I'm always pleased when I come across articles suggesting that too little money is being spent on HIV treatment and care and not enough is being spent on prevention. I'll be even more pleased when prevention campaigns try to expand on and explain exactly what they mean by words that have strong religious connotations, such as 'fidelity', 'faithfulness' and 'abstinence'. We probably can't do without such words but prevention campaigns need to address the circumstances in which people live, especially the circumstances that determine when, where, with whom and how often they have sex.
Slick advertising campaigns are all very well for pumping out slogans that the media can repeat endlessly but the messages, ultimately, need to make sense to people. It needs to be possible for them to protect themselves from dangers like sexually transmitted infections, unplanned pregnancies and HIV. After all, if a certain sort of behaviour is 'immoral' it needs to be possible for people to avoid it and if a certain sort of behaviour is 'moral' it needs to be possible for people to behave in that way.
For example, if having sex with someone to whom you are not married or having sex with many different people are examples of immoral behaviour, it needs to be possible for people to avoid engaging in these activities. But many people, sometimes referred to as 'commercial sex workers', are often just people who have been left with no other option when it comes to providing for themselves and their families. They need to be pragmatic because the people who are wagging the moral finger at them are certainly not offering them an alternative.
Similarly, fidelity and faithfulness are great for people who are in a certain sort of relationship, for example, marriage or any long term partnership. But both (or all) parties in a relationship need to observe the principle. Where one or both parties have other, concurrent sexual partners, there is little point in recommending 'abstinence' until marriage. If one partner chooses to 'abstain' until marriage, the other partner may not choose to. Then, even the partner who abstains could still become infected with HIV.
And plenty of research has shown that, despite lengthy HIV prevention campaigns in most countries in the world, a lot of people do not only have one partner in their lifetime, a lot of people don't only have one partner at a time and a lot of people don't see being in a long term relationship or being married as a reason not to have sex with someone else every now and again, or even frequently.
HIV prevention campaigns can continue to do what they have been doing for over two decades, lecturing people about what they should and shouldn't do, or they can look at some realities. Firstly, some people don't always do what they 'should' do and some often do what they 'shouldn't' do. Secondly, others are not always in a position to do what is considered moral or avoid what is considered immoral. These campaigns may have some kind of moral high ground but they do not have much relevance to the way people lead their lives.
Even campaigns that advocate for the use of condoms need to ensure that people are enabled to use condoms. If you are depending on sex for your income, using a condom may protect you; but agreeing to sex without a condom will pay better, often far better. If you are married or in a stable or long term relationship you may find it difficult to get your partner to use a condom. Apparently, many refuse to use a condom with their spouse or long term partner.
Slogans, wristbands and media campaigns may (or may not) have done great things in the past but they will never be enough on their own. If people are forced to have sex for money, there is a serious economic problem. If people are not able to choose to use a condom there could be a legal problem and perhaps an issue of gender inequality that needs to be addressed. There are people, usually women, who are required to sleep with their boss to get a job, keep a job, get promotion or even to get paid. This suggests serious corruption and lack of protection for people who may be particularly vulnerable.
Unless these prevention campaigns address these and other circumstances in which people live, they might as well not bother. Young girls are being encouraged or even forced to have relationships or even to marry older men, sometimes their teachers, in order to get some financial support, school fees or some other benefit. There is no point in telling them that what they are doing is wrong or in telling them about the virtues of abstinence, fidelity, condom use, virginity or any other platitude.
Campaigns in the past in Uganda, Senegal and even Kenya, have been called 'successful' but as long as people are prevented from protecting themselves, HIV and other sexually transmitted diseases will continue to spread. There may continue to be fluctuations but for real, long term success, people need to be able to avoid risky situations, they need to be self reliant, they need to be far more autonomous than they are now. The economic, health, educational, legal, employment and other conditions facing people in Kenya and other developing countries need to change drastically. The hot air of publicity will never achieve anything on its own.
Showing posts with label economy. Show all posts
Showing posts with label economy. Show all posts
Tuesday, June 23, 2009
Saturday, April 11, 2009
Prediction Versus Observation
Nobody could have predicted the development and spread of HIV/AIDS in the decades leading up to the 1980s, when the disease was identified. Why would I (or anyone) say something that seems so mind-numbingly obvious? Well, predictions relate to the future, they don't relate to the present or the past. Ok, that's pretty obvious as well.
But try this: in Kenya and other African countries, it was mind-numbingly obvious in the 1980s that, if any epidemic, natural disaster, economic crisis or other highly threatening event were to occur, many people would be adversely affected. Despite post independence improvements and optimism, the majority of people were poor and vulnerable, they had limited access to health, education and other social services. Things were improving, but not fast enough.
There were economic crises, there were oil crises, there were crop failures and famines, there were high rates of disease of various kinds and, inevitably, many people suffered and died prematurely. In the 1980s, it was obvious that most people in Kenya were highly vulnerable as a result of earlier events and also because of rising poverty and disease and decreasing levels of coverage of services that would reduce exposure and mitigate the effects of exposure to disease and other processes.
In the 1980s, there was a clear need for development to reduce the spread of disease, to reduce rising levels of malnutrition and food insecurity, to increase levels of education, to develop infrastructure, especially water and sanitation. Countries like Kenya had a lot of developing to do. The country lacked resilience and would continue to suffer badly every time disaster struck.
The economic fundamentalism of wealthy countries in the 1980s, which continued into the 90s and beyond, dictated that what developing countries needed was, exclusively, economic development. Maybe at the time it seemed like a good bet, that if the economy was ok, everything else would be ok. Perhaps it wasn't clear that most people would remain poor and vulnerable, even when the economy was doing well (whatever 'doing well' happens to mean). If it wasn't immediately clear, it became clear; economies, even in poor countries, waxed and waned. But disasters, diseases, poverty, starvation, etc, and their devastating effects, continued.
But in what way were economies improving? An article I came across recently points out that African economies grew by 1.8% in the 80s and 2% in the 90s and never kept up with population growth. The goal to halve absolute poverty by 2015 is predicated on the achievement of 7% economic growth. At the same time, the percentage of people living below the poverty line increased from 42.6% in the 80s to 44.1% in the 90s and 45.7% in 2003.
Over the decades following the identification of HIV/AIDS, researchers continue to make clear that HIV is transmitted as a result of many factors. These factors relate to the economy, the environment, infrastructure, labour, legal issues, equality, especially gender equality, human behaviour, especially, sexual behaviour and many others. Additional factors and their respective significances are being discovered all the time. Those involved in work to reduce the transmission of HIV and to mitigate its effects cannot be faulted for not knowing about things that have yet to be discovered.
But rather than approach HIV as the multifaceted threat that it is, most approaches to HIV ignore the broader picture of extreme underdevelopment in which HIV transmission needs to be viewed. Most approaches treat HIV as a disease that is spread by sexual intercourse and a disease that can be fought by influencing people's sexual behaviour. There are exceptions, of course, but most of the big HIV money goes into these approaches.
It’s true, HIV is mostly spread by sexual intercourse in developing countries like Kenya and it is vital to understand sexual behaviour and to influence it to the extent that people's levels of exposure and vulnerability can be reduced. But levels of exposure and vulnerability increase during times of economic and social stress. There is an increasing number of poor and unemployed people in Kenya right now. There have been high levels of civil disturbance for some time and there may be more to come. The poor working practices found in Export Processing Zones (EPZ, a polite term for sweat shops), mines, sugar, tea and flower plantations, continue. These, and other conditions, need to be addressed as a matter of urgency.
It has proved very hard to influence people's sexual behaviour and that will probably always be the case, the dangers of sexually transmitted infections (STI) notwithstanding. But services to screen and treat people for common STIs should already be an integral part of Kenya's health services. Children and adults can receive sex education and can be given access to family planning advice and services. These benefits already relate to human rights to which people were entitled long before HIV became an issue. HIV wasn't predictable but high levels of poor health and low levels of education have long been obvious. The fact that people were vulnerable to anything that struck has long been obvious.
In addition, the success of HIV interventions, whether they relate to health, education or anything else, depends on the levels of health, education and other social services in a country. It has never been a secret that, without these services, interventions would have little impact and mitigation of the effects of disease (or any other threat) would be difficult.
The virus may be an 'act of god' but levels of vulnerability are due to decades of underdevelopment and decades of impoverishment of developing countries by developed countries. There were good times in wealthy countries but most people in developing countries never experienced any good times. Now that times are bad again in wealthy countries, no doubt, developing countries will suffer even more.
It's not as if developing countries could never have done anything to help. Oxfam have estimated that the financial bailout package currently in operation represents $1250 for every person on the planet. The same amount of money could lift 1.4 billion of the world's poorest people out of poverty for fifty years. This package is unprecedented, but large financial packages have been made available in the past for wars, following wars and for really important things like the race to the moon.
But I don’t see the global financial industry sacrificing a handful of failed financial institutions for the benefit of a few billion people. As for whether it will work, the bailout package is probably as effective as eating beetroot to protect against HIV.
There is little point in approaching HIV as it were the first infectious disease in the history of medicine to be entirely independent of people’s living conditions. The areas of underdevelopment that were involved in the spread of HIV have been more or less ignored since HIV has been identified. Yet, any measure to reduce transmission of HIV requires those areas of underdevelopment, all of them, to be addressed. Once they have been addressed, HIV transmission will reduce and efforts to reduce transmission further and mitigate the impacts of HIV have a greater probability of success.
There are serious HIV epidemics in many developing countries because they are underdeveloped; the people are vulnerable. As long as they stay underdeveloped, people will continue to be vulnerable and the HIV epidemics will remain. Future predictions are tenuous and difficult but we should all be perfectly capable of making observations about the present and the past.
But try this: in Kenya and other African countries, it was mind-numbingly obvious in the 1980s that, if any epidemic, natural disaster, economic crisis or other highly threatening event were to occur, many people would be adversely affected. Despite post independence improvements and optimism, the majority of people were poor and vulnerable, they had limited access to health, education and other social services. Things were improving, but not fast enough.
There were economic crises, there were oil crises, there were crop failures and famines, there were high rates of disease of various kinds and, inevitably, many people suffered and died prematurely. In the 1980s, it was obvious that most people in Kenya were highly vulnerable as a result of earlier events and also because of rising poverty and disease and decreasing levels of coverage of services that would reduce exposure and mitigate the effects of exposure to disease and other processes.
In the 1980s, there was a clear need for development to reduce the spread of disease, to reduce rising levels of malnutrition and food insecurity, to increase levels of education, to develop infrastructure, especially water and sanitation. Countries like Kenya had a lot of developing to do. The country lacked resilience and would continue to suffer badly every time disaster struck.
The economic fundamentalism of wealthy countries in the 1980s, which continued into the 90s and beyond, dictated that what developing countries needed was, exclusively, economic development. Maybe at the time it seemed like a good bet, that if the economy was ok, everything else would be ok. Perhaps it wasn't clear that most people would remain poor and vulnerable, even when the economy was doing well (whatever 'doing well' happens to mean). If it wasn't immediately clear, it became clear; economies, even in poor countries, waxed and waned. But disasters, diseases, poverty, starvation, etc, and their devastating effects, continued.
But in what way were economies improving? An article I came across recently points out that African economies grew by 1.8% in the 80s and 2% in the 90s and never kept up with population growth. The goal to halve absolute poverty by 2015 is predicated on the achievement of 7% economic growth. At the same time, the percentage of people living below the poverty line increased from 42.6% in the 80s to 44.1% in the 90s and 45.7% in 2003.
Over the decades following the identification of HIV/AIDS, researchers continue to make clear that HIV is transmitted as a result of many factors. These factors relate to the economy, the environment, infrastructure, labour, legal issues, equality, especially gender equality, human behaviour, especially, sexual behaviour and many others. Additional factors and their respective significances are being discovered all the time. Those involved in work to reduce the transmission of HIV and to mitigate its effects cannot be faulted for not knowing about things that have yet to be discovered.
But rather than approach HIV as the multifaceted threat that it is, most approaches to HIV ignore the broader picture of extreme underdevelopment in which HIV transmission needs to be viewed. Most approaches treat HIV as a disease that is spread by sexual intercourse and a disease that can be fought by influencing people's sexual behaviour. There are exceptions, of course, but most of the big HIV money goes into these approaches.
It’s true, HIV is mostly spread by sexual intercourse in developing countries like Kenya and it is vital to understand sexual behaviour and to influence it to the extent that people's levels of exposure and vulnerability can be reduced. But levels of exposure and vulnerability increase during times of economic and social stress. There is an increasing number of poor and unemployed people in Kenya right now. There have been high levels of civil disturbance for some time and there may be more to come. The poor working practices found in Export Processing Zones (EPZ, a polite term for sweat shops), mines, sugar, tea and flower plantations, continue. These, and other conditions, need to be addressed as a matter of urgency.
It has proved very hard to influence people's sexual behaviour and that will probably always be the case, the dangers of sexually transmitted infections (STI) notwithstanding. But services to screen and treat people for common STIs should already be an integral part of Kenya's health services. Children and adults can receive sex education and can be given access to family planning advice and services. These benefits already relate to human rights to which people were entitled long before HIV became an issue. HIV wasn't predictable but high levels of poor health and low levels of education have long been obvious. The fact that people were vulnerable to anything that struck has long been obvious.
In addition, the success of HIV interventions, whether they relate to health, education or anything else, depends on the levels of health, education and other social services in a country. It has never been a secret that, without these services, interventions would have little impact and mitigation of the effects of disease (or any other threat) would be difficult.
The virus may be an 'act of god' but levels of vulnerability are due to decades of underdevelopment and decades of impoverishment of developing countries by developed countries. There were good times in wealthy countries but most people in developing countries never experienced any good times. Now that times are bad again in wealthy countries, no doubt, developing countries will suffer even more.
It's not as if developing countries could never have done anything to help. Oxfam have estimated that the financial bailout package currently in operation represents $1250 for every person on the planet. The same amount of money could lift 1.4 billion of the world's poorest people out of poverty for fifty years. This package is unprecedented, but large financial packages have been made available in the past for wars, following wars and for really important things like the race to the moon.
But I don’t see the global financial industry sacrificing a handful of failed financial institutions for the benefit of a few billion people. As for whether it will work, the bailout package is probably as effective as eating beetroot to protect against HIV.
There is little point in approaching HIV as it were the first infectious disease in the history of medicine to be entirely independent of people’s living conditions. The areas of underdevelopment that were involved in the spread of HIV have been more or less ignored since HIV has been identified. Yet, any measure to reduce transmission of HIV requires those areas of underdevelopment, all of them, to be addressed. Once they have been addressed, HIV transmission will reduce and efforts to reduce transmission further and mitigate the impacts of HIV have a greater probability of success.
There are serious HIV epidemics in many developing countries because they are underdeveloped; the people are vulnerable. As long as they stay underdeveloped, people will continue to be vulnerable and the HIV epidemics will remain. Future predictions are tenuous and difficult but we should all be perfectly capable of making observations about the present and the past.
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