While there were clearly significant differences between the impact of HIV in developed and developing countries, differences linked to the epidemiological patterns found in various societies, AIDS became a reality in a world where global communications had already broken down many of the traditional frontiers and differences between countries. It is perhaps symbolic that the first AIDS cases diagnosed - though almost certainly not the first to exist - were found among homosexual men, for the gay world is a particularly international one, involving rapid mobility and cross-cultural contacts. Without accepting Randy Shilts' rather fanciful concept of 'Patient Zero', an airline steward who infected large numbers of homosexual men across North America¹, there is little doubt that HIV was spread rapidly via international travel, and the common explanation for relatively high infection rates among homosexual men in places as dispersed as San Juan, Sydney and Zurich was their interaction during the early 1980s with American gay men.

It is tempting to postulate two simultaneous epidemics, one in the developed world, beginning in North American gay ghettoes and moving from there into injecting drug user and haemophilic populations, the other, far more generalized, beginning in Central Africa and spreading not into specific communities but into the 'general population'. While Africa was not necessarily the source - certainly not the only source - this latter pattern was repeated in the Caribbean, South and South-east Asia and the rest of Africa. This has some parallels to early mappings of the epidemic which spoke of Patterns I, II and II based on different epidemiological patterns. Just as these are too simple - in some parts of the world, e.g. Brazil, one could find evidence for all three patterns simultaneously - so too is a divide between the developed and the developing world in terms of the political and social response. Denial and the availability of resources for prevention, care and community organization is not always linked to levels of development or affluence: few societies have been as reluctant to come to terms with the challenge of AIDS as was that very rich country Japan. Community responses were often strongest in countries with relatively few resources, such as Uganda or Zambia.

Nor were social responses to HIV/AIDS necessarily that different across frontiers. Unfortunately denial, ignorance and persecution on the basis of AIDS has been almost universal, and the stigma of the disease has clearly been compounded by its association with already stigmatized forms of sexual (and drug-using) behaviour. Almost all societies went through periods in which there were attempts at branding AIDS as a disease imported by foreigners, whether it was Japanese gay bars refusing admission to westerners, the banning of foreigners (in practice white foreigners) from prostitution complexes in Indonesia, or Indian doctors refusing to treat African students. (Typical of many reactions were the comments of one Indian state health minister that: 'There is a risk of foreigners giving us this disease called AIDS on a platter'.²) AIDS panics have taken different forms in different societies, but it would be foolhardy to assume they have been less frequent in societies with greater levels of education and affluence, and an increasingly globalizing media ensured that the scare stories, and those portraying AIDS as a disease of 'the other', spread rapidly across the world.³

Just as the epidemiology of AIDS must be understood within its social context, so too must the community response. The decade in which AIDS was recognized, conceptualized and named was a decade in which the Western world was undergoing the economic rationalizations of Reagan and Thatcher. As Elizabeth Fee and Daniel Fox have written: 'Containing health costs had become a major objective of governments in the United States and Western Europe, and these governments were reluctant to recognize, let alone deal with, the potentially devastating costs of coping with a new epidemic.'⁴ These concerns were reflected in the 'structural adjustments' imposed on developing countries by international agencies led by the International Monetary Fund and World Bank which also meant severe reductions in the size of the public sector.

There is considerable literature on the impact of 'structural adjustment' on developing countries, and the ways in which it has both increased income gaps within many countries, hastened rapid migration to the shanty towns which now make up the majority of Third World metropolitan areas, and hit women particularly hard.⁵ In a 1993 letter to the President of the World Bank, written by the Inter-Church Coalition on Africa, the 'single greatest factor' contributing to the poor health of the developing world was identified as the Bank's own emphasis on the diverting of resources to debt servicing and the development of export industries.⁶ Moreover, AIDS developed in a world in which political upheavals, particularly in Eastern Europe and the former Soviet Union, would start to reshape the post-World War II map of the world, while destroying public services in places torn by civil strife such as Bosnia and Georgia.

Whether because of 'structural adjustments' in South America and Africa, the impact of civil strife and military rule in Burma and Cambodia, or the collapse of Communism in Eastern Europe, the spread of the epidemic has often been directly related to larger questions of political economy. One cannot understand, for example, the role of prostitution in Thailand, and the growing importation of young girls into Thai brothels from neighbouring Burma and Laos, without understanding the inter-connected power of the military and certain government and business interests. The opening up of Vietnam and Cambodia to tourism and the subsequent development of a large sex industry have dramatically increased the risk of spreading HIV infection.⁷ The war on drugs, whether in the 'golden triangle' of South-east Asia or in South America and US cities, has changed patterns of drug consumption, often increasing rather than decreasing needle use as against inhalation or smoking.

From the former Soviet empire of Eastern Europe and Central Asia come disquieting reports of the spread of HIV as basic services (including blood screening and the availability of disposable syringes) break down, as population mobility and commercial sex increases, and as there are no resources available for prevention or for basic information. As one writer put it: 'The Berlin Wall acted as the world's biggest condom'⁸ since its collapse HIV has the potential to spread rapidly in Eastern Europe. In Poland there has been a marked increase in needle use, alongside a shortage of syringes, and stringent Catholic restrictions on providing condoms. Many hospitals in the former Soviet Union lack facilities for proper sterilization, and HIV information is rarely available.⁹

I prefer a formulation which stresses the centrality of political economy to vulnerability to AIDS and its impacts to that which has been framed by Jonathan Mann and adopted by the Global AIDS Policy Coalition (of which I am a member: this is clearly a friendly disagreement over priorities). In a statement of the Coalition one sentence is central: 'The critical relationship between societal discrimination and vulnerability to HIV is the central insight gained from a decade of global work.'¹⁰ But 'societal discrimination', whether due to difference of gender, class, race, nationality, sexuality or occupation, grows out of the political economy of a given society, namely those arrangements which determine the allocation of resources both nationally and internationally. In a number of cases 'development' itself contributes to the conditions making for vulnerability, as when economic changes force many out of rural life, pushing young men to leave their villages for the cities or minefields, and young women into urban factories or 'hospitality' work, disrupting families and increasing commercial sex.¹¹ Political economy, too, helps explain the ways in which AIDS research is both funded and directed. If, as is generally believed, about one third of all HIV/AIDS research is controlled by the pharmaceutical industry, it becomes important to note that this is essentially an industry dominated by large firms concentrated in half a dozen countries, with development and research led by the United States, Japan and a handful of Western European countries.¹²

If the epidemic developed in a world of structural adjustments and privatization, it also developed in a world in which feminism and gay assertion meant the existence, in at least some places, of existing organizations and communities able to respond to the new crisis. The very idea that community-based organizations should play a leading role in meeting the challenge of a public health crisis is related to a whole series of political and social developments over the past twenty years. The redefinition of public health, sometimes described by the term 'the new public health', achieved official status with the adoption in 1986 by an international conference of 38 countries of what has become known as the Ottawa Charter. This declaration is committed to a policy of 'health for all', stressing the importance of primary health care, of the promotion of healthy life styles and of prevention and health promotion. Most significant for our purposes, the Ottawa Charter, through its focus on the creation of supportive environments and the 'enabling' of communities through development of personal skills and health advocacy, is 'in a real sense a challenge to professional practice as it is found throughout the world.'¹³ As the Charter states: 'Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities, their ownership and control of their own endeavours and destinies.¹⁴

In a sense AIDS, already developing at the time the Ottawa Charter was adopted, proved an acid test for the principles of 'the new public health'. (It may also have showed the limits of this new paradigm, particularly in its failure to place respect for basic human rights in a sufficiently central position.) No other disease, Jonathan Mann has claimed, has so revolutionized attitudes to the meaning and provision of health care. The old paradigm, Mann notes:

focused on discovering the external agents of disease, disability and premature death. Inevitably the emphasis was medical and technological, involving experts and engineers, and for certain purposes this approach was quite effective. However this paradigm envisioned a fundamental dichotomy between individual and social interests; accordingly, and in concert with the spirit of the age, governments were called upon a mediate and to prevent disease through laws and the work of bureaucracies. Attention to behavioural, social and societal considerations was often rudimentary and naive. Public health systems often favoured coercion and compulsion without considering their effects on human rights.¹⁵

Already when AIDS was first conceptualized many of the assumptions of this old paradigm were being challenged. The requirements imposed by a new epidemic, which could not be cured nor prevented through bio-medical means, made new models of public health particularly relevant, as concepts of empowerment and self-esteem came to be central in the development of new strategies for education and intervention. Perhaps most significant, leaders like Mann developed an analysis of human rights as central to any AIDS strategy, not just for moral reasons but also because their abuse made it more difficult to reach and affect those people who were most vulnerable to HIV.¹⁶

Concern for human rights is a theme which runs through this book. For the moment let me note that there are two basic sorts of rights which have engaged community groups, namely those involving protection against discrimination and those ensuring equal access to information, support and care. The former have received considerable attention, with reference to issues such as travel, compulsory testing, confidentiality etc. The latter is less often discussed under the rubric of human rights, yet it is central: the greatest abuses of human dignity in the current epidemic are found in the extraordinary inequality of resources available to provide both basic information, preventive measures and even palliative care to those with HIV/AIDS. Access to condoms, to clean needles and to basic medical treatment is as essential to empowerment and self-esteem as is protection against discrimination and persecution, and larger concerns such as food and shelter have immediate consequences for HIV care and prevention.¹⁷ All too often, access to such basic services is distorted by patterns of discrimination based on gender, race, sexuality and the larger inequalities of the global political economy.

The 'new public health' built on the interest in 'community organizing' that had been growing in most Western countries since the late 1960s (and become a major ingredient of development theory in many Third World countries). The new interest in 'community organizing' stemmed both from those with a commitment to grass-roots participation and from those interested in cutting back the role of the state, leading to sometimes strange alliances (in theory at least) between new right and new left critiques of the state. Particularly in the English-speaking industrialized world, cut-backs, economic rationalization and 'de-institutionalization' have been the framework within which conservative governments have seen community organizations as worthy of support. As Rosamund Thorpe suggests, governments have fostered community organizations as an alternative to more costly direct interventions, while at the same time such organizations develop from the anger of those who find the existing state system is unable to meet their demands.¹⁸ While there may seem to be a division between those who see the voluntary sector as complementary to government, and those who see it as posing a fundamental challenge, by the early 1980s considerable numbers of people had been exposed to the ideas of participatory involvement, community organizing, opposition to large scale bureaucracy, and the need to transform political consciousness as a means of transforming social structures.¹⁹

For somewhat different reasons the idea of 'community development' was also enthusiastically fostered by various United nations programs from the 1960s onwards, as a 'third way' towards economic development. As J.A. Ponsioen wrote in 1962: 'Community development is not only a method of development... The ideology of community development rejects the authoritarian way of developing countries - the Soviet approach - and the individualistic way through competition for material welfare - as was the Western approach. The ideology of community development appeals to the citizens of a community to develop their own initiative.'²⁰ The influence of concepts of community development would become increasingly significant as international development agencies, both inter-governmental and private, became increasingly concerned with HIV/AIDS from the late 1980s on.

The stress on development would be accompanied by a somewhat belated recognition of the significance of gender, as there came to be a greater understanding of the double impact of HIV on women as both those at greater risk of infection and those on whom the burdens of care most heavily falls. In many developing countries, governments and development agencies have turned to women's organizations in order to develop AIDS-specific programs. But a feminist analysis had already impacted on the response to HIV in the developed world. As Eve K. Sedgwick wrote: 'Feminist perspectives on medicine and health care issues, on civil disobedience, and on the politics of class and race as well as of sexuality have been centrally enabling for the recent waves of AIDS activism. What this activism returns to the lesbians involved in it may include a more richly pluralized range of imaginings of lines of gender and sexual identification.'²¹

See also "On Global Queering" a short article by Dennis Altman available on the Web (toghether with readers responses to his text)

Back to [the top of the page] [the contents of this issue of MOTS PLURIELS]