AIDS in Africa

An epidemic of gigantic proportions is taking hold in Southeast Asia, home to an even larger number of powerless and poverty stricken people. It will be interesting to see if any notion of structural violence is at last invoked to advance our understanding of the dynamics of the pandemic or if we will discover that previously quite “well-behaved” Asians are as “promi- scuous” as Africans. 

The fundamental public health lessons of the past 150 years are known even to lay people. It is well understood that the overall health status of populations and their capacity to fight off infection is related primarily to food, water, sanitation, and housing. According to an article by E. Stillwaggon, “HIV/AIDS in Africa: Fertile Terrain,” published in the Journal of Development Studies (August 2002): “A century of clinical practice demonstrates that people with nutritional deficiencies, parasitic diseases, generally poor health and little access to health services or who are otherwise economically disadvantaged have greater susceptibility to infectious diseases whether they are transmitted sexually, by food, water, air or other means.” 

Curiously, in the case of HIV/AIDS, seriously deficient immune systems have been ignored as a factor of vulnerability and determinant of the high levels of infection in desperately poor populations. 

Pasteur’s dictum, “the microbe is nothing, the terrain is everything,” is still the best summary of century-old public health wisdom. The focus on individual behavior is almost as absurd in the response to AIDS as it would be if it were applied to the response to tuberculosis. A sound public health approach to TB does not exhort people in high prevalence areas not to breathe too much on each other—not understanding that they are breathing more or less like every other human being on earth. It addresses the sanitary, nutritional, and housing arrangements, which determine their high vulnerability.  

Breathing and having sex—though not quite in the same category—can both reasonably be seen as everyday human behaviors. The peculiar focus on the exotic, the unusual, the immoral, and the illegal has obscured the simple fact that AIDS is overwhelmingly transmitted through heterosexual, penetrative, vaginal sex. Few people know that when AIDS hit the headlines as a “gay plague” in California it was already a well established heterosexual epidemic in Africa. The unimportance, in the eyes of the world, of African people in general, and of African women in particular, may partly explain this neglect. The common sense interpretation of the facts is that high risk physical and economic environments, coupled with dangerously weakened immune systems, leave people highly susceptible to all kinds of infections including HIV. 

A Racist Theory? 

T he fight against AIDS in Africa has been dominated by long-standing Western prejudices against African sexuality and cultural practices. A striking example was in the early 1980s, when speculation about the Haitian origin of AIDS and the role of bizarre voodoo practices led to a wave of anti-Haitian discrimination. As with Jamaica, the Dominican Republic, and Trinidad, it turned out that tourists (mainly U.S. homosexuals) were the most likely source of virus transmission. It has been pointed out that in the absence of penicillin, the war-ravaged Europe of the late 1940s would have been devastated by epidemics of syphilis and gonorrhea. 

The international AIDS community has pursued a singularly unsuccessful strategy with religious conviction, rather than with good science or even common sense. Evidence, in the rather odious academic area known euphemistically as “sexual networking,” is flimsy. Rates of sexual activity do not appear to vary much between populations (though of course there are always groups within populations who either take more risks or have more risks imposed on them). What seems to emerge from the literature with consistency is that multiple, mostly serial, casual, and unprotected sex is common in Africa, Europe, the U.S., and parts of Asia, with most men everywhere having more partners than most women (WHO 1995). 

Furthermore, rates/types of sexual activity do not appear to have a clear relation with prevalence of HIV infection. A major multi-site study undertaken by UNAIDS in four sub-Saharan African cities showed that most parameters of risky sexual behavior were not consistently more common in the high HIV prevalence sites than in the relatively low prevalence sites. 

Gender Diversions 

T he implicit assumption that African people have more or less “brought it on themselves” through their “promiscuity” has evolved through a superficial, neo-liberal gender analysis into a much more explicit accusation of African men. If such an apolitical gender debate has resulted in shifting the blame from all African people to all African men, it has failed. No one disputes that women, particularly in developing countries, are not only biologically more vulnerable to sexually transmitted infections including HIV, but they are also acutely vulnerable socially, culturally and economically. Women have to exchange sex for material favors for their own and their children’s survival in many poor countries. For as long as they do not control when, where, with whom, with or without protection, they have sex—they will be at risk. 

However, women in Europe are clearly at far less risk than men in Africa. If we take as a rough indicator of risk, the average prevalences of less than 0.1 percent and 25 percent for Europe and Africa respectively, it becomes clear that neither individual behavior nor gender inequality accounts for the spread and pattern of the pandemic. Sound feminist analysis, rooted in social justice, recognizes oppression of women in poor countries within the context of the oppression of entire communities of men, women, and children, none of whom have any meaningful control over their lives. 

Women in sub-Saharan Africa carry a risk of contracting HIV infection at a rate 500-1,000-fold compared to women in the rest of the world. This is quite a large difference to explain in terms of African and European male sexual behavior. 

A Disease Of Poverty 

I n common with all sexually transmitted infections (STIs), HIV/AIDS has a particular relationship to poverty. The poor are more vulnerable to HIV infection than the rich—notwithstanding transient vulnerabilities of richer men who can afford to use prostitutes—of which much has been made. The fact remains that 95 percent of infections are in developing countries; and more than 70 percent are in sub-Saharan Africa where over 80 percent of the deaths have occurred. Women are more vulnerable than men; young women are far more vulnerable (4 to 5 times) than young men. Oppressed and marginalized “minorities”—blacks and Hispanics in the U.S., refugees and street children everywhere—are more vulnerable than dominant majorities.  

There are plausible explanations, in terms of biological vulnerability, for the very high rates of HIV transmission among poor populations. The major biological factors of interest are malnutrition and chronic co-infection with other diseases of poverty, notably, parasitic infection, tuberculosis, malaria, and other tropical diseases. These factors are known to seriously impair and interfere with immune function, and to be responsible for the bulk of infectious disease—whether bacterial, viral, or parasitic. 

The thesis that is proposed for the huge variation in prevalence between countries is that HIV-negative people whose immune systems are weakened by poor nutrition and constantly challenged by co-infections are more vulnerable to HIV infection; and that HIV-positive people, in the same condition, are more infectious to others. The result is high population transmission rates. 

There is no shortage of evidence on the adverse, even devastating effects of malnutrition, under-nutrition, and specific nutritional deficiencies on immune function, susceptibility to infection and capacity to cope, once infected. 

The term nutritionally acquired immune deficiency syndrome (NAIDS) is applied to immunological dysfunction associated with malnutrition in infants and small children. Is it unreasonable to suppose that a similar mechanism may operate in adolescents and adults and may be worth investigating and even—as a precautionary principle—acting on? The average African household is caught in a poverty cycle of low food production, low income, poor health, malnutrition, poor environmental sanitation, and infectious disease. Food security, as primary prevention, should be a priority strategy in the fight against AIDS in Africa. With water and sanitation, it has the huge advantage of simultaneously reducing population vulnerability to all the other diseases of poverty. 

This brings us to the second major factor, chronic co-infections, most of which are also related to the failure to meet basic needs. There is ample evidence that co-infections not only interfere with immune function, but they also increase viremia—the level of HIV circulating in the body. High viremia, unsurprisingly, is associated with increased risk of transmission.  

Parasitic infections, which affect over a quarter of the world’s population, overwhelmingly in developing countries, may play a particularly important role in high population transmission rates of HIV and TB. Some researchers have suggested that in order to control both these epidemics, parasitic infections must be controlled first. The only co-infection that has received due attention is sexually transmitted infection (syphilis, gonorrhea, chancroid etc), which is known to substantially increase vulnerability to HIV infection. Prevention and control of STI has been recognized as a key strategy in the fight against AIDS. 

Interestingly, the fact that the modes of transmission are the same for STIs as for HIV—both are blood borne diseases, which can be transmitted sexually—has meant that the focus on individual behavior and individual agency can go unchallenged. This would not be the case if the co-infection to be prevented or controlled as a factor of susceptibility to HIV infection were intestinal worms or enteritis. 

With the exception of some brave and outspoken NGOs, the mainstream international AIDS community steadfastly refuses to address poverty, powerlessness, and inequality. It is not that the AIDS community does not talk about poverty. On the contrary, it is the most fashionable subject at the moment. Poverty reduction (rather than eradication) is on everyone’s lips in the alliance of WB/IMF/WTO/G8, the UN agencies dealing with AIDS, government aid agencies, and “charitable” foundations, such as Ford, Rockefeller, and Bill and Melinda Gates. 

In sanctimonious tones, they lament the persistence of poverty, but in a perverse reversal of logic, they advocate for massive attacks on a few killer diseases (malaria, TB, and AIDS) in order to “create prosperity.” No amount of health delivered to Haitians or Tanzanians today is going to provide them with prosperity tomorrow or the next day. It will allow them to survive where others die in rather precarious conditions, perhaps until the next bout of illness. 

Many will protest that the connections with poverty have been recognized from the start. This is true, but it has invariably been in terms of the economic impact of AIDS on communities, in particular on their productivity rather than poverty as the root cause of extreme susceptibility to all infections including HIV. 

Even when social and economic factors, such as labor migration, exchange of sex for survival, gender power imbalances and population movements, have been identified as contributing to vulnerability, the solutions proposed are still focused on the residual action possible at the level of individual behavior. 

The most striking example of this is the provision of condoms at the pithead of mines in South Africa to tens of thousands of migrant laborers slaving to bring up gold for white-owned transnational corporations and to thousands of migrant women selling sex to feed and clothe their children. Migrant labor and sex slavery are unhealthy—even life threatening—socially constructed phenomena, which can therefore be socially deconstructed. Examination of poverty and powerlessness as root causes of AIDS would threaten these kinds of production arrangements. They would also imply a fundamental shift in the international economic order, massive redistribution of the earth’s resources, and an end to the fantastically exploitative rela- tions between North and South. 

The overwhelming power of vested interests confines both the research agenda and the strategies of the international AIDS community to the sphere of the individual in order that structural, economic, and political inequalities neither be brought to light nor questioned. 

The Declaration of Alma Ata (International Conference on Primary Health Care) in 1978 explicitly recognized structural inequalities and macroeconomic factors as determinants of poverty and therefore of population health status. As this approach threatened the status quo, it was politically sanitized and reduced to a few technological interventions. By the early 1980s, neoliberal dogma was already being imposed in international fora and primary health care had more or less been abandoned. 

However, the only progress possible in public health today, and in the fight against AIDS, is a return to the wisdom of Alma Ata—armed at the turn of the century with 20 years’ more evidence of the negative health effects of savage, free market neoliberalism. The “triumph” of capitalism in the Russian Federation, for example, has been accompanied by the collapse of health services and spectacular increases in rates of illness and death.  

Trillions Rather Than Millions? 

T he sums made available through international aid are pitiful compared to the sums that would be released through debt cancellation, fair trade, and measures to end the continued pillage of developing country resources. These amount to trillions rather than millions. It is not hard to understand the preference for international aid. First, it brings about one and half times more back to the donor country than is received by the recipient country. Second, it is immediately used to service the debt to Northern banks—far larger sums than are available to the health and education sectors of debtor countries. Third, even though it may increase the size of the crumbs from the rich person’s table, it does not threaten the international economic order. On the contrary, it deepens the dependency that is so profitable to the developed countries and so devastating to developing countries.  

It is the responsibility of international health authorities to identify the determinants of health (and disease) and to advocate for policy and action, which will contribute most effectively to the goal of health for all, even if this lies outside the health sector. If food, water, sanitation, basic health care, and housing are the quickest, cheapest, most effective ways of achieving health for all, then the international health community should be advocating this. 

If these basic needs can only be met when countries’ national capacities are freed from the strangulation of debt and unfair terms of trade and from the destabilizing chaos of financial flows then they must recommend this. If national food security requires a degree of protectionism rather than unfettered free trade, it must be strongly advocated. There could be no clearer public health imperative. If the obstacle to such advocacy is the hand that feeds the international AIDS community, then the time has come to bite it. That hand is the alliance of WB/IMF/WTO, the G8—even occasionally the UN—and the transnational corporations influencing their policies. 

The beauty of a fair international economic order lies in the fact that nations, communities, and families left to their own devices are quite capable of meeting their own basic needs. Removing the obstacles to self determination is the task to be accomplished. 

The international AIDS community needs to ally with the tremendous movement for social and economic justice today. As a start it might wish to make immediate debt cancellation and the introduction of a Tobin-type tax its funding source for the first few years, followed swiftly by the first steps towards fair trade, bringing trillions of dollars to public health efforts within the long promised new international economic order.