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Dr Sophie Harman is a lecturer in International Politics at CityUniversity London. As well as teaching courses on the Global Politicsof Health, Disease and Global Governance, Sophie has conductedextensive research into the politics of HIV/AIDS in East Africa.

A GLOBAL PROBLEM

Of the 40 million people living with HIV/AIDS around the world, 25million live in sub-Saharan Africa. Many people living with HIV areable to live healthy and productive lives: they can look after theirchildren, go to work, and have healthy relationships with otherpeople. The problem is, this lifestyle is not available to many ofthose living with the disease in sub-Saharan Africa

HIV/AIDS is an epidemic driven by poverty. Lack of education and

employment, whether you are born a girl or a boy, or live in a rural or urbancommunity can all enhance an individuals exposure to HIV infection. If thesocio-economic factors are combined with poor health systems fragmentedafter years of bad financial advice from international organisations, war andstate corruption, and the creation of new infrastructures, then you have themother of all international headaches. So how do you begin to think abouttackling such a problem?

The good news is that many people have become committed to tacklingHIV/AIDS. Disease is not limited to one country with increased globalinteraction, migration, security concerns, and changing approaches todevelopment, HIV/AIDS has come to affect all of us.

Decision makers

Over US$10billion is channelled to fighting HIV/AIDS every year. This moneycomes from international organisations such as the World Bank, bilateraldonors such as the US government, international non-governmentalorganisations such as Care International, philanthropic foundations, andgovernment budgets within sub-Saharan Africa. The money goes towards arange of activities and structures from individuals supporting a group oforphans in a rural village, to drug dispensaries in urban healthcare centres,and the establishment of AIDS-specific agencies within governmentstructures.

Such is the level of aid being channelled to combat the disease, newstructures and institutions to enhance the involvement of people living withHIV/AIDS in local communities have been established. The aim of newinstitutions such as the Global Fund to fight AIDS, TB and Malaria, is toinclude those infected and affected by the epidemic in global decision-making. These types of decisions focus on how money to combat theepidemic should be spent and what issues need to be tackled. However, the

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key question government, policy-makers, public health and developmentexperts should ask is do these structures and financial contributions work?

Put simply, it is hard to tell. The Joint United Nations Programme on HIV/AIDS(UNAIDS) and the World Health Organisation are responsible for gathering aglobal database on how many people are living with HIV and AIDS, how many

deaths have occurred and the rate of new infection. These statistics areavailable via their websites and published annually on World AIDS Day 1 stDecember. Over recent years, indicators from sub-Saharan Africa suggestprogress has been made against the epidemic, as numbers of people infectedwith the disease have gone down in many countries.

This is not necessarily a result of global interventions working, but could bethat many people died in that year, or that previous estimates were incorrect.Reliable data is hard to come by, especially in rural areas where many peopledo not visit health centres. The large number of actors, such as the WorldBank, United Nations and domestic governments, involved in the AIDSresponse makes it impossible to accurately pinpoint or measure what has or

has not worked, and who is or is not responsible. This is where research intointernational politics comes in.

Improving matters

Students and scholars of international politics approach the relative successor failings of global interventions by asking the following types of questions:where is the power, how is it expressed, who holds it, and what are itsimplications? In asking these questions a different picture emerges as to therelative success in fighting the disease, than the statistics indicate. Researchsuggests that what has come to constitute the governance of HIV/AIDS isevery bit a headache as the social and economic determinants that drive high

rates of infection.

The large amount of money and people involved in combating HIV/AIDS hasled to confusion as to where the money goes, who is responsible for what, alack of direction, and a fudging of institutional structures all factors whichprevent money from reaching people in need. Confusion and problems withthe structure of these new organisations limits the ability of people living withHIV/AIDS and affected by the epidemic to express their opinion. Whilst theyhave a say in theory, this does not translate to practice where, agenda-setting is conducted at the global level, often in Geneva, New York City andWashington DC. The result is the application of the same blueprint policies,prescribed at a global level, to communities throughout sub-Saharan Africa.Community actors and governments then become accountable for theseglobal decisions and implement them at the local level.

The system is highly problematic for scholars of international politics as theactors involved in global decision-making have the power and influence tocommunicate how the HIV/AIDS problem should be addressed. Those affectedby HIV/AIDS do not. There are no checks or balances to make sure the rightpeople have this power and influence, as global actors such as the World

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Bank are not held to account for their role in combating HIV/AIDS. The WorldBank, for example, is able to devolve responsibility for its decisions to statesin sub-Saharan Africa, who in turn implement these strategies and work withcommunity groups. Global ideas are then translated into nationalprogrammes that are applied in the community. The chance for communitiesto participate in politics is therefore limited. Where it exists it is structured in

such a way as to maintain the power of global decision-making.

This type of top-down power is the norm in international politics and in thepast has led to the fragmentation and collapse of state-provided socialservices such as free healthcare and free education two factors that arenow driving infection rates and limiting the ability of states to address theepidemic. What we see is HIV/AIDS, poverty and international politics in acycle which continues to combat this global crisis in the short term, leavingserious repercussions for the long term ability of states and communities tofully address their countries health concerns.

Through the study of international politics we are trying to understand how

international systems of governance work and establish how they can beimproved. This, it is hoped, will help to improve funding structures for healthprojects such as those combating HIV and AIDS globally.