[afro-nets] AIDS Policy Critique (excerpts)

[Claudio Schuftan <claudio@hcmc.netnam.vn>]

World AIDS Day: The Clock Is Still Ticking
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By Hein Marais

AIDS. It killed roughly 3 million people last year, most of them
poor, and most of them in Africa. Between 34 and 42 million peo-
ple are living with HIV. Absent antiretroviral therapies, AIDS
will have killed the vast majority of them by 2015.

In such a world, time can seem a luxury, and the rigours of
critical enquiry an indulgence. We need things done now, yester-
day, last year. Indeed, an overdue sense of urgency has taken
hold in the past five years - much of it thanks to relentless
AIDS advocacy efforts. All this has helped put and keep AIDS in
the spotlight. It has popularized knowledge of the epidemic,
helped marshal billions of dollars in funding and goad dozens of
foot-dragging countries into action. It has worked wonders.

But alongside these achievements are some troubling trends.
There has emerged a misleading sense of certitude steering in-
stitutional responses in ineffectual directions. Awkward gaps
are cleaving the AIDS world - gaps that detach advocacy from
epidemiological and social research.

Strong advocacy tends to convey unequivocal information. But in
achieving this, vital complexity and ambivalence is often
snipped and siphoned out. At times, research findings are casu-
ally interpreted or contradictory evidence is ignored. Sometimes
intuitive reasoning is made into empirical evidence.

All this occurs in good faith - and with the pressures of time
and the need to spur countries into action. But it shouldn't
stand in the way of doing the right things and doing them prop-
erly. And that's the danger we're flirting with at the moment.

Effective advocacy is not simply a neutral catalyst - all the
more so when the advocacy carries the imprint of key donors and
multilateral agencies. This has very practical consequences.
Big-gun advocacy often prefigures key elements of AIDS program-
ming around the world. We are seeing AIDS advocacy (and policy)
'interpreting' AIDS research and analysis.

Some examples. By the early 2000s the view that conflict led to
rising HIV rates was in wide circulation. Evidence for this as-
sertion was scant. It now appears that chronic conflicts might
actually have curbed the spread of HIV by limiting mobility. It
might be that the threat of a surging epidemic is greater as
peace is recuperated and as normality returns in post-conflict
settings. The lesson? Assumptions, no matter how logical they
seem, should be tested before they're paraded as facts.

It is becoming increasingly evident how multifaceted and complex
the responses of people and systems are to the epidemic.

One example is the understandable temptation to distil general-
ized and ubiquitous "truths" from highly localized research
findings to extrapolate them to all of a country or continent.
 From this there might emerge a claim that, says, "AIDS is cut-
ting agricultural productivity by one-third in Africa". In advo-
cacy terms, of course, this has great currency. But it matters
that the statement is inaccurate.

Neither the epidemic's effects nor the responses they elicit
necessarily adhere to a predictable, homogenous, linear paths.
This has important bearing on the kinds of policies and inter-
ventions. Reality is rendered mechanistic as a predictable se-
quence of events.

Another example. There is ample evidence showing that the ef-
fects of AIDS in rural households, particularly those engaged in
agricultural production, are pernicious. But then came a grand
leap of logic. With little but anecdotal evidence, a causal and
definitive link was asserted between the AIDS epidemic and the
food shortages. The reasoning hinged mainly on reduced labour
inputs (due to illness and death of working-age adults). But
these inputs figure among a wide range of variables needed to
achieve food security - including marketing systems, food re-
serve stores, rain patterns, soil quality, food prices, income
levels, etc. It is difficult, perhaps even impossible to un-
scramble the effects of AIDS on rural communities and food secu-
rity from economic, climatic, environmental and governance de-
velopments.

Singling AIDS out as a primary factor is a lot easier than tack-
ling the other, more prickly factors - many of them tied to for-
midable interests and forces - that are at play. But it can be
misleading and tempt short-sighted policy responses. Policy re-
sponses are more likely to make a difference if AIDS is made to
take its place alongside the other micro and macro culprits. The
over-privileging of AIDS lets decision-makers off the hook by
endorsing fashionable courses of action that can fail to go to
the heart of the matter.

The ground zero of this epidemic is where community and house-
hold life is built. There's the danger, though, that unless
these mechanisms are buttressed with other structural support,
we may end up fencing off much of the AIDS burden within al-
ready-strained households and communities. Yet, such forms of
structural support have been systematically neglected in many of
the hardest-hit countries. Indeed, much of social life has been
subordinated to the reign of the market and the state shorn of
its ability to fulfil societal duties.

Overall, a potentially treacherous distance is opening between
the imperatives of advocacy and outlines of big-league program-
ming, on the one hand, and rigorous epidemiological and social
research and analysis, on the other. Part of it is inflected
with institutional "cultures" and ideologies. Part of it is
panic-induced; it's 2004, and we can count the national "success
stories" against the epidemic on one hand.

But part of the problem also lies in a failure to reconcile AIDS
- as a short-term emergency and a long-term crisis. It's become
second-nature to hitch the word "AIDS" to "development". Google
that phrase and the search en gine will fling 5 million hits
back at you. AIDS advocacy has assimilated very little of the
critical knowledge built in development theory and practice over
the past quarter century. There is precious little genuine, mul-
tidisciplinary rigour evident in the AIDS discourse. It is as
if, once declarative truisms are achieved, serious reflection
becomes a luxury.

All this is unfortunate and, ultimately, counter-productive. Be-
cause AIDS advocacy is not just about sharing vital knowledge,
it is aimed also at promoting specific types of practice and
forms of policy. If that knowledge is stunted, we run a real
risk of embarking on inappropriate action. And all the while,
that clock would still be ticking.

* World Aids Day is on 1 December.

* Hein Marais is a South African writer and journalist. A former
chief writer for the Joint United Nations Programme on HIV/AIDS
(UNAIDS), his work is focused largely on AIDS and on political-
economic issues.