Third World Quarterly, Vol. 25, No. 2, pp. 385–404, 2004
When ‘development’ devastates:
donor discourses, access to HIV/AIDS
treatment in Africa and rethinking the
landscape of development
PERIS S JONES
ABSTRACT If globalisation is the mighty tremor shaking the landscape of the
‘project of development’, then, in certain regions of the world, HIV/AIDS is surely
its epicentre. Nonetheless, for all the burden of the disease, Western donor
policy on HIV/AIDS still remains largely silent about the provision of anti-retroviral treatment. This paper seeks explanations for this pervasive medical neglect
and donor preference for prevention programmes over treatment. The postcolonial approach taken in the paper is to regard donor policy on HIV/AIDS—as
illustrated by the UK’s Department for International Development and the
Norwegian Agency for Development Co-operation—as cultural and political
exchanges framed by prevailing representations of Africa. The different ‘logics’
which skew policies towards prevention are identified. For donors and African
states alike, HIV/AIDS policies—like development interventions more generally—
would benefit immensely by foregrounding the human right to health, including,
critically, promoting treatment within a genuine ‘prevention–care–treatment’
policy continuum.
What is it about Africa that allows the world to write off so many people—to make
people expendable—when all the money needed is found for war on Iraq? Is it so
overwhelming? Have wealthy countries simply washed their hands of Africa? Is it
too far away? Is it subterranean racism? (Stephen Lewis, United Nations Special
Envoy for HIV/AIDS in Africa, Mail and Guardian, 29 November–5 December,
2002)
By the beginning of the 21st century, if globalisation is the mighty quake
shaking the landscape of the ‘project of development’—in both its practice and
theorising—then, in certain regions of the world, HIV/AIDS is surely the epicentre.
The processes associated with globalisation, and especially in its current form of
global misgovernance (Stiglitz, 2002; Pieterse, 1998; Schuurman, 2000), are at
the vanguard of a rapidly (re)emerging ‘ill-health curtain’, drawn between the
‘First’ and ‘Third’ Worlds, and replete with stark differences in life expectancy
and with rising infant mortality a feature of many African countries (Heywood,
Peris S Jones is a Research Fellow, South Africa Programme, at the Norwegian Centre for Human Rights,
PO Box 6706, St Olavs Plass, NO-0130 Oslo, Norway. Email: [email protected].
ISSN 0143-6597 print/ISSN 1360-2241 online/04/020385-20  2004 Third World Quarterly
DOI: 10.1080/0143659042000174879
385
PERIS S JONES
2002a: 218; UNDP, 2002).1 HIV/AIDS’ devastating burden of disease not only
reinforces a geography of global inequality, it also reverberates across all
development initiatives (see UNAIDS/WHO, 2002; Barnett & Whiteside, 2002;
Third World Quarterly, Special Issue, 23 (2) 2002; Booker & Minter, 2001).
While the epidemic demands an appropriate commensurate multisectoral pooling
of knowledge and resources from the local to the global (UNAIDS, 2002; UNGASS,
2001), it is particularly noticeable that access to treatment for HIV/AIDS has
hitherto been forgone as a serious policy option by most international donors.
Although these drugs have been shown to extend life and are considered by the
World Health Organisation (WHO) Action Programme as ‘essential’ and an
integral dimension of fulfilling the right to health, Western donor policy on
HIV/AIDS remains largely silent about their provision and much more preoccupied
with preventative programmes (Panos, 2000).2 The silence becomes deafening
when we consider WHO estimates, that, of the 4 100 000 people in Africa in
urgent need of anti-retroviral therapy (henceforth ART)3 only 50 000, or 1%,
receive treatment for HIV/AIDS (WHO, 2002). Moreover, there is also growing
evidence of the inadequacy of prevention programmes (with the notable exceptions of Thailand, Senegal, Uganda and Cuba) to halt the spread of the disease
(Campbell & Williams, 2001: 135; Campbell, 2003).
These predominant donor policy positions certainly have their counterpoint in
the severe constraints African countries face in their resource allocations, as well
as in the artificially high prices for ART which are imposed by the specific
political economy of the pharmaceutical industry and its patent protection
(Heywood, 2002a; Thomas, 2002). There are also variable levels of effective
response of African governments to the disease, which, in the case of South
Africa’s reticence, for example, as Campbell and Williams (2001) note, has
actually served to exacerbate Western donor ‘ownership’ of hiv prevention
programmes. Certainly, therefore, African states also have corresponding obligations to fulfil human rights-based approaches to the epidemic. And, it is, of
course, also noted here that more is involved than simply prescribing drugs.
There is a need for adequate health infrastructure, and skilled health personnel
to enable regular consultations for patients, testing of viral load and cd4 cell
counts, and also testing for drug resistance, in order to check if they are working
properly (Barnett & Whiteside, 2002: 44).
Although contributory factors, none of these adequately explain the policy
choices that are made by donors with existing resources, nor the reluctance to
mobilise new resources.4 After all, the HIV/AIDS epidemic has involved as much
a battle of ideas as a battle about bodies, organisms and cells (Cameron, 2001).
As a result, policy choices can be considered as informed by, and situated
within, prior cultural interpretations of the disease (Craddock, 2000). Without
being seen in this light, we can not account for what restricted access to
treatment says more generally, as Stephen Lewis suggests in the quotation
above, about the tendency to ‘write off’ Africa, rendering its inhabitants
apparently ‘expendable’.
It follows, therefore, in this paper that, in addition to its political economy, the
struggle to extend access to HIV/AIDS treatment—like ‘development’ itself—
should be considered as cultural and political exchanges. Seen in this way, the
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DONOR DISCOURSES AND ACCESS TO HIV/AIDS TREATMENT IN AFRICA
so-called ‘postcolonial’ and ‘post-development’ inquiries can provide additional
complementary insights into the specific ‘rationalities’ setting the parameters of
donor responses. This literature is comprised of many diverse influences and
directions but is nonetheless broadly concerned with the ethics of North–South
relations. It argues that the construction of these relations is premised upon
representations of the North as the privileged centre of knowledge, authority and
power, representations which exclude the voice of the excluded subaltern, or
‘Other’. ‘Post-development’ perspectives reflect a more specific disenchantment
with and critique of modernist development practices and therefore can be
considered as also reverberating around the terrain of development (Crush, 1995;
Simon, 1998; Bell, 1994, 2002; Bell & Slater, 2002; Blaikie, 2000; Pieterse,
1998). With donor silence on ART regarded as ‘demeaning, insulting and
disempowering’ (Cameron, 2001), the struggles surrounding access to treatment
speak directly to postcolonial and post-development issues and vice versa.
Indeed, we can liken these struggles over treatment to broader Western geopolitical intrigues in the ‘Third World’, and to what Mbembe (2002) suggests is ‘the
ultimate expression of imperial sovereignty [which] seems to reside, to a large
extent, in the power and the capacity to dictate who may live and who must die’.
This article is principally concerned with explaining donor rationalisation of its
position on treatment. However, in light of this, the article also informs the
broader so-called ‘impasse in development’ and suggests possible directions for
a reconstituted terrain of the ‘project of (post)development’.
In order to arrive at a position that allows a more integrated response to
HIV/AIDS along a prevention–treatment continuum, the paper discusses the
following issues. First, it begins by providing a brief overview of the meaning
of the right to health in the context of the formidable challenges to sub-Saharan
Africa’s ‘crisis’. Second, a dynamic approach is then taken by focusing upon the
cartographic imagery of Africa and how representations of ‘crisis’ actually frame
development interventions. To this end, the postcolonial enquiry proffers a more
subtle view of Africa’s ‘crisis’, as also intimately connected to ‘Western’
interpretations of its peoples and landscape. In particular the role of ‘othering’—
that is the mobilisation of cultural and racial differences—will be looked at in
relation to how this may inform the discursive cues donors take in relation to
Africa.
Third, donor policy priorities towards HIV/AIDS are illustrated through reference to the key UK Department for International Development’s (DFID) policy
documents, as well as those of the Norwegian Agency for Development
Co-operation (NORAD). Several themes emerge which construct what is deemed
developmentally ‘feasible’ for Africa. This developmentalist position is reinforced by consideration of specific issues, including the opportunity cost of
treatment, equity in treatment, and sexual behaviour. These issues contribute to
what is termed an ‘optic of developmentalism’, skewing policy away from
treatment towards prevention. These rationalities are considered therefore as
‘framing’ policy responses.
The article is written in the spirit of reconstituting rather than rejecting the
‘project of development’. As such, it is more in line with post- rather than
anti-development perspectives in so far as post-development theory and practice
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PERIS S JONES
‘does not deny globalization or modernity but wants to find ways of living with
it and imaginatively transcend it’ (Hoogvelt, 1997: 18). It should be obvious that
HIV/AIDS is considered an issue that calls for more not less intervention to meet
urgent material needs. Such intervention, however, must nonetheless consider
these more critical approaches in order to expose the ‘optic’s’ developmental and
ethnocentric gaze.
Vulnerability to
HIV/AIDS
and the right to health
Of the 42 million adults and children estimated to be living globally with
at the end of 2002, a staggering 95% were located within the so-called
‘Third’ World. More specifically, 29.5 million—70%—were in sub-Saharan
Africa (UNAIDS/WHO, 2002). Interpreting how and why an entire region should be
so vulnerable to HIV/AIDS is a necessary prelude to understanding the motivations
underpinning donor intervention. In the first decade of the 21st century one is
hard pressed to envisage a more stark marker of the fundamental differentials
between (and within) regions than glaring contrasts in health. Decades after
decolonisation from the former European colonial powers, it is almost impossible to comprehend that a number of countries in sub-Saharan Africa have
actually witnessed a dramatic reversal in developmental fortunes, as reflected, in
part, in the plummeting life expectancy of inhabitants. Sub-Saharan Africa is
characterised by the UN as:
HIV/AIDS
currently the worst-affected region, where HIV/AIDS is considered a state of emergency which threatens development, social cohesion, political stability, food security and life expectancy and imposes a devastating economic burden, and that the
dramatic situation on the continent needs urgent and exceptional national, regional
and international action. (UNGASS, 2001: 2)
HIV/AIDS
generates poverty, contributes to famine, consumes both household and
government resources, and induces regional instability, as well as the social
exclusion and discrimination associated with its stigma (UNAIDS/WHO, 2002).
This anti-development must surely call into question the ability of donor policy
in its existing form to achieve the eight Millennium Development Goals. Five of
these goals—halving poverty (as defined by those living on less than US$1 a
day); universal primary education; eliminating gender disparity in primary and
secondary education; reducing the under-five mortality rate by two-thirds; and,
above all, halting and reversing the spread of HIV/AIDS, malaria and other
diseases threatening humanity—are to be achieved by 2015. Vulnerability to
HIV/AIDS reflects ‘the lack of power of individuals and communities to minimise
or modulate their risk of exposure to HIV infection and, once infected, to receive
adequate care and support’ (Gruskin & Tarantola, 2001, emphasis added).
Minimising vulnerability is therefore directly related to realising both political,
civil, social and economic rights. At the same time, HIV/AIDS appears to render
the fulfilment of social and economic rights, which includes the right to health,
even more of a distant dream.
These social and economic rights are entrenched across a range of human
rights instruments (such as covenants and treaties). With regard to achieving
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DONOR DISCOURSES AND ACCESS TO HIV/AIDS TREATMENT IN AFRICA
freedom from want, ‘health is a fundamental human right indispensable for the
exercise of other human rights’ (International Convenant on Economic, Social
and Cultural Rights (CESCR), General Comment 14), and is itself also dependent
upon those other rights (such as the right to housing, water, etc). Article 12 of
the CESCR recognises ‘the right of everyone to the enjoyment of the highest
attainable standard of physical and mental health’. These are but part of a
considerable array of international human rights law developed in the past three
decades which gives specific substance to rights in the form of standards that
elaborate the rights and map out the corresponding obligations of states (Eide,
2003).
Rather than discussing the contested terms of their evolution, discourse and
machinery, the fundamental point of relevance here is to note the failure of
international human rights covenants to influence state (and private) practice in
relation to the promotion of the right to health in the context of globalisation
(Heywood, 2002a; Evans, 2002). This is in part, according to Eide, because
economic globalisation and the project to universalise human rights seem to be
running on different tracks (Eide, 2003). Moreover, ‘the success of the post-war
project to place human rights at the centre of global politics has been very
limited, most notably in the attempt to secure acceptance of socio-economic
rights as legitimate claims’ (Evans, 2002: 213). This limited success is, in
particular, a consequence of what Evans regards as the dominance of a liberal
consensus on human rights. One result has been to effect a bias towards civil and
political rights rather than social and economic rights. It is not so much that
globalisation and rights run on different tracks, therefore, as that human rights
having been commandeered by this liberal project in order to lend support to free
market economics and the freedom to create wealth, as embodied in the values
of the World Trade Organization (WTO). The outcome has been the downgrading
of social and economic rights to the status of mere aspirations and the
widespread failure to realise freedom from want (Evans, 2002). Nonetheless, at
the beginning of the 21st century there does appear to be an emerging dialogue
on human rights and economic activities (Eide, 2003: 261).5
There is little doubt that some of Africa’s external challenges with regard to
economic globalisation are formidable (see Zack-Williams, 2002; Hoogvelt,
2002). Debt repayments, for example, as noted by Cheru (2002), exceed the
amount proposed by UNAIDS for the Global Fund to fight HIV/AIDS, malaria and
tuberculosis. The introduction of user fees related to the ‘cost recovery’ of
structural adjustment is therefore another obvious factor in undermining the right
to health, and other rights in the CESCR (Narayan, 2000). Suffering from growing
poverty and worsening nutrition (itself associated with biological conditions
enhancing susceptibility to infection), the poor, already on the margins of
survival, have little control over health and other costs (Poku, 2002).
Indeed, other tangible effects of economic globalisation concern the organising rules of the international trade system, and the pricing of and access to
essential life sustaining drugs in the treatment of HIV/AIDS. Drugs patented by
multinational pharmaceutical corporations have been shown to be far more
expensive than generically manufactured drugs (Panos, 2000; Oxfam, 2002). The
high price of ART has recently been the target of unprecedented international
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mobilisation to get it reduced and made more accessible to the millions who
need ART. According to Thomas (2002: 252, 253), for example, ‘Despite the
denials of pharmaceutical companies, the fact is that differential access to ARV
drugs because of cost contributes to the uneven global experience of HIV/AIDS’.
This has been called ‘global apartheid’ by Booker (2001). The widespread
activist mobilisation against pharmaceutical profiteering has put access to treatment at the forefront of combating the disease. It has therefore contributed
greatly to decreasing prices at the same time as galvanising global dialogue and
action regarding HIV/AIDS more generally. The availability of essential drugs, as
defined by the WHO Action Programme, is an integral dimension of the right to
health, whose core content includes treatment, control of epidemics, as well as
prevention (Article 12 2c, CESCR; UN Economic and Social Council, CESCR,
General Comment 14; UN Commission on Human Rights Resolution 2001/33).
Recently the UN General Assembly Special Session on HIV/AIDS also identified
a specific role for medication by ‘recognizing that access to medication in the
context of pandemics such as HIV/AIDS is one of the fundamental elements to
achieve progressively the full realization of the right of everyone to the
enjoyment of the highest attainable standard of physical and mental health’
(UNGASS, 2001: 3). Yet treatment remains severely restricted. On one level, the
predominant policy position is morally unacceptable, and a flagrant denial of the
fundamental human right—the right to life for those infected and affected. On
another level it does not even reflect a logical policy approach, as we will
explore later in the article. The complex causes of and manifestations associated
with the HIV/AIDS epidemic seemingly invite commensurate comprehensive and
multi-layered policy responses to the epidemic. This should reflect an integrated
approach wherein prevention, care, support and treatment are seen as mutually
reinforcing and equally valid (UNGASS, 2001: 3; Panos, 2000). But is this an
approach taken onboard by donors?
Before turning to these donor policies we need first to situate them within the
broader terrain of the ethics of North–South relations. The knowledge produced
concerning these relations is critical not only to how we understand the ‘African
crisis’, but to how we then use it to construct a vantage point from which to
intervene.
Interpreting the African crisis: the postcolonial inquiry
Prevailing interpretations of the African crisis are particularly important, given
that, not least, these interpretations inform the discursive cues which prime
international donor (including HIV/AIDS) policies. The link between knowledge
and power is evident in that the land and peoples of Africa have been
represented and constructed in particular ways for the Western reading public,
especially from the late 19th century (and further back (Mudimbe, 1994)) to the
present. The Victorian metaphor of the ‘Dark Continent’, according to Jarosz
(1992: 105), ‘identifies and incorporates an entire continent as Other, as a
negatively valued foil for western notions of superiority and enlightenment’.
While this metaphor has been used in a variety of manners by explorers,
missionaries, travellers and literary authors it nonetheless rests upon a duality of
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DONOR DISCOURSES AND ACCESS TO HIV/AIDS TREATMENT IN AFRICA
dark/light, Africa/West. Africa was constructed or invented by Europeans and
Americans as ‘demanding’ imperialisation based on the moral, religious and
scientific grounds of the so-called ‘civilizing mission’ (Brantlinger, 1985: 167).
The metaphor of the ‘Dark Continent’ is not therefore merely concerned with
communicative function. It is laden with political undertones in that it depicts
relations between coloniser and the colonised as deemed necessary in order to
penetrate the ‘pall of darkness’ (Jarosz, 1992; Brantlinger, 1985: 198). As a
mode of enquiry, the postcolonial (and to some extent ‘post-development’)
approaches are particularly useful for exposing ethnocentric orientations in the
analysis of the ‘developing world’.
Of particular significance for post-World War Two development discourse and
practice is how such metaphors as the ‘Dark Continent’, the ‘Orient’ persist.
More generally, they are bound up, according to Bell, with a ‘combination of
moral concern and fascination with the exotic [which] forms the basis of our
geographical imagination and continues to underlie much contemporary interest
in non-Western societies’ (Bell, 1994: 193). To what extent are interpretations
of Africa’s contemporary crisis filtered through these historical understandings
and representations of the ‘Dark Continent’? Our readings of Africa’s ‘crisis’—
whether related to economic or political instability—tend, following Chabal
(1996), all too readily to ascribe motives and characteristics and claims of
‘Africanness’ to explain away contemporary predicaments.
This is not merely a simplistic denial of the continent’s profound challenges.
Rather, it is a call to place Africa’s ‘failures and frailties’ in the context of an
‘analysis based on the degree of conceptual clarity and range of historical
knowledge which we would deem suitable for the understanding of the politics
of our own societies (Chabal, 1996: 32). Africa is interpreted through the
‘politics of the mirror’, which is not only an historical product of the West’s
imagination but, moreover, occurs at a time when the West grapples with its own
sense of identity (Chabal, 1996). The continent has been incorporated into
Western thought in order to bestow a positive identity on the West itself. The
‘postcolonial inquiry’ therefore seeks to destabilise these prevailing representations and accepted wisdom through interrogating the manner in which spatial
metaphors and temporality are embedded in Western discourses, thus rewriting
the hegemonic accounting of time (history) and the spatial distribution of
knowledge (power) that constructs the ‘Third World’ (McEwan, 2001: 2). The
postcolonial critique is directed at de-centring Northern dominance and reclaiming alternative subaltern voices silenced in meta-narratives associated with
Northern representations of the ‘Other’ of the so-called ‘Third World’ (Said,
1978; Mudimbe, 1994). Multi- and bilateral development interventions are also
subject to these critiques which attempt to show why many development
projects—like the ones directed towards dealing with HIV/AIDS—do not succeed
(see Escobar, 1995; Sachs, 1992).
I wish to leave aside Chabal’s claim that postcolonial studies are only relevant
for the West’s own internal interrogation of itself and relations with the Other,
and that it has little to offer studies within the ‘postcolony’ in the ‘Third World’.
Although undoubtedly a by-product of the powerful critiques made by Third
World scholars from within Western institutes, the applicability to the ‘post391
PERIS S JONES
colony’ is clearly valid (Werbner & Ranger, 1996; Mbembe, 2001). And while
the postcolonial inquiry is particularly relevant here for an internal critique of
‘Western’ development donors, it is also of use to improve development
interventions, such as HIV/AIDS prevention and management programmes (see
Ogden, 1996, for example). The relevance of the inquiry is heightened in light
of the HIV/AIDS crisis in Africa, which often falls hostage to biased accounts of
the ‘crisis’. Again, Jarosz attaches much of the explanatory power of the ‘Dark
Continent’ to representation of HIV/AIDS in Africa as ‘perhaps the most pertinent,
recent manifestation of the metaphor’. Public discourse has been replete with
racial stereotyping, moralistic reasoning and xenophobic policies (Schoepf in
Jarosz, 1992). Not only has Africa been represented as the cradle of HIV/AIDS, it
is also depicted by academics through the lens of sexual practices which are seen
as abnormal, untamed and dangerous (Jarosz, 1992). In the crudest accounts
African sexuality is shorn of its political, economic and social context, and
instead infused with moralising about unfettered African activity.
The way the African has been socially constructed by the West is well
documented (Krebs, 1999; Hyam, 1992; McClintock, 1995). Frequent references
to ‘allegedly promiscuous sexual customs of Africans’ were connected to
pervasive Victorian fears of ‘backsliding’, or racial and moral ‘regression’, often
with powerful Biblical, ‘Garden of Eden’ sexual temptations (Brantlinger, 1985).
When overlain with a strong epidemiological and medical imprint upon analysis
of factors in the transmission of HIV/AIDS, it is no surprise that specific
groups—such as female sex workers—have had identities ascribed to them
through this public discourse and medical imprint (Craddock, 2000). Craddock
warns that we need to be vigilant about the familiar Western assumptions that
create a ‘moral optic’ in the analysis of risk from HIV/AIDS. This interpretation
of African sexuality re-emerges in the section looking at guiding donor statements and themes.
Susceptibility may take many forms but, according to Barnett and Whiteside
(2002), historical dislocation, inequality, civil unrest, population mobility, radical changes in community beliefs and standards ‘have been constant motifs in
the story of HIV/AIDS in Africa’. Perhaps we also require additional postcolonial
readings of ‘imperialism’ which encompass cultural, political and social interactions and exchanges. The signification and mobilisation of racial or cultural
differences—known as ‘othering’—has been identified as not only constituted by
economic flows but, arguably, also constitutive—witness the meagre trickles of
ART to Africa—of them. This approach is particularly useful for understanding
development interventions.
The optic of developmentalism
The spatial tropes looked at in the previous section, such as the ‘Dark Continent’, have provided the most enduring metaphors for Western misrepresentation
of the Other. These metaphors have also provided the intellectual foundations for
the tutelage (previously the ‘civilising mission’), management and intervention
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DONOR DISCOURSES AND ACCESS TO HIV/AIDS TREATMENT IN AFRICA
upon which modern development is premised (Slater, 1993; Bell, 1994; Simon,
1998). The invention of the idea of the ‘Third’ World has been regarded, in some
quarters at least, as inseparable from the idea and practice(s) of post-World War
Two ‘developmentalism’ (Escobar, 1995).
‘Developmentalism’ can be described as a tendency to reduce the problems of
improving life in poor countries to one of a compulsion to promote ‘development’ by looking at them and knowing them only through the lens of ‘developmentalism’ and what they are not. Through this optical lens, the landscape of the
‘Third’ World has been constructed as if ripe for the challenge of international
development agency intervention. Not only has the term ‘Third World’ become
a badly fitting categorisation that inaccurately represents and homogenises huge
and diverse regions and populations. It is also downright harmful—even lethal
in the context of HIV/AIDS policy—because it subordinates these territories to the
gaze of Western (and certain local) eyes, which legitimates particular types of
intervention. It is this cartography and the postcolonial attempts to destabilise its
privileging of the ‘First World’ ethnocentrist knowledge and practice underpinning it, which is scrutinised here. In particular, we need to explore how the
donor tendency to view the continent through a lens of ‘developmentalism’
contributes to shaping HIV/AIDS policies.
In keeping with the tone of the paper, however, we should state that the
HIV/AIDS crisis is much too profound to forgo attention to material needs and
(modernist) developmental interventions, which many postcolonial and post- and
anti-developmentalist interpretations, rather self-indulgently, seem to disregard
(eg Escobar, 1995). Indeed, there has been a noticeable failure to generate
meaningful engagement between these issues, that is, those regarded as more
conventionally developmentalist—such as the development projects and programmes associated with the HIV/AIDS epidemic—and these intellectual and
theoretical critiques, often caricaturing development practices (Sylvester, 1999;
Simon, 1998). It is with one eye on scrutinising the nature and type of this
intervention—particularly that pertaining to Western donor intervention—that
we can begin to make interventions more relevant and appropriate to subaltern
groups who are the ‘target’ of development. The other eye is on the lack of
credible alternative programmes of much of the anti- and post- development
brigade. A reconstituted ‘project of development’ could also place the contingencies of development at its centre, an issue returned to in the conclusion.
We turn now to look at how these discourses feed into donor policy and how
they contribute therefore to framing policy on HIV/AIDS.
Donor policy on
HIV/AIDS
treatment
A brief discursive review is first undertaken of the UK’s (DFID) and Norway’s
(NORAD) overseas aid policies, before discussing their specific policy on HIV/
AIDS. There are remarkable parallels between DFID’s and NORAD’s overall
development strategies. One is the organising theme of ‘eliminating’ and
‘fighting’ poverty (DFID, 2000; NMFA, 2002). Indeed, the Millennium Develop393
PERIS S JONES
ment Goals, including halving the number of poor surviving on less than $1 a
day by 2015, are common objectives. Both strategies are infused with a moral
discourse emphasising moral duty to the poor. ‘Norway as one of the richest
countries in the world has an obligation to take this seriously’ because, we are
told, ‘poverty is an attack on human dignity’ and it is ‘morally and politically
intolerable that basic human rights are being violated in such a massive and
constant way’ (NMFA, 2002: 6). The vehicle for delivering us from poverty, we
are also told, is common to both, namely, globalisation, seen as essentially
benign (NMFA, 2002: 39). It is better management that is required, rather than
allowing oppositional voices from within the Third World to identify problems
intrinsic to the neoliberalism both strategies promote. It is not so much the moral
concern, which is necessary for commitment to distant strangers, which is
problematic. It is rather how this morality is connected to who is considered to
provide the necessary leadership in effecting better management.
There is a fascinating interplay and apparent contradiction in these key
guiding documents between the ideal of partnership and co-operation—as stated
on numerous occasions—and, who exactly is considered to possess the appropriate skills for this management process. As with DFID, NORAD also places
emphasis upon ‘national ownership’ and upon developing ‘countries taking over
the leading role themselves’ (NMFA, 2002: 43). However, Bell and Slater (2002)
suggest that DFID’s strategies situate developing countries in the position of being
passive recipients to be managed and monitored, and in need of having
(Western) technology and knowledge (read ‘globalisation’) bestowed upon them.
There is an echo of modernisation theory for Bell and Slater, because DFID’s
policy positions, while draped in the terms of egalitarian ‘partnership’ between
donor and recipient, in fact reflect a more deep-seated geopolitical ‘continuation
of tutelage under a globalizing guise’ (Bell & Slater, 2002: 351). Another area
of commonality is that both strategies propose the move away from isolated
projects to consolidating and channelling assistance through sector-wide programme and budget support to national poverty reduction strategies (NMFA,
2002).
The Norwegian strategy does differ slightly, however, in that, first, there is
more emphasis placed upon distribution of wealth, reducing debt burdens and
creating a fairer system of world trade. Second, there is a welcome self-critique
through recognition of the need to ‘remedy the deficiencies in donor co-ordination in development co-operation’ and to change the ‘administrative burden
caused by international assistance’. This self-reflection is another important
reminder that development assistance is not the static entity sometimes portrayed
in post- and anti-development accounts. Dialogue is ongoing within different aid
agencies in the West and between the latter and their considerably varied
bilateral recipients.
It does, however, also suggest some continuities, such as the West still being
the privileged centre of knowledge, and issues surrounding access to HIV/AIDS
treatment show up some of these continuities and the limits of an apparent
two-way donor–recipient relationship. The rationalities underpinning policy on
HIV/AIDS are revealed in order to explain adherence to prevention programmes
rather than treatment.
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HIV/AIDS:
developmentalism’s opportunity cost, or ‘whatever is appropriate
and feasible for the setting’
HIV/AIDS
is a priority area for DFID’s and NORAD’s overseas aid. The clearest
message coming through their respective strategies is that, first, for DFID:
Prevention must remain the priority. Only prevention can make the difference
between 38 million infected worldwide by 2000 or 40 to 45 million. (George
Foulkes, Under-Secretary of State for International Development, 1999)
‘We know that four things work’, stated the Under-Secretary (Foulkes, 1999),
with funding priorities focused upon information, condoms, STD treatment and
safe blood. In a package of aid announced by Prime Minister Tony Blair to
combat HIV/AIDS in developing countries, for example, of almost £28 million,
over half was directed towards another important priority, the International AIDS
Vaccine Initiative. The remainder of this package was to assist a regional
Southern Africa Task Force and to fund 700 volunteers from the UK Voluntary
Service Overseas, apparently ‘to raise awareness of the HIV epidemic in Southern
Africa’. Of an additional package of over £100 million, also pledged in 1999, for
HIV/AIDS in Africa, almost all was directed at broad health sector support and
sexual and reproductive health:
Until there is an affordable vaccine or cure, the most effective way to arrest the HIV
epidemic is to reduce risky behaviour that might lead to infection and spread of HIV
(DFID, Press release, 12 November 1999, emphasis added).
In the same paragraph HIV/AIDS is described as a ‘death sentence for poor and
marginalised people’ and DFID’s goals are stated as ‘to contain the spread of HIV
and to minimise the impact’. Although true that ART is not a cure in the long
term, it has been shown to extend life considerably for people living with
HIV/AIDS in the West. But at this stage of DFID’s policy the issue was sidestepped.
Even in its most recent major strategy paper for HIV/AIDS, DFID’s (2001)
position was that:
Responses will vary from country to country, but the priority will be strategies to
promote prevention, whilst reducing the impact of AIDS (DFID, 2001a: 2).
There is recognition of the broader inequalities fuelling and being fuelled by
HIV/AIDS and reference to the role of poverty. Prevention, however, is still the
guiding philosophy. Meanwhile, the Norwegian policy to combat the epidemic
was stated as follows:
There will continue to be a focus on preventing new infection, with emphasis on
greater breadth and diversity. Prevention and the consequences of HIV/AIDS will be
evaluated in all development programmes and integrated where relevant. (NMFA,
2002: 60).
And, with a rhetorical flourish, the more recent policy positions do mention
treatment:
Norway will seek to ensure that treatment is more easily available and cheaper for
everyone, including poor people.
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PERIS S JONES
This reference to treatment was perhaps a response to the international pressure
that has grown tremendously in recent years to broaden access to ART by
reducing high prices (Heywood, 2002a). So, around the time the Norwegian and
DFID (2001a) strategies were being drafted, donor discourse began to adapt, at
least at the level of rhetoric, to external pressures concerning access to treatment.
Having established prevailing policy priorities, we now turn to the specific
‘rationalities’ considered as creating ‘valid’ statements on HIV/AIDS policy. There
is a range of themes consistent in rationalising policy approaches which inform
a so-called ‘developmentalist’ perspective.
Too poor, too unsophisticated
Taking the most obvious ‘logic’ first, when faced with the grinding poverty in
much of Africa, it is perhaps unsurprising that development interventions have
been modernist and seek to instil modern capacity (Simon, 1998). Yet what is
particularly striking is that treatment is seen as ultra-modern, and too technical
for Africa’s existing health capacity. At the end of the 1990s, when faced with
growing public pressures to provide ART access in Africa, Foulkes’ (1999)
response illustrates an almost reflexive developmentalist action in that:
Facts help in such a debate. Where resources and optimal clinical systems exist to
administer potentially highly toxic anti-retroviral drugs, they can and do transform
the lives of those with HIV. But this is not the case in most of Africa, where even
basic systems for health care delivery are not in place.
It is not only a question of ensuring availability of affordable drugs and vaccines
but, according to DFID’s white paper (2000: 35), ‘that there are effective systems
to deliver these to all who need them’. Indeed, we are told that ‘even if they
were free, it is not feasible for health systems in many poor countries to deliver
these drugs safely and equitably’ (DFID, 2001a: 8). This reflects the core concern
of developmentalist perspective. That is, priority is given to what Africa is
considered to lack: ‘long term development of stronger, pro-poor, sustainable
health systems (DFID, 2001a: 8) and ‘more cost-effective and appropriate measures’. These are revealed as the prerequisites for considering ‘safe delivery of
treatment and care for HIV/AIDS’. ‘Whatever is appropriate and feasible for the
setting’ is the guiding philosophy. The donor discourse juxtaposes the issue of
ART as, on the one hand, inherently sophisticated—or more accurately in their
own language, as a ‘technical debate’—with, on the other, Africa’s immediate
needs. In short, Africa is seen as too lacking in adequate development to be
considered for treatment. A doctor writing in the NORAD newspaper Bistandsaktuelt was taken as contributing to the prevailing wisdom by suggesting that
spending should focus upon STDs because they ‘demand few resources, cost little
and can be a good entry point to begin to talk to people about HIV/AIDS
(Bergraav, 2002a, author’s translation).
There is a complementary emphasis therefore placed upon ‘cost effectiveness
and opportunity costs relative to other health care priorities’ (DFID, 2001a: 7).
NORAD’s senior advisor on HIV/AIDS puts this perspective as follows:
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DONOR DISCOURSES AND ACCESS TO HIV/AIDS TREATMENT IN AFRICA
The poorest countries struggle with weakly developed health systems and budgets
cut to the bone. Most things are missing, especially professionals and medicines; in
addition to HIV/AIDS these countries have other poverty related problems, like, for
example, high mother and child mortality rates. It is therefore difficult for politicians to meet increasingly strong demands for treatment and at the same time
improve health services in the poorest rural areas. (Bergraav, 2002a, author’s
translation).
Africa is simply too underdeveloped to cope with the complexity of treatment.
This negative imagery of Africa is also reinforced through claims that Africans
do not have the sophistication to adhere to treatment regimes. Consider, for
example, this statement from USAID: ‘Ask Africans to take their drugs at a certain
time of the day, and they don’t know what you are talking about’ (in Farham,
2002a: 95). Farham, however, cites one study carried out at the Diana, Princess
of Wales HIV Research Unit, Somerset Hospital, Cape Town (see Farham, 2002a,
for more information) which witnessed 88.5% adherence after 48 weeks. This
was related, she believes, to patients being given regular information and support
by medical staff and counsellors, as well as group therapy.
In the same NORAD article quoted above, however, there is an indication that
NORAD believes there is also an inevitable zero-sum game between treatment and
prevention. Treatment is regarded as detrimental to prevention and other health
services. Above all, the treatment lobby is seen as powerful in comparison with
other groups, where ‘it is not easy to mobilise strong pressure groups for poor
mothers who die in labour, or children who die due to bad nutrition or of
infectious diseases’ (Bergraav, 2002a, author’s translation). For all the talk of a
prevention–treatment continuum (DFID, 2001: 8), treatment, nonetheless, is
regarded as an uncertain bet and a luxurious alternative, rather than considered
an integral component of combating HIV/AIDS and associated problems. Ironically, it is the treatment activists and advocates of medicines for HIV/AIDS who
are caricatured as lacking nuance and being simplistically for treatment and,
somehow, therefore, against these other developmental dimensions necessary for
a comprehensive response (Bergraav, 2002b). In fact, the more innovative
projects surrounding mother to child transmission (MTCT) of the virus and ART
more generally see both prevention and treatment as reinforcing one another
(Farham, 2002a).
It is of course easy to identify with the enormous challenges donors encounter
in the context of constrained health infrastructures and funding. However, there
is a tendency in this prevailing ‘wisdom’ to overlook where capacity is available
and where it could be used to develop ART treatment. There are sweeping
generalisations about capacity in the continent that preclude more serious
consideration of treatment. Even where such facilities are not present, especially
in rural areas, ‘that this should be an argument for not, at least, making the drugs
available, defies comprehension and acceptance’ (Cameron, 2001). While pausing to reflect upon this deeply disempowering outcome, other issues also feed
into and reinforce this perspective.
The high price of ART, for example, in relation to government budgets and
incomes is also seen as making extensive treatment prohibitive. However, the
concerted global campaign to lower the prices demonstrates that there is scope
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PERIS S JONES
for large reductions in costs. It also shows that price is moveable. Indeed, to their
great credit, both DFID and NORAD openly state in their strategies that they also
advocate lowering the high cost of essential ART. Nonetheless, price continues to
be used as an argument against broadening provision. In order to illustrate how
the prevailing discourse bestows a ‘wisdom’ cutting across different political
party lines, in a 2001 meeting of the British Parliamentary Development
Committee (a cross-party body advising on and scrutinising British overseas aid)
it was proclaimed that ART ‘especially in Africa, even as part of an overall
scheme…was widely agreed to be impractical, primarily due to their high costs,
and the fact that anti-retroviral drugs are complex to administer’ (Parliamentary
Development Committee, 2001). In the same discussion of the role of the Global
Fund, the committee even advised that DFID ‘would need to take a strong
negotiating stand’ on the issue of ART because it was regarded as depleting the
Global Fund and as also contributing to increasing inequalities in health systems
(see below). Similarly, the DFID guidance note on ‘The Prevention of Mother to
Child Transmission of HIV’, while supporting the prevention of MTCT is still
‘committed to helping governments develop their health systems’ to enhance
‘the conditions in which MTCT prevention could operate effectively and cost-effectively in the future’ (DFID, 2001b: 6, 7). Policy still adheres to prevention and
health systems development. Wider discourses of health perhaps still prioritise
primary health care as the greater and more appropriate development priority. In
conjunction with these wider discourses, additional factors can also be taken into
consideration for how they contribute to framing Africa’s landscape and peoples
as unsuitable/unsophisticated enough for treatment.
Too corrupt
One additional issue concerns equity in treatment, an issue raised by both DFID
and NORAD. Like the Development Committee discussed above, the DFID 2001
strategy is riddled with references to concerns over equitable treatment. And,
during a seminar presentation, the NORAD representative on HIV/AIDS also raised
the spectre of corruption as an additional ‘dilemma’ involving treatment.
Treatment was interpreted as the creator of new ‘inclusions’ and ‘exclusions’.
Scarce drugs would seemingly contribute to corrupt practices, as the more
powerful would use their influence to secure these drugs. The implication was
that there needed to be some system of prioritisation in place in order to
adjudicate who would actually receive the scarce anti-retrovirals based upon
specific criteria (Bergraav, 2002b) before extending ART treatment.
While not necessarily in disagreement with this view, two points should be
considered. First, we must scrutinise how the issue of equity is applied particularly to treatment, and not to the same extent to other developmental issues.
When there is a development project focusing upon building houses in a
township, for example, since not everyone will receive a house at the outset of
the project because of limited resources, this does not imply that the housing
programme in question should not begin. Ethical and equity criteria associated
with health treatment are therefore not being applied in quite the same way as
housing provision and other ‘development’ programmes. Second, given that
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DONOR DISCOURSES AND ACCESS TO HIV/AIDS TREATMENT IN AFRICA
drugs can extend life, and that existing supply is extremely limited, continuing
restrictions upon availability will in itself surely encourage corrupt practices.
This is not an intrinsic characteristic of Africa, rather a reflection of the role of
ART in determining life or death. Again, these ‘logics’ are taken to preclude
extending availability. These so-called ‘dilemmas’ are therefore imaginary ‘redherrings’, according to Heywood (2002b), because failure to provide treatment
per se should be regarded as the greater factor contributing to inequality and
denying the right to life. Not to act upon existing capacity, as well as extending
capacity, is the more deeply disempowering effect.
There is one final particularly potent issue that can also be considered as
reinforcing the ‘preventive’ logic.
Behavioural change hypothesis: or too sexual?
The ‘behavioural change hypothesis’ has been the prevailing public health
orthodoxy explaining people’s vulnerability to HIV/AIDS. It is an approach
premised upon narrow epidemiological definitions of the individual and certain
‘risk groups’, assuming that people make rational choices based upon the
information given to them about health risks. This approach tends not to
recognise the interplay between broader societal factors, development issues and
the HIV/AIDS epidemic. Poku (2002) regards the multilateral donor Medium Term
Plans (MTPs), which are the principal organising structures for the design and
implementation of country responses to HIV/AIDS in Africa, as still largely
focused upon these narrowly defined public health concerns, despite over 20
years of the epidemic.
While the NORAD and DIFD approaches are notionally grounded in developmental, human rights and societal issues, the majority of bilateral funding is
nonetheless rooted in a view of the individual requiring a change of behaviour.
DFID has as its starting point in its HIV/AIDS strategy that it is ‘a communicable
disease driven by the behaviour of individuals’ (DFID, 2001a: 6) and talks about
changing ‘risky behaviour’. ‘Interventions that work to prevent sexual transmission’, we are told, are condoms, combinations of strategies to deliver
condoms, behaviour change programmes—which ‘are an essential and effective
part of strategies to reduce high-risk behaviour’—voluntary counselling and
testing, and improved diagnostics and management of other STDs. NORAD gives
a more explicit emphasis to ‘encouraging the active involvement of men’ and to
‘promoting male responsibility’ (NMFA, 2000; 2002).
This focus upon individual responsibility has echoes in earlier representations
of the ‘Dark Continent’ and the long history of Western depictions of unfettered
African sexual appetites. There is perhaps a possible connection to donor
discourse on analysis of ‘risk’ which produces a ‘moral optic’ viewing individual
behaviour. Furthermore, public discourse can have the effect of ascribing social
identities to particular groups, often acting to reassure those ‘normal’ groups
who project their own fears of disease onto ‘high risk’ groups, and women in
particular (Craddock, 2000). This is not to imply that individuals should be
absolved from all responsibilities but, rather, that the ‘vulnerability’ of specific
individuals, groups and regions to HIV/AIDS should be situated within a more
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thorough analysis of the ‘interaction of institutional, cultural, social, economic
and historical contingencies of place’ (Craddock, 2000: 154; Campbell, 2003).
Donor funds, as we have seen, tend to concentrate upon prevention programmes
rooted in Western science, which often underplay complex social dynamics
(Campbell, 2003; Campbell & Williams, 2001). Whether such information—for
example, about condom use—has altered behaviour, is highly doubtful in many
settings. Rather, economic and ideological constraints, most notably to do with
constructions of gender (like ‘being a man’, the expectations about ‘the role of
a woman’) appear also to be determining factors in shaping behaviour. In one of
DFID’s own regional strategy papers for Southern Africa, it is recognised that, for
all the information and condom programmes, condom use is still low (DFID,
2002). Although awareness about HIV/AIDS was claimed to be ‘nearly universal’,
DFID claimed that this was ‘not translating into behaviour change’. Nonetheless,
‘improving access to relatively simple treatments required for frequent opportunistic infections is’, it was stated, ‘a more immediate priority than provision of
anti-retroviral drugs’ (DFID, 2002).
Conclusion
HIV/AIDS marches on, causing intolerable burdens upon states, families and
individuals. To declare African countries too poor and unsophisticated for
treatment not only prevents a more comprehensive approach to decreasing
vulnerability to HIV/AIDS; it also exacerbates the problem. The predominant
emphasis hitherto in donor policy circles upon prevention is simply being
outstripped and overwhelmed by the huge increases in those infected. Donors
should therefore act upon the directives of international human rights conventions and covenants which are crystal clear about broadening access to treatment
of HIV/AIDS as an integral dimension of the right to life, dignity and health care.
Otherwise, contrary to the role intended for ‘partnership’ in development
assistance, policy decisions will continue to have a noticeably disempowering
effect. While this paper has been principally concerned with donor responses,
this should also in no way detract from the corresponding obligations African
states have to fulfil human rights for their citizens. Some state policies on
HIV/AIDS, especially in South Africa, may in fact have been driven by some
degree of over-reaction to the more outlandish colonial, late apartheid and racist
discourses associated early on with the epidemic (Mbali, forthcoming). One way
around this impasse is for donor and recipient governments alike to foreground
policy responses to HIV/AIDS within corresponding obligations to respect, protect
and promote the rights to health, dignity and life.
In order to shift these prevailing donor mind-sets, however, as shown in the
paper, a necessary starting point is to strip away the inherent ‘logics’ underpinning policy. Donor bias towards prevention, and the fact that donors place an
‘opportunity cost’ upon treatment, and never perform a ‘cost–benefit’ analysis of
prevention programmes, requires urgent redress. Given the huge burden of
HIV-related disease in Africa, this surely warrants much greater efforts to treat
the large numbers infected while also developing effective preventive vaccines
(Weidle et al, 2002). In resource-poor settings, treatment approaches could be
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DONOR DISCOURSES AND ACCESS TO HIV/AIDS TREATMENT IN AFRICA
rethought in terms of providing standardised regimens adapted to circumstances
(Weidle et al, 2002). To this end, urgent consideration should be given to the
lessons emerging from Botswana’s efforts towards universal provision of ART.
Although replete with problems, such as insufficient numbers of skilled medical
personnel, and difficulties in extending coverage to rural areas (Mail and
Guardian, 10–16 January 2003) the programme is, nonetheless, a potent challenge to prevailing ‘wisdoms’ which have hitherto set the parameters of what is
possible in Africa. Botswana’s rapid learning by facing the problems directly
through practice and building capacity—financed by government and private
donors—has forever broken the mould of (lack of) expectation concerning ART
in Africa.
Donors therefore need urgently to assess where and how prevention and
treatment are being combined successfully. The tremendous stigma and discrimination associated with HIV/AIDS represent additional barriers to health care.
Unequal power relations exclude people from participating equally and fully in
the social, economic and political dimensions of society. Much of the discrimination against people living with HIV or AIDS is based upon ignorance and fear.
The fatalism associated with HIV/AIDS contributes to discrimination because the
disease is such a marker of early death. Treatment might contribute to prevention
because people would be more likely to seek blood tests and lessen discrimination towards those living with the disease (AIDS Law Project, 2001). Treatment
will create new opportunities for prevention ‘because it will create a larger
demand and infrastructure for HIV testing and create settings for counselling’
(WHO, 2002; AIDS Law Project, 2001). Indeed, some highly innovative projects
addressing MTCT promote the synergy of prevention and treatment by treating
mother as well as child, and in turn, take HIV-positive mothers on these MTCT
programmes and offer paid employment as peer educators, contributing to
destigmatisation (see Farham, 2002b: 107). If there is any likelihood that ART
can be a useful tool in chipping away at the wall of silence and stigma
surrounding HIV/AIDS—not least in South Africa—this should provide another
compelling argument for donors to support extending access immediately.
Finally, donors need also to look at the potential role of ART in easing the high
levels of morbidity and mortality which are placing devastating financial and
social burdens upon states, NGOs and society more generally. Worker absenteeism, food insecurity and the rapid increase in the number of orphaned children
are three areas in which ART could surely have a mitigating impact. In South
Africa, for example, one study calculates that the net cost of ART to government
could be at least a third lower than the direct cost of treating opportunistic
infections and orphans.6
Teasing out some of the flaws in donor (over)emphasis upon prevention is a
way to make intervention strategies more effective. In so doing, the paper is an
unapologetic reconstitution of more modernist and ethical pursuits and objectives
rather than an acceptance of the dead-end of post-development’s termination of
the ‘project of development’ per se (Escobar, 1995). Reflections upon what
directions should be taken now for ‘post-development’, following Nustad (2001),
can be assisted, first, by maintaining the fundamental critiques of development.
That is, its apparatus, as shown, induces particular effects often related to the
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PERIS S JONES
narrowness of the developers’ conception of their task; extending bureaucracy;
and de-politicising poverty. Most critical for altering HIV/AIDS policies, development ‘is built upon certain assumptions, such as the agency of an outside
intervening body’ (Nustad, 2001: 487). In a postcolonial fashion, revealing the
flawed logics of this ‘body’ and its ambiguities and contradictions is intended to
make development interventions better. Self-critique is a powerful weapon in
this regard. Treatment campaigners could also concentrate on the contradictions
contained within an apparently authoritative Northern donor account of HIV/AIDS.
Second, to this end, we need to insist that development interventions should
recognise the ways in which they are transformed on the ground. Whether
rejected outright, failing (Campbell, 2003), or, in terms of their implementation,
infused with new meanings by the agency of participants themselves (Nustad,
2001; Bell, 2002; Simon, 1998; Ogden, 1996), the point is not merely to provide
a deconstruction of donor policy. Rather, the postcolonial critique can expose
some of the underpinning ideas, logics and statements in order to use these
contradictions to reconstruct a donor policy reflecting a more holistic approach
to HIV/AIDS. This reconstruction, critically, must be shorn of any ethnocentric
pretensions, with less adherence to the optic of ‘developmentalism’; it should
recognise the political struggles over development interventions.
Notes
Earlier versions of this article were presented at the ‘Intellectual Crossroads’ seminar series, hosted by the
Department of Sociology, University of Pretoria; the Institute for Human Rights, Åbo Akademi University;
the Norwegian Centre for Human Rights, University of Oslo; and the session on ‘Postcolonial Geographies’
at the 2003 Institute of British Geographers conference, London. The author would like to thank the
participants for their feedback. Finally, comments given by Katie Willis and Morag Bell are warmly
acknowledged. The usual disclaimers apply.
1
Botswana, for example, had a life expectancy of just 40.3 years in 2000 (undp, 2002) which has recently
gone down to roughly 39 years, whereas between 1970 and 1975 it was estimated at 53.2 years; Zambia,
Uganda, Rwanda, Malawi, Mozambique, Namibia and Zimbabwe all have lower life expectancy now than
20 years ago. Most tellingly, for sub-Saharan Africa as a whole, life expectancy at birth, 1970–75 was
45.3 years but by 1995–2000 this had risen only to 48.8 years. This is in marked contrast to much higher
overall levels and bigger increases in all other regions except Central and Eastern Europe and the CIS
(undp, 2002).
2
At the time of writing, apparently significant changes in donor policy on treatment are still mainly at
the rhetorical level. Although gradually being accepted in principle, donor funding of treatment reflects
either extremely small-scale bilateral projects and/or, in aggregate, serious shortfalls in multilateral donor
funding to the Global Fund.
3
Anti-retroviral treatment (ART) suppresses HIV and hence preserves the immune system and mitigates
susceptibility to opportunistic infections. Although not a cure, for those able to comply with the treatment,
art can greatly enhance the quality and also the length of life.
4
As welcome as the recent Bush Administration announcement to commit US$15 billion to HIV/AIDS in
Africa and Haiti over five years is, it should be noted that this is mainly for bilateral aid, with a continuing
US reluctance to contribute to the Global Fund, and also resistance to encouraging the production of
generic medicines (see tac.org.za).
5
Eide mentions the work of the Sub-Commission on Promotion and Protection of Human Rights which
established a working group on tncs in 1999, as well as the Committee on Economics, Social and Cultural
Rights’ 1998 statement on globalisation (see Eide, 2003).
6
Nicoli Nattrass, in Mail and Guardian, 20–27 March 2003, full report available at www.uct.ac.za/depts/
cssr/papers/wp28.pdf.
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