January 28, 1999
Ivan Wolffers, Amsterdam
is rather unfortunate to see how the discussion on "the impact of the
economic crisis on the HIV/AIDS epidemic" has been diverted to a discussion
on testing. If Dr. Frerichs manages to do so with each of the discussion topics
that are planned, I foresee that we have not much done by the time the Congress
starts. However, Dr. Frerichs is not to blame for this. Though I do not
sympathise a lot with the issue he brings up time and time again, it is
fascinating to see how incompatible his views are with the social-economic and
cultural context in developing countries. Yet, many of us like such easy
technological solutions for complicated problems, and dive into the discussion.
who believe that testing is the answer to the HIV-epidemic often come from
societies where concepts like "right to choose," "market,"
"individual responsibility" and "risk" are the basis for
programming the minds. Health is seen as a product, that can be bought; social
context is ignored; culture only exists in other countries; and "risk"
is the basis for understanding why people get ill. The background of people
believing in testing is often that of cultures where insurance systems function
relatively well and where health care systems are involved in a continuous
struggle to prove that their outputs are worth the inputs.
living with the realities of developing countries (and especially the
inhabitants of developing countries belonging to the unfortunate: the women
without education, the rural population not finding employment, the migrants,
the street children, the sex workers etc) do not live in the wonderful
"market place" where everything seems to be available and marketable
and where responsible behaviour of the individual is the road to prevention of
disease, understood as bad luck in the computer game of individual risks. For
them health is not a product but a condition and an experience. Their health is
related to them being poor. No, these are the people who still (the use of this
word is almost cynical) live in communities, where individual behaviour is less
important than the cultural values and social economic conditions. They are
vulnerable, and that is another concept than "risk." It puts emphasis
on other factors than the individual. It demands attention for the conditions
that make it impossible that people even think about individual risks.
testing as THE means to prevent people to get HIV-infected is like demanding
from people in such situations to become like the believes in testing, who make
such a big effort in promoting it. It almost implies colonisation of the mind.
It means individualisation instead of community activities, it means insurance
thinking instead experiencing health as a condition of the factors of life, it
means that people have to think that they are in control over their lives
(empowerment as we call this) while in fact they feel every day that it is not
like that. They might feel empowered if they would have been to the right school
in California, but not if you come from Klong Toey, Phnom Penh or a slum in
Surabaya. What is happening is what we call "decontextualisation" and
it leads to the myth of biological control.
have used the term "believers in testing" on purpose, because like in
religion, those who think it is the only way out of the HIV-crisis only seem to
see one thing and they develop a tremendous capacity for ignoring the realities
of life. Science is supposed to be a tool to learn something about reality. I am
a medical doctor and at the same time a medical anthropologist. In medicine we
learn to concentrate on the biological factors because the social realities are
so confusing. But how, for instance, was most improvement made in Europe against
(the first medicine that really worked) was only introduced in 1948, but in most
Northwestern European countries (even after having gone through the second world
war) the disease was practically under control because people had better
nutrition and improved housing. This all belongs to the area of disturbing
factors and we should not thank doctors for getting rid of tuberculosis, but
politicians, action groups and voluntary organisations who have been fighting to
improve the conditions that are really decisive about health or disease. I guess
that the same can be said about HIV/AIDS.
is probably very useful in the area where Dr. Frerichs lives, but why doesn't he
make a better effort to study the realities (the disturbing factors) in a world
he only knows of occasional consultancies, before trying to market this tool to
other countries where it does not fit that well? By the way, isn't it odd that
since we recently heard that Mongolia is open for HIV/AIDS work and so many
consultants are lobbying for jobs in Mongolia, that international organisations
have exactly selected someone who favours and promotes HIV-testing?
let's remember: aren't we to blame to jump immediately in the discussion about
the testing forgetting that we were supposed to discuss these "disturbing
factors." Those of us who are really active at grass root level can see
what is happening due to the crisis: In the CARAM programme (HIV/AIDS and
mobility) we SEE the increase of undocumented migrants from Indonesia to
Singapore and Malaysia (to such an extent that the authorities in Singapore this
week even demanded from president Habibie to act more powerful to stop this) and
we know how vulnerable they are to get HIV-infected; in our sex work projects we
see more indirect sex work with all its consequences for the dissemination of
HIV/AIDS. We could have shared our experiences in this discussion instead of
exchanging impressions about Mongolia.
Care and Culture, Amsterdam
behalf of CARAM Asia, Kuala Lumpur
note: One thing to consider in light of this posting is whether we still need
the final discussion theme - testing approaches in Asia and the Pacific!
January 28, 1999
Kearsley Stewart, CDC, Atlanta
- regarding the potential value of voluntary counseling and testing (VCT), Bob
Watt (#71) appears to have unknowingly given a
good reason for supporting VCT. If all Ugandans and Thai conduct their
intimate relationships assuming that their partner is HIV+ (safer sex
practices), then when the time comes to conceive a child, the need for testing
is certainly clear. Since children are conceived all over the country, testing
needs to be available and trusted all over the country.
and elite Ugandans are using testing as one step in the planning process for
expensive public weddings. Monogamy is now "in" among the youth and
the ability to test is usually reported as a part of future life plans AND
BEHAVIOR for these adolescents caught in the epidemic.
of course, is still there. For example, in my VCT project in rural western
Uganda, a polygamous man came in with his "favorite" wife, leaving the
other two wives at home. We counselled him and his partner, and the next week
they all came in as a family (results were given individually, not to the
- are most of the data which indicate that VCT is not an effective component of
an HIV/AIDS prevention program from low-prevalence settings? Perhaps the results
would be different in high prevalence settings?