The Neoliberal Model in Times of AIDS

World maps illustrating areas of high poverty largely overlap those of high HIV/AIDS prevalence. It’s no coincidence that both poverty and AIDS have run rampant in these last two decades of neoliberalism. Yet, while the AIDS epidemic devastates entire countries, those responsible for neoliberalism try to blame the virus on poverty, a real feat of ideological juggling.

Bernardo Useche y Amalia Cabezas

The most recent United Nations figures show the true magnitude of the tragedy: approximately forty million people are currently living with the Human Immunodeficiency Virus (HIV) or are suffering from illnesses associated with Acquired Immunodeficiency Syndrome (AIDS). In 2003 alone, five million people joined the list of those who tested HIV-positive and nearly three million others died from complications associated with AIDS. Given the seriousness of this situation, the UN’s World Health Organization (WHO) and UNAIDS launched a plan to provide antiretroviral medications to three million AIDS patients in the next two years—approximately half the patients currently estimated to need this kind of treatment. The WHO strategy incorporates plans recently proposed by the World Bank and the US government.

On the face of it, this global strategy appears to be a humanitarian gesture and a decisive intervention by the international health organizations and the White House to control this devastating disease. However, to thoroughly understand the true dimension of the AIDS pandemic and the possible scope of the WHO-World Bank-Bush government plans, it is essential to consider the socioeconomic world context in which the disease has been gestating over the last two decades. This context, one of whose main aspects is the prevalence of multinational pharmaceutical companies’ interests above those of the patients who are supposed to benefit from their medicines, is where we should situate the debate over the new antiretroviral therapies. The reality is that the implementation of neoliberal economic policies in recent decades has created conditions in which it has proven impossible to detain or reduce the number of infections—despite the best efforts of thousands of scientists, the investment of billions of dollars and the efforts of innumerable organizations working on prevention programs.

Epidemics are also explained
by economic tendencies

Social epidemiology, defined initially as “the study of the role of social factors in the etiology of an illness,” grew out of Friedrich Engels’ study of the living conditions of English workers in the 19th century. In public health, this area of study currently includes different theories and approaches to help understand and deal with illnesses, particularly epidemics or pandemics such as AIDS, none of which reduce prevention and treatment of an illness and the attention provided to strictly biomedical or behavior aspects. How historical, political and economic tendencies influence the dissemination of an illness among different populations and how social forces and factors affect individuals’ bodies and generate pathologies also need to be considered.

In the case of HIV/AIDS, Nancy Krieger has pointed out that “neoliberal economic policies such as the North American Free Trade Agreement (NAFTA), which result in economic austerity plans, environmental degradation and growing intra- and inter-regional social disparities in health, are of particular concern.” The study of the effect of health service organization and coverage and of drug production and marketing systems on a specific society’s most vulnerable population is also important to epidemiology and social medicine.

A country’s health depends
on the equality of its society

All studies agree that the AIDS pandemic is concentrated in the poorest countries and among the poorest sectors of wealthy countries, to such an extent that the maps of world poverty can largely be superimposed over those showing HIV/AIDS prevalence. But very few works analyze the close relationship between the causes of the affected nations’ socioeconomic reality and the so-far uncontainable advance of the epidemic during the last two decades. With a few very valuable exceptions, they are limited to describing the situation without clearly defining the fundamental responsibility of the economic globalization model imposed on nations in these times of AIDS.

British epidemiologist Thomas McKeown demonstrated that progress in controlling a population’s illnesses cannot be attributed to vaccines, antibiotics and improved medical treatments alone, given that the general socioeconomic conditions and the way they affect nutrition constitute an even more essential health factor. For example, cases of tuberculosis had been falling in Great Britain for a hundred years before the introduction of the vaccine. And without denying the vital importance of advances in biomedicine, epidemiological studies currently confirm that a population’s health expectations are directly associated with quality of life, which in turn is determined by environmental health, nutritional status, water quality, housing, education, working conditions and emotional and psychological factors that benefit human development throughout the life cycle.

The health situation in a given country or geographical area does not depend just on the inhabitants’ income, although it has been demonstrated that the lower people’s income, the greater the presence of diseases and the lower the life expectancy; it also depends on the degree of equality within the society. It has been proven that health expectations are greater in countries with relatively less income and social inequality among the population. This explains the differences in life expectancy and other health indicators among industrialized countries. Sweden, Switzerland and other developed countries, for example, have better health rates and higher life expectancy than the United States, a country that despite having the most powerful economy on earth also has abysmal social inequalities, with 46 million citizens currently unprotected because they cannot afford health insurance.

Blame the victim

The increasing impossibility of isolating health problems from social inequalities presents us with an ideological dilemma. Are the sick to blame for their illnesses or do they result from social inequality? In her study on the social history of pellagra, a nutritional illness that mainly affects peasants who survive almost entirely on maize consumption, Daphne Roe concludes that there are only two kinds of observers: those who believe that pellagra is societally produced, the result of the inhuman practice of condemning the poor to a diet that can’t even keep a dog healthy, and those who think it is the fault of those who suffer from it.

The social history of AIDS has largely been one of apportioning blame to the victims. At the beginning, AIDS was even defined as the disease of the four “h”s: homosexuals, Haitians, hemophiliacs and heroin addicts—to which one could more recently add “hookers.” From the ideological point of view, blaming the victims hides the fundamental role the socioeconomic context plays in generating and propagating illnesses, instead placing responsibility for prevention and treatment exclusively on the shoulders of individuals, thus evading the state’s obligation to care for its population’s health. Poverty also creates the alienating conditions that lead to a culture of intravenous drug use. And in the concrete case of Haiti, Paul Farmer established that, contrary to the widely disseminated stigma that blames Haitians for introducing the AIDS epidemic to the United States, the sexual tourism of US citizens to Haiti was what turned AIDS into an epidemic in that country, given the poverty affecting the population there.

Along with emphasizing transmission of the AIDS virus as essentially a problem concerning the individuals involved, prevention efforts focused on trying to modify individual risk behaviors and attitudes for the first 20 years of the pandemic. This unilateral approach, which ignores the socioeconomic factors behind AIDS, failed insofar as the most vulnerable people continue practicing sexual behaviors considered risky as well as consuming and injecting drugs. But it triumphed inasmuch as it blocked any in-depth debate on the responsibility of the neoliberal economic model implemented throughout the world during this period, with its social consequences providing the right context for the epidemic’s progress.

Neoliberal famines
go hand in hand with aids

Neoliberalism is nothing other than a set of economic theories and policies developed by contemporary monopoly capital to consolidate its global expansion and achieve total control of the world markets it needs to survive. Following the collapse of the Soviet empire, the contradictions between the United States and the other economic powers and other nations have worsened as the result of the US strategy to bolster and expand its economic, political and military power. A new world order has emerged characterized by what could be called a First World, limited to the United States; a Second World, consisting of Europe and other highly industrialized countries, including China, Japan and Russia; and a pauperized Third World spread across the whole of Africa, Asia and Latin America.

The distribution of the HIV/AIDS infection matches the current world socioeconomic order, confirming Paul Farmer’s theory that the health of the world’s poor is affected primarily by infections and violence, while the rich suffer from chronic illnesses associated with ageing. The 21 nations with the greatest AIDS prevalence in the world are, not coincidentally, found in Sub-Saharan Africa—whose dramatic levels of misery largely resulted from the neoliberal measures imposed by the structural adjustment programs of the International Monetary Fund (IMF) and the World Bank.

Famine and AIDS go hand in hand on the African continent. As UN Special Envoy for HIV/AIDS in Africa Steven Lewis explained, the whole world now understands that when the body has no food to consume, the virus consumes the body, and with the body’s immune systems weakened by lack of food, the illness progresses much quicker and people die faster. The main cause of the recent famines, with their inevitable malnutrition and death, are not the droughts and other natural disasters that frequently afflict Africa, but rather the elimination of agricultural subsidies, privatization of public services and complete opening up of the economy, measures that are an integral part of the structural adjustment programs demanded of the African nations by the international agencies since 1986.

Zimbabwe: A tragic case

Let’s take Zimbabwe as an illustrative case. According to a study by the Joint Center for Political and Economic Studies in Washington, the average real economic growth in Zimbabwe during the eighties was 4% a year. During those years, food security developed somewhat and the manufacturing sector was strengthened, which contributed to a diversification of exports. At the same time, health services increased and life expectancy rose from 56 to 64, while child mortality fell from 100 to 50 live births.

In 1991, Zimbabwe received a US$484 million loan conditional on the structural adjustment of its economy. The demands of the adjustment included reducing public spending, deregulating the financial market, eliminating manufacturing protections, liberalizing the labor market, reducing the minimum salary and eliminating labor stability, all to guarantee reduction of the fiscal deficit. Zimbabwe’s economy entered into recession a year later and between 1991 and 1996 per capita private consumption fell 37%, salaries fell 26% and unemployment rose, while food prices skyrocketed.

The IMF’s recipe, which required the Zimbabwean government to slash spending by 46%, above all by cutting health workers’ salaries, had disastrous effects on public health. The vast majority of the population was left without access to health services or medicine. Malnutrition and the incidence of illnesses such as tuberculosis rose dramatically. Life expectancy is currently down to 38 and it is hardly surprising that 2,500 people die of AIDS every week or that between five and eight million people—around 70% of the population—need international food aid to survive. Even so, the IMF has initiated procedures to expel Zimbabwe for not having consistently accepted all of the economic reforms it has “recommended.”

Social catastrophes that are spreading AIDS

The situation is similar in the other African nations. Zambia, where AIDS left some 600,000 children orphaned in 2001, liberalized its economy, including agriculture, in 1991 under World Bank-imposed conditions. It is currently in its fourth consecutive year of food crisis and over three million inhabitants have nothing to eat. The same happened with Malawi and Mozambique, are also suffering from chronic food insecurity.

In 1991, the Malawi government had grain deposits in even the most remote parts of the country and could thus sell cheap food, saving a large part of the population from famine. The IMF “recommended” selling part of these food reserves to guarantee payments on the country’s foreign debt, at the same time enriching private traders. Ten years later food cost ten times more and with the elimination of agricultural subsidies, the price of maize rose by 400% between October 2001 and March 2002. Peasants started eating unripe maize, resorting once again to the diet responsible for pellagra, and there was generalized famine: in 2002, seven million of Malawi’s total population of ten million suffered from pellagra. Between 2001 and 2005, an estimated 125,000 children under the age of five died of AIDS in Malawi. The IMF- and World Bank-imposed obligation to remove all forms of protection from the agricultural sector in Zimbabwe, Zambia, Malawi and Mozambique was catastrophic.

The situation is the same in the rest of the world. In the United States, where neoliberal measures are also increasing social inequalities with every passing day, new HIV infections are concentrated among Afro-Americans and Latinos. In neoliberal Russia an estimated three million people are intravenous drug users—one of the most important AIDS risk factors—and half that number are infected with HIV. While the national prevalence is very low in China, serious epidemics are concentrated in the most impoverished regions, which is where the epidemic of severe acute respiratory syndrome originated as well. In Latin America and the Caribbean, the lack of social and economic equity provides a favorable context for the AIDS epidemic to reach disastrous proportions in the coming decades, according to the UN’s advisr for Colombia Ricardo García. The most serious situation corresponds to some of the region’s most economically depressed countries: Haiti and the Dominican Republic. And in countries like Colombia it is predicted that 1.6% of the population will be infected with HIV by 2010.

The current anti-AIDS “crusades”
of the IMF, World Bank, WHO and Bush

In recent years, the correlation between poverty and AIDS prevalence has become irrefutable, with 95% of the cases located in the pauperized Third World. Meanwhile, the US government and the World Bank, which are the main bodies responsible for the neoliberal reforms that have destroyed national economies and starved vast sectors of the world population, have launched a great world campaign to combat the pandemic.

In January 2003, President Bush used his State of the Union speech to announce a US$15 billion program to provide antiretroviral drugs to two million people infected with HIV in 12 African countries, as well as Haiti and Guyana in the Caribbean. For its part, the World Bank began financing projects and developing an AIDS policy in 1986. In 2000, the World Bank and the IMF jointly decided to incorporate their anti-AIDS plans into their development assistance programs, arguing that AIDS is increasingly influencing poor countries’ economies by reducing both productivity and the work force, causing delayed economic growth in the affected countries. At that time, the Bank illustrated its point using the case of Zimbabwe, a country whose 1% drop in economic growth was attributed to the fact that 25% of its adults were HIV positive.

Finally, in December 2003, the WHO urged that these projects be coordinated with the UN Global Fund to Fight AIDS, Tuberculosis and Malaria, established in 2001, and launched an initiative known as “Treating three million by 2005.” As its name suggests, the WHO campaign proposed providing antiretroviral medicines to three million AIDS patients in the next two years.

It is worth analyzing the origin, philosophy and political and economic content of these anti-AIDS crusades to assess if they will indeed translate into relief for those people and regions in the grip of the epidemic.

Is AIDS the cause of poverty?

World Bank Director General Mamphela Ramphele categorically stated in the capital of Lesotho on June 1, 2003, that “our dream is a world free of poverty. But we now know that that mission will remain only a dream until the world is free of AIDS.” Paraphrasing the title of Doctor Rambphele’s speech that day—“HIV/AIDS: Turning adversity into an opportunity”—it could be said that the adversity of the AIDS tragedy has represented an opportunity for the agencies of international capital to blame the epidemic for the poverty caused by their own policies. Worse still, they intend to postpone any hope of economic recovery in impoverished nations until AIDS has disappeared from the planet.

Such words are not isolated. World Bank documents have been insisting on this idea for some time now. One stated that while it is still not clear if poverty increases the probability of HIV infection, there is strong evidence that HIV/AIDS causes and increases poverty. The US government also defends the idea the AIDS is a cause of poverty. As US Secretary of Health, Tommy Thompson, recently stated, “Poverty, unfortunately, is a common symptom of AIDS.”

Given these tendencies, it’s no surprise that the very first paragraph of the introduction to the document in which the WHO set out its strategy to “Treat three million people by 2005” establishes that “HIV/AIDS is destroying families and communities and sapping the economic vitality from countries. The loss of teachers through AIDS, for example, contributes to illiteracy and lack of skills. The decimation of civil servants weakens core government functions, threatening security. The burden of HIV/AIDS, including the death toll among health workers, is pushing health systems to the brink of collapse. In the most severely affected regions, the impact of disease and death is undermining the economic, social and political gains of the past half-century and crushing hopes for a better future.”

The champions of “free trade” want to blame the economic ruin, loss of political conquests, illiteracy, destruction of health systems and social problems on a biological agent, a virus, rather than on their imposed structural adjustments, privatization programs and other reforms. This position, which tries to explain the social, economic and political reality based on biology alone, not only contradicts the general principles of history and betrays a certain cynicism, it also ignores the fact that AIDS has simply exacerbated existing illnesses like tuberculosis in countries with a long history of poverty.

A world of clients rather than patients

Hundreds of millions of poor people in the world suffer and die from infectious diseases for which there are almost no cheap and effective medicines, despite the existence of the scientific and technological knowledge to develop them. Likewise, while North America, Europe and Japan consume 82.4% of the medicines produced in the world, Asia and Africa consume just 10.6% of those available on the market, despite accounting for two-thirds of the world’s population.

Patrice Trouiller and colleagues have documented the reason for this criminal inequity very well: in the neoliberal economy it is not the population’s health needs but rather the financial interests of the large-scale pharmaceutical industry that influence both the research to develop new drugs and the production and marketing of available medicines. In a world with no patients, just clients, and in which the state is abandoning its public health responsibility, the drug transnationals don’t invest in medicines to treat illnesses affecting poor people with no money to pay for them; their production and sales strategies focus on the market sector from which they can obtain greater profit margins.

A large market of sick people
with no capacity to pay

Although there is currently no cure for AIDS, anti-HIV medicines have been developed that the vast majority of scientists and members of the medical community believe can delay the disease’s progress and reduce mortality by up to 80%. The same “free trade” policies that have allowed the drug-producing corporations to do such great business out of these medicines have also intensified the misery of people who need them. One could say that in the case of the AIDS pandemic, neoliberalism has been responsible for exacerbating to the extreme one of the basic contradictions of the capitalist economy by creating an immense potential market for the new antiretrovirals—forty-two million people with HIV/AIDS—almost none of whom have the capacity to buy them.

Only 8% of the six million AIDS patients who currently require medicines to improve their health have access to antiretrovirals, a figure that in countries such as South Africa is as low as 1%. It is estimated that the current cost of treating a person with HIV/AIDS in the United States is about $20,000 a year, including the value of antiretroviral therapy, lab tests, medical visits and medicines to prevent or treat opportunistic illnesses.

WHO believes this situation can now be resolved: “The prices of antiretroviral drugs, which until recently put them far beyond the reach of low-income countries, have dropped sharply. A growing worldwide political mobilization, led by people living with HIV/AIDS, has educated communities and governments, affirming treatment as a human right. The World Bank has channeled increased funding into HIV/AIDS. New institutions such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and ambitious bilateral programs, including the United States Presidential Emergency Plan for AIDS Relief, have been launched, reflecting an exceptional level of political will and unprecedented resources for the HIV/AIDS battle. This unique combination of opportunity and political will must now be seized with urgent action.”

The pharmaceutical patent monopolies

The economic context must be analyzed to evaluate whether the suffering of people affected by AIDS can be relieved and the number of deaths diminished through the kind of campaign undertaken by the WHO, UN and US government to provide antiretroviral therapy to three million people with HIV/AIDS.

Since 1995, the patents corresponding to anti-AIDS medicines have essentially depended on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement established by the World Trade Organization (WTO). In practice, these TRIPS back up the patents of the transna-tional pharmaceutical corporations, guaranteeing them a market monopoly and exorbitant profit margins. As is the norm in neoliberal strategies aimed at eliminating competition by national products to benefit big capital, mainly from the United States, the WTO initially allowed its member countries to produce generic medicines during the first years after intellectual property rights came into force. A few countries, including South Africa, India and Brazil, used this regulation to start producing generic versions of medicines used to treat AIDS and demonstrated that companies run by the state or national capital could substantially reduce prices and generate profits while at the same time attending to the health needs created by the epidemic in their own countries.

The US government and representatives of the pharmaceutical companies soon started pressuring for “respect” for the patent monopolies. In 2000, 39 companies sued the South African government. During the 14th International AIDS Conference in Barcelona in 2002, there were mass protests rejecting transnational corporations that deal in these medicines while millions of poor people throughout the world are dying without access to them. On August 30, 2003, in a measure to forestall a repeat protest at the WTO meeting in Cancún, México, the Bush administration and the large-scale pharmaceutical industry agreed that poor countries could temporarily continue buying generic medicines, while adding a clause stipulating that all member countries would soon only be able to buy medicines patented by the transnational companies.

The Bush plan:
Big business for the transnationals

At the same time it is promoting its own commercial interests in the WTO, the United States is continuing to negotiate bilateral agreements and regional treaties such as NEPAD in Africa, CAFTA in Central America and the FTAA in Latin America as a whole. This ongoing attempt to impose its neoliberal policies includes respect for the patents held by the drug producing and marketing monopolies. President Bush’s anti-AIDS initiative was launched independently of the existing Global Fund to Fight AIDS, Tuberculosis and Malaria with the evident aim of directly controlling both the project’s philosophy and the money that Washington will invest in the campaign.

Bush named Randall Tobias to run the program in Africa. Tobias had no experience either working in that region or managing AIDS-related programs, but he is a major Republican Party contributor and represents the interests of the large-scale pharmaceutical industry, having been general manager of Eli Lilly, a powerful pharmaceutical company.

In Bush’s plan, the US government will subsidize the capital investments in anti-AIDS medicines by buying up the medicines the companies can’t sell to the impoverished nations of Africa and the Caribbean due to their high prices. In the words of South African finance minister Trevor Manuel, there is a risk that most of the budgeted $15 billion announced by Bush will end up directly in the coffers of US pharmaceutical companies. It is hence no surprise that big laboratories such as Bristol-Myers Squibb, which controls the patent of the antiretroviral drug Stavudine (Zerit®), support the initiative and are competing to obtain their share of the $15 billion or that the giant corporations that produce the anti-HIV drugs are financing the lobbying of Congress in support of the White House anti-AIDS plan.

A plan with commercial benefits
and ideological control

The Bush administration’s fight against AIDS is governed by its policy of globalizing the free trade agreements that benefit its own interests. This was made clear recently by US Trade Representative Robert Zoellick, when he stated that they aren’t thinking of discussing new economic development models for African countries; they are simply looking at how to apply development based on market laws in very poor regions. The aid dedicated to the fight against AIDS will thus surely be conditioned on the nations accepting the economic measures prescribed by the World Bank and the IMF. This is the only explanation for the “altruism” of the big consortiums that have signed up for the anti-AIDS campaign and have already created a Global Coalition of 130 transnational companies against the epidemic.

The anti-AIDS plans that are beginning to be implemented, particularly Washington’s initiative to take antiretroviral medicines to countries in Africa and the Caribbean, also contain a strong ideological component that promotes sexual abstinence as the basis for HIV-prevention. In May 2003, the US Congress introduced an amendment to the Bush initiative obliging it to invest a third of the millions earmarked for prevention into projects whose only objective is chastity. This is yet another of the neoliberal paradoxes: the very promoters of economic policies that leave millions of people unemployed and force many women to turn to prostitution to survive are now the standard bearers of a sexual morality that the vast majority of the population finds it impossible to fulfill in real life. But this does not stop them proclaiming it as the most effective way of combating the AIDS pandemic.

Sex and AIDS transmission

Any attempt to address this apparent contradiction and illuminate the powerful reasons behind the promotion of sexual abstinence as a means of prevention needs first to clarify certain questions about how sexual life affects HIV transmission.

With a few exceptions—such as Paul Duesberg, who argues that AIDS is not transmissible but is rather a set of diseases caused by malnutrition, drug addiction and the toxicity of anti-HIV drugs—most scientists believe that the main form of HIV transmission is via sexual relations with a previously infected person. Since the virus was discovered, it has been insisted that the highest-risk behavior is anal intercourse between homosexuals or heterosexuals and that in vaginal intercourse the virus is most easily transmitted if the infected person is male. Researchers believe that the number and concurrence of sexual partners and the frequency of sexual activity with new partners also play an important part in increasing the probability of transmission.

In the United States, the AIDS epidemic was initially identified among male homosexual drug users. Not until 2003 was it estimated that heterosexual contact produced a third of all new infections in the United States and Canada, while intravenous drug users sharing infected needles caused 25%. In Africa, in contrast, the epidemic was associated right from the start with heterosexual transmission and the WHO estimated in 2002 that 99% of the continent’s HIV/AIDS cases were due to sexual transmission. This assertion has started to be refuted by the lack of studies firmly backing up such calculations and the underestimating of other possible means of transmission, such as use of needles and other medical instruments and equipment that do not comply with basic biosecurity norms due to the deteriorating health services and terrible conditions in which they are provided. A study by Gisselquist and Potterat estimates that sexual transmission could be responsible for between 25% and 29% of male HIV cases and between 30% and 35% of female cases in Africa.

Abstinence doesn’t work

In the sex education offered to young people in the United States, programs currently predominate whose sole aim is to promote abstinence, despite the lack of any definitive demonstration of their effectiveness. A systematic evaluation of these programs by Douglas Kirby concluded that “the weight of the evidence indicates that abstinence-only programs do not delay the onset of intercourse.”

One clinical observation that often surprises health personnel is that the fear of infection does not necessarily lead to the suspension of sexual relations in the case of couples in which just one person is HIV positive and both are informed of the situation. More surprising still is that some groups intentionally practice unprotected sex with a high probability of becoming infected, in what amounts to a kind of Russian roulette. This is the case with the phenomenon known as “barebacking,” which consists of homosexual anal intercourse without a condom with partners who are either HIV positive or whose status is unknown.

Western culture has been promoting sexual abstinence unsuccessfully for two thousand years. In contemporary market societies, this failure is not only due to the fact that the determination to universalize abstinence ignores the human need for pleasure and intimacy that are characteristic of eroticism. As the contradictions of social life determine expressions of sexuality, neoliberal-style society creates the perfect conditions for the dissemination and extension of old and new forms of prostitution, the commercialization of all sexual expressions and the generation of cultures and lifestyles that revolve around sexual experimentation.

Studies of barebacking have found that, apart from emotional satisfaction and erotic gratification, sociological reasons related to what is referred to in the rich countries as “health marketing” underlie this phenomenon: an apparent backlash reaction to the tediusly intense marketing of antiretroviral medicines insisting that AIDS is no longer deadly and the fatigue triggered by the constant and aggressive publicity from condom manufacturers. Other factors in today’s market society that pave the way to behaviors such as barebacking include the commercial exploitation of Internet sites to find sexual partners, the increased number of night clubs and other businesses that offer a place and an opportunity for anonymous sexual activity and the omnipresence of all kinds of drugs.

Controlling sexuality for political control

So why does the US government insist on campaigning to impose a repressive sexual morality when its economic policy is accelerating an increase in all kinds of prostitution and the marketing of all expressions and aspects of sexuality? The answer may lie in the ideological and political spheres. Since control of something as intimate as one’s individual sex life is a way to control the general behavior of individuals, socially controlling the sex life of a community facilitates the control of that community’s general behavior.

The first centuries of Christianity were ones of resistance against fierce Roman persecution, the cruelest of which took place under Emperor Diocletian. Like other patriarchal societies of antiquity, the Christians accepted sexual pleasure as something natural, although they did discriminate against women and condemn homosexuality. Bishop Augustine, later sainted, established the sexual morality that praises abstinence until marriage and intercourse between married couples only for reproductive means at a moment in history in which the Romans needed to subject all Christians and concentrate their power on confronting the barbarian threat. In a little known but well documented story, Bishop Augustine decided to reinterpret the Book of Genesis, stating that Adam’s sin in paradise not only corrupted our sexuality, it made us incapable of genuine political freedom. The Empire, which under Constantine had already understood the importance of a single religion in consolidating the state, now combined its military campaigns with the promotion of this new doctrine of subjection and sexual abstinence. As a result, the Christians were soon finally conquered and their beliefs converted into the Empire’s official religion.

The AIDS virus incubated
in the ecosystem of inequity

Neoliberalism expresses the interests of big capital concentrated in the giant monopolistic corporations. Based on the thinking of neoclassic economics, it proposes that the state should be increasingly small and miserly and thus should concentrate on eliminating public services, public sector workers and state housing, education, food and health programs. In recent decades, US governments and their closest allies have promoted globalization under neoliberal principles and “free trade” economic policies and imposed them on the nations of the world mainly through the international agencies under their control—the IMF and the World Bank—as a supposed panacea for all social problems.

Neoliberal ideology found its perfect application in the World Bank and IMF structural adjustment programs that have devastated Latin America, Africa, Asia and the Caribbean over the last 20 years. Promoting privatization, fiscal austerity, deregulation, market liberation and the cutting back of the state, these programs have increased and globalized poverty, migration, unemployment and temporary work contracts and produced extremely polarized income and living conditions across the world to the exclusive benefit of big capital.

AIDS was incubated and has been propagated in this ecosystem of social inequity and it will be impossible to prevent and combat it in any effective way without going after the conditions that are generating the pandemic and continuing its expansion throughout the world. The anti-AIDS initiatives implemented by the Bush administration and the World Bank are set within the US government’s strategy of neoliberal globalization, a strategy that also guides the projects of the United Nations and the WHO. All of these plans basically consist of creating funds for channeling money donated by the governments of developed countries and philanthropic organizations attached to the big corporations as human aid to be used mainly to purchase and distribute antiretroviral medicines and AIDS prevention programs that promote sexual abstinence. These kinds of anti-AIDS programs also serve to reinforce the implementation of neoliberal policies in the countries to which the “aid” is offered.

An alternative proposal

Any alternative proposal to confront the AIDS pandemic with any probability of success should include the following basic points:

* Defend work and production in order to promote the independent economic development of nations, guaranteeing their food security and hence adequate nutrition for their population. A population with severe malnutrition is easy prey for the illnesses that characterize AIDS.
* Stop and reverse the privatizations, particularly those that have eliminated public services and health systems, so the state can fulfill its responsibility to provide services and treat those affected.
* Allow the production of generic medicines, eliminating the patent monopolies conceded by the WTO to the pharmaceutical transnationals under the guise of respecting intellectual property.
* There is enough scientific evidence to confirm that drug addiction is directly associated with AIDS. Therefore, prevention and treatment of drug addiction must form an integral part of AIDS prevention and treatment.
* Guarantee the necessary scientific debate on the causes, prevention and treatment of AIDS. The complaint by Paul Duesberg and his colleagues that their hypotheses have not been empirically refuted and should be tested with duly controlled studies to the benefit of HIV/AIDS patients deserves to be taken seriously by the scientific community.
* Research cannot be limited to the commercial interests of a handful of companies that invest much more money into publicizing a few products that are immensely profitable for them than into basic research to develop the medicines that are really needed.

Pending scientific questions
and rejectable moral prejudices

The most advanced medicines must be made available to the patients who really need them, the vast majority of whom are from the poor countries. But the management of HIV is complex. As even those who defend antiretroviral therapy point out, the severe toxicity of these pharmaceutical agents must be considered very seriously when prescribing their use, despite their notable effects so far.

It is important to insist that antiretroviral medicines are not a cure for AIDS and that there is not complete unanimity among those who defend them. There are still many questions related to the use of this kind of therapy that science has yet to solve. The serious problems related to all of these pharmaceutical agents, just over 20 of which have so far been approved in the United States, include their high toxicity, the loss of effectiveness as the organism develops resistance after a certain amount of time and the difficulty for patients to stick to the treatment adequately.

Resisting the discrimination and stigma attached to people and communities affected by the epidemic must be an integral part of the calls for and actions aimed at social change, as such stigmas fuel, reinforce and reproduce existing inequalities related to class, race, gender and sexuality.

Prevention programs must be based on scientific knowledge about the AIDS epidemic, not on prejudices about sexuality or people’s behavior. When she heard that a third of the money from Bush’s initiative will be invested in programs that impose sexual abstinence, Lorraine Cogan, an American who has educated health professionals in 11 African countries on issues related to AIDS, stated that it was inappropriate for the United States to establish the standards governing the whole world. She argued that each country, culture and society should have its own standards, rules, norms, taboos and lifestyles.

Defeating the neoliberal
model to defeat AIDS

After 20 years of the epidemic during which the systematic quantification and analysis of the relation between poverty, economic models and AIDS has been abandoned, empirical studies are beginning to emerge that demonstrate that the incidence of AIDS increases with economic impoverishment and that to reduce the syndrome’s prevalence it is essential to expand and strengthen the public health systems. This is why, as Paul Farmer stated in his report to a US Senate Commission, the fight against AIDS is the fight against poverty. And given that poverty in the contemporary world is of neoliberal origin, it will be impossible to defeat AIDS without defeating the neoliberal model.

Bernardo Useche is a professor at the University of Texas’ School of Public Health and Amalia Cabezas is a professor in the Women’s Studies Department of the University of California, Riverside.

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