AIDS TREATMENT NEWS Issue #225, June 16, 1995
In strongly worded letters of May 18 and May 19, the World
Bank tried to persuade the British journal AIDS not to
publish an editorial review on AIDS prevention by researchers
at the Center for AIDS Prevention Studies of the University
of California. AIDS published the article anyway (Peter
Lurie, Percy Hintzen, and Robert A. Lowe, Socioeconomic
Obstacles to HIV Prevention and Treatment in Developing
Countries: The Roles of the International Monetary Fund and
the World Bank, AIDS. 1995; volume 9, number 6, pages 1-8.)
The main point of the controversial article is stated in its
"By the year 2000, 90% of all HIV infections will have
occurred in developing countries. Worldwide efforts to stem
the HIV epidemic have to date emphasized inducing behavior
change in individuals at high risk for HIV infection. In this
review we argue that social and economic forces have also
played a role in promoting the spread of HIV, and that these
have been largely overlooked in favor of factors that operate
at the individual level. The failure to consider all aspects
of HIV transmission may be inhibiting our ability to reduce
the spread of HIV infection."
The authors argue that an economic approach called structural
adjustment programs "which began in the early 1980s and is
spearheaded by the International Monetary Fund (IMF) and the
World Bank, may have created conditions favoring the spread
of HIV infection in the developing world."
The authors point out that the current debt crisis of
"developing" countries has not always been there but started
after 1973, when the OPEC oil embargo quadrupled world prices
for oil, and also led to a worldwide recession which
decreased demand for those countries' exports. Developing
countries borrowed to cover the shortfall; then interest
rates greatly increased and the borrowing could no longer be
sustained. The World Bank and International Monetary Fund
responded by imposing structural adjustment programs on
desperate governments of poor countries, which led to greatly
increased hardship and reduction of public services,
including health services, in order to control inflation and
redirect production toward exports.
The article is especially concerned about four alleged
consequences of these programs:
* The decline of the rural subsistence economy -- forcing
rural farmers to leave their families to search for work in
the cities, where they are more likely to contract HIV, and
leading to higher food prices and worse nutritional status,
increasing vulnerability to HIV.
* Development of a transportation infrastructure. HIV
notoriously tends to spread along truck routes.
* Migration and urbanization. Between 1960 and 1990, the
urban population growth in sub-Saharan Africa was higher
than in any other region of the world. A consequence of
this migration is that men are more likely to have multiple
sex partners, and women are financially dependent and less
likely to be able to negotiate for safe sex when their men
* Reduced spending on health and social services. Health
spending declined 26% in sub-Saharan Africa between 1980
and 1985. When the World Bank required Kenya to charge
$2.15 for STD clinic services, visits fell 35-60%. In
northern Nigeria, a 56% increase in the number of maternal
deaths has been attributed to structural adjustment
The CAPS article recommends the following changes in
development programs to help deal with these problems:
* Focus on the satisfaction of basic human needs such as
food, housing, and transport, by reducing spending on
military and luxury goods.
* Encourage diverse agriculture, instead of producing a few
products for export.
* Support marginal producers and subsistence farmers, by
shifting from large infrastructure projects to small
projects using appropriate technology.
* Place more emphasis on human resource development in
* Move from paternalistic to cooperative development policy
making, allowing the citizens of developing countries to be
* Change the charter of the World Bank and International
Monetary Fund to allow rescheduling or canceling of debt.
* The World Bank and International Monetary Fund should
require an AIDS Impact Report on future adjustment
programs, so that their influence on HIV transmission --
good or bad -- will be considered.
Lead author Dr. Peter Lurie told the San Francisco newspaper
BAY AREA REPORTER, "If we are serious about stemming this
global epidemic, everything -- including these 'sacred cow'
economic programs -- will have to be on the table."
World Bank officials, in letters to AIDS on May 18 and May
19, said that "this paper falls well below the critical
standards and intellectual rigor for which AIDS has acquired
a reputation. Some of it is just demonstrably wrong. Some
reveals a very poor grasp of development economics,
structural adjustment and the role of the World Bank and the
IMF... To accept such flawed material as an Editorial Review
appears particularly ill-advised..."
"Much of the argument in the Review can be condensed into one
sentence: Economic development, which disrupts traditional
ways of life and leads to greater mixing of people through
commerce and migration, is conducive to the spread of
disease, including AIDS. That is broadly true, but then the
disease-limiting conclusion should be to restrain
development, or even to reverse it, ignoring the fact that
economic development overall is responsible, through the
growth of income and knowledge, for enormous reductions in
disease burden. There is in any case no reason to single out
one disease in determining development policy. The authors
also ignore completely the question of whether, in economies
badly out of equilibrium, there is any real alternative to
adjustment, to putting one's economic house in order...
"It is worse than a pity -- it is a shame -- that a reputable
journal which would never think to publish medical nonsense,
should allow itself to be used to publish nonsense of other
Comment: Where the Process Stops
Almost all AIDS prevention activity has focused on getting
individuals to change their behavior. The contribution of the
University of California article has been to open the door to
thinking about institutional change as well, as an additional
approach to preventing HIV transmission.
The hidden issue in this case is what costs of economic
reform are acceptable, and what costs are not. If the World
Bank and International Monetary Fund designed economic
reforms that would make it impossible for thousands of the
rich and powerful to make a living, it is inconceivable that
those programs would be implemented. Instead, the computers
would continue to hum, the meetings and conference calls
would continue to drone on, until another plan was developed.
The new plan might not be as efficient as the first one. It
might take longer to get results; it might even focus on the
informal subsistence economies in which people were in fact
surviving, and try to improve those, instead of trying to
supplant them with big-organization, wage-work, export-
Domestically, the comparable issue is the policies of the
U.S. Federal Reserve, which control inflation by deliberately
maintaining unemployment, forcing prices down through the
desperation of workers. Here also the health impact should be
weighed along with other factors when policy is set. But
again reform is unlikely, as institutions are unlikely to
acknowledge any responsibility for the health consequences of
Both the authors of the article, and the journal AIDS,
deserve credit for illuminating a problem which needs
attention. But until there is the will to deal with the
problem, it will be hard to find solutions.