The quicksand of quick fixes: the vexing temptation to make
AIDS manageable', by Hein Marais
It killed roughly 3 million people last year, most of them poor,
and most of them in Africa. Between 34 and 42 million people are
living with HIV. Absent antiretroviral therapies, AIDS will have
killed the vast majority of them by 2015.
such a world, time can seem a luxury, and the rigours of critical
enquiry an indulgence. We need things done now, yesterday, last
year. Indeed, an overdue sense of urgency has taken hold in the
past five years-much of its thanks to relentless AIDS advocacy
efforts. Along with sets of received wisdoms, a more or less standardized
framework for understanding the epidemic and its effects has evolved,
and a lexicon for expressing this knowledge has been established.
All this has helped put and keep AIDS in the spotlight. It has
popularized knowledge of the epidemic, countered the earlier sense
of paralysis or denial, helped marshal billions of dollars in
funding and goad dozens of foot-dragging countries into action.
It has worked wonders.
alongside these achievements are some troubling trends. There
has emerged a roster of truisms that, in some respects, convey
a misleading sense of certitude, and that might even be steering
institutional responses in ineffectual directions. As well, awkward
gaps are cleaving the AIDS world-gaps that threaten to detach
the staples of advocacy from the riches of epidemiological and
social research, and spoil the kind of multidisciplinary ferment
that the struggle against AIDS dearly needs.
advocacy tends to convey trim, crisp, unequivocal information.
But in achieving this, vital complexity and ambivalence is often
snipped and siphoned out. At times, research findings are casually
interpreted or contradictory evidence is ignored. Sometimes intuitive
reasoning is made to stand-in for absent empirical evidence. Much
of the time, eclectic dynamics are jammed into simplistic, AIDS-centric
this occurs in good faith-and with the pressures of time and the
palpable need to spur countries into action snapping at advocates'
heels. But it shouldn't stand in the way of doing the right things
and doing them properly. And that's the danger we're flirting
with at the moment.
advocacy is not simply a neutral catalyst. It also invests activities
with a specific content and character-all the more so when the
advocacy carries the imprint and financial heft of key donors
and multilateral agencies. This isn't just a matter of how knowledge
is being constructed and assimilated; it has very practical consequences.
Big-gun advocacy often prefigures key elements and features of
AIDS programming around the world. But we're seeing an unhappy
antinomy develop between the streamlined demands of AIDS advocacy
(and their translation into policy), and the generation and interpretation
of reliable AIDS research and analysis.
examples. By the late 1990s it was widely assumed that conflict
heightened the likelihood of HIV spread. Why? Because people are
dislodged from their homes, their "normal" rhythms of
social organization are disrupted, they lack access to many essential
services, and women especially are vulnerable to sexual violence
and might be forced to adopt, in the preferred euphemism, risky
survival strategies (i.e. trade sex for favours, goods and services).
It made good, intuitive sense. And by the early 2000s the view
that conflict led to rising HIV rates was in wide circulation.
for these assertions was scant, though. Data from the Balkans
showed no sign of significantly expanding epidemics there, for
instance. In Africa, neither Angola, Sierra Leone, Sudan nor the
Great Lakes region offered evidence that conflicts there were
triggering rising HIV rates. (Instead, in northwestern Kenya,
for example, the HIV infection rates in some refugee camps in
2002 were found to be much lower than they were in surrounding
areas.) It now appears that chronic conflicts like that in Angola
might actually have curbed the spread of HIV by limiting mobility
(transport infrastructure was badly damaged, trading networks
were truncated etc.). 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
Indeed, thanks to the massive output of AIDS impact literature
in the past 5 years it's becoming increasingly evident how multifaceted
and complex the responses of people and systems are to the epidemic-and
not least in southern Africa, where AIDS is hitting hardest. Yet,
the popularized knowledge of AIDS impact is, in some cases, as
roughly-hewn as it is loud.
example is the understandable temptation to distil generalized
and ubiquitous "truths" from very specific, usually
highly localized research findings. Thus, labour losses attributed
to AIDS on a single farming estate in Zimbabwe, for example, can
end up being extrapolated to all of Zimbabwe (or even to "Africa"
as a whole). From this there might emerge a claim that, say, "AIDS
is cutting agricultural productivity by one-third in Africa".
In advocacy terms, of course, this has great currency-it is the
stuff of headlines and sound bytes that jolt. But it matters that
the statement is inaccurate-and not just for didactic reasons.
epidemic's socioeconomic impact is varied and complex, and operates
as part of a web of other, richly varied factors. 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 interventions that are most
likely to trump or at least cushion the epidemic's impact. Once
such variety and contingency is scrubbed out-and reality is rendered
as a mechanistic and predictable sequence of events-the effects
can be both unhappy and wasteful.
example. There has emerged a palpable tendency to single out and
over-privilege AIDS as a debilitating factor, as illustrated during
the 2002-2003 food crisis in southern Africa. There is ample evidence
showing that the effects of AIDS in rural households, particularly
those engaged in agricultural production, are pernicious. Where
one or two key crops must be planted and harvested at specific
times of the year, for example, losing even a few workers at the
crucial planting and harvesting periods could scuttle production.
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.
reasoning hinged mainly on reduced labour inputs (due to widespread
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 reserve stores, rain patterns, soil quality,
affordability of seeds, fertilizers and pesticides, security of
tenure, food prices, income levels, access to and the terms of
financing etc. It is difficult, perhaps even impossible to unscramble
the effects of AIDS on rural communities and food security from
economic, climatic, environmental and governance developments.
The epidemic's apparent effect on food production occurred in
concert with a series of other factors, including aberrant weather
patterns and an ongoing narrative of unbridled market liberalization,
hobbled governance and wretched policy decisions.
AIDS out as a primary, salient factor can be misleading and tempt
short-sighted and ineffectual policy responses. It's also a lot
easier than fingering and tackling the other, more prickly factors-many
of them tied to formidable interests and forces-that are at play.
When it comes to the epidemic's mangling consequences, policy
responses are more likely to make a genuine difference if AIDS
is made to take its place in the dock alongside the other culprits,
which often include agricultural, trade and macroeconomic policies,
land tenure and inheritance systems, and the capacity of the state
to provide and maintain vital support services in rural areas.
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.
ground zero of this epidemic is where community and household
life is built. And there's no doubt that, win or lose, the outcome
of societies' encounters with AIDS ultimately depends on how communities
and households are able to respond. This is widely recognized,
hence the emphasis on so-called community safety nets and household
"coping" strategies in AIDS impact writing and policy
outlines. There's the danger, though, that unless these mechanisms
are buttressed with other, stout forms of structural support,
we may end up fencing off much of the AIDS burden within already-strained
households and communities. Yet, such forms of structural support
have been systematically dismantled or neglected in many of the
hardest-hit countries-typically as part of structural adjustments
demanded by international financial institutions. Some of those
same institutions are now enthusiastic fans of community resilience.
Indeed, after years of scorched-earth social policy directives
they are now casting "the community" in an almost redemptive
role. And this while much of social life has been subordinated
to the reign of the market and the state shorn of its ability
to fulfill societal duties.
safety net and coping pieties sometimes skip around other important
facets. Since many informal safety nets tend to centre on reciprocity,
they run the risk of reproducing the inequalities that characterize
social relations at community level. One study in Kagera, Tanzania,
for example, found that the poorest households plunged deeper
into debt because they lacked the wherewithal to enter into reciprocal
arrangements. Women in particular found themselves sidelined.
"Communities" and "the poor" are not homogenous.
a potentially treacherous distance is opening between the imperatives
of advocacy and outlines of big-league programming, on the one
hand, and rigorous epidemiological and social research and analysis,
on the other. Part of this is a hazard of advocacy, which tends
to favour declamation over explanation. 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.
Understandably, there's a rush on.
part of the problem also lies in a failure to reconcile the schizoid
aspects of 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 engine
will fling 5 million hits back at you. This implies a buzzing
cross-pollination of expertise, inquisitiveness and knowledge-building.
That's an illusion, though. AIDS advocacy might have embraced
some of the lingo, but it has assimilated very little of the critical
knowledge built in development theory and practice over the past
quarter century, not to mention other pertinent fields such as
sociology, political geography and economics. There is precious
little genuine, multidisciplinary rigour evident in AIDS discourse.
And the smorgasbord feel of many AIDS programmes reflects this
shortcoming. It's as if, once declarative truisms are achieved,
serious reflection becomes a luxury. In a race against the clock,
programmes and strategies must now be crafted. New insights or
complicating information become a headache. And so the incipient
interdisciplinary dialogue splutters into the intellectual equivalent
of a one-night-stand. Don't call me, I'll call you.
this is unfortunate and, ultimately, counter-productive. Because
AIDS advocacy is not just about sharing vital nuggets of knowledge,
it is aimed also at promoting specific types of practice and forms
of policy. If that knowledge is stunted, stripped of its riches
and whittled into slim proclamations, we run a real risk of embarking
on inadequate or inappropriate action. And all the while, that
clock would still be ticking.