead seems so long overdue!

Simon said...

Hi Claire
The GHI seems to have been mooted in the early 2000s but now it has 63 billion in funding, I'm not sure if it was in operation before. It is referred to as a follow up to PEPFAR and certainly seems to broaden scope. But it's also referred to as the Obama GHI. Reading around this site, it's as if the US wants to take over world health (with the fancy title 'global health':


It makes an institution like UNAIDS seem like the anachronism it has always been but whether it means they will be abolished is not clear.

I agree with some of what you say but at the start of the epidemic attention was given to non-sexual transmission, including medical transmission. It was only when the whole thing became politicized that they dumped that aspect. So targeting health care for improvement is long overdue.

But I'm not sure if I agree that rates are not increasing exponentially. In some demographics and in some areas, incidence is still high enough to keep prevalence high for a long time. A large proportion of Kenya's prevalence comes from a small part of Nyanza province and no one has figured out why this is so, yet.

In other countries, where the epidemic is at a different stage, it is becoming clearer that certain sectors of the population are still at much higher risk than others. Girls and young women in Swaziland and South Africa.

There is hope that some attention will be given to the very thing that the HIV industry has been trying to avoid for so long: medical transmission and other non-sexual transmission. We'll see.

Interestingly, the initiative, which may well be a new name and slightly new approach than that taken by PEPFAR, is phasing out strategies that are non 'evidence based', a term much loved by PEPFAR, UNAIDS and other doctrinaire behavioral paradigm fundamentalists. And this includes abstinence-only programs (though not abstinence programs, it's a thin line).


GHI also aims to bring harm reduction strategies back in, such as needle exchange for IDUs. Importantly, it proposes strengthening work forces and encouraging production of generics in developing countries, including 2nd and 3rd line drugs, which could make all the difference if they are serious about this. Also emphasizing local capacity and NGOs rather than giving all the money to American ones!

Perhaps the authors haven't heard of the Alma-Ata Declaration, or perhaps they have but find it politically expedient not to admit to it. But it may just be a repackaging of Bush's well funded travesty.