Mbeki vs. the AIDS Establishment... (15)
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I would like to support Dr. S. Chandiwana's point that moving on from
the debate about the cause of AIDS is now essential. He is also cor-
rect to seek a proactive lead "in addressing the problem of AIDS as
it requires African solutions where resources are limited".
The Durban Conference created a unique opportunity for African-, de-
veloping country-, and community-based leadership on AIDS to emerge.
The question is, who of us is prepared to step forward to grasp it?
--
Top-down or bottom up on AIDS - can you even hear the question?
The XIIIth International AIDS Conference was always going to be a
conference focusing on AIDS in southern Africa. Even as the 12,500
delegates made their way to Durban, it was also inevitably going to
be a highly charged and political event.
In recent weeks and months the South African President, Thabo Mbeki,
had declared on the one hand that HIV was tearing through the country
at an unprecedented rate, while on the other expressing doubts about
the underlying scientific thinking linking the virus with AIDS.
Civil society in South Africa was visibly preparing its public dis-
play of anger � the TAC march in Durban - at government decisions not
to provide, among other things, AIDS drugs to prevent transmission of
HIV from mothers to their unborn children.
Academics in the country had recently completed and published a
critical analysis of the national response to AIDS, including ac-
counts of government tardiness, ineptitude and ill-conceived planning
in relation to the epidemic.
With a direct challenge to Mbeki's position coming in the form of a
petition by 5000 of the world's top scientists just days before the
conference began, the conference theme - 'Breaking the Silence' -
felt eerily prophetic.
The build-up to AIDS2000 could not have been scripted better to en-
sure greater political and media attention - or delegate expectations
for that matter.
So it was inevitable that President Mbeki's speech during the opening
ceremony on Sunday left most delegates feeling disappointed. He had
not, and could not, lay the debate to rest unequivocally. Thankfully
though, the conference immediately took on a life and character of
its own that rapidly opened discussion in other more critical areas.
From the outset, the impact of the conference being the first to
take place in the developing world was obvious. When specialists
stood up to talk, they were compelled to refer to the realities of
AIDS in the region. This came from simply being here in South Africa,
but also resulted from audience comments, questions and stories of
their life or their community living with the epidemic.
It was impossible to talk about drug treatments without mentioning
their appallingly restricted availability here. In recommending safe
sex campaigns, speakers were obliged to translate the cost of a con-
dom in relation to daily income in a local setting. When we spoke of
the link between sexual violence and HIV transmission, we also heard
the poignant first-hand accounts of women living in the rape capital
of the world.
Of the delegates at the previous world conference, held in Geneva in
1998, around 2000 were from developing countries. In Durban, it was
more like 6000. As the week progressed, it became clear that this is
what set the conference apart from past events - the juxtaposition of
research, the established international AIDS community and the col-
lective voices of thousands living with and responding to HIV/AIDS
every day. We should be honest about what a wake-up call this was for
many of the western delegates.
This partly dissolved previous boundaries between the two usual
halves of the conference - the scientific and community programmes.
In turn, it also led to an unusually blunt look at the two dominant
paradigms of the AIDS 'world'. The first is a top-down approach,
which maintains that HIV/AIDS should be controlled and managed by fi-
nancial, biological and technological means. A first-world interven-
tionist view. The second states that people can and should be in
charge of their own lives and that individual decisions and local
cultural traditions are crucial to preventing the spread of HIV and
minimise its impact. An idea that places people and communities at
the centre of the response to the epidemic.
And these were not just lucky by-products of the conference. The or-
ganisers deliberately set out to merge the two elements of the pro-
gramme more than ever before. Debate sessions were incorporated to
deliberately provoke discussion in overlapping areas of work.
There were some interesting examples of new research focused right at
the interface between the 'top-downers' and the 'empowerers'.
In one of the most interesting presentations of the week, research
from Uganda, Malawi, Zambia and Kenya questioned some of the estab-
lished views about how interventions to reduce the spread of HIV ac-
tually work. There has been a recent reduction in HIV prevalence in
Uganda. Among pregnant women from more than 20% to 9%, and in army
recruits from 18.5% to 8%. The important news was that the reduction
now appears to be more closely related to people having a lower num-
ber of sexual partners - rather than a higher level of condom use. In
countries like Zambia and Malawi, where sex partner numbers have not
declined, equivalent levels of condom use to Uganda have not slowed
down the spread of HIV.
Other factors that were shown to slow the spread of HIV in the Uganda
study were: knowing somebody who had died of AIDS, and talking with
family and friends about the epidemic. Despite limited options and
resources, Ugandans seem to have developed personal and culturally
appropriate behavioural strategies, which have dramatically reduced
HIV prevalence.
Is this a 'Social Vaccine' in Africa ? It is effective, it is avail-
able, and is based on solutions developed by African communities. Of
course this is counter to the top-downers view, which asserts that
programmes such as condom promotion should be scaled up to the na-
tionwide level in countries with runaway epidemics.
I cannot help wondering how different the response to Mbeki might
have been if, instead of questioning the cause of AIDS, he had chal-
lenged the interventionist rationale for condom promotion or mass me-
dia campaigns to stem the spread of HIV?
One of the quotes seen frequently during the conference week was
taken from Jonathan Mann, the late intellectual leader of the AIDS
response, when he said:
"The definition of the problem determines the way we solve the prob-
lem."
The uniqueness of the Durban conference - and the opportunity it has
created for developing country or 'community' leadership - is that it
has left the AIDS community suspended between its two dominant ways
of defining the problem.
The question now is whether the conference delegates and others work-
ing on HIV & AIDS throughout the world can maintain this process of
debate, or whether we will all revert to our respective paradigms
once we are home again in the four corners of the world.
The first option requires intellectual leadership from individuals in
those countries most affected by the epidemic. It is not sufficient
to merely denounce and refer back to previous thinkers like Mann. Co-
gent questions have to be asked today. Information must be shared
that makes governments, NGOs and international organizations account-
able for their work. The roles and methods of participation in debate
and discourse have to be redefined. Slipping back into the dominant
top-down paradigm requires only one thing - silence.
The electronic podium awaits and the clock is ticking.
--
Tim France, PhD
Health & Development Networks (HDN)
mailto:tfran@hdnet.org
http://www.hdnet.org
HDN provided electronic information support to the AIDS2000 confer-
ence.
To receive session reports and discussions following on from the
AIDS2000 conference, send an e-mail to:
<join-breakthesilence@aids2000.com>
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