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AIDS Treatment News
World Bank in AIDS Prevention Controversy
John S. James
June 16, 1995
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.) Thesis The main point of the controversial article is stated in its first paragraph: "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 return.

* 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 programs.

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 developing countries.

* Move from paternalistic to cooperative development policy making, allowing the citizens of developing countries to be heard.

* 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." Antithesis 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 sorts." 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- oriented industries.

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 their actions.

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.

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