Thought Matters

Thursday 25 November 2004, 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 people 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, 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.

But 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.

Strong 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 frameworks.

All 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.

Effective 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.

Some 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.

Evidence 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 as facts.

Eclectic realities

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.

One 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.

The 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.

Another 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.

The 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.

Singling AIDS out as a primary, salient factor is 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. But it can be misleading and tempt short-sighted and ineffectual policy responses. 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.

The 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 fulfil societal duties.

The 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.

Overall, 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.

But 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.

All 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.

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