Another World AIDS Day is behind us, and the usual spatter of annual reports and politicians’ eager promises continue to reverberate through the media. If you’re like me, you’re probably tired of the whole show at this point. After all, it’s 2012; we were supposed to have this epidemic licked by now. Why, despite billions of dollars’ worth of interventions and three decades of high-profile messaging, does AIDS remain such a pressing problem?
This is particularly puzzling in the case of southern Africa, where close to 20 per cent of the adult population carries HIV. In Swaziland, where I am from, the figure reaches 42 per cent in antenatal clinics. These numbers are shocking in any context, but in light of the massive prevention effort that has been underway since the 1980s they truly boggle the mind. Clearly something isn’t working in our battle against AIDS.
The anti-AIDS effort is failing because it fundamentally misperceives the problem. It starts from the assumption that the AIDS burden reflects a culture of sexual promiscuity, moral depravity and basic ignorance among Africans. This is why the primary AIDS programmes – the World Bank, UNAIDS and most NGOs – peddle “awareness” and “behaviour change” as the frontline solutions.
Not only does this narrative carry obvious racist undertones, it’s also just not true: southern Africans are not ignorant about HIV/AIDS. In fact, statistics show that most of them are highly knowledgeable about it and often know more than their Western counterparts. The problem is that this knowledge doesn’t translate into behaviour change. A recent study shows that awareness “changes the behaviour of, at most, one in four people – generally those who are more affluent”. In other words, “behaviour change” programmes are failing at a rate of 3 to 1.
This disparity tells us a lot. Wealthy people respond to awareness campaigns because their participation in risky sexual behaviour is voluntary. Not so with the poor. For them, risky sexual behaviour is generally compelled by structural factors beyond their control. In southern Africa, poor people are often forced to pursue labour migration and engage in transactional sex just to make a living. These are the key drivers of HIV transmission.
We need a new way to approach the problem. Instead of targeting sexual behaviour, we need to target the conditions under which sexual behaviour occurs. That’s where the true pathology lies. In southern Africa, this means shifting the blame from the victims of AIDS to a specific set of powerful actors who have rigged the regional economy for their own benefit and subjected millions of people to conditions that facilitate the spread of HIV. AIDS is not a disease, it is a symptom – a symptom of an unjust global order.
The labour migration system
One reason that southern Africa has higher HIV rates than other poor regions is that it is shaped by a unique system of rotating migration. During the colonial era, European capitalists needed a steady supply of cheap black workers for their mines, plantations and factories. To get it, they restricted Africans’ access to arable land and imposed taxes to force them onto the labour market. But Europeans didn’t want African workers to settle permanently in urban areas. Instead, they ferried workers in on a temporary basis and then sent them back to the “native reserves” when they were used up.
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The rotating migration system allowed Europeans to rake in huge profits. Companies could pay migrant workers much less than what permanent urbanites required to support their families, since the difference was covered by unpaid subsistence activities in the reserves. This system continues to this day: for instance, unskilled workers in South Africa come from as far afield as Malawi and return home as infrequently as once a year.
When HIV hit the continent in the early 1980s, it spread rapidly through these migration networks. It was an epidemic waiting to happen. In South Africa, HIV prevalence is nearly three times higher among migrant workers than among non-migrants. Migration increases high-risk sexual behaviour among men who are away for long periods of time, and this increases HIV prevalence among their female partners tenfold.
These high prevalence rates have to do with the conditions that characterise migrant destinations, like mines and plantations. These are zones of hyper-exploitation: high injury rates, depression and loneliness among workers mixed with the steady supply of alcohol and prostitutes that managers dish out to suppress dissent encourages unsafe sex. Poor healthcare services in these zones means that even easily curable STIs go untreated, which makes HIV transmission up to 400 per cent more likely. This is why the highest prevalence rates in the world are found at migrant workplaces, sometimes reaching as high as 70 per cent.
If people know about these risks, then why migrate in the first place? The short answer is that they usually have no choice. Remittances sent home by migrants are critical to household survival, and many households have no other source of income; they cannot afford to forfeit such staple earnings in favour of geographical solidarity. When families are forcibly strung across the subcontinent, “abstinence” and “fidelity” – the values promoted by HIV prevention campaigns – become impossible ideals for both men and women.
Rules imposed by the West
The colonial system severely constrained Africans’ livelihood options, but the new order of capitalism has gone much further. Beginning in 1980, the IMF and the World Bank imposed free-market shock therapy on African economies in line with neoliberal principles. They did this through “Structural Adjustment Programmes” that cut spending on services like healthcare, privatised public assets and cut trade tariffs (a major source of revenue for poor countries) in order to pry open new markets and create “investment opportunities” for Western companies. They also raised interest rates to keep inflation low so that the value of debts to the West would not diminish, even though this hampered governments’ ability to spur growth.
We were told that structural adjustment would generate development. Quite the opposite. While sub-Saharan Africa enjoyed a steady per capita growth rate of 1.6 per cent during the 1960s and 70s, beginning in the 1980s growth began to fall at a rate of 0.7 per cent per year. The average GNP shrank by around 10 per cent under structural adjustment, and the number of Africans living in basic poverty nearly doubled. Inequality has soared to unprecedented rates, enriching corrupt local elites (consider the rapid rise of South Africa’s black bourgeoisie) at the expense of a growing underclass.
These policies have been particularly rough on rural farmers. The abolition of price controls, subsidies and tariffs have all made it harder for farmers to make a living. In addition, free trade rules have allowed big agribusinesses, often foreign-owned, to capture vast swathes of the region’s best farmland. As a result, farmers are forced to move to urban slums in search of better fortunes. But since there’s no formal employment available in the cities anymore they can’t afford to live there permanently, so they migrate back and forth. It’s like colonialism 2.0.
Sex for money
The other key driver of HIV transmission in southern Africa is transactional sex: when women exchange sex for money. Most AIDS gurus talk about transactional sex as if it were a choice that women make, or they cast African men as sexual predators. But it’s not that simple. Women engage in transactional sex with wealthier men because they lack access to the resources they need to live. This often entails relinquishing control over the terms of sexual intercourse, such as condom use.
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Given these conditions, campaigns that focus on awareness promotion among women have precious little effect. Report after report concludes that increased knowledge does not assist women to avoid risky sexual behaviour: their financial desperation is grave enough to outweigh concerns about their own health. In other words, women are willing to risk one health threat (HIV) in order to stave off another, more immediate one (hunger).
Women who secure formal employment feel less pressure to engage in transactional sex, but such employment is almost impossible to find. Structural adjustment decimated employment levels by exposing infant industries to crushing competition and jacking up interest rates. Unemployment now sits at close to 40 per cent in much of the region – far worse than before Western banks showed up with their promise of “development”.
The World Trade Organisation joined the attack on African economies at its inception in 1995, and has directly contributed to the region’s AIDS burden. For example, Swaziland’s once-thriving textile industry was flattened in 2005 when the WTO liberalised the global textile trade. Factories shut down overnight as producers relocated to Asia for cheaper labour, putting some 30,000 women instantly out of work. Many of these women turned to transactional sex to fill the breach, and the fight against AIDS suffered a monumental setback.
One of the most troubling things about the AIDS epidemic is that it could have been stopped so easily by rolling out life-saving antiretroviral drugs (ARVs) early on. Not only do ARVs prevent HIV from developing into AIDS, they also reduce transmission rates and increase people’s willingness to get tested.
But Western pharmaceutical corporations have colluded in pricing these essential drugs way out of reach of the poor. When they were first introduced, patented ARVs cost up to $15,000 per yearly regimen. Generic producers were able to manufacture the same drugs for a mere fraction of the price, but the WTO outlawed this through the 1995 TRIPS agreement to protect Big Pharma’s monopoly.
It was not until 2003 that the WTO bowed to activist pressure and allowed southern Africa to import generics, but by then it was too late – HIV prevalence had already reached devastating proportions. In other words, much of the region’s AIDS burden can be directly attributed to the WTO’s rules and the corporations that defended them. And they are set to strike again: the WTO will cut patent exemptions for poor countries after 2016.
This dearth of basic drugs has gone hand-in-hand with the general collapse of public health institutions. Structural adjustment and WTO trade policies have forced states to cut spending on hospitals and staff in order to repay odious debts to the West. Swaziland, ground-zero in the world of AIDS, has been hit hard by these cuts. When I last visited, I found that many once-bustling clinics are now empty and dilapidated. Neoliberalism has systematically destroyed the first line of defence against AIDS.
The point I want to drive home is that the policies that deny poor people access to life-saving drugs and destroy public healthcare come from the same institutions and interests that helped create the conditions for HIV transmission in the first place.
Shifting the blame
In light of all this, the rhetoric of “individual responsibility”, “behaviour change” and “moral depravity” that defines AIDS discourse begins to seem quite absurd. Let’s be frank: it is not the culture of African peasants and workers that is morally depraved, but the culture of institutions like the WTO and the IMF. Economist Joseph Stiglitz has exposed these institutions as some of the most corrupt and anti-democratic in the world, run by a cabal of elite corporate interests.
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The forced neoliberalisation of Africa was not just blind devotion to economic ideals that turned out not to work. It was intended to create crisis and debt. Western states, banks and corporations have made off with trillions of dollars from privatisation, mineral extraction, cheap labour and debt service – a net flow of wealth from poor countries to rich countries that vastly outstrips the meagre aid that trickles the other direction.
If anyone needs a dose of behaviour change, it’s the institutions that have orchestrated this heist. The AIDS epidemic is a symptom of the crisis they have caused, and it will rage on as long as the plunder continues.
If we’re to be serious about rolling back AIDS, we need a new approach. We need to release poor countries from structural adjustment so they can rebuild their economies using tariffs, subsidies, state spending and low interest rates – the very policies that rich countries use. We need to cancel odious debts so poor countries can spend money on health services instead of interest payments. We need to amend TRIPS to decommoditise life-saving drugs. And we need to tweak the WTO’s Agreement on Agriculture to ban the dumping of subsidised farm products on poor countries. This means reforming the World Bank, the IMF and the WTO, where voting power is monopolised by rich nations and special interests.
The World Bank and the Gates Foundation – the biggest funders of AIDS prevention – cannot be entrusted with these tasks, as they have clear interests in the very policies (debt service, structural adjustment and patent laws) that have created the problem in the first place.
In sum, battling AIDS means challenging the power of rich nations over the world’s resources; it means creating a world in which economic policies are democratically ratified, and where capital is harnessed to benefit humanity rather than the other way around. The AIDS crisis provides an extraordinary opportunity to do this. With more than 1 million deaths due to AIDS in southern Africa alone each year, never has there been a more powerful mandate to interrogate the tenets of neoliberal capitalism.
Note: This argument is available with full citations here.
Dr Jason Hickel lectures at the London School of Economics. He has contributed political critique and analysis to various magazines, including Le Monde Diplomatique, Foreign Policy in Focus, The Africa Report, and Monthly Review. He is currently working on a new book titled The Development Delusion: Why Aid Misses the Point about Poverty.