In the wake of U.S. President George Bush's trip to several African nations, and after his State of the Union speech declaring $15 billion of spending for global AIDS prevention and care, American newspapers have rallied in support of the "compassionate conservatism" represented by Bush's "commitment" to anti-AIDS efforts. Certainly, the $15 billion number has turned out to be an inflated figure, as most of the money is recycled from existing spending and only $1.4 billion has been appropriated this year (with little indication of renewal in subsequent years) [1]. But where the money is actually going has been left mostly unexamined. Not only is the funding circumventing the Global Fund for AIDS, TB and Malaria, being spent almost entirely through bilateral USAID initiatives known for their inefficacy (and diversion towards abstinence-only, anti-abortion initiatives), but more importantly the majority of funds are being spent in line with a common and fallacious public health dogma: that "information is everything", and preventing the spread of HIV means "promoting education" [1-5].
This "health belief model" seems intuitive and obvious: if people just know how HIV is transmitted (and stop being in "denial" about it) -- the rhetoric goes -- the transmission of HIV will diminish [6]. Sounds credible enough; but this argument has been consistently promoted by a group of public health workers and international financial institutions who ignore most of the available data we now have on AIDS prevention initiatives [2]. While the development banks and others have promoted the Ugandan case as a "model" (at one point claiming that effective "bereavement counselling" in the country was a reason for praise, rather than preventing the deaths to begin with [7]), the Ugandan "model" appears to be promoted without much examination of the data. Certainly, prevention initiatives in Uganda have reduced HIV prevalence in certain populations. But the prevalence rates have increased in some sections of Uganda while decreasing in others; in particular, the wealthier urban areas have seen a decrease in infection rates, while infection has rocketed upwards in the rural and poorer zones.
What is also often ignored is that even in sectors where prevalence has reduced, the reduction mathematically represents a decline in incidence well before the government's prevention initiatives began, and corresponds more to social demographic changes and economic reforms than "education" initiatives [8]. What is perhaps most problematic about the Ugandan case is that the so-called "model" it offers makes several wrong assumptions. Given that the top epidemiological predictor for HIV infection around the world is not "risk behaviour" but rather a low income level, those most vulnerable to infection will not benefit from a model focused on "education" -- a model that assumes people in poverty have the agency to control the circumstances of their lives, even in the context of gender inequality or in environments without income opportunities other than trading sex for money [9-15]. As Dr. Paul Farmer and colleagues recently noted, "Their risk stems less from ignorance and more from the precarious situations in which hundreds of millions live" [7]. And dozens of surveys support this fact, confirming that -- despite our presumptions -- those most at risk for HIV often do know how the virus is transmitted, and even in the highest prevalence areas have sex rates lower than in many regions of the U.S. and Japan [13, 16-20].
Sex is not as much the issue as the context under which sex occurs, yet several social scientists studying AIDS are guilty of trying to define an African "system of sexuality" and render sexual behaviour the problem rather than examining why sex among the poor seems to lead to HIV transmission so much more often than sex among the wealthy [21-24]. In interviews, those most vulnerable regularly discuss other concerns about life (access to clean water and food, gaining financial independence, and so forth) that take precedence over preventing HIV transmission [19, 25-30]. Yet the "targeted" public health rhetoric ignores these and even equates the concerns of the poor with the rhetoric of politicians by labelling both "in denial" [30, 31].
In the South African mining sector, for example, a recent group of surveys established that the "norm" of masculinity (expressed through soliciting prostitutes) in "South African culture" increases the risk of HIV transmission [32]. To locate "culture" as the problem is to ignore the perspectives of the miners themselves (who, in fact, are from a variety of different locations as distinct as rural sectors of Malawi and Mozambique and urban areas like Johannesburg). As one miner put it: "Every time you go underground you have to wear a lamp on your head. Once you take on that lamp you know that you are wearing death. Where you are going you are not sure whether you will come back to the surface alive or dead. It is only with luck if you come to the surface still alive because everyday somebody gets injured or dies"[32].
In the context of a 42% injury rate, it would be natural to think that catching a disease that could kill you ten years down the road might be less pressing than trying to gain some control over life -- or perhaps even enjoying life in some minor way (through alcohol or sex) before getting crushed by falling rock. But the psychologists who quoted this miner (and published their analysis in a top-ranked medical journal) labelled him "in denial," and claimed that his "low self-esteem" was the cause of his increased risk for HIV infection [32]. A similar survey among prostitutes labelled them "liars" (in "denial" of their agency) when they attributed their prostitution to lack of opportunity and coercion [25].
"Culture" (whether a distant African one or a "culture of poverty" among the poor in wealthy countries) is often described as a barrier to effective intervention, assumed to be a fixed, unalterable thing defined by the dominant groups in power, while the marginalized have no culture themselves or are guilty of having a sub-culture that renders them vulnerable to HIV or promotes crime and delinquency [20, 21, 33-38]. Culture, denial, stigma and conspiracy theories are taken to be the causes rather than the effects of social and economic problems. At other points, culture is focused upon to devise "culturally-competent" solutions to change the low efficacy of HIV prevention initiatives [39, 40]. In both of these cases, "culture" is conflated with the structural violence of inequality and lack of access to resources -- and when these issues are un-addressed, even the most "culturally-competent" prevention initiatives still focus on merely co-opting local culture to suit the needs of "targeted" interventions [41]. In this context, even after messages are adapted to "local norms" (ignoring the universal context of HIV-transmission, that of inequality and lack of access to resources), "providing information about health risks changes the behaviour of, at most, one in four people -- generally those who are more affluent and better educated" [42].
In response to accumulating data that the majority of education initiatives are failing, the public health community is now committing another behaviouristic mistake; instead of examining the political and economic contexts of prevention, it has now returned (unawares, I suspect) to a colonial rhetoric: claiming that the inefficacy of such initiatives is due to the individualistic nature of the interventions, ignoring the "collectivist African traditions" (thereby conflating all of the many social scenes in Africa into one "African system") [39, 42]. In colonial times, "venereal" syphilis among miners (which later turned out to be non-venereal syphilis and yaws) would be explained by the loss of "African traditions", which reportedly promoted female chastity by exerting group control over young women (paralleling the modern "revival" -- and partial invention -- of "traditions" like virginity testing in the context of AIDS [43]) [44, 45]. Mine workers were simultaneously taught to be individualistic and capitalistic in the mines, then returned to be collectivistic at their rural homes when they became ill (a very "cost-effective" strategy for mine owners to avoid paying for medical care) [18, 46]. The context of illness, and its relationship to their position in the economic field of relations, went unquestioned. Now, public health behaviourism aims to solve HIV transmission by holding "group rituals" for education -- so, perhaps, the "self-esteem" problems can be pushed aside as "traditions" solve all of the barriers to effective HIV prevention [39, 42].
What this rhetoric ignores and often disguises is that the background for increasing HIV transmission is a background of neoliberalism -- a context where the movement of capital is privileged above the ability of persons to secure their own livelihoods. Increasing migration is correlated precisely to the break-up of marriages as rural farms are destroyed after the liberalization of markets results in sharp drops in primary commodity prices; (mostly male) labourers travel to urban areas to work [13, 47, 48]. In vast sectors of southern Africa, miners are housed in all-male barracks for months at a time, worked six days a week, and given alcohol to "keep them happy" (or keep them from rebelling) on the seventh day -- when intoxication and depression lead to the solicitation of prostitutes. They are returned home to die, and find either their wives have left them to find a better source of income and support, or are waiting themselves to be infected with HIV [13]. The "rural women's epidemic" of HIV -- that is the sub-epidemics of women in rural zones who have been infected by their migrant male husbands (most of whom have already died at the time of surveys) -- is not so "surprising" or "unusual" in this context [47].
AIDS, then, is a symptom as much as it is a disease. In the context of the new South African Customs Union (SACU) trade agreement with the United States, it will be a most severe symptom. The SACU deal promotes rapid liberalization and the movement of capital over the securing of stable employment and better livelihoods, privileging companies who wish to set-up base temporarily and shift the means of production at will. If similar deals in East Asia and the Caribbean are any indication, both TB and HIV will increase markedly in this context as migration and poverty render "monogamous marriage" a nonsensical idea and force both women and men in poverty to move constantly and find new sources of income wherever they can [13, 47].
The SACU deal also links this neoliberal context to the distribution of resources, particularly medicines, which are often discussed through a rhetoric divorced from the context of HIV prevention. The trade deal will render generic medicines extremely difficult to procure, providing a more than two-decade-long monopoly for patented medicines [49]. Public health officials have not strongly voiced their opposition to this (leaving NGOs to take on the task), and have focused on the "cost-effective" prevention initiatives instead. The "prevention versus treatment" dichotomy should have been defeated by the numerous models indicating that access to vital health resources like antiretroviral drugs is part of the process of improving livelihoods, rather than being dichotomously opposed to effective disease prevention. Indeed, effective treatment provision often helps to reduce stigma, denial and blame, in addition to reducing HIV transmission [50, 51]. Brazil has certainly demonstrated this definitively, having reduced HIV prevalence (and incidence) after providing universal access to antiretrovirals. Despite being threatened by the US Trade Representative for producing generic medicines, Brazil has allowed the use of generic medicines, saving the country hundreds of millions of dollars and reducing HIV prevalence by over 50% [51].
The claim has been that such measures are not "cost-effective" in the manner of education initiatives (which themselves are declared cost-effective by predicting "high return on investments" in spite of the emerging data to the contrary). But "cost-effectiveness" is not based on a law of nature -- in its current form, the means for calculating such effectiveness assume that distinct health interventions are competing with one another, as if all health outcomes were pulling from the same pot of money, and the overall effect on society will be discrete, whether or not a plague is taking place [41, 52, 53]. The logic, like the "health belief model", seems intuitive, but it is notable that not all societies think this way; indeed, many assume instead that health is multiplicative -- that healthiness among some members of society contributes to healthiness among others as work-capacity and social esteem are promoted by the lack of disease [54]. As WHO senior advisor Jim Yong Kim recently declared, "For years, we have assumed that health spending must be pulled from a fixed pot of money, without examining who determines how big the pot is or how ill health plays upon the maintenance of the economy and general society." Brazil decided to counter the World Bank claims about the "cost-ineffectiveness" of its programs by calculating the "cost-effectiveness" differently; when it took into account the cost of hospitalizations saved by properly treating AIDS patients and thereby preventing them from having recurring opportunistic infections (reducing hospital visits by 80%), and included the costs of mass death to the Brazilian economy, the cost of antiretrovirals suddenly seemed quite affordable [51].
Yet in this context, a new rhetoric against generic medicines was deployed to counter the idea that other countries could follow Brazil's path. The US Trade Representative threatened Argentina, Thailand, South Africa and other countries when all of them attempted to regulate the prices of pharmaceuticals or introduce competition into the monopolistic patent regimes [55]. The USTR's claim was that generic drug use would reduce innovation, but like many claims about AIDS, this one ignored all available data. According to the industry's own tax records (obtained from the Securities and Exchange Commission), Merck this year spent 13% of its revenue on marketing and only 5% on R&D, Pfizer spent 35% n marketing and only 15% on R&D, and the industry overall spent 27% on marketing and 11% on R&D [56].
Most AIDS drugs were produced under significant public funding, and 85% of the research (including clinical trials) for the top five selling drugs on the market were produced through taxpayer funding [57]. Meanwhile, all of sub-Saharan Africa constitutes only 1.3% of the pharmaceutical market, so as one former pharmaceutical executive put it, providing generics to this market would result in a profit loss equivalent to "about three days fluctuation in exchange rates" [58, 59]. But the drug industry's fight for this market and middle-income country markets is serious, as the growing inequality in poor countries under the context of neoliberalism manufactures a new market among the wealthy and a sector for industry expansion [60].
Realizing the problems with claims about patents and pharmaceuticals, developing country trade ministers pushed through a deal at the November 2001 trade conference in Doha, Qatar. The resulting "Doha Declaration on TRIPS and Public Health" (referring to the Trade Related Aspects of Intellectual Property Rights, or TRIPS, Agreement) would allow poor countries to import generic medicines, especially if they lacked the capacity to produce such medicines themselves [61]. Although it passed unanimously, the US Trade Representative managed to become the only trade minister out of the WTO's 145 member country ministers to block the implementation of the Doha accord [62]. A deadlock still exists as the US insists upon limiting the scope of countries eligible to import generics. The US has once again co-opted the public health rhetoric, claiming that only a few iconic, extremely poor countries should be the focus for the deal [60]. Such an exclusionary policy would not only violate the Declaration itself (which claims that the WTO will promote "access to medicines for all" [61]) and deny medicine access to the majority of people who need it, but would destroy economies of scale and other necessary means to build efficient and effective generic drug production facilities, and prevent competition to lower prices and increase quality [63, 64]. Such is the nature of "free trade".
The "culture" rhetoric also re-appears in this framework. U.S. presidential candidate Howard Dean, claiming to be the "Democratic wing of the Democratic party", has argued that antiretrovirals are of humanitarian importance but should not be emphasized because they are not as "culturally appropriate" as prevention initiatives. Culture once again becomes the basis for justifying inequality. And it is simultaneously blamed as reports are produced about the increasing prevalence of drug resistance in the U.S. and Europe. Drug resistant strains of viruses emerge when patients intake medicines irregularly, and while the reports of resistance are all from Northern countries, they have been projected onto the South under the assumption that "if drug resistance emerges here, it'll emerge there", particularly in the "cultures of denial" (as The Boston Globe put it) [65-67]. Some public health workers have even suggested that antiretrovirals should only be accessible to those patients "most likely to comply", yet what this denies is that those most likely to comply are those least likely to have HIV -- they are the wealthy and the people with resources needed to control the circumstances of their own lives.
Drug resistance can be more effectively countered by scaling-up antiretroviral treatment and providing sustained and equitable distribution; resistance propagates most often because people who are denied medicine are desperate to get it, so a black market flourishes, allowing people to trade medicines and take improper regimens [50]. The drug resistance excuse is, like most excuses about AIDS, a vestige of past public health excuses, first deployed to suggest that persons with drug-resistant TB should not receive treatment (resulting in multi drug resistant TB as those people -- fated to die -- struggled to survive and receive pills wherever they could). Only when multi-drug resistant TB hit New York City populations did treatment for it suddenly become "cost-effective" [68].
Yet the public health community uses examples like these to suggest that they have no options besides meagre education-based interventions. As one group of health workers put it, "as ordinary citizens, we are not in a position to change the political and economic system" [69]. While such an analysis effectively loses the marathon before the race has even started, it also ignores the numerous health models (often constructed by activists rather than public health programs) that have effectively changed political and economic contexts for HIV transmission rather than subscribing to fatalism. In the context of the poorest location in the poorest country in the Western hemisphere (the central plateau of Haiti), public health workers have managed to provide free antiretroviral treatment without producing primary resistance and have effectively begun to stem HIV transmission by providing new models for food provision, income generation and continuity of health care distribution [7, 50].
In the context of southern Africa, campaigners have forced the Coca-Cola company to change its labour policies and provide family housing, reduce migration-based networks of product distribution, and provide complete health packages including antiretroviral drugs (www.treat-your-workers.org). So the fatalism must be tempered by an awareness of such models, which are now abounding as those infected and affected by AIDS refuse to sick back and watch the inefficacy and behaviouristic prevention initiatives produced by the public health community.
What the health community ignores is that that public health must be less about coercion and more about facilitation. In addition, there are many campaigns focused exclusively on inequality between countries -- but these often present the idea that "Third World" starvation will be solved when "First World" people eat less ice cream. Indeed, between country inequality is tremendously important. But increasingly the First vs. Third World rhetoric produces claims that public health work has competing interests -- for example, between lowering prescription drug costs in wealthy countries and lowering them in poor countries (although the data indicate that the pharmaceutical industry can easily afford both) -- instead of questioning the rhetoric of "cost-effectiveness" and the zero-sum approach to health provision. We must increasingly focus on the inequalities that take place within countries, as these point us toward routes to facilitate better health rather than attempt to coerce people whose life circumstances render the rhetoric of hygiene ineffective and often ridiculous [70-75].
When we examine within-country inequalities, we begin to see the major trends -- that the poor (even the relatively poor in wealthy nations) are consistently those marginalized in the context of AIDS, whether they are located in the poor neighbourhoods of Washington D.C. or the mining fields just outside of Johannesburg; that the wealthy in both rich and poor countries use migrant labour and threaten the health of the poor to increase their share of capital; and that AIDS is a symptom of the breakdown of social relations that occurs in the context of growing inequalities [12-14, 20, 25, 26, 28, 38, 41, 47, 48, 50, 53, 76-81]. AIDS is effectively a symptom of Empire, which operates by producing inequalities everywhere, keeping resources inequitably distributed so that they may be accumulated by a few, and rendering problems like disease a side-effect of capital accumulation [82].
Empire is threatened not simply by local resistance but by resistances that occur when people in similar circumstances between different nation-states -- people in both poor and rich countries -- realize that inequality is central to this issue. Anti-AIDS efforts are funded currently to increase labour potential and prevent economic collapse by keeping workers economically productive, or by focusing so much on "behaviour" and "culture" that the context in which "behaviour" occurs is rendered unproblematic [82-84]. Therefore, the current anti-AIDS efforts bolster and disguise the mechanisms of Empire. AIDS becomes the product of individual irresponsibility and anonymous Third World destitution -- the plague captured in pictures of dying babies and public health saviours desperate to convince the natives to adopt better hygiene practices. To expose this rhetoric's basic fallacy will require serious questioning of public health's behaviouristic trends, as well as the dominant economic and political themes that render HIV a plague of the poor.
* For a list of the references used in this article please click on the link provided.
1. Editorial
2. Equity in Health
The quest for drugs to fight the world's most neglected tropical infectious diseases gained fresh momentum with the formal launch of the "drugs for neglected diseases" initiative this week. Médecins Sans Frontières has teamed up with five international public organisations to promote affordable and effective drugs against leishmaniasis, human African trypanosomiasis, and Chagas' disease, among other infections that affect millions of people across Asia, Africa, and Latin America.
Aids activists are angry about the government's indecision over providing anti-Aids drugs and look set to resume their civil disobedience campaign. A final decision about returning to civil disobedience could be made at the Treatment Action Campaign's (TAC) national congress, which is to be held in Durban within the next two weeks. Provincial meetings ahead of the congress have already voted overwhelmingly in favour of a return to the disobedience campaign, which was suspended in April after a meeting between TAC representatives and Deputy President Jacob Zuma.
Gaps in child mortality between rich and poor countries are unacceptably wide and in some areas are becoming wider, as are the gaps between wealthy and poor children within most countries. Poor children are more likely than their better-off peers to be exposed to health risks, and they have less resistance to disease because of undernutrition and other hazards typical in poor communities. Regular monitoring of inequities and use of the resulting information for education, advocacy, and increased accountability among the general public and decision makers is urgently needed, but will not be sufficient. Equity must be a priority in the design of child survival interventions and delivery strategies, and mechanisms to ensure accountability at national and international levels must be developed.
Not-for-profit groups and some individuals are using "creative routes" to provide antiretroviral drugs to HIV-positive people in developing countries, the New York Times reports. Some organisations channel unused medications from U.S. patients who have changed medications, taken a break from treatment or died to patients in developing countries, and other organisations purchase low-cost generic versions of the drugs in other countries and import them, sometimes illegally, into neighbouring countries.
A new information gathering programme will soon provide an essential database of medical and other humanitarian needs in the agricultural heart of Swaziland to fill gaps in the national records and bring much needed insight into how to best counter the spread of HIV/AIDS.
Frustration is mounting among activists over the Namibian government's delay in providing anti-AIDS drugs to its HIV-positive citizens. The government announced in April this year that it had budgeted US $10.9 million for the purchase of antiretroviral (ARV) drugs for HIV-positive people. But while the health ministry has on numerous occasions indicated their intention to provide treatment, this had not been translated into action, activists told PlusNews.
The cash-strapped Global Fund to fight HIV/AIDS, Tuberculosis (TB) and Malaria fell under the spotlight in July, when ministers from 14 countries met in Paris, France, to address the fund's financial woes. The fund, which has committed US $1.5 billion to programmes in 92 countries in the last 18 months, faces a lack of money for proposals waiting to be funded in October.
Governments, international organisations, foundations and nongovernmental organisations in 2003 will spend an estimated $4.7 billion to address the AIDS epidemic in low- and middle-income countries, but that amount is less than half of the more than $10.5 billion that will be needed each year by 2005 to fight the epidemic in those countries, according to a new UNAIDS report.
The World Health Organisation (WHO) presented a challenge to African countries last year by setting a target of three million HIV-positive Africans to be on antiretroviral (ARV) HIV/AIDS therapy by 2005. Almost a year later, a workshop on scaling up access to care and treatment for people living with HIV/AIDS (PWAs) in 17 East and Southern African countries has been held to assist them in reaching that goal. HIV/AIDS programme managers and health officials from the 17 countries emerged with country-specific "road maps" to guide them in expanding their treatment programmes.
Just a few days before his visit to Africa, President Bush announced that Randall Tobias, the former chairman and CEO of Eli Lilly Co., will take the new position of "Czar" in charge of U.S. global HIV/AIDS funding. The move to position a drug company executive centrally in global health policymaking is nothing new for this administration, but the openness of this gesture to the industry suggests that there is little shame in reversing the progress of the last several years, particularly in the realm of medicine treatment access, says this commentary on the web site www.zmag.org
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3. Human Resources
Zimbabwe is experiencing a debilitating flight of professional and skilled people escaping the country's economic crisis, a study funded by the UN Development Programme (UNDP) has found. A large number of Zimbabweans had taken up South African citizenship and there were probably more Zimbabweans in South Africa than in the United Kingdom, the country with the highest official tally of expatriate Zimbabweans.
South Africa is suffering from a ‘brain drain’, or loss of its professionals – but how serious is the problem and what effect is it having on the homeland? This study attempts to assess the number of emigrants and the skills being lost, and asks whether the loss is permanent. Skills loss due to emigration has recently become a high-profile public policy issue in South Africa. A major, unresolved question is the actual scale of the problem and its impact. There has been growing suspicion that South Africa’s official emigration data, SSA, significantly underestimate the number of South Africans leaving the country to settle abroad. This report by the University of Cape Town attempts to assess the true extent of emigration by examining data from the recipient countries.
Human resources are an essential element of a health system's inputs, and yet there is a huge disparity among countries in how human resource policies and strategies are developed and implemented. The analysis of the impacts of services on population health and well-being attracts more interest than analysis of the situation of the workforce in this area. This article presents an international comparison of the health workforce in terms of skill mix, socio demographics and other labour force characteristics, in order to establish an evidence base for monitoring and evaluation of human resources for health.
This paper reviews the challenges facing the public health workforce in developing countries and the main policy issues that need to be addressed in order to strengthen the public health workforce. The public health workforce is diverse and includes all those whose prime responsibility is the provision of core public health activities, irrespective of their organizational base. Although the public health workforce is central to the performance of health systems, very little is known about the composition, training or performance of the workforce. The key policy question is: Should governments invest more in building and supporting the public health workforce and infrastructure to ensure the more effective functioning of health systems?
4. Public-Private Mix
Does competition improve hospital services? Do market forces in healthcare benefit the poorest members of society? Reforms which involve exposing hospitals to market forces are being introduced in many developing countries. However, very little is known about how these markets operate, particularly in developing countries. The University of Zambia, together with the London School of Hygiene and Tropical Medicine, considered the effect of competition among hospitals in Zambia. The study concludes that there is potential for competition in the hospital market to have beneficial effects in terms of prices, quality and efficiency. However, there is also the risk that faced with this competition, hospitals will be less able to charge private prices which allow them to cross-subsidise public patients.
5. Resource allocation and health financing
Africa has a right to demand support from the international community in its fight against AIDS, tuberculosis, malaria and other diseases, Professor Jeffrey Sachs, executive director of the Earth Institute at Columbia University, told a meeting of African heads of state in Maputo, Mozambique in July. Professor Sachs said that only a very small fraction of the more than $10bn (£6.2bn; €8.8bn) needed each year to effectively combat these illnesses had yet been allocated to African countries.
Economists said at the international AIDS conference on HIV pathogenesis and treatment in Paris on July 14 that nations with a high HIV/AIDS burden should spend more of their resources on antiretrovirals, a move which directly contradicts current medical opinion. The medical community has said that handing out antiretrovirals would be a waste of resources; could worsen drug resistance; and instead it urged preventative measures. Three pilot studies presented at the meeting from the Ivory Coast, Senegal, and Uganda--funded by UNAIDS--found that with a little help to set up medical infrastructure, drugs can be delivered, even to remote areas, without increasing drug resistance. (Access requires registration.)
Estimating the costs of health interventions is important to policy-makers for a number of reasons including the fact that the results can be used as a component in the assessment and improvement of their health system performance. Costs can, for example, be used to assess if scarce resources are being used efficiently or whether there is scope to reallocate them in a way that would lead to improvements in population health. As part of its WHO-CHOICE project, WHO has been developing a database on the overall costs of health interventions in different parts of the world as an input to discussions about priority setting.
6. Governance and participation in health
HIV is rampant among young people in South Africa, despite sound knowledge about sexual health risks. Levels of perceived vulnerability among this group are low and unprotected sex is common. Researchers from the London School of Economics studied a participatory programme seeking to empower young people to change gender norms as an HIV prevention strategy.
How can we tell if teenagers are responding to HIV/AIDS awareness campaigns? Is it acceptable to conduct randomised trials in schools to find out? University College London, together with the University Zimbabwe and the London School of Hygiene and Tropical Medicine, looked into the sensitive topic of interviewing and testing teenagers for sexually-transmitted diseases (STDs) including HIV, in a feasibility study for a large community randomised trial. It found that communities in Zimbabwe were enthusiastic about taking part in trials in schools and recognised the importance of these.
7. Monitoring equity and research policy
Several African governments have in recent years set themselves ambitious poverty reduction strategies. What impact have the institutional mechanisms had for mainstreaming the goal of poverty-reduction into processes of government decision-making? Preliminary findings from current research on institutional and process issues in national poverty policy at IDS suggests that practice on policy processes and institutions relating to poverty reduction has improved. In many sub-Saharan African countries, there has been considerable progress in information collection about poverty levels, characteristics and trends and, increasingly, an attempt to find mechanisms to ensure that the evidence on poverty informs the design of policy. Perhaps the most fundamental evidence of a heightened focus on poverty reduction in policy concerns the extent to which it is identified as a priority in a country’s national development strategy.
8. Useful Resources
This document brings together promising practices identified by the USAID-Private Voluntary Organisation community. This includes many ideas and experiences of different organisations that seem likely to combat HIV/AIDS successfully. Several of these practices are new and as such, do not yet have hard evidence to show that they work. However, rather than wait for documented success, they are published here to share all the practices available to spur ideas and action. This compendium is aimed at any person or program interested in mitigating the spread of HIV/AIDS, though the emphasis is on those in Africa seeking new ways to act.
THE PUSH JOURNAL is an objective, free full-text online clipping service. It's a great tool for journalists covering issues related to AIDS/HIV, reproductive health, issues relating to women and girls, global population or refugee issues and the environmental, medical and family issues which surround them. If you work with slow or unpredictable Internet connections, you can choose to receive the full-text news stories in an easy-download text version. Each day's edition of PUSH JOURNAL carries story headlines at the top and complete versions of each story below. PUSH adds no text or commentary.
The Supply Initiative: meeting the need for reproductive health supplies, has a new monthly newsletter that provides updates on the Supply Initiative activities, as well as news, materials and events related to condom and contraceptive shortages.
For a selective list of HIV/AIDS websites for health professionals, libraries and publishers in developing countries, please visit the HIV/AIDS section of INASP Health Links: http://www.inasp.info/health/links/ INASP Health Links is an internet gateway to more than 500 selected websites, including more than 100 HIV/AIDS sites.
The Support for Analysis and Research in Africa Project (SARA) is a user-friendly guide that has been designed to help healthcare workers use data collected at their health facility to solve common problems in service delivery and improve their response to community needs. It is intended for doctors, nurses, and midwives in both community health centres and rehabilitated district health centres.
9. Jobs and Announcements
This piece explores what the author describes as a "striking and deeply mysterious" denial of the reality of AIDS in South Africa. This country has one of the highest infection rates in the world and an equally high level of awareness about how to avoid being infected. Why, the author asks, have so many HIV prevention programmes - like those addressing high-risk youth - been so radically unsuccessful? Epstein explains that many of the efforts to change the sexual behaviour of young people in South Africa have tapped into what youth seem to respond to most readily - material culture, images of beauty and glamour, and fun/play.
Southern African AIDS Training Programme (SAT) is pleased to announce our latest publication "Counselling Guidelines on Stress Management". SAT is a regional collaboration that supports community responses to HIV and AIDS through in-depth partnerships in Malawi, Mozambique, Tanzania, Zambia and Zimbabwe and wider networking, skills exchange and lesson sharing throughout the region. SAT funding and skills building activities support partners in a wide range of relevant activities - HIV prevention, HIV and AIDS care and support, impact mitigation, networking and information exchange, HIV-related advocacy on gender and human/child rights. SAT partners are operating at community, national and regional levels.
This is to inform you that the selection process for the vacancies in the NGO Liaison Committee of the UNAIDS Programme Coordinating Board from North America, Europe, LAC and Africa regions has been completed. As you may know, the UNAIDS PCB has five seats reserved for NGO sector delegates on a regional basis. Each delegate NGO has an Alternate.
This important book on the politics of the World Trade Organisation (WTO), which takes the lid off how the WTO really works, and what really happened before, at, and after the Fourth WTO Ministerial Conference in Doha in 2001, on the basis of interviews with 33 Geneva-based delegates to the WTO and 10 Secretariat staff members. This is the ammunition the critics of the WTO have been waiting for. It reveals the systematic subversion of an ostensibly democratic system to ensure that the "agreements" that are reached are those the major powers - primarily the US and the European Union - want, irrespective of the views of interests of most developing countries, who form the great majority of the membership.
Galillee College, Israel, will hold an international workshop for health professionals, the Health Systems Management Program, between November 20 - December 8, 2003. Tuition scholarships are available for qualified candidates that are citizens of a developing country in Africa (Living expenses and airfare are not included.) For more information, email rgottlieb@galilcol.ac.il or visit the Galillee College website: http://www.galilcol.ac.il/health.htm
The 3rd International Conference of the International Society for Equity in Health will be hosted by the Health Systems Trust (HST), a South African-based NGO, the Southern African Regional Network on Equity in Health (EQUINET) and the Global Equity Gauge Alliance (GEGA), an international consortium of initiatives to support health equity. The meeting will bring together researchers, policy-makers, practitioners and others concerned with equity in health to develop an international health agenda for governments, universities and organisations all over the world.
As part of the African Technologies for Education and Workforce Development Initiative (AFTECH), the Africa-America Institute is pleased to invite you to participate in our online discussion on HIV/AIDS and its Impact on Workforce Development (Southern Africa) that will run until August 13.
The Africa Population and Health Research Centre (APHRC) invites applications from qualified candidates for the position of Research Trainee. The description of the position is available through the link provided. For more information about APHRC, please visit the website: http://www.aphrc.org
The Chief Specialist and/or head of school post may be filled by one person fulfilling both roles or by two separate people, one as the Chief Specialist and one Head of School. These appointments may be at Professorial or Associate Professorial level. The Epidemiologist will be a dynamic person with excellent skills in Epidemiology and/or Biostatistics who will lead the Epidemiological research and training undertaken by the School of Public Health. The incumbent will be expected to stimulate epidemiologic research within the School and the Faculty.
The Nuffield Council on Bioethics published a Report, ‘The ethics of research related to healthcare in developing countries’, in April 2002. A follow-up workshop will be held in February 2004 to explore developments in this area since the publication of the report. The workshop, co-hosted by the South African MRC and the Nuffield Council on Bioethics, will bring together researchers who are actively involved in externally-sponsored research related to healthcare in developing countries, for three days in Cape Town. The focus of the workshop will be to discuss and debate ethical and regulatory issues raised by new and recently revised guidelines and to identify obstacles to their effective implementation.