world aids day: the clock is still ticking

[Guest guest]

WORLD AIDS DAY: THE CLOCK IS STILL TICKING

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 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.

* World Aids Day is on 1 December.

* Hein Marais is a South African writer and journalist. A former

chief writer for the Joint United Nations Programme on HIV/AIDS

(UNAIDS), his work is focused largely on AIDS and on political-

economic issues. He is the author of South Africa: Limits to Change -

The Political-economy of Transition (Zed Books/UCT Press). This

article first appeared in the e-newsletter of the Isandla Institute,

which can be visited at http://www.isandla.org.za/.

[Guest guest]

Hi to all list readers,

Well I found this a very realistic read in a perfect world view where

communities views and reasoned epidemiology guides all action.

What I found difficult to cull is what do we do on a day to day basis when

we are still seeing people dying when access to treatment or other health

management strategies for their deteriorating condition, is still not within

their grasp.

We hear about generic drug efficacy being defective and along side that we

hear that proprietory medicines are usually given away free to countries in

need or for a price cheaper than the generic substitutes. Show me someone

where that is happening please.

I was visited by a positive indian man brought by his friend. I found a very

frightened and uptight fellow who used to be a champion junior wrestler. His

wife left him after she found out he was positive His access to meals and

even adequate clean drinking water in sufficient amounts daily was just

beyond him.

He had a temperature and described PCP like symptoms and a poor appetite. I

tried to explain that appetite is controlled to some extent by the body's

capacity to process the food we eat and adequate hydration is imperative to

digestion.

I asked him about how he saw his future and he said he was just waiting to

die. I asked him about his CD4 count and he said he had a report but he

couldn't remember what was on it. Clearly he didn't understand the

importance of the numbers in fighting back.

I asked him to try to organise a supply of potable water equivalent to 2

litres a day and asked about his support network. He didn't have one. Even

his family had blamed him for his condition and after his wife found out he

was +ve she also left apparently uninfected.

He was desperately lonely and uninformed. I asked him to start drinking

water and to take some paracetamol for his fever and then described what one

needs to do to fight the virus if there is no capacity for ARV medicine.

I then asked him to come back the next day with the blood reports that he

had but had not understood and we talked about a management strategy which

would begin with some understanding of weight loss, eating patterns,

appetite stimulation and relaxation techniques. Above all he was told that

there are people who love him even if he can't imagine that right now.

He was very limited in his english but far superior to my hindi so I

arranged for someone to sit with us who wasn't his friend and who might just

explain what I was saying to him as an impartial stranger.

He returned the next day. His body was more relaxed. His fever was gone and

he agreed to some remedial massage during which time some explanation of how

the body's immune system functioned and what made the job of immune

protection easier or harder.

We then shared a meal which he seemed to enjoy for the first time in ages.

It was very difficult for me to describe what was happening with this fellow

but I have been hearing daily reports on how much he has responded. By the

way his blood CD4 count was at a range that was well managable without ARV's

but he didn't have a clue about that aspect of his health.

We finished the evening with an arm wrestle which he won because I am old

enough to be his father but the effect of the effort and the discourse,

limited though it was due to language, just indicates that if we start early

enough we can keep people well without resorting to ARV's. We must of course

provide an accepting environment with an adequate level of nutrition based

on food groups and taken in small amounts throughout the day. He said that

his rest the night before was better than he could remember since his

diagnosis. Since he had some chest infectivity he was shown some sleeping

positions with pillow formations that minimised obstruction to his airways

and he was encouraged to go for slow walks each morning before the air

became too polluted with instructions as to a walking and breathing pattern

that ensures his lungs breath out most of the stale air that had accumulated

with his shallow breathing practices that had become habitual.

I was encouraged by the speed of his response and the enthusiasm that he

displayed to both knowing more and practicing what he had been taught.

I am not quite sure where that fits between:-

>streamlined demands of AIDS advocacy (and their translation into policy),

>and the generation and

>interpretation of reliable AIDS research and analysis

but it is often where the rubber hits the road where I work.

Geoffrey

Geoff Heaviside

Convenor - Brimbank Community Initiatives Inc

Secretary - International Centre for Health Equity Inc

Member - Australasian Society for HIV Medicine Inc

P.O. Box 606 Sunshine 3020

. Australia.

Ph: 0418 328 278

Ph/Fax : (61 3) 9449 1856

or in India

Mr Geoff Heaviside

Mobile : (91) 9840 097 178 (Only when in India)

Kenya Mobile (254) 721362901

" Concern for what is right causes us to do our best - Knowledge of what is

best inspires us to do what is right. "

>From: " yamanjanl " <yamanjanl@...>

>Reply-AIDS treatments

>AIDS treatments

>Subject: world aids day: the clock is still ticking

>Date: Sun, 28 Nov 2004 15:07:23 -0000

>

>

>WORLD AIDS DAY: THE CLOCK IS STILL TICKING

>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 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.

>

>* World Aids Day is on 1 December.

>

>* Hein Marais is a South African writer and journalist. A former

>chief writer for the Joint United Nations Programme on HIV/AIDS

>(UNAIDS), his work is focused largely on AIDS and on political-

>economic issues. He is the author of South Africa: Limits to Change -

>The Political-economy of Transition (Zed Books/UCT Press). This

>article first appeared in the e-newsletter of the Isandla Institute,

>which can be visited at http://www.isandla.org.za/.

>

>

>

>

[Guest guest]

Thanks for the encouragement Calle and hello to other readers to whom I have

taken the liberty of circulating the response,

DNP+ is the one NP+ in India that does not link with the umbrella network of

INP+ and it is the one that reaches closest to where this fellow is.

I have recruited him to help me in some work that can happen with

unaffiliated people who can and should be more well.

Delhi is a strange place when it comes to networks. I think I will link him

directly to INP+ as an ambassador.

In any event I have just worked out a vitamin and mineral supplement program

that I am sure will make him feel better and maybe even get him to go back

to his work in the physical education field.

His former wife has divorced him and remarried and I am linking him with the

matchmaking services here for positive singles wanting similar partners in

the hope that he can meet someone and re-establish his matrimonial status.

Through that I feel that his status within his family of origin will also

improve.

Of course economically he cannot afford the supplements but enough is in

hand to get him started and if he responds the way I think he will we should

have holding pattern to maintain his reasonably high T cell count.

The problem is that he is just one of so many who could be better informed

and better motivated if the VCT's actually did what is necessary rather than

just count the number of infected people for the government.

Today I was reading a lead article as a preamble to World AIDS Day in the

Hindustan Times written by Raveena Aulakh in Chandigarh. The article is

about empowering women but it lack all the empowerment material that sero

discordant partners need and instead leaves people in discordant

relationships feeling like there is no hope for sex within a sero discordant

mariage relationship. When is this going to stop? Last time I was in

Chandigarh I read an important peice written by an Indian Doctor educated in

CDC in USA who claimed that fungal disease reduces the life expectancy of

HIV +ve individuals from two years to one one year if untreated.

This was another piece of hopelessly inaccurate medical information which

was part of a key note address at a symposium in Chandigarh.

I am becoming increasingly frustrated in so many places I visit here.

Today I have my hotel trying to track the cell number of the article writer

in the hope that by tomorrow December 1st we can have something more hopeful

printed for sero discordant couples here.

Dr is saying some relevant things and everyone here is just smiling

and saying it can't work in India. Well I believe it can but only if it

contains factual information. Part of the article focusses on how a negative

wife can protect herself having discovered that her husband is +ve. The good

Doctor Ajay who I know well says to just use condoms and she said what if it

breaks? His reply was use two which is not the best advice because using two

condoms increases the risks of breakage.

Nothing appears about other ways of reducing the risks including some

discussion on the reasons why condoms break at all and why they are not 100%

effective. Surely this lady who was brave enough to challenge convention and

actually ask how she could protect herself deserves more information that to

use two condoms. She has determined to use abstinence as the only sure way.

Where does that leave her? and where indeed does it leave her husband? Both

should be able to practice safe sex or their relationship will crumble and

both will seek partners elsewhere such as is already happening.

There is nothing about how to monitor her husband's positive status to

determine when risk is minimal. There is nothing about safer sex behaviour

and techniques that can ed to an even better sex life than the traditional

missionary position where the whole business is over in about 20 minutes.

There is nothing to explain how to minimise the risk of condom breakage and

even whether intercourse in every sexual encounter is even necessary. So

much is missing for this lady and her husband and every other sero

discordant couple. Much is made of the empowerment issue regarding the

gender imbalance here but this is always stated as an ultimatum rather than

a balanced description of making condoms part of enjoyable lovemaking or

using programs such as Australia's T T T T program to encourage couples to

be able to abandon protection safely and with some confidence of sexual

health and safety. The only safety aspect we hear about is pre-marital

testing which is anything but reliable and safe for either party unless

certain conditions which are contained in the T T T T program are followed.

Your reply to me prompted me to write rather than sit here and seeth. I

would also appreciate talking to other contributors to this article

including Indu Bala of Unnat Bharat Vikas, Dr Saroha of Chandigarh SACS,

Shreshtha Mehta, Bhawna Puri, Dr Ushwinder Kaur Popli, and Manjula Sharma of

SOSVA.

I also wanted to take issue with the School AIDS Education Program in 41

schools doing workshops for years 11 and 12.

I am not sure how many 14 year olds study in years 11 and 12 in India but

since that is the age when infection rates start in India and possible

elsewhere as well, what's the point of waiting till they are in year 11 and

12 to warn them of the risks.

Ok now I will go and have lunch. I found a place in Chandigarh that will

make me a nice chicken and coleslaw sandwich with some chips and some coffee

and not a whiff of masala, chili or curry in sight.

Geoffrey

Geoff Heaviside

Convenor - Brimbank Community Initiatives Inc

Secretary - International Centre for Health Equity Inc

Member - Australasian Society for HIV Medicine Inc

P.O. Box 606 Sunshine 3020

. Australia.

Ph: 0418 328 278

Ph/Fax : (61 3) 9449 1856

or in India

Mr Geoff Heaviside

Mobile : (91) 9840 097 178 (Only when in India)

Kenya Mobile (254) 721362901

" Concern for what is right causes us to do our best - Knowledge of what is

best inspires us to do what is right. "

>From: " Almedal, Calle " <almedalc@...>

><gheaviside@...>

>Subject: FW: world aids day: the clock is still ticking

>Date: Mon, 29 Nov 2004 14:16:07 +0100

>

>Hi

>Did you connect the man to an HIV+ organisation?

>Have you seen Postive Development on www.gnpplus.net ?

>Thanks for your engagement ands writings

>Hugs

>Calle

>

>

> world aids day: the clock is still ticking

> >Date: Sun, 28 Nov 2004 15:07:23 -0000

> >

> >

> >WORLD AIDS DAY: THE CLOCK IS STILL TICKING

> >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 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.

> >

> >* World Aids Day is on 1 December.

> >

> >* Hein Marais is a South African writer and journalist. A former chief

> >writer for the Joint United Nations Programme on HIV/AIDS (UNAIDS), his

>

> >work is focused largely on AIDS and on political- economic issues. He

> >is the author of South Africa: Limits to Change - The Political-economy

>

> >of Transition (Zed Books/UCT Press). This article first appeared in the

>

> >e-newsletter of the Isandla Institute, which can be visited at

> >http://www.isandla.org.za/.

> >

> >

> >

> >

>

>

>

>

>

>

>

>

>http://www./group/

>http://www./group/aids-africa (a group made up of

>Africans worldwide) Join Digital Africa- an information technology group

>that discusses IT in Africa at

>http://www./group/digafrica

>