This article is the fifth in our series on the World AIDS 2014 Conference which opens today in Melbourne
The important achievements of science and global funding in providing treatment and prevention for AIDS have been considered by funding agents and governments as an aspect of global investment in biosecurity. We adopt the concept of bio-insecurity to describe the ways in which neglect with respect to HIV management, water, transport and energy versus attention to global economic pressures may increase the insecurity of the lives of poor men and women. We argue that only alleviation of the bio-insecurity of poor populations and the implementation of prevention and treatment within this social context can fully stem the AIDS epidemic.
Based on fieldwork in South Africa, we look at the less dramatic forms of bio-insecurity facing poor populations and the political choices facing new democratic states in addressing these issues. Our own work has focused on the lives of women, sometimes lacking governmental support for fundamental public health measures, trying to access needed medications and other forms of health care.
Multiple and diverse daily challenges with respect to transportation, water and energy, are faced by poor women and their families in South Africa. Such problems, which might be characterized as bio-insecurity, need to be seen in the light of the costs and impact of national and global policies which have been inappropriately characterized as promoting biosecurity. Here we might include a broad range of policies such as the Trade Related Aspects of Intellectual Property Rights (TRIPS), the promotion of global policies on water, and national efforts to build new business-friendly airports and transnational highways rather than affordable public transportation. At the same time, we find a widespread failure to provide local facilities that require education, training and support , funding and implementation of basic programmes.
World Trade Organization (WTO) policies protecting patents and promoting international trade, and global policies with respect to water and the environment, have been developed with the stated aim of building more stable national economies and, in the case of water, global environmental preservation. However, examination of their impact in specific places raises questions about their effects on the poor households of women, men and children crucial to the social reproduction of a healthy and educated population.
Current market-driven policies relating to the WTO and water and economic stability are associated with a neoliberal discourse that Watts describes as “resilience”. This corresponds to the current capitalist regime of flexible accumulation which has replaced the industrial era - as explained by Harvey. The new discourse followed the break up of the Bretton Woods agreements, which were put in place after World War II. Under Bretton Woods, global structures, such as the UN and the financial institutions, operating from a Keynesian economic perspective, channeled economic programmes directly through the states. We can see such past efforts to build effective state governments as corresponding to an industrial era with, as some have labelled it, a Fordist regime of accumulation. The new discourse of resilience and flexibility can be directly linked to a new form of governance with an increasing emphasis on civil society and individual entrepreneurship, which may bypass national governments in the Global South or else may be fully adopted by them. As Foucault claimed, such neoliberal thinking, rather than solving problems, purports to manage risk in an unpredictable future in which we can expect that those who do not have their own forms of “resilience” will die. Thus, the disconnect between global policies to prevent HIV and treat AIDS and the ongoing suffering of people at the local level, can be understood as part of larger global conditions which often lead, among the poor of Africa and elsewhere to “letting them die”.
However, in spite of the neoliberal global discourse, we can also see people at all scales struggling to survive, implementing realistic communal projects and working towards a more equitable social transformation. Little or no funding or resources are assigned directly to them.
In addressing these questions, why consider South Africa? South Africa, along with other Southern African countries, has had the highest rates of AIDS in the world since the mid-1990s, and is now, with 5.6 million people living with HIV, the country with the largest population of people living with HIV. South Africa has a powerful record of collective action and political mobilization for change. Following forty years of struggle, domestic and international movements transformed a fascist state based on a black/white racial divide into an interracial democracy. Yet, twenty years after liberation, South Africa has become one of the most unequal economies in the world.
AIDS and bio-insecurity
We find bio-insecurity for women in South Africa, in relation to three topics: first prevention of HIV and treatment of AIDS; second, the physical environment, water, transport and energy; third, neglect of novel improvements to the environment.
HIV and AIDS: prevention and treatment
Despite the recent battles over pricing (WTO, TRIPS) and denialist government policies, South Africa is now actively pursuing preventive and treatment advocacy and research. Nevertheless, as the country with the highest rate of HIV in the world and a co-existing TB epidemic, too often with resistance making its appearance, present day problems are not easily resolved. Despite the outstanding research of Caprisa and other groups, local discoveries - for example the effectiveness of the microbicide Tenofovir - have not been implemented. There is still inadequate co-ordination of support of family planning and barrier use in prevention both of peri-natal transmission and contraception.
The current enthusiasm in the US and parts of Europe for total community involvement and early treatment of all those with HIV calls for universal testing, and early initiation of treatment before sickness or symptoms are established. It has been argued that this regime might be best for patients over the long term, but it requires a level of adherence which is most certainly undermined by situations of bio-insecurity, such as lack of transportation to the clinic, lack of adequate housing and clean water. Lapses in treatment or prevention, due to such bio-insecurity will be costly in terms of drugs and resistance. The problem is not whether a microbicide or female condom is scientifically effective: that has been shown. Quite apart from the ethical issues of prescribing drugs with major side effects to people before they may actually need them, the problem lies in global support for local conditions where people can effectively follow regimens of prevention. In spite of major investments in global policies, poor women are subject to many forms of violence and lack of public resources. In other words, bio-insecurity, cannot fully benefit from new scientific advances aimed at biosecurity unless the bio-insecurity is also addressed. Bio-insecurity will triumph over global scientific technologies if full support is not made available to improve local conditions in culturally grounded and appropriate ways.
Water, transport and bio-insecurity
We select two elements, water and transport, directed at the global level, but without adequate evaluation on the effects at the local level, hence without improving bio-insecurity.
Water is needed for drinking, cooking, washing, gardening. Unless there is a free supply, piped in at the level of village and home, there will be illness, exhaustion, potential physical danger (from crocodiles or assailants) and bio-insecurity. When water is rationed, or households are charged for clean water, people look for alternative sources. Sending women for miles to the nearest pond or river is no substitute for free clean water, especially as rivers and ponds are notorious for spreading disease.
In terms of transportation: motorways and airports do not help the poor woman to travel from the village to the health centre, to shop, nor to take her children to school. Walking 5 miles carrying an infant, or accessing a shared and inconvenient bus or a prohibitively expensive taxi to seek health care, is bio-insecurity.
How to promote local biosecurity
Free, piped convenient water; cycles or tricycles designed for local needs and available at the individual or village level, with or without power, energy appropriate to upgrade cell phones or cooking materials, have all been designed but where are they at the population level? Night lighting by reusable energy is available globally but missing locally. We need to integrate cell phones with access to clinical care. All of these cheap useful technologies have already been invented but are not widely implemented. In addition, we need reproductive advice, including support for barrier methods for contraception and microbicides and female condoms for HIV protection. Only with local biosecurity in place, can preventive methods, whether they be microbicides, universal treatment, pre-infection treatment or other global policies, be implemented effectively.
Bio-insecurity should be removed and improvements to quality of life made available at the level of the poor woman and her family. Such attention to local needs must be a key structure of any effective HIV plan.
This article is part of 50.50's long running series on AIDS Gender and Human Rights exploring the ways in which global policies ignore the gender dimensions of the pandemic, and the impact this has on women's human rights. We are publishing articles daily during the 2014 World AIDS Conference in Melbourne July 20-25