More than “best practices” for HIV-AIDS control:

redressing the class-based organization of public health and health communication

Bella ModySchool of Journalism and Mass Communication

University of ColoradoBoulder

http://spot.colorado.edu/~mody

IAMCR Taipei 2005

Outline• The class-based nature of HIV prevalence• Socio-political versus medical causes of the

disease• Class-biased benefits of AIDS media campaigns• Proposal for a socially-rooted multi-sector

long term health-and-development approach that is biased in favor of the poor

• My thesis: equitable multidimensional national and local development is the best protection against HIV-AIDS

The class-based nature of HIV-AIDS prevalence• Predominantly a disease of poor countries and

poor people (95% of PLWA are in developing countries)

• Increasing number of children-headed orphan households

• A disease that kills 15-24 yr olds who are the future of their countries

• Spread by poor villagers forced to sell blood and drugs and/or migrate to the city for work to support their families in the village

The causes: proximate medical, distal socio-political• Proximate medical causes: sex with multiple partners,

infected needles, contaminated blood, pregnant mother-to-child

• Distal socio-political enabling conditions: power inequities in terms of low education, employment skills, purchasing power (to buy condoms, antibiotics and ARV meds); gender hierarchies that prevent women from refusing sex, limited job opportunities, a stigmatization-prone culture; a public health infrastructure based on the ability to pay as a result of structural adjustment conditions (WB-IMF) and national responses (e.g. Deng “reforms” require provinces in China to raise their own funds for healthcare)

• Health education interventions (e.g. CDs, videos, music, house visits, counseling, media campaigns) alone are inadequate:

-Address distal conditions (e.g. lack of employment, poor agric prospects, poor public health infrastructure) that lead to proximate causes, e.g. willingness to sell blood and drugs to make money, migration to the city for work to support the family in the village, inability to pay for antibiotics to treat early genital ulcers or treat AIDS symptoms with ARV meds

• Health education media messages and interpersonal counseling are class-biased

-Prevention media messages have reached fewer than 1 in 5 at risk over the last 20 years

-HIV awareness has increased primarily in the urban middle class

-Men are reached more often than women: more women are being infected than men presently

-Extension workers prefer to talk to young, educated and upper income people

• Why is multidimensional equitable national and local development the best intervention?

Poverty, lack of jobs and socio-political conditions influence -lack of ability to read instructional texts on prevention and

the consequences of HIV-AIDS-age at which individuals start sex-the viability of abstinence and monogamy (the AB of ABC)-the neglect of condoms-willingness to sell blood to earn money-earning income by dealing in injectable drugs and

subsequent vulnerability to their use -access to good primary healthcare to prevent and treat

HIV-AIDS

• Recognition of the need for holistic structural reorganization attempts against HIV-AIDS is not new:

-World Bank and UNAIDS’ Convergent Community Action: design of national AIDS control orgs that include staff in medicine, information extension, counseling, testing, and drugs

-Gates Foundation: integrate strategic elements with communication and advocacy

-DFID India: link info-education-communication to other interventions

Recommendation:• Go beyond individual-targeted medical-model-based

interventions-Health interventions needed to address distal enabling

causes such as social group inequalities in resources by economic class, gender and region

(ex: micro-credit combinations with HIV-AIDS interventions in Morocco)

-Lessons from 19th century infectious disease declines in England, child health in the 1980s

-Recent statistics indicate 99% of the women who die in pregnancy and childbirth are from low and middle income countries

My proposal:• Design a long-term development-and-health infrastructure

activation approach at the lowest unit that- simultaneously mobilizes all non-health sectors of development

infrastructure complicit in causing AIDS, e.g. agriculture, education, health

-learns from rather than imitates someone else’s “best practices”, e.g. successful AIDs orgs in Brazil, Thailand and pre-Bush Uganda

-builds social choice, citizen participation and democratic deliberation into the design and functioning of local health and development institutions

-uses health education interventions via media and face-to-face as one essential component