Alexander Irwin, Joyce Millen, Dorothy Fallows. Global AIDS: Myths and Facts: Tools for Fighting the AIDS Pandemic. Cambridge: South End Press, 2003. x + 273 pp. $19.00 (paper), ISBN 978-0-89608-673-9; $40.00 (cloth), ISBN 978-0-89608-674-6.
Reviewed by Sarah Richardson (Department of International Health, Boston University School of Public Health)
Published on H-Africa (April, 2004)
Motivating HIV/AIDS Activists through Information, Hope, and Shame
Motivating HIV/AIDS Activists through Information, Hope, and Shame
Global AIDS: Myths and Facts presents a difficult challenge to the academic reviewer, as it is not written to engage a scholarly audience about HIV/AIDS control in developing countries. The authors set out explicit goals of motivating laypeople in the United States and other affluent countries to become activists for equitable access to prevention and care (especially provision of antiretroviral drugs [ARVs]) for people with HIV/AIDS in developing countries. The book provides information and hope for greater equity through social and political activism, but its heavy-handed moral tone may be more offensive than inspirational. H-Net readers will recognize Irwin and Millen as co-editors of the Partners in Health's Dying for Growth: Global Inequality and the Health of the Poor, and as faculty at the Institute for Health and Social Justice at Harvard University. Their newest book, co-written with Dorothy Fallows, is more a manual for activists than a comprehensive examination of the issues involved with delivery of ARVs to the millions who need them. As Zackie Achmat, the world-famous South African AIDS activist, writes in the preface, "this book is a call to join the struggle and build a movement of international solidarity against AIDS." Appropriate to the authors' aims, Global AIDS is published by South End Press, a nonprofit organization with the goal "to meet the needs of readers who are exploring, or are already committed to, the politics of radical social change" (p. 271).
The format of the book is well tailored to the aim of informing and persuading westerners with little or no knowledge of the developing world and the HIV/AIDS epidemic. After the preface by Achmat, which reviews the South African Treatment Action Campaign's fight for equitable access to ARVs, Paul Farmer's introduction sets out the book's goals both to combat misconceptions about the epidemic and its control and to inspire action for "radically expanded AIDS treatment for the poor and ... a united global fight against the disease" (p. xxi). Farmer also lays out the moral argument that underpins the book: you are either fighting for equal access to AIDS prevention and treatment as prescribed, or you are complacent and accepting of inequity. Following the introduction is a glossary of basic definitions and descriptions of HIV- and AIDS-related terms and concepts. Each of the subsequent ten chapters begins with a popular myth about AIDS, then briefly discusses how the myth may seem reasonable on the surface, with a more lengthy rebuttal bringing in social, economic, political, and ethical contexts of the issue. At the end of each chapter, the main arguments are restated, and in the later chapters, recommendations about how to counter the myth are given. The conclusion sums up the major arguments for the primacy of the HIV/AIDS movement, ending with an even more pointed moral argument. The book is relatively short (192 pages of text), and is written in a straightforward style and simple language for maximum accessibility. Photographs of AIDS activists and HIV-positive people from around the world, fighting for and receiving treatment and care, give the reader an idea not only of the real people behind statistics, but also that much has been and can be accomplished.
The ten myths that the authors have challenged can be seen in three rough categories: fallacies about the disease in the developing world, programmatic/technical obstacles to treating and curing the disease, and myths about fighting AIDS. In the first category, the myth that AIDS is an African disease and of little concern to Americans is easily dispelled with presentation of global HIV/AIDS trends and the point that "there is nothing intrinsically African about the key factors driving the spread of HIV/AIDS--above all poverty, socioeconomic inequality, instability and armed conflict, and the disempowerment of marginalized groups" (p. 15). This argument is key to the authors' goals of bringing HIV/AIDS out of the medical domain and into the realm of social and political activism. The second myth ascribes the epidemic to "dangerous behavior" of poor people. By putting these "risky" behaviors in socio-economic contexts of gender, power, and economic inequity, the authors show those actions to be reasonable. For example, commercial sex work by poor women who have no other options is more appropriately seen as survival sex. Understanding the reasons vulnerable people are forced into behaviors they know may put them at risk of HIV infection is critical, but the authors gloss over circumstances where people can and should take responsibility for their actions. For example, the authors characterize "health experts [who] have criticized people's apparent unwillingness to use condoms ... [or] to reduce their number of sexual partners" (p. 19) as "misleading," which I understand when the example is the wife, who is powerless to ask her husband to use a condom, but not when the target is the husband, who has the power to make that choice. While focusing exclusively on abstinence, monogamy, or other behavioral messages is certainly not effective, to rule them out entirely contradicts the book's argument for comprehensive prevention and treatment programs. The third myth, and the last in the category of "developing countries as the problem," is that corruption in developing countries is so bad that funding will not serve its intended purpose. Here the authors' argument is that things are improving, and that more investment with improved oversight can even serve to reduce corruption and mismanagement further. The examples of Uganda, Brazil, and Thailand are used to show potential for successful ARV programs even with corruption. "There is no need to wait until corruption has been purged before moving to scale up assistance to developing countries for the fight against HIV/AIDS" (p. 57). This is a compelling, but not entirely convincing, argument, as specifics of scaling up assistance in the countries with the worst corruption, mismanagement, and lack of infrastructure are not addressed.
In chapter 4, the myth that, for economic and logistic reasons, prevention should be fully accessible before treatment is delivered is strongly countered with an argument for combined prevention and treatment programs as the most effective method of controlling the epidemic. The authors further note that prevention advocates can ally with treatment activists for political leverage, and they return to the wider vision of social change at the conclusion: "AIDS can become the 'wedge issue' that enables a new level of awareness, debate, and action to attach the full range of global health inequalities" (p. 70). The next three myths, that high cost and poor infrastructure make effective ARV distribution impossible, that funding vaccines rather than ARVs is the best solution, and that drug companies are too powerful to overcome, are all dealt with in similar fashion. The reader is given examples of where ARV treatment has been successfully implemented, and when drug companies have been pressured to provide ARVs at greatly reduced cost by activists (most notably in the South African case). In my opinion, the most informative, balanced, and convincing chapter is "Myth Six: Vaccines." Here the authors explain the limits and potential of development of vaccines, and the synergistic effect of a "fully developed AIDS control program--prevention, treatment, and vaccine research" is clear. But it still depends on a big "if": "if the political will and the necessary resources can be mobilized, these key elements ... will reinforce one another" (p. 113). In the last chapters, the authors debunk the myths that AIDS treatment would unfairly take up developing countries' limited resources and that there is nothing to gain for the western affluent countries and nothing laypeople can do to solve the problem, and show readers how they can take part in shaping political will and marshaling resources to spur a comprehensive attack on the epidemic.
There is plenty of hopeful and inspiring information in this book, but the authors are clearly not satisfied with making an intellectual appeal based on scientific and economic evidence; rather, they are trying to link readers morally to the cause. "AIDS activism may not become the center of your life. But it can, and should, be a part of what all of us do and think about on a daily basis" (p. 184). The authors state that while we have our daily concerns, we in the affluent west will be judged by future generations as morally bankrupt for not taking action on HIV/AIDS. Here the message is very reminiscent of post-Holocaust soul searching and it becomes overbearing. The conclusion echoes the book's appeals first to reason, in summing up the main arguments that are forceful in themselves, then to guilt, which, for me at least dampened my enthusiasm. "We can elect to continue with our lives, detached while millions of human beings perish.... Or we can take action to overcome this fatal imbalance and assist people in need.... By the choices we make with respect to AIDS, we are defining our moral selves, and determining the ethical character of the world we will inhabit and leave to future generations" (p. 192). This will sell to young people who are not already working to assist people in need, but for those who are working to change the world (or a small part of it), although not on the issue of AIDS, it seems alienating and damning--AIDS activism as the one true faith.
The authors' decision to frame these issues in terms of right and wrong helps to reach their target readers, but precludes dialogue and discussion, since any critic is not only scientifically wrong, but morally questionable. In sum, this book serves its purpose vis-a-vis its intended audience, and it is a useful handbook for those who are curious about HIV/AIDS and their possible roles in the fight to overcome the epidemic. I recommend it to high school and college students, community groups, and even open-minded politicians. Global AIDS: Myths and Facts offers a concise summary of the main points of the controversy surrounding AIDS control in developing countries. As such it is helpful to health professionals who need to be conversant with these critical issues, if they can set aside the moral tone. For those in the field who are already convinced of the value and urgency of provision of ARVs to developing countries, this book is less informative, and may even be frustrating in the sense that it demands unquestioned acceptance rather than open discussion.
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Sarah Richardson. Review of Irwin, Alexander; Millen, Joyce; Fallows, Dorothy, Global AIDS: Myths and Facts: Tools for Fighting the AIDS Pandemic.
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