World AIDS Day: the clock is still ticking

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 it 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.