Fighting AIDS or responding to the epidemic : can public health find its way ?

"AIDS is first of all a [. . .] issue". The sentence is found in scores of documents drafted by national and international organisations. The word in parentheses tells us much about the author and contributes little to the understanding of the syndrome or its spread. For the health educator searching for messages to alter attitudes and behaviour, infection with human immunodeficiency virus (HIV) is above all an individual and behavioural issue; for the social and economic planner it is a social issue; for the gay or feminist activist it is a human rights issue; for the public health specialist it is a health issue; and for the international bureaucrat it is a multisectoral issue. This last definition has the advantage of being almost unassailable because nobody really knows what it means outside the boardroom, where terms like this have their own reality.

A complex issue, by definition, has many different facets. There is no reason why HIV should differ from any other aspect of the human condition. Cardiovascular disease is a social issue; war and unemployment are health problems; and hydroelectric power generation raises questions about human rights. We seem to be perfectly content to live with this complexity, so why is there a compulsion to define exactly what kind of issue AIDS is?

The answer to this question lies in the peculiar nature by which HIV entered our collective conscience. When the world first heard about HIV, when "global mobilisation" began, AIDS was an abstract concept to all but a few groups who had already experienced death and sickness in their midst. Even now, over a decade into the epidemic, this is the prevailing situation in a large part of the world. The idea that HIV was a microbial invader that had to be fought with a single-minded and not too complex machinery was a choice few of us questioned because abstract problems lend themselves to simplistic solutions. Why introduce complexity where no complexity is experienced? Thus the "global fight against AIDS" was born, modelled on the tried although not always successful recipe of disease eradication, and borrowing the jargon of war to inject it with passion.

The same documents that declare AIDS to be one issue or another bemoan the problem of the war on HIV in their first paragraphs: "In the absence of an effective vaccine or cure . . .". In other words, a traditional war was being planned, but there were no traditional weapons. The search for the magic intervention began. Was it to be health education, abbreviated as IEC (for information, education, communication) to give it a high-technology flair? Low interest credit for women? Condom social marketing? Community development? Peer education among prostitutes? Sexually transmitted disease (STD) control? Female education? Whatever the intervention, it had to show results and it had to be cost-effective. The representatives of the financing agencies demanded as much.

A successful war demands an army of loyal soldiers, and the public health professionals and their institutions quickly fell into line. They become instant health education experts, condom marketers, community developers, and, of course, cost-effectiveness analysts. Some even became quite good at it. But where was the discipline of public health? It seems that it moved to Cuba, where, as Scheper-Hughes tells us, the war on AIDS is being won with the traditional public health methods.[1] But then, the Cuban success is not quite credible, and the response is neither feasible nor acceptable anywhere else.

Every war has its victims. The victim of the war on AIDS is the discipline of public health. While our institutions are desperately searching for the recipe to "stop AIDS" as quickly and cheaply as possible, our attention is being averted from what we know best. Is it really so important that all doctors demonstrate the use of a condom to their patients? Do we really need to spend so much time and effort to find the conclusive proof that treatment of sexually transmitted infections slows the spread of AIDS? Do we need a high-powered public health professional to coordinate the activities of prostitute collectives and boy scout troops? Surely we have enough on our hands.

The countries in which I work are facing a potentially devastating epidemic of tuberculosis. We have decades of experience on how to respond to such a threat. Why is this not the central preoccupation of the public health specialists working in AIDS? HIV has finally brought the long-hidden epidemic of sexually transmitted infections out of the closet. We know about the tremendous toll of suffering and disability associated with STDs, so why are we spending so much time trying to convince ourselves and others that STDs facilitate HIV transmission? Surely the fact that there is a serious neglected public health problem should be sufficient for us to move into action. We have known for decades that the health care services in Africa are woefully inadequate and we can now observe them being stretched to another limit because of AIDS. This is sufficient cause to rethink the methods of delivering medical care on this continent. Why are we even discussing the cost-effectiveness of screening blood for transfusion? Is it important that contaminated blood contributes little to the spread of HIV? Is that an acceptable reason to transmit a preventable infection?

The HIV pandenic has given new steam to the tuberculosis and STD treatment programmes and has led to new initiatives in providing care for the sick. It has generated improvements in the safety of transfused blood. But these are orphan activities. They have to be justified in terms of their effectiveness to stop AIDS and they are constantly threatened with cuts if they are not found to be cost-effective. All too frequently they are tossed into the salad of a project which includes anything from puppet theatre to demographic modelling.

Of course, we need public education campaigns. We need economic and demographic impact analyses. We need human rights conferences. We need puppet theatre, and we need condom marketing. These activities are all appropriate public responses to the HIV epidemic. They are as appropriate and as necessary as tuberculosis and STD treatment services. But how can one possibly measure the effects of these diverse activities on a single cost-effectiveness scale? This can only be done if "stopping AIDS" is the focus. One becomes a consumate watcher of minute trends, a neurotic seeker of minimal effects. Programmes are being evaluated to death and turned upside down regularly to concur with current fashions of what is more effective at preventing HIV infection. Technical agencies become political lobbies for the activities they have staked for themselves.

The concept of a war on AIDS with its goal to stop HIV is seriously flawed and should be discarded. Most regions in the world have a well-established epidemic of HIV. This epidemic requires a social response ranging from a review of legislation to a rethinking of the national industrial devlopment plans. It also urgently requires new programmes, new approaches, and some radical reforms in health care and in public health. These needs are unrelated to the goal of stopping the epidemic. They are the needs of adapting our public and private lives to the fact that we live in the times of HIV. The role of public health in responding to this fact should be to take HIV into consideration in the practice of public health. For me and for most readers of The Lancet, AIDS is and will always remain a health issue. But that is due to our choice of profession. Our biggest potential contribution to the global response to AIDS is to practise this profession well.

1 Scheper-Hughes N. AIDS, public health, and human rights in Cuba. Lancet 1993; 342: 965-67.