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Frerichs, R.R. On being drawn into the testing discussion....

SEA-AIDS Network, January 29, 1999.

Posted in response to:

SEA-AIDS, January 28, 1999

From Ivan Wolffers, Amsterdam

It 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.

Those 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.

Those 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.

Introducing 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.

I 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 tuberculosis?

Streptomycin (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.

Testing 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?

But 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.

Ivan Wolffers

Health Care and Culture, Amsterdam 

on behalf of CARAM Asia, Kuala Lumpur 

Moderator's 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!

SEA-AIDS, January 28, 1999

From Kearsley Stewart, CDC, Atlanta

First - 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.

Middle-class 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.

Abuse, 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 group).

Second - 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?

Kearsley Stewart

CDC/Emory University

Atlanta, GA

R.R. Frerichs Posting

I share with Dr. Wolffers his concern that discussions which started in one area (in his case, the theme PRE-ICAAP 1: Asian economic crisis), has been diverted to other issues. If SEA-AIDS was devoted to only the pre-ICAAP theme and a users group had been established to address only this issue, then certainly the discussion should be limited. Yet this did not occur. Instead, the PRE-ICAAP messages were woven into the general SEA-AIDS messages, with provocative points here and there leading to varied responses.

What started the current testing discussion was Dr. Wolffers' own posting (#66) rather than the posting of others. In (#66) he started out by clearly describing in a thoughtful manner the economic crisis in Asia. Then all of a sudden he made the following point which addressed testing:

Apart from increased vulnerability of internal migrants, in the situation of international migrants we see extra problems due to the economic crisis. To create employment for the local population authorities are embarrassed with having a vast migrant population from abroad (people they have been attracting before to make their economies bloom). In many countries authorities have turned to forced testing and repatriation as a means to solve their problem with international migrants. A small sample of news items from international media in 1998 may be convincing

From the newsroom of the BBC World Service

*UAE deports foreigners infected with HIV (the figure of 6000 is mentioned). 

*New York Times (12/01/98) Saudi Arabia 349 with HIV deported.

*Associated Press (September 04 1998) Singapore to test ALL foreign workers for AIDS.

*The Sun (18-8-98) Fomena 87 Foreign workers HIV carriers Kuala Lumpur. 

"All who were found unfit were deported as we don't want them to be around and spread the disease to our people.."

Thus Dr. Wolffers in his economic posting brought up the troublesome notions of "forced testing" and deportation of HIV infected immigrants. When all of us submit our ideas to SEA-AIDS, we recognize that they are subject to question and discussion -- often with short turn-around. I found his inclusion of immigrants and testing to be intriguing and asked that he and his colleagues clarify the policy implications [see (#66)]. Specifically, I concluded (#66) with the following suggestion:

"Given the thoughtful nature of much of what Wolffers and colleagues wrote, I would like to encourage them to draft an effective testing policy for countries in Asia to consider, specifically focusing on foreign workers. In considering the policy, however, they should keep in mind the epidemiological reality of the disease, including transmission pathways. Broad principles such as human rights are important to consider, and certainly elevate our social horizons. If not biologically practical, however, our adherence to a poorly conceived human rights mandate can cause great harm."

This posting was followed by a series of reactions of varying temperament that spoke to my wayward personality and partially to the testing issue, but perhaps not to the broader economic theme that Dr. Wolffers and his colleagues would like to address. I suspect that if he had not brought up the subject of testing, that the rest of us would not have been diverted from the main economic theme.

Finally, I would encourage Dr. Wolffers to explore more fully the notion of the "myth of biological control" which he briefly described in (the above) posting. I gather that he means that people in developing countries would not be able to use the results of testing to guide their behavior. This seem like a curious conclusion, but perhaps I did not fully understand his meaning.

So do Dr. Wolffers and I agree on any points? We likely agree that broad health education programs and social marketing of condoms are desirable strategies. We also likely agree that programs aimed at high risk groups such as commercial sex workers, men who sex with men, and intravenous drug users are important to include in a well designed intervention or prevention program. Where we perhaps disagree is with the role that testing has in all this. My preference is that HIV/AIDS Control Programs start with a well designed surveillance system that includes behavioral data, information on STDs, as well as prevalent HIV. When such a system demonstrates that HIV is present and is increasing, I have encouraged societies to be more aggressive in their response, adding an active testing program to the mix.

Most of us who favor testing do not denigrate the value of other approaches -- far from it. On the other hand, some who favor general approaches to HIV control do not consider the need for testing, and give little thought to practical testing strategies of use in the developing world. Perhaps this is why some developing countries like having foreign consultants or teachers who are willing to address many possible solutions, offering respect to local health professionals who most decide for themselves what is right or proper for their own country.

In reviewing the literature, I sense that all successful control programs in the developing world have relied on testing in one way or another. This point was made most recently by Kearsley Stewart (see above) and Dr. Kenrad Nelson (see #71).  Perhaps if Dr. Wolffers and his colleagues disagree, they would be willing to point to a country where the HIV epidemic has been reduced that has not relied on testing as part of the control strategy. Focusing on such specific examples would enrich our discussion, adding luster that might otherwise be diminished when discussing the personality of fellow writers.

In concluding, I liked the Moderator's Note that appeared at the end of Dr. Wolffers posting:

"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!" 

Perhaps not, if others feel there is nothing more to say. On the other hand, perhaps others will have additional thoughts to contribute on testing, exemplifying the free and open flow of ideas that characterize SEA-AIDS. If the topic was dull or easy to solve, few would have anything to say, including thoughts that reflect personal frustration.

Note: Following this posting, Dr. Wolffers and I continued our discussion for quite some while via email but were unable to forge an agreement on our view of disease and the role of testing.