Recovering from AIDS: Re-balancing social health priorities and practice

‘Schmalhausen’s Law is a general principle that organisms in unusual or extreme conditions, at the boundary of their tolerance for any one aspect of their life conditions, are extremely sensitive to stressors in all aspects of their life conditions … A whole-system strategy for confronting infectious disease has to be much broader than traditional medical and public health efforts. Health is determined in a much larger arena that includes land use, demography, pollution and waste disposal, wildlife and agriculture, poverty and inequality’. – Richard Levins, Harvard School of Public Health

Bjørn Lomborg is the head of the Copenhagen Consensus Center, and adjunct professor at the Copenhagen Business School. He is also the influential, and controversial, author of two books on climate shift and how to deal with it: ‘The Skeptical Environmentalist’ and ‘Cool It’.

Lomborg and the Copenhagen Consensus Center have turned their attention to HIV and its impact, especially its impact in the Global South.[1] Noting that Bernhard Schwartländer of UNAIDS has calculated that spending of at least US$22 billion per year will be needed by 2015 to achieve universal access to HIV prevention, treatment, care, and support, Lomborg states:

‘The lamentable reality is that securing US$22 billion in annual funding by 2015 will be practically impossible. So, it is worth asking another question: what could we achieve with just a small increase in the current funding?’

To answer this question the Center, in partnership with a new entity called the Rush Foundation,[2] have created a new initiative, ‘RethinkHIV’.[3] The initiative promises to ‘engage some of the world’s top HIV economists, epidemiologists, and demographers in this vital discussion about priorities’:

‘Teams of researchers have written 18 papers identifying the most effective ways to tackle the epidemic, looking at what has been proven to work, and at what could be scaled up or replicated elsewhere in Africa.

‘All of them calculate the costs and benefits of their proposed solutions, and will compete to convince a panel of five world-class economists, including three Nobel laureates, that they have the very best solutions. The Nobel Laureates’ findings will point to the most effective avenues for additional funding. This approach, the “Copenhagen Consensus” process, is the same one that has been applied every four years to global challenges, and will next take place in 2012.’

It is too early to tell whether this initiative will bear fruit. None of the papers have been released, the deliberation hardly begun, and the biases, pre-dispositions – and perhaps, self-interest[4] – of the various participants remain to be scrutinised. But the very fact of the initiative may be an opportunity for those working on-the-ground within civil society to come forward to share their own experiences and conclusions about the way forward. Such input could very usefully emphasise the need for such any ‘re-thinking’ to go beyond consideration of HIV, to focus as well on other variables implicated in the AIDS phenomenon.

Since the very outset of the crisis there have been attempts to introduce a more dynamic, comprehensive, and critical discourse that treats the phenomenon of HIV and AIDS in a more holistic socioeconomic frame of reference.[5] Such a framework is essential to assist our assessment of current health practice, and guide reform for the future. An important contribution that collected some of the alternative discourse was the 2004 collaboration between the South-Asia-based People’s Health Movement (PHN) and Third World Network (TWN), which resulted in the excellent primer, ‘AIDS: In Search of a Social Solution’, [6] an indispensible collection for anyone investigating variations on the prevailing paradigm, and political-economic approaches to addressing the condition and its devastating effects.

Within the alternative spectrum there inevitably exists a diversity of experiences, views and approaches, as the collection published by TWN and PHM reveals. Within this diversity lies the potential for substantive exchange of experiences, ideas, and learning. At the same time, building such an exchange will also mean being open to challenging the hegemonic quality of the dominant discourse, and the power of the global institutions that drive the international development and health agenda, now including the most powerful philanthrocapitalists[7] in the world, such as Bill and Melinda Gates and their foundation.[8] In the face of this dominance, it has been difficult to ground alternative perspectives sufficiently to launch a broader critical dialogue capable of affecting the way things are currently seen and done. The People’s Health Movement, with its ground-breaking ‘Mumbai Declaration’ from the Third International Forum on People’s Health in January 2004,[9] represents perhaps the most significant attempt, although even this effort as it has developed is not inclusive of all perspectives that need to be brought into a circle of exchange and sharing.

Still, it is possible to find common threads that comprise a base for building a dialogue toward a more comprehensive discourse that situates HIV and AIDS in a broader frame of social health and political-economic justice.

At the core of an alternative perspective is that AIDS is a syndrome (AIDS is an acronym for ‘acquired immune deficiency syndrome’). Rather than one discrete disease, it is a condition in which a person’s immune system is severely compromised and left vulnerable to a broad range of infections and diseases that debilitate and can lead to death. It is a definitional construct that captures many pre-existing disease phenomena in one basket for purposes of investigation, diagnosis and treatment. The most determinant predictors of immune suppression and associated disease, in the north and the south, are factors related to social and economic status or to medical treatment itself. And increasingly, many in the campaign against acute immune deficiency and its effects are asking that resources be prioritised in the area of basic health promotion and social-economic transformation, rather than merely on pharmaceuticals that at best can reach only a small minority, and even then, with mixed results.

This is a perspective that should be given special attention by the ‘RethinkHIV’ initiative. In an important paper prepared in cooperation with Third World Network, Richard Levins, from the Harvard School of Public Health wrote in 2003:

‘Schmalhausen’s Law is a general principle that organisms in unusual or extreme conditions, at the boundary of their tolerance for any one aspect of their life conditions, are extremely sensitive to stressors in all aspects of their life conditions. Thus malnutrition inhibits the immune system and makes people more vulnerable to infection. Pesticide poisoning can prevent absorption of vitamin A, and this in turn reduces the T-cells and macrophages that are part of the body’s defences. Diabetes makes bacterial infections more dangerous. Diarrhoea can make it easier for pollutants to pass through the lining of the gut, while any sexually transmitted diseases that irritate the reproductive tract facilitate the entry of HIV. Social and emotional stress and anxiety reduce immune capacity. Poor people are often afflicted by multiple insult, allowing even more ailments to accumulate. Therefore any struggle against poverty and racism and abuse based on gender is also a public health issue, and the health of a community has to be looked at not only disease by disease but also as a whole. Vulnerability itself becomes an object of study…

‘The single-minded reliance on chemical therapies leaves us vulnerable … A whole-system strategy for confronting infectious disease has to be much broader than traditional medical and public health efforts. Health is determined in a much larger arena that includes land use, demography, pollution and waste disposal, wildlife and agriculture, poverty and inequality.’[10]

There has been a tendency to obscure this fundamental understanding for fear of ‘confusing’ people, undermining prevention programmes, and eroding support for programme funding and investment in pharmacological treatment and research.

Those advocating a comprehensive approach to health programming and public education do not insist that poverty is the sole cause of extreme and chronic immune deficiency, nor that viruses and microbes have no role. In fact, most resist precisely the notion that acute immunodeficiency is a single phenomenon or that it has a solitary cause. They do say that the factors and conditions that lead to such immune suppression are dominant among poor populations, that the poor are the most vulnerable, and that it is on poverty and its roots that we should focus. A virus is a convenient target to rationalise financial resources and medical responses, but it also obscures other factors in the political economy that would focus responses on long-term social and economic transformation of the conditions that make people vulnerable to the diseases that take advantage of chronic immune deficiency. More discussion of these dilemmas is necessary, and this new initiative provides an important opportunity for independent, alternative input that should not be missed.

BEYOND HIV

In his text, ‘Rethinking Aids: The Tragic Cost of Premature Consensus’[11] Robert Root-Bernstein[12] described a host of factors in the development of acute immunodeficiency. In common with most health activists who seek a broader social health approach to AIDS, Root-Bernstein does not dismiss the role of HIV as one of many possible co-factors in what he proposes as a synergistic model of the AIDS condition.[13] But this model also incorporates an extensive list of proven non-viral causes of immuno-suppression, many of them treatment-related (such as chronic antibiotic use, or blood transfusions), or social/health factors (such as malnutrition, unsafe sexual practices, and stress), as well as endemic diseases and environmental factors.[14] The ‘RethinkHIV’ initiative will need to ensure that the purview of research is sufficiently broad to include these critical factors, and the interactions among them, exploring the broader phenomenon of widespread acute and chronic immunosuppression, rather than examining HIV exclusively.

WHO reports[15] that well over 20 per cent of the Earth’s more than six billion people are sick or malnourished at a given time, with the ten leading maladies being: Hepatitis B (2 billion); Tuberculosis (1.7 billion –WHO estimated in 2003 that almost 33 per cent of the human population passively carried the TB bacillus, although only about 2-3 million acutely vulnerable people are actually stricken with the disease); Anaemia (1.5 billion); Hookworm (ancylostomiasis – 700-900 million) ; Roundworm (ascariasis –700 million); Diarrheal diseases (amoebiasis and giardiasis – 680 million); Whipworm (trichuriasis – 500 million; Malaria (270 million); Iodine deficiency (200 million); and Schistosomiasis (parasitic infection – 200 million). Obviously many of these maladies are suffered concurrently by hundreds of millions of people worldwide, most in the Global South, and many such as tuberculosis are increasing yearly.

Every one of these most-common inflictions are also serious factors leading to the development of chronic life-threatening immunodeficiency.[16] When suffered in combination with chronic malnutrition and its vitamin deficiencies (particularly vitamins A, B6, B12, as well as thiamin, riboflavin, nicotinamide and carotene), critical immunosuppression is inevitable and, if not remedied, so are the plethora of opportunistic infections that lead to death. The link between immunosuppression and historic endemic conditions and diseases underscores the importance of focusing on socio-economic factors in the prevention and treatment of chronic life-threatening immunodeficiency.

Malnutrition is universally prevalent in countries and regions identified as epicentres of AIDS. Malnutrition is known to increase susceptibility and vulnerability to parasitic infections and their effects. As well, the immunodeficiency that accompanies malnutrition – as result, for example, of even small deficiencies of critical nutrients such as Vitamin A – leads to a marked increase in mortality during other infectious disease.

In addition, the rarely-publicised problem of the ‘antibiotic epidemic’ in the Global South exacerbates the already existing risks of chronic life-threatening immunosuppression. The widespread and indiscriminate over-the-counter black market trade in antibiotics and self-diagnosis and treatment of incidental and chronic infection, creates pervasive immunosuppression among populations where these practices exist.[17]

This is the history of the poor, not only in the Third World but also in the more affluent industrialised country where by far the majority of diagnosed, and undiagnosed, acute immunodeficiency occurs among the poor, the socially marginal (particularly ethno-minorities), and the uprooted. The preponderance of chronic life-threatening immunodeficiency is related to long-standing social and endemic causes that increase people’s vulnerability to all infections. In recent times, attention is also being focused as well on non-communicable diseases, which are becoming recognised as a ‘hidden’ curse among the poor, in the north and the south.[18]

The perception of acute chronic immunodeficiency as a single-factor disease has been critical in influencing how AIDS is dealt with everywhere in the world. This is particularly so in the Global South, as governmental aid donors, multilateral organisations, and the international non-government sector participate in promoting and implementing AIDS programmes in virtually every country. We have seen a diversion of attention worldwide from the chronic problems caused by the conditions of poverty, war and repression – realities that kill countless millions every year. The amount of international aid money devoted to HIV-related programs has skewed health funding to the extent that a preponderance of health spending goes into such programs, and obscures other development issues that demand critical attention.

This model has not merely impacted the emphasis of funding but has also influenced the way that health care is carried out. We have seen the practice of medicine skewed, to the detriment particularly of the weakest and most marginalised, and to women. Most people in the Global South suffering from various endemic conditions are left without appropriate treatment, in a cruel system of triage that also brings with it the stigma and social isolation[19] that flows from the constant association of HIV with illicit and ‘un-natural’ sexual practices. Indeed, the fixation on (imagined) African sexuality and norms[20] within the conventional HIV/AIDS paradigm only underscores the need for a broader and more critical discussion.[21]

Of greatest concern is how the AIDS model has intruded on the reproductive health and rights of women. Pregnant women and their children have become the single most important target of formal interventions. It is they who have become the test subjects, and it is on their backs that the quest to halt the spread of HIV has been placed.

Fortunately some of these excesses have begun to be turned around, although the stigma on breast-feeding continues to be a significant problem in areas where fear of HIV infection dominates other health concerns.[22] Further, we are seeing new initiatives gaining ground that once again undermine the reproductive freedom and the rights of women, such as the call for ‘voluntary’ sterilisation of African women.[23]

In addition, the anti-viral chemotherapies prescribed to gestating mothers and their infants can be toxic both to the woman and to her developing child in the womb and in the first months after birth – especially if they are already immuno-compromised through illness, malnutrition or other factors. Recently the risks of such treatments have been acknowledged more publically, and important advocates have spoken out against the use of at least some of the most common ARVs, such as nevirapine.[24] But a more extensive conversation is required about the practice and its justifications.

Finally there is the grave question of human experimentation. Vaccine research now leads the way, but all manner of human drug testing is being undertaken in Africa, and elsewhere, with the support of national governments. This trend is reinforced by the global preoccupation with HIV that dominates foreign aid budgets of virtually all OECD nations, and the funding priorities of major globalised philanthro-capitalist institutions such as the Gates Foundations.[25]

OBSCURING INJUSTICE: THE MEDICALISATION OF UNDERDEVELOPMENT

After all these years public attitudes are still dominated by ignorance and prejudice that represent a threat to the human rights and quality of life of AIDS victims, as well as for those suspected of carrying the virus. Groups in society considered susceptible are also the most vulnerable – the indigent poor, minorities wherever they live, women and children as described above, and immigrants and refugees seeking entry to industrialised nations from ‘non-white’ Third World countries, especially from Africa, and the Caribbean.

Yet to challenge current practice is difficult, because in questioning the priorities of the international public health establishment, we risk falling into a polemic that diverts attention from the reality that legions of poor and marginal around the world are ill and dying as a direct result of the wretched conditions of their lives, and the acute immuno-suppression that is the chronic condition of the poorest and least defensible.

But the reality remains that neither prevention nor treatment are currently available to those most at risk. They are certainly not available among the most marginal populations in the Global South and will never be accessible to them on any meaningful scale. This is the very premise of the initiative announced by the Copenhagen Consensus Center. To the limited extent that pharmaceuticals do become available to some, it will be at the expense of investments in community health and social transformation that, in the final analysis, are the most effective responses to the phenomena presently attributed solely to HIV.

More critically still, even if less harmful drugs were to be finally made sufficiently available, the infrastructure required to safely administer and monitor the use of the drugs and other medicines is not available in any of the regions and locales currently portrayed as epicentres. The investment that is required to build and support such infrastructure has been diverted to developing and purchasing the drugs themselves rather than to building health systems that are a precondition to sustained and effective universal treatment, let alone the effort required in disease prevention and mitigation through social and economic interventions.

Building such health systems has to become the first priority, along with an intense re-emphasis on public health and social medicine, bolstered by sustained measures to increase economic and social equality.

Meredith Turshen of Rutgers University and her French colleague, Annie Thebaud-Mony, long ago – at the very outset of this disaster – warned that AIDS is merely the most recent manifestation of what they referred to as the ‘medicalization of underdevelopment’[26] This warning is at the heart of the issue. As with Richard Levin, quoted earlier, Robert Root-Bernstein emphasises:

‘…the continued validity of one of the oldest and most fundamental truths of medical science: Public health measures are always more effective in controlling disease than are all the medicines in the world ...If we want to control Aids…[W]e need to solve the social, economic, health education and medical care problems that create the conditions that permit AIDS to develop in the first place.’[27]

These are social problems rooted deeply in global economic structures and require political and social interventions. More than philanthropy, what is required is social and economic justice. Without justice, the scourge of chronic acute immunodeficiency and its associated opportunistic conditions will remain as universal as will the existence of poverty itself.

© Brian K. Murphy, 2011

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* Brian K. Murphy is an independent policy analyst in global development issues, formerly with the Canadian social justice organisation, Inter Pares. In addition to major papers and journal articles, he has contributed to several books and is the author of ‘Transforming Ourselves, Transforming the World, An Open Conspiracy for Social Change’, ZED Books (London) and Fernwood (Halifax), 1999.
* Please send comments to editor[at]pambazuka[dot]org or comment online at Pambazuka News.

NOTES
[1] See, Lomborg, Bjørn, Rethinking the Fight against HIV: http://www.project-syndicate.org/commentary/lomborg76/English
[2] See http://www.rushfoundation.org/
[3] See: http://www.rethinkhiv.com/
[4] The web site of the Rush Foundation states: “The Rush Foundation was set up in September 2010, when its founders were granted the right to negotiate an access agreement on behalf of UK company SEEK, whose HIV vaccine has successfully completed phase II human trials in July 2011. The foundation will negotiate, at the time of the licensing process, a low-income country distribution/pricing concession from the licensor which licenses the IP for commercial development. The Rush Foundation’s objective is to ensure that the vaccine is available at minimal cost to the most affected regions of the world, and in particular sub-Saharan Africa. In addition to our work on the access agreement, we aim to alleviate suffering on the ground by sponsoring sustainable innovative initiatives, pioneer new behavioural change campaigns, as well as stimulate policy debate at the top, in order to generate new thinking and new solutions. We seek to stay away from well-beaten tracks and focus on areas that are either ignored or poorly served by previously existing efforts.”

More information about the UK company, SEEK, is available at http://www.seekacure.com/ The site explains that SEEK is a trademark of PepTell Limited, a UK registered company, based in London. The claims that a HIV vaccine developed by the company has successfully completed Phase II Human Trials can be seen at http://www.seekacure.com/news/110718_SEEK_announces_clinical_proof_of_efficacy_in_HIV_vaccine.html.

[5] See, as just two examples: Murphy, Brian K, “The Politics of Aids”, in Resurgence, Vol 47, June, 1994, pp 33-40, published by Third World Network (Penang); and Decosas, Josef (Southern African AIDS Training Programme, Harare, Zimbabwe), The Social Ecology of AIDS in Africa. Draft paper prepared for the UNRISD project, HIV/AIDS and Development, March 2002: http://bit.ly/oztwCi Also see Robert Root-Bernstein and Stephen J. Merrill, “Etiology and Pathogenesis of AIDS”, in: Standish, LJ, C Calabrese, ML Galantino, eds. AIDS and Complementary & Alternative Medicine: Current Science and Practice, St. Louis, MO, Churchill-Livingston/Harcourt/Mosby, 2001.
[6] AIDS, In Search for a Social Solution, produced by Third World Resurgence, published by Third World Network (Penang) and People’s Health Network (Bangalore), 2004.
[7] See Edwards, Michael, Just Another Emperor, The Myths and Realities of Philanthrocapitalism, Demos, 2008, available at http://www.futurepositive.org/emperor.php and/or http://bit.ly/pC1lgN

[8] For discussion of some of the generic issues concerning the influence of such foundations on public health policy, see Wiist, Bill, Philanthropic Foundations and the Public Health Agenda, Corporations and Health Watch, August 2011, available at:
http://bit.ly/r9W5vz
[9] This document is reproduced on pp 150-151 of the above-cited, AIDS, In Search for a Social Solution, as is the “Asian People’s Charter on HIV/AIDS”, presented at the XV International AIDS Conference in July, 2004 (pp148-49). For more on the People’s Health Movement: http://www.phmovement.org/ .
[10] Levins, Richard, “The re-emergence of infectious diseases on the public health agenda”. The paper appeared in Third World Resurgence #155/156 (Third World Network, Penang), and was submitted by TWN at the October 12-15, 2003 conference, “Within and Beyond the Limits to Human Nature”, sponsored by the Heinrich Böll Foundation and the Institut Mensch, Ethik und Wissenschaft. The full paper is available at: http://www.biopolitics-berlin2003.org/docs.asp?id=176 One of the world’s foremost biomathematicians, Richard Levins is the John Rock Professor of Population Sciences at the Harvard School of Public Health and a visiting scientist at the Institute of Ecology and Systematics in Cuba.
[11] Root-Bernstein, Robert, The Tragic Cost of Premature Consensus, MacMillan/Free Press, NY 1993.
[12] Root-Bernstein is one of the world’s most eminent scientists and science historians, whose formative years included extended stints as a research assistant to both Thomas Kuhn and Jonas Salk. See the extensive curriculum vitae for Root-Bernstein at http://www.pwias.ubc.ca/geninfo/people/cv.root-bernstein.pdf
[13] See for example, Root-Bernstein, Robert S. and Stephen J. Merrill, “The Necessity of Cofactors in the Pathogenesis of AIDS: a Mathematical Model”, J. theor. Biol. (1997) 187, 135–146, available at https://www.msu.edu/~rootbern/
[14] The range of such infections and conditions is documented more extensively in my paper: Murphy, Brian K, The Political Economy of Aids (2004), originally published by the late Nick Regush on his RedFlagsWeekly site, now available at http://aras.ab.ca/articles/popular/20040217-PoliticalEconomyOfAIDS.pdf
[15] See, The Global Health Council, The Impact of Infectious Diseases, available at:
http://www.globalhealth.org/infectious_diseases/ ; and, WHO, The global burden of disease: 2004 update http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html ; also WHO: http://www.who.int/neglected_diseases/2010report/en/index.html ;
[16] Root-Bernstein, Robert S. and Stephen J. Merrill, “The Necessity of Cofactors in the Pathogenesis of AIDS: a Mathematical Model” , op cit. See also: Root-Bernstein, Robert, “The Cofactor Theory of AIDS”, in AIDS Vaccines and Related Topics, pp145-159; Editor: Aldar S. Bourinbaiar, Research Signposts, Kerala, India, 2004.

[17] See for example, Antibiotic use "excessive", say specialists; Drug misusage is problematic in Southeast Asia, IRIN, 14 April 2011: http://www.irinnews.org/report.aspx?reportid=92475
[18] “… while long seen as illnesses of the industrialised world, the “big four” non-communicable killers – cardiovascular diseases, cancers, chronic respiratory illness and diabetes – are now also responsible for the majority of deaths in the developing world, outstripping infectious diseases such as HIV and malaria everywhere except in parts of Africa.” .See, Jack, Andrew, “World leaders debate disease burden”, Financial Times, September 18, 2011: http://on.ft.com/qnUu0N; Manson, Katrina, “Africa struggles to control a prolific killer”, Financial Times, September 16, 2011: http://www.ft.com/intl/cms/s/0/b438139c-e07d-11e0-bd01-00144feabdc0.html ; See also, Freudenberg, Nicholas, “Corporations Undermine UN Effort to Reduce Chronic Diseases”, September 24, 2011, CommonDreams.org: http://bit.ly/qm5X7a
[19] See, for example, Blystad, Astrid and Karen Marie Moland , “Technologies of hope? Motherhood, HIV and infant feeding in eastern Africa”, in Anthropology & Medicine, Volume 16, Issue 2, 2009, pp. 105-108 (Research conducted under auspices of the Centre for International Health, University of Bergen, Norway): available at http://bit.ly/n8jw6i
[20] See, Tamale, Sylvia (Editor), African Sexualities, A Reader, Fahamu Books/Pambazuka Press, 2011: http://bit.ly/nTkNG1
[21] See, Geshekter, Charles, A Critical Reappraisal of African AIDS Research and Western Sexual Stereotypes, prepared for Presentation to General Assembly Meeting Council for the Development of Social Science Research in Africa [CODESRIA">
Dakar, SENEGAL 14-18 December 1998,
REVISED – May 5, 1999; available at http://bit.ly/p963bG Also useful on this theme, although not focusing specifically on Africa or the Global South, are: Walldby, Catherine, Aids and the Body Politic, Biomedicine and Sexual Difference, Routledge, (London & New York), 1996; and Sontag, Susan, AIDS and its Metaphors, Farrar, Straus and Giroux (New York), 1989.
[22] Blystad, Astrid and Karen Marie Moland, op. cit.
[23] Anso Thom, “US project planning to sterilise HIV+ women in SA”, Health-e—South African Health News Service, April 11, 2011: http://bit.ly/mUHSjM
[24] See Bosley, Sarah, “UN accused of risking women and children's health”, The Guardian, December 17, 2010, http://bit.ly/oVCYri
[25] Wiist, Bill, Philanthropic Foundations and the Public Health Agenda, op cit.
[26] See Turshen, Meredith and A. Thébaud-Mony, "Combattre le SIDA au nom de la "civilisation"? in Le Monde Diplomatique, April, 1991:24.
[27] Root-Bernstein, Robert, The Tragic Cost of Premature Consensus, op cit, pp 367-368.