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The Vicious Cycle of AIDS, Poverty, and Neoliberalism

IRC Americas
A New World of Citizen Action, Analysis, and Policy Options
The most recent United Nations figures show the true
magnitude of the tragedy: approximately 40 million peo-
ple are currently living with the Human
Immunodeficiency Virus (HIV) or are suffering from ill-
nesses associated with Acquired Immunodeficiency
Syndrome (AIDS). In 2003 alone, five million people
joined the list of those who tested HIV-positive and near-
ly three million others died from complications associat-
ed with AIDS.
Faced with a tragedy of epic proportions, the UN’s
World Health Organization (WHO) and UNAIDS launched
a plan to provide antiretroviral medications to three mil-
lion AIDS patients in the next two years—approximately
half the patients currently estimated to need this kind of
treatment. The WHO strategy incorporates plans recently
proposed by the World Bank and the U.S. government.
At first glance, this global strategy appears to be a
humanitarian gesture and a decisive intervention by the
international health organizations and the White House
to control this devastating disease. However, to thorough-
ly understand the true dimension of the AIDS pandemic
and the possible scope of the WHO-World Bank-Bush
government plans, it is essential to consider the socioeco-
nomic world context in which the disease has been ges-
tating over the last two decades.
This context continues to be defined by the prevalence
of multinational pharmaceutical companies’ interests
above those of the patients who are supposed to benefit
from their medicines. Neoliberal economic policies in
recent decades have created conditions in which it has
proven impossible to detain or reduce the number of
infections, despite the efforts of scientists, the investment
of billions of dollars, and the work of innumerable organ-
izations in prevention programs.
Epidemics and Economics
Social epidemiology, defined initially as “the study of
the role of social factors in the etiology of an illness,”
grew out of Friedrich Engels’ study of the living condi-
tions of English workers in the 19th century. Today this
area of public health looks at how historical, political,
and economic tendencies influence the dissemination of
an illness among different populations and how social
forces and factors affect individuals’ bodies and generate
In the case of HIV/AIDS, Nancy Krieger has pointed out
that “neoliberal economic policies such as the North
American Free Trade Agreement (NAFTA), which result in
economic austerity plans, environmental degradation,
and growing intra- and inter-regional social disparities in
health, are of particular concern.” The study of the effect
of health service organization and coverage, and of drug
production and marketing systems on a specific society’s
most vulnerable population is also important to epidemi-
ology and social medicine.
All studies agree that the AIDS pandemic is concentrat-
ed in the poorest countries and among the poorest sec-
tors of wealthy countries. But very few works analyze the
close relationship between the causes of the affected
nations’ socioeconomic reality and the so-far uncontain-
able advance of the epidemic during the last two
decades. With a few very valuable exceptions, most
research simply describes the situation without clearly
defining the fundamental responsibility of the economic
globalization model imposed on nations in these times of
British epidemiologist Thomas McKeown demonstrated
that progress in controlling a population’s illnesses can-
not be attributed to vaccines, antibiotics, and improved
medical treatments alone, given that socioeconomic con-
ditions and their effects on nutrition constitute an essen-
tial health factor. Without denying the importance of
Americas Program Special Report
The Vicious Cycle of AIDS, Poverty, and
By Bernardo Useche and Amalia Cabezas | December 1, 2005
World maps illustrating areas of high poverty largely overlap those of high HIV/AIDS prevalence. It’s no
coincidence that both poverty and the HIV-AIDS pandemic have run rampant in these last two decades
of neoliberalism, since the root causes of both can be found in the economic model.
advances in biomedicine, epidemiological studies cur-
rently confirm that health expectations are directly asso-
ciated with quality of life, which in turn is determined by
environmental health, nutritional status, water quality,
housing, education, working conditions, and emotional
and psychological factors that benefit human develop-
ment throughout the life cycle.
Health in a given country depends not only on inhabi-
tants’ income, but also on the degree of equality within
the society. Health expectations are greater in countries
with relatively less income and social inequality among
the population. This explains the differences in life
expectancy and other health indicators among industrial-
ized countries. Sweden, Switzerland, and other devel-
oped countries, for example, have better health rates and
higher life expectancy than the United States, a country
that despite having the most powerful economy on earth
also has abysmal social inequalities, with 46 million citi-
zens currently unprotected because they cannot afford
health insurance.
Blaming the Victim
The undeniable link between health problems and
social inequalities presents an ideological dilemma. Are
the sick to blame for their illnesses or do they result from
social inequality? The social history of AIDS has largely
been one of apportioning blame to the victims. At the
beginning, AIDS was even defined as the disease of the
four Hs: homosexuals, Haitians, hemophiliacs, and heroin
addicts—to which one could more recently add “hook-
ers.” All these categories carried implicit derogatory
social connotations.
Blaming the victims hides the fundamental role
socioeconomics plays in generating and propagating ill-
nesses, instead placing the “cause” on the victims and
saddling them with the responsibility for prevention and
treatment. The state’s obligation to care for its popula-
tion’s health is obscured.
Yet the causes are closely interlinked to social factors
beyond the victims’ control. Poverty often creates the
alienating conditions that lead to a culture of intravenous
drug use. And in the concrete case of Haiti, Paul Farmer
established that, contrary to the widely disseminated
stigma that blames Haitian immigrants for introducing
the AIDS epidemic to the United States, it was the sexual
tourism of U.S. citizens to Haiti—fueled by the poverty
that left Haitians with no other means of livelihood—that
started the AIDS epidemic on the island.
As a result of viewing AIDS transmission as essentially
a problem concerning the individuals involved, preven-
tion efforts focused on trying to modify individual risk
behaviors and attitudes for the first 20 years of the pan-
demic. This unilateral approach, which ignored the
socioeconomic factors behind AIDS, predictably failed in
stopping the epidemic. But it succeeded in blocking in-
depth debate on the responsibility of the neoliberal eco-
nomic model implemented throughout the world during
this period, and the social consequences provided a
breeding ground for the epidemic’s progress.
Neoliberal Famines and the
Spread of AIDS
Neoliberalism is the set of economic theories and poli-
cies developed by contemporary monopoly capital to
consolidate its global expansion and achieve control of
the world markets it needs to survive. The distribution of
the HIV/AIDS infection matches the current world socioe-
conomic order. In this era, health problems have been
polarized along with distribution of wealth, as born out
by Paul Farmer’s theory that the health of the world’s
poor is affected primarily by infections and violence,
while the rich suffer from chronic illnesses associated
with aging. The 21 nations with the highest AIDS preva-
lence in the world are found in Sub-Saharan Africa,
where dramatic poverty largely resulted from the neolib-
eral measures imposed by the structural adjustment pro-
grams of the International Monetary Fund (IMF) and the
World Bank.
Famine and AIDS go hand in hand on the African conti-
nent. As UN Special Envoy for HIV/AIDS in Africa Steven
Lewis explained, when the body has no food to consume,
the virus consumes the body. When the body’s immune
system is weakened by lack of food, the illness progress-
es much quicker and people die faster. The main cause
of the recent famines, with their inevitable malnutrition
A New World of Citizen Action, Analysis, and Policy Options
p. 2
Blaming the victims
hides the fundamental role
socioeconomics plays in
generating and propagating
and death, are not the droughts and other natural disas-
ters that frequently afflict Africa, but rather the elimina-
tion of agricultural subsidies, privatization of public serv-
ices, and complete opening up of the economy, measures
that are an integral part of the structural adjustment pro-
grams demanded of the African nations by the interna-
tional agencies since 1986.
Zimbabwe: A Tragic Case
Zimbabwe sadly illustrates the point. According to a
study by the Joint Center for Political and Economic
Studies in Washington, the average real economic growth
in Zimbabwe during the 80s was 4% a year. During
those years, food security developed somewhat and the
manufacturing sector was strengthened, which con-
tributed to a diversification of exports. At the same time,
health services increased and life expectancy rose from
56 to 64, while child mortality fell from 100 to 50 live
In 1991, Zimbabwe received a US$484 million loan
conditional on the structural adjustment of its economy.
The demands of the adjustment included reducing public
spending, deregulating the financial market, eliminating
manufacturing protections, liberalizing the labor market,
reducing the minimum salary, and eliminating labor sta-
bility, all to guarantee reduction of the fiscal deficit.
Zimbabwe’s economy entered into recession a year later
and between 1991 and 1996 per capita private consump-
tion fell 37%, salaries fell 26%, and unemployment rose,
while food prices skyrocketed.
The IMF’s recipe, which required the Zimbabwean gov-
ernment to slash spending by 46%, above all by cutting
health workers’ salaries, had disastrous effects on public
health. The vast majority of the population was left with-
out access to health services or medicine. Malnutrition
and the incidence of illnesses such as tuberculosis rose
dramatically. Life expectancy is currently down to 38,
between five and eight million people—around 70% of
the population—depend on international food aid to sur-
vive, and 2,500 people die of AIDS every week. Even so,
the IMF has initiated procedures to expel Zimbabwe for
not having consistently accepted all of the economic
reforms it “recommended.”
Social Catastrophes Feed the
AIDS Epidemic
The situation is similar in the other African nations.
Zambia, where AIDS left some 600,000 children
orphaned in 2001, liberalized its economy, including agri-
culture, in 1991 under World Bank-imposed conditions. It
is currently in its fourth consecutive year of food crisis
and over three million inhabitants have nothing to eat.
Malawi and Mozambique are also suffering from chronic
food insecurity.
In 1991, the Malawi government had grain deposits in
even the most remote parts of the country and could sell
cheap food, saving a large part of the population from
famine. The IMF “recommended” selling part of these
food reserves to guarantee payments on the country’s
foreign debt, at the same time enriching private traders.
Ten years later food costs ten times more and with the
elimination of agricultural subsidies, the price of maize
rose by 400% between October 2001 and March 2002.
Peasants started eating unripe maize, resorting once
again to the diet responsible for the disease pellagra, and
there was generalized famine. In 2002, seven million of
Malawi’s total population of ten million suffered from pel-
lagra. Between 2001 and 2005, an estimated 125,000
children under the age of five died of AIDS in Malawi.
Even in the United States, where neoliberal measures
also increase social inequalities, new HIV infections are
concentrated among Afro-Americans and Latinos. In
neoliberal Russia an estimated three million people are
intravenous drug users—one of the most important AIDS
risk factors—and half that number are infected with HIV.
In Latin America and the Caribbean, the lack of social
and economic equity provides a favorable context for the
AIDS epidemic to reach disastrous proportions in the
coming decades, according to the UN’s adviser for
Colombia, Ricardo García. The worst cases so far corre-
spond to the region’s most economically depressed coun-
tries or regions. In Colombia, it is predicted that 1.6% of
the population will be infected with HIV by 2010.
A New World of Citizen Action, Analysis, and Policy Options
p. 3
Even in the United States,
where neoliberal measures also
increase social inequalities,
new HIV infections are
concentrated among
Afro-Americans and Latinos.
The Current Anti-AIDS “Crusades”
of the IMF, World Bank, WHO, and
Bush Administration
Ninety-five percent of AIDS cases occur in the pauper-
ized Third World. In response, the U.S. government and
the World Bank, which are the main bodies responsible
for the neoliberal reforms that have destroyed national
economies and starved vast sectors of the world popula-
tion, have launched a worldwide campaign to combat the
In January 2003, President Bush announced a US$15
billion program to provide antiretroviral drugs to two mil-
lion people infected with HIV in 12 African countries,
Haiti, and Guyana. For its part, the World Bank began
financing projects and developing an AIDS policy in
1986. In 2000, the World Bank and the IMF jointly decid-
ed to incorporate their anti-AIDS plans into their develop-
ment assistance programs, arguing that AIDS is increas-
ingly delaying economic growth by reducing productivity
and the work force. At that time, the Bank illustrated its
point using the case of Zimbabwe, a country whose 1%
drop in economic growth was attributed to the fact that
25% of its adults were HIV positive.
In December 2003, the WHO urged that these projects
be coordinated with the UN Global Fund to Fight AIDS,
Tuberculosis, and Malaria, established in 2001, and
launched an initiative known as “Treating three million
by 2005.” As its name suggests, the WHO campaign pro-
posed providing antiretroviral medicines to three million
AIDS patients in the next two years.
It is worth analyzing the origin, philosophy, and politi-
cal and economic content of these anti-AIDS crusades to
assess if they will indeed translate into relief for those
people and regions in the grip of the epidemic.
Is AIDS the cause of poverty?
World Bank Director General Mamphela Ramphele cate-
gorically stated on June 1, 2003, that “our dream is a
world free of poverty. But we now know that that mission
will remain only a dream until the world is free of AIDS.”
Paraphrasing the title of Doctor Rambphele’s speech that
day—“HIV/AIDS: Turning Adversity into an
Opportunity”—it could be said that the adversity of the
AIDS tragedy has represented an opportunity for the
agencies of international capital to blame the epidemic
for the poverty caused by their own policies. Worse still,
they attempt to postpone any hope of economic recovery
in impoverished nations until AIDS has disappeared from
the planet.
Such words are not isolated. World Bank documents
have been insisting on this idea for some time now. One
stated that while it is still not clear if poverty increases
the probability of HIV infection, there is strong evidence
that HIV/AIDS causes and increases poverty. The U.S.
government also defends the idea the AIDS is a cause of
poverty. As U.S. Secretary of Health, Tommy Thompson,
recently stated, “Poverty, unfortunately, is a common
symptom of AIDS.”
Given these tendencies, it’s no surprise that the intro-
duction to the document in which the WHO set out its
strategy establishes that “HIV/AIDS is destroying families
and communities and sapping the economic vitality from
countries. The loss of teachers through AIDS, for exam-
ple, contributes to illiteracy and lack of skills. The deci-
mation of civil servants weakens core government func-
tions, threatening security. The burden of HIV/AIDS,
including the death toll among health workers, is pushing
health systems to the brink of collapse. In the most
severely affected regions, the impact of disease and
death is undermining the economic, social, and political
gains of the past half-century and crushing hopes for a
better future.”
The champions of “free trade” seek to blame economic
ruin, loss of political conquests, illiteracy, destruction of
health systems, and social problems on a biological
agent—the virus—rather than on their imposed structural
adjustments, privatization programs, and other reforms.
A New World of Citizen Action, Analysis, and Policy Options
p. 4
The champions of “free trade”
seek to blame economic
and social problems on a
biological agent—the virus—
rather than on their imposed
structural adjustments,
privatization programs,
and other reforms.
A World of Clients, Not Patients
Hundreds of millions of poor people in the world suffer
and die from infectious diseases for which there are
almost no cheap and effective medicines, despite the
existence of the scientific and technological knowledge to
develop them. Likewise, while North America, Europe,
and Japan consume 82.4% of the medicines produced in
the world, Asia and Africa consume just 10.6% of those
available on the market, despite accounting for two-thirds
of the world’s population.
Patrice Trouiller and colleagues have documented the
reason for this criminal inequity: in the neoliberal econo-
my it is not the population’s health needs but rather the
financial interests of the large-scale pharmaceutical
industry that influence both the research to develop new
drugs and the production and marketing of available
medicines. In a world with no patients, just clients, and
in which the state is abandoning its public health respon-
sibility, the drug transnationals don’t invest in medicines
to treat illnesses affecting poor people with no money to
pay for them; their production and sales strategies focus
on the market sector from which they can obtain greater
profit margins.
Although there is currently no cure for AIDS, anti-HIV
medicines can delay the disease’s progress and reduce
mortality by up to 80%. The “free trade” policies that
have allowed the drug-producing corporations to make
record profits off these medicines have also intensified
the misery of people who need them. In the case of the
AIDS pandemic, neoliberalism has been responsible for
exacerbating to the extreme one of the basic contradic-
tions of the capitalist economy: It created an immense
potential market for the new antiretrovirals—42 million
people with HIV/AIDS—among a population without the
capacity to buy them.
Only 8% of the six million AIDS patients who currently
require medicines to improve their health have access to
antiretrovirals, a figure that in countries such as South
Africa is as low as 1%. It is estimated that the current
cost of treating a person with HIV/AIDS in the United
States is about $20,000 a year, including the value of
antiretroviral therapy, lab tests, medical visits, and medi-
cines to prevent or treat opportunistic illnesses.
WHO believes this situation can now be resolved: “The
prices of antiretroviral drugs, which until recently put
them far beyond the reach of low-income countries, have
dropped sharply. A growing worldwide political mobiliza-
tion, led by people living with HIV/AIDS, has educated
communities and governments, affirming treatment as a
human right. The World Bank has channeled increased
funding into HIV/AIDS. New institutions such as the
Global Fund to Fight AIDS, Tuberculosis, and Malaria and
ambitious bilateral programs, including the United States
Presidential Emergency Plan for AIDS Relief, have been
launched, reflecting an exceptional level of political will
and unprecedented resources for the HIV/AIDS battle.
This unique combination of opportunity and political will
must now be seized with urgent action.”
But despite all the “political will” a fundamental obsta-
cle remains—the pharmaceutical patent monopolies.
Since 1995, the Trade-Related Aspects of Intellectual
Property Rights (TRIPS) Agreement established by the
World Trade Organization (WTO) has backed up the
patents of the transnational pharmaceutical corporations,
guaranteeing them a market monopoly and exorbitant
profit margins. As is the norm in neoliberal strategies
aimed at eliminating competition by national products to
benefit big capital, mainly from the United States, the
WTO initially allowed its member countries to produce
generic medicines during the first years after intellectual
property rights came into force. A few countries, includ-
ing South Africa, India, and Brazil, used this regulation to
start producing generic versions of medicines used to
treat AIDS and demonstrated that companies run by the
state or national capital could substantially reduce prices
and generate profits while at the same time attending to
the health needs created by the epidemic in their own
A New World of Citizen Action, Analysis, and Policy Options
p. 5
In the neoliberal economy
it is not the population’s
health needs but rather
the financial interests of the
large-scale pharmaceutical
industry that influence
both the research to develop
new drugs and the
production and marketing of
available medicines.
The U.S. government and representatives of the phar-
maceutical companies soon started pressuring for
“respect” for the patent monopolies. In 2000, 39 compa-
nies sued the South African government. During the 14th
International AIDS Conference in Barcelona in 2002,
there were mass protests rejecting transnational corpora-
tions that deal in these medicines while millions of poor
people throughout the world are dying without access to
them. On August 30, 2003, in a measure to forestall a
repeat protest at the WTO meeting in Cancún, México,
the Bush administration and the large-scale pharmaceuti-
cal industry agreed that poor countries could temporarily
continue buying generic medicines, while adding a clause
stipulating that all member countries would soon only be
able to buy medicines patented by the transnational
The Bush Plan: Big Business for
the Transnationals
At the same time it is promoting its own commercial
interests in the WTO, the United States is continuing to
push bilateral agreements and regional treaties such as
NEPAD in Africa, CAFTA in Central America, and the
FTAA in Latin America as a whole. This ongoing attempt
to impose its neoliberal policies includes increased patent
protection. President Bush’s anti-AIDS initiative was
launched independently of the existing Global Fund to
Fight AIDS, Tuberculosis, and Malaria with the evident
aim of directly controlling both the project’s philosophy
and the money that Washington will invest in the cam-
Bush named Randall Tobias to run the program in
Africa. Tobias had no experience either working in that
region or managing AIDS-related programs, but he is a
major Republican Party contributor and former general
manager of Eli Lilly, a powerful pharmaceutical company.
In Bush’s plan, the U.S. government will subsidize capi-
tal investments in anti-AIDS medicines by buying up the
medicines the companies can’t sell to the impoverished
nations of Africa and the Caribbean due to their high
prices. In the words of South African finance minister
Trevor Manuel, there is a risk that most of the budgeted
$15 billion announced by Bush to fight AIDS will end up
directly in the coffers of U.S. pharmaceutical companies.
It is hence no surprise that big laboratories such as
Bristol-Myers Squibb, which controls the patent of the
antiretroviral drug Stavudine (Zerit®), support the initia-
tive and are competing to obtain their share of the $15
billion, or that the giant corporations that produce anti-
HIV drugs are financing lobbying of Congress to support
the White House anti-AIDS plan. Under this plan, 130
transnational companies have joined a Global Coalition
against AIDS.
The Bush administration’s fight against AIDS is gov-
erned by its policy of globalizing the free trade agree-
ments that benefit its own interests. This was made clear
by former U.S. Trade Representative Robert Zoellick,
when he stated that they aren’t thinking of discussing
new economic development models for African coun-
tries; they are simply looking at how to apply develop-
ment based on market laws in very poor regions. The aid
dedicated to the fight against AIDS will be conditioned
on the nations accepting the economic measures pre-
scribed by the World Bank and the IMF.
Washington’s initiative to take antiretroviral medicines
to countries in Africa and the Caribbean also contains a
strong ideological component that promotes sexual absti-
nence as the basis for HIV-prevention. In May 2003, the
U.S. Congress introduced an amendment to the Bush ini-
tiative obliging it to invest a third of the millions ear-
marked for prevention into projects whose only objective
is chastity. This is yet another of the neoliberal paradox-
es: the very promoters of economic policies that leave
millions of people unemployed and force many women
into prostitution are now the standard bearers of a sexual
morality that the vast majority of the population finds
impossible to fulfill in real life. But this does not stop
them proclaiming it as the most effective way of combat-
ing the AIDS pandemic.
Any attempt to illuminate the reasons behind the pro-
motion of sexual abstinence as a means of prevention
needs first to clarify certain questions about how sexual
life affects HIV transmission.
A New World of Citizen Action, Analysis, and Policy Options
p. 6
In the words of South African
finance minister Trevor Manuel,
there is a risk that
most of the budgeted
$15 billion announced by Bush
to fight AIDS will end up
directly in the coffers of U.S.
pharmaceutical companies.
With a few exceptions, most scientists believe that the
main form of HIV transmission is via sexual relations
with an infected person. Since the virus was discovered,
it has been insisted that the highest-risk behavior is anal
intercourse between homosexuals or heterosexuals and
that in vaginal intercourse the virus is most easily trans-
mitted if the infected person is male. Researchers believe
that the number and concurrence of sexual partners and
the frequency of sexual activity with new partners also
play an important part in increasing the probability of
In the United States, the AIDS epidemic was initially
identified among male homosexual drug users. Not until
2003 was it estimated that heterosexual contact pro-
duced a third of all new infections in the United States
and Canada, while intravenous drug users sharing infect-
ed needles caused 25%. In Africa, in contrast, the epi-
demic was associated from the start with heterosexual
transmission. Lately other possible means of transmis-
sion, such as use of needles and other medical instru-
ments and equipment that do not comply with basic
biosecurity norms due to the deteriorating health servic-
es and terrible conditions in which they are provided are
being examined.
The problem with the abstinence approach to AIDS
control is that it doesn’t work. In sex education offered
to young people in the United States, current programs
promote abstinence, despite the lack of any definitive
demonstration of their effectiveness. A systematic evalua-
tion of these programs by Douglas Kirby concluded that
“the weight of the evidence indicates that abstinence-
only programs do not delay the onset of intercourse.”
How the AIDS Virus Incubated in
Neoliberalism expresses the interests of big capital con-
centrated in the giant monopolistic corporations. Based
on the thinking of neoclassic economics, it proposes
reduction of the state including eliminating or privatizing
many public services, public sector workers, and govern-
ment housing, education, food, and health programs. In
recent decades, the U.S. government and its allies have
promoted globalization under neoliberal principles and
“free trade” economic policies and imposed them on the
nations of the world mainly through the international
agencies under their control—the IMF and the World
Bank—as a supposed panacea for all social problems.
World Bank and IMF structural adjustment programs
have devastated Latin America, Africa, Asia, and the
Caribbean over the last 20 years. Promoting privatization,
fiscal austerity, deregulation, market liberation, and the
cutting back of the state, these programs have increased
and globalized poverty, migration, unemployment, and
temporary work contracts, and produced extremely
polarized income and living conditions across the world
to the benefit of big capital.
AIDS was incubated and has been propagated in this
system of social inequity and it will be impossible to pre-
vent and combat it in any effective way without going
after the conditions that are generating the pandemic.
The anti-AIDS initiatives implemented by the Bush
administration and the World Bank are set within the
U.S. government’s strategy of neoliberal globalization, a
strategy that also guides the projects of the United
Nations and the WHO. All of these plans basically consist
of creating funds for channeling money donated by the
governments of developed countries and philanthropic
organizations attached to the big corporations to be used
mainly to purchase and distribute antiretroviral medi-
cines and fund AIDS prevention programs that promote
sexual abstinence. These anti-AIDS programs also serve
to reinforce the implementation of neoliberal policies in
the countries to which the “aid” is offered.
Advanced medicines must be made available to the
patients who really need them, the vast majority of
whom are from the poor countries. But the management
of HIV is complex. As even those who defend antiretrovi-
ral therapy point out, the severe toxicity of these pharma-
ceutical agents must be seriously considered when pre-
scribing their use, despite their notable effects so far.
It is important to insist that antiretroviral medicines
are not a cure for AIDS and that there is not complete
A New World of Citizen Action, Analysis, and Policy Options
p. 7
AIDS was incubated and
has been propagated in this
system of social inequity and
it will be impossible to
prevent and combat it in
any effective way without
going after the conditions that
are generating the pandemic.
unanimity on their use. There are still many questions
related to the use of this kind of therapy that science has
yet to solve. The problems related to these pharmaceuti-
cal agents, just over 20 of which have so far been
approved in the United States, include their high toxicity,
the loss of effectiveness as the organism develops resist-
ance after a certain amount of time, and the difficulty for
patients to stick to the treatment adequately.
Prevention programs must be based on scientific
knowledge about the AIDS epidemic, not on prejudices
about sexuality or people’s behavior. It is inappropriate
for the United States to establish the standards governing
the whole world, as it seeks to do in its abstinence pro-
grams. Each country, culture, and society has a right to
maintain its own standards, rules, norms, taboos, and
Defeating the Neoliberal Model to
Defeat AIDS
After 20 years of ignoring the relationship between
poverty, economic models, and AIDS, empirical studies
are finally beginning to emerge that demonstrate that the
incidence of AIDS increases with economic impoverish-
ment and that to reduce the syndrome’s prevalence it is
essential to expand and strengthen public health sys-
tems. Paul Farmer stated in his report to a U.S. Senate
Commission that the fight against AIDS is the fight
against poverty. And given that poverty in the contempo-
rary world is of neoliberal origin, it will be impossible to
defeat AIDS without defeating the neoliberal model.
Bernardo Useche is a professor at the University of
Texas’ School of Public Health and Amalia Cabezas is a
professor in the Women’s Studies Department of the
University of California, Riverside. The full version of
this article appeared in the August 2005 issue of
Revista Envio and this version is
reprinted with permission. The IRC Americas Program thanks our partners at Envio
in Managua for the translation from Spanish.
Published by the Americas Program of the International Relations Center (IRC, online at ©2005. All rights reserved.
The Americas Program
“A New World of Citizen Action, Analysis, and Policy Options”
Recommended citation:
Bernardo Useche and Amalia Cabezas, “The Vicious Cycle of AIDS, Poverty, and Neoliberalism,” (Silver City, NM: International Relations Center, December 1, 2005).
Web location:
Production Information:
Writers: Bernardo Useche and Amalia Cabezas
Editor: Laura Carlsen, IRC
Production: Chellee Chase-Saiz, IRC
p. 8 Printed on Recycled Paper
An Alternative Proposal
An alternative proposal to confront the AIDS pandemic with any
probability of success should include the following basic points:
Defend national employment and production to promote inde-
pendent economic development, guaranteeing food security
and adequate nutrition for the population. Apopulation with
severe malnutrition is easy prey for the illnesses that charac-
terize AIDS.
Stop and reverse privatizations, particularly those that have
eliminated public services and health systems, so the state
can fulfill its responsibility to provide services and treat those
Allow the production of generic medicines, eliminating patent
monopolies conceded by the WTO to pharmaceutical transna-
tionals under the guise of respecting intellectual property.
Expand prevention and treatment of drug addiction as an inte-
gral part of AIDS prevention and treatment.
Guarantee the necessary scientific debate on the causes, pre-
vention, and treatment of AIDS.
Research cannot be limited to the commercial interests of a
handful of companies that invest more money into publicizing
a few profitable products than into basic research to develop
the medicines that are really needed.
Resisting the discrimination and stigma attached to people and
communities affected by the epidemic must be an integral part
of confronting the AIDS pandemic. Stigmas fuel, reinforce, and
reproduce existing inequalities related to class, race, gender,
and sexuality.
... Supported by the existing literature [14,22,28], we ask for the intersection between gender, race, social inequality and HIV vulnerability in Colombia. Studies across Colombia do suggest that HIV infection is related to social inequity and political economic forces since most people living with HIV are poor and have minimal access to health care, education, and secure jobs [36][37][38][39]. Our study took place in Cartagena -the country's main port city on the Colombian Caribbean Coast-, which reported an HIVincidence of 21 per 100,000 inhabitants in 2009, much higher than the national average, of which 95% were acquired by heterosexual contact and 70% were identified as women with a stable partner [40]. ...
... The interplay of inequalities that take place in Cartagena mirrors the global system of inequalities that led to HIV infection discussed previously in the international literature [29,36,53,[57][58][59][60][61]. However, the specific insertion of a racialised global sexual tourism industry, within embedded historical structures of racialisation and marginalisation, suggests a historically-driven connection between social inequalities, racialised sexualities and sexual tourism in setting the scene for HIV infection and vulnerability in Cartagena. ...
Full-text available
Background: Cartagena, Colombia's main port on the Caribbean Coast, reported an HIV incidence of 7.5 per 100,000 inhabitants in 2007 with 90.0% transmission by heterosexual contact and 70 identified as women with a stable partner. Studies across Colombia illustrate that HIV infection relates to social inequalities; most people with HIV live in poverty and have minimal access to health care, education, and secure jobs. The purpose of this article is to analyse the relationship between social inequalities, sexual tourism and HIV infection in Cartagena, Colombia. Methods: Data come from a five-year participatory ethnography of HIV in Cartagena in the period 2004-2009, in which 96 citizens (30 of whom were living with HIV) participated in different data collection phases. Techniques included participant observation, in-depth interviews and thematic life histories. Out of this material, we selected three life histories of two women and a man living with HIV that are representative of the ways in which participants expressed how social inequalities make it virtually impossible to engage in safe sex practices. Results: At stake is the exchange of condomless sex for goods within the widespread sexual tourism networks that promote an idealisation of dark-skinned men and women as better sexual performers. Our results illustrate the complex interplay of social inequalities based on class, skin colour, gender and sexual orientation. Furthermore, they suggest a synergistic effect between poverty, racialization, and gender inequalities in the historical maintenance of social dynamics for a fruitful growth of a sexual tourism industry that in turn increases vulnerability to HIV infection. Conclusions: Although the convergence of social inequalities has been thoroughly reported in the literature on social studies of HIV vulnerability; distinctive dynamics are occurring in Cartagena, including a clear link between the contemporary globalised sexual tourism industries and a racialised social structure - both having historical roots in the colonial past-.
... The lack of empathy in neoliberal policy has not gone unnoticed by its critics. For example, according to a report by Useche and Cabezas (2005) neoliberal policies have been complicit in the uneven incidence of HIV infection. They maintain that, in its emphasis on the bottom line, neoliberal structural adjustment policies have been insensitive to the AIDS pandemic. ...
Full-text available
This doctoral dissertation reports on a participatory ethnography of HIV/AIDS in Cartagena, Colombia conducted in collaboration with 96 inhabitants. The main objective of this study was to obtain a thorough understanding of the comprehensive social context of HIV infection and vulnerability in Cartagena. The 96 inhabitants involved in this participatory ethnography represented various areas of the city and included inhabitants from diverse ethnic, gender, sexual orientations and socioeconomic backgrounds, representatives from local government and nongovernmental organizations, and people living with HIV (LWH). Participants took part in the study through open-ended interviews (40 individuals), life histories (30 individuals), focus group discussions (26 individuals), and multiple conversations about research focus, methodology and results. As part of the participatory approach, these participants were also invited to share their views on necessary actions and priorities to address the local epidemic. To further our understanding of how HIV infection takes shape in everyday life, the 30 life histories that participants LWH shared, were separately analysed by the author of this dissertation. This doctoral dissertation, presents the process and outcomes of this participatory ethnographic approach as well as the author’s reflections on the process and outcomes of this research. While Chapters One, Two and Six are not presented in the edited version submitted to international peer-reviewed journals, Chapters Three to Five comprise co-authored papers in the format in which they have been published or submitted to peer-reviewed journals. Chapters Three and Four each present different sections of the outcome of the collective analysis, the ‘Local-Scientific diagram’ (L-S diagram) that provides a schematic overview of elements and processes of the social context of HIV infection and vulnerability in Cartagena, also illustrated by the life histories. Chapter Five focuses in further detail on the L-S diagram and discusses the proposals of participants for actions towards HIV prevention. Chapter One exposes the need for an ethnographic study to understand the complex and dynamic character of the social context of HIV infection and vulnerability in Cartagena. Departing from concepts of ‘environment’, ‘social determinants’ and ‘social context’ used in Public Health, Medical Anthropology, Sociology, and in the Latin American Social Medicine tradition; the operationalisation of the concept ‘social context’ used in this dissertation is revealed as: as complex and dynamic socio-historical processes in which diverse elements (i.e., local-national-global cultural notions, historical, structural, political and economical processes) interact setting the scenario for HIV vulnerability and infection. This operationalisation was applied in the process of our participatory research, in agreement with the participants and based on the findings of our collective research. Chapter Two presents in detail the methodology used in this five-year participatory ethnography conducted between 2004 and 2009 with 96 citizens of Cartagena. In this chapter it is described how different participatory methods and data collection techniques were used throughout 6 steps, in which participants were involved as active actors in the research process. For example, in the first fieldwork, through indepth interviews with participants not living with HIV and life histories of inhabitants living with HIV, several local and structural elements related to the high rates of HIV infection in the city became evident. In the second fieldwork, group discussions with participants in the first fieldwork, with groups of key representatives of local governmental and non-governmental organizations and with people who were interested in the epidemic and/or affected by it were conducted to critically evaluate the analysis made by the researcher of the previously-collected data. In these group discussions, the local and structural elements were discussed in a process of collective analysis that resulted in a Local-Scientific diagram. Later, in the same groups and based on the Local-Scientific diagram, participants formulated proposals for structural actions towards HIV prevention. Chapter Three focuses mainly on the elements of the social context of HIV infection related to the cultural notions of illness, risk and gender roles. It is shown how participants’ everyday interpretations of HIV/AIDS, their views with regard to risk of infection, and the preventive strategies they use can be interpreted as a contemporary bricolage (i.e., a construction resulting from a process in which people make sense of reality and act upon it by actively merging elements from different discourses). This bricolage involves merging local conceptions with elements from health professionals’ discourse on HIV. We describe the traditional gender roles of machismo and explain how participants in our study considered the transgression of traditional gender roles to be a major risk for HIV infection. We illustrate how participants integrated the concept of ‘risk groups’ (i.e., sex workers and MSM), which are broadcasted through mass-media and other HIV prevention interventions, with local gender roles constructions and show how they accordingly created the notion of “AIDS carriers” (“women from the street” and “men who allow penetration by other men”). This notion, in turn, structured participants’ everyday interpretations of HIV infection, risk and prevention. The latter, namely avoidance of sex with people identified as “AIDS carriers”. We argue that in trying to understand and deal with phenomena such as HIV/AIDS, people do not replace local discourse with professional knowledge provided by Public Health Institutions, but rather select familiar elements from available sources (e.g., HIV prevention campaigns, radio, newspaSUMMARY 121 pers, and local discourse) and actively fit them into a local cultural logic. We argue that insight into these contemporary bricolages allows us to see how Public Health discourse rooted in individual prevention and ‘risk groups’ are easily reinterpreted as part of the logic of machismo’s traditional gender roles; and therefore it paradoxically increases inhabitants’ HIV vulnerability, stigmatization of people living with HIV, and intolerance to sexual diversity. Moreover, we argue that although these bricolages and the consequent preventive strategies seem to increase HIV vulnerability, participants still create room for critical reflection on their interpretations, and have awareness of inherent contradictions in these interpretations. In other words, participants realised that changes in their own perceptions of risk were necessary to confront the local HIV/AIDS epidemic. Chapter Four centres on the interplay between local and global elements of the social context of HIV infection in Cartagena and discusses social inequalities, poverty and the global trend of sexual tourism. In this chapter we explore the relationship between diverse social inequalities, national and transnational sexual tourism, and HIV infection in Cartagena as depicted in the L-S diagram. With the help of examples from three thematic life histories of a man and two women living with HIV, we show how the interplay of social inequalities based on class, skin colour, gender and sexual orientation, as well as the way in which such inequalities merge with the growing sexual tourism industry in Cartagena, play out in real life and how they impact people’s vulnerability to HIV infection. The chapter paints a synergistic effect between poverty, racialisation and gender inequalities, and links the historical maintenance of racial and other social categories with the increasing growth of the sexual tourism industry and vulnerability to HIV infection. We claim that although the convergence of social inequalities has been thoroughly reported in the literature on social studies of HIV/AIDS; distinctive dynamics are occurring in Cartagena, such as the clear link between the contemporary globalized sexual tourism industries and Cartagena’s racialised social structure, -both of which have historical roots in the colonial past-. Chapter Five describes the two main results of the collaborative analysis conducted in Phases II and III of our participatory ethnography. First, we present the L-S diagram that pictures HIV infection in Cartagena as a social phenomenon. This phenomenon is rooted in a complex and dynamic interplay between local interpretations of body, ethnicity, class, gender roles, family structure, sexuality, sexual risk, the historical social exclusion that derives from these interpretations, the local dynamics of the performance of the government, and the international sex tourist industry. Based on the L-S diagram, participants proposed a variety of actions to address the local epidemic, prioritizing structural actions that require involvement of multiple actors at the local, national and international level. These actions aim not only to increase risk awareness, safe sex practices and other behaviouralchanges through diverse strategies rooted in the local culture (i.e., critical reflection through de boca en boca and conversaciones grupales), but also to generate largescale structural changes by the government and the private sector including health insurance companies and the tourism industry. Chapter Six presents the author’s reflections on the implications and contributions of the findings of this doctoral research to the analysis of social contexts of HIV infection and vulnerability, as well as to the local response to the HIV/AIDS epidemic. It is argued that the richness of the collaborative analysis conducted in this study, the consistency of its findings with those of international studies and their further confirmation by the examples supplied by the life histories, suggest that a methodology of participatory nature that ensures careful attention to and inclusion of participant voices and experiences is an important tool in problem analysis and needs assessment in health promotion. It is also stressed that the results obtained through the use of our methodology not only reinforce the need for the academic sector and the civic society to play active roles in the fight against AIDS, but also suggest that the inclusion of participants as partners in the research process could contribute toward a democratic construction of social policy and public health actions. Limitations in the sampling and analysis processes are discussed. Challenges in the participatory nature of the methodology are highlighted, such as the difficulty to reach a balance in the relation between participants and researcher. It is explained how constant efforts to reach some degree of balance in the dialogue were made by the researcher through reflection exercises and the continual requests for feedback from the participants regarding her interpretations and analysis of the shared information. In line with the proposed joining of forces of the academic sector and civic society in the fight against AIDS, it is stated that the dialogue does not end here and further participatory research around the initiation, implementation and evaluation of the proposed actions is required. To conclude, it is maintained that partnership with populations during the research process such as the one created in this study should be part of any future HIV project, along with careful reflection on the methodological challenges that come with such an approach.
Stigma and discrimination towards individuals infected with HIV or AIDS have been recognized as worldwide issues, but they show specific characteristics among different socioeconomic and cultural contexts. It is a complex and dynamic process whose genesis, manifestations, and consequences are influenced by different elements that interact from biological to social dimensions, affected by prejudice and social inequalities. The approaches for the explanation and understanding of these processes have been diverse: theoretical reflections through historical, psychological, social, or mixed focuses and empirical tests through quantitative and qualitative research. In this chapter, we discuss issues related with HIV infection in the world and Colombia, based on a review of empirical research and different conceptual approaches to theories of stigma and discrimination in health, reported in local and international literature. We reviewed the medical, political, social, and cultural aspects that underlie stigma and discrimination associated to HIV infection, as well as the ethical and legal regulatory responses, and explored their relationship with the perceptions of those who suffer experiences related to stigma and discrimination worldwide and in Colombia. Our review and hermeneutical analysis of the rulings of the Colombian Constitutional Court in response to the writ for the protection of fundamental rights filed by people living with HIV, illustrates with examples the rifts and gaps found between ethical and legal theories based on fundamental rights and the right to health in Colombia.
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