When we attempt to fully understand how HIV/AIDS has become so prevalent in so many countries, especially in Southern Africa, we very quickly find ourselves discussing structural economic change, poverty, globalisation, transnational corporations, imperialism, gender bias, and capitalist property rights. Our understanding also calls for a comprehension of the dynamics of peasant societies and of urban and peri-urban links with rural households through migration, remittances and the mutual interdependence of kinship and family obligations. In addition, there is also the role of belief systems, and the problem of how we interpret these as ideologies premised on pre-capitalist versus capitalist, or global capitalist, production imperatives, touching on such areas as stigma, ‘family values', women's role, or clinical versus faith based treatments.
It is through such channels that HIV/AIDS strikes at the heart of the labour reproduction process, and in the various responses, which it then prompts from capital and state it serves to highlight both the adaptability and the fundamentally entrenched nature of that process within a system that is no less capitalist than it is global. These aspects are explored further by Bujra elsewhere in this issue but we should note here that the process does not occur in a historical medico-social vacuum. Important questions arise when trying to account for widely different experiences across the continent, ranging from the exceedingly high rates of much of Southern Africa, where the history of migrant labour and divided families is strong, to the relatively low rates of HIV prevalence in most of West and North-East Africa, but where low national rates disguise wider regional variations within countries which are difficult to explain, together with more obvious rural-urban differences. In other parts of the continent there are unknown, but very probably high, levels of incidence in war-torn regions with large numbers of displaced people. Yet it is an oversimplification to identify poverty and civil disorder alone as a key driving force in the spread of the pandemic when one of the highest rates in Africa is found in Botswana, which also has one of the highest levels of per capita income south of the Sahara.
In the most stricken societies, where rates of both infection and affliction of HIV/AIDS are highest, the impact on everyday economic production is profound. Macroeconomic calculations often put the impact at a reduction of between 1% and 2% in the annual rate of growth of GDP for the duration of the pandemic where levels of positive seroprevalence of above 20% of the adult population prevail, as in South Africa, Botswana, Zambia, or Lesotho (UNAIDS, 2004). On a day to day level, in rural areas these aggregate percentages manifest themselves in reduced time preparing, tending and harvesting crop and livestock, in absence for funerals, in reduced marketed surplus, and diminished skill acquisition by orphaned children, while in the employed sector the direct impact is felt in high rates of absenteeism due to sickness and attending funerals, in low levels of productivity, in high rates of attrition, loss of skills, and high annual recruitment costs.
Globalisation
It is ironic that the direction of these trends should coincide with that of those global forces which are ensuring that African production remains predominantly agriculturally based, or at most at the preliminary stages of processing. The combined impact of trade liberalisation in developing countries, continued agricultural subsidies in the European Union and the US, and restructuring of the food supply chain by transnational corporations to favour contract producers all have made it increasingly difficult for African countries to escape from their historical dependency on raw material exports, creating, according to Gibbon, a revived form of mercantilism (Gibbon, 2004) within the global economy. Globalisation thus has many facets. The trend towards contract farming which favours large commercial farms or plantations (in tea, coffee, green vegetables, cut flowers) increasingly marginalises small peasant producers together with their local traders, forcing many to take employment as day labourers on commercial farms, others to migrate to urban centres and, particularly young men, to engage in extra-legal activities or banditry or young women as bar workers. These examples of peasant labour displacement are seen by some as the manifestations of a wider restructuring process of de-peasantisation (Bryceson, 2000).
If we add the impact of HIV/AIDS to these trends it is clear that the small farming household, or low-wage earning household, has come under increasing pressure from two arms of a pincer movement: the direct and indirect costs of adult morbidity on farm production due to the effect of HIV/AIDS, on the one side, and the driving forces of international capitalism favouring large scale commercial agro-produc-tion, casualisation, outsourcing and contracting out of wage labour, on the other. The net result is that the burden of the costs of AIDS falls primarily upon the families of those infected, generating at the micro level a downward spiral of decreased productivity, diminished income, reduced nutritional levels, increased proneness to opportunistic disease, eventual death of one or more adults and the likely collapse and break-up of the household. The latter outcome in turn puts pressure on other households within the extended family as increasing numbers of orphans and other dependents have to be accommodated, often accompanied by significant gender implications for widows and orphaned daughters. Where the disease affects family members working in urban areas or in migrant jobs elsewhere then remittances will decline and possibly cease altogether while the person suffering from AIDS will frequently return to their home village seeking help and support in their illness. The effect of the loss of productive ability is compounded by the high costs of medication from both formal and informal sources and in social terms by the stigma which appears universally to be attached to this disease. Poor peasant households thus break up and middle peasantries find themselves increasingly impoverished. Rather than the generalised de-peasantisation of Bryceson and others, perhaps a more accurate description is a re-peasantisation, at least for the many for whom the process of primitive accumulation which produces a middle peasantry (or yeoman class) is halted, while the abandoned land holdings of the worst afflicted households are taken up by richer peasants and consolidated into fully market oriented small-scale commercial farms. Thus the process of capitalisation of agriculture accelerates while income and wealth differentials widen.
The impact on the poor and the impoverishment of others is not, of course, unnoticed by many governments and international agencies–resulting in a multitude of aid programmes, with varying degrees of coordination and commitment, now being implemented. The humanitarian response is invariably compromised, however, by the geopolitical objectives of donor nation states and those who control them–hence conflict and social dystopia in the eastern Democratic Republic of Congo attracts less international attention than the fear of instability in the oil rich Middle East. Yet, in so far as these compromises are the product of the drive to create the conditions for further capitalist globalisation, they also do not neglect totally those troubled parts of the world which are not necessarily of immediate concern to international capital and its agents but whose continuing instability carries potential threats. So the advanced capitalist nations of the world, led by the United States, have also responded to the HIV/AIDS pandemic in Africa as a crisis, which is not in their interests to ignore. This is evident in the fears by both the Clinton and Bush administrations that HIV/AIDS raises serious strategic and security threats to the USA itself through a perceived potential for political and economic destabilisation in the worst affected areas (O'Manique, 2004; Tsadkan & de Waal, 2003).
The nature of the response by the West, however, reveals the complexity of contemporary links between capital and state (national and international) and their various ideological mutations, representing in the United States, for instance, the outcome of intensive lobbying by 'faith-based’ groups in civil society on the one hand, and by US based transnational drug companies on the other. The influence of each of these major constituencies is subsequently felt in US policy on international forums such as the WTO and UNAIDS conferences. At the national level of countries with high rates of HIV prevalence, a parallel set of internal confrontations and negotiations are present. Thus, indigenous churches, local branches of international churches, village committees, and Cabinet members alike, often highly patriarchal, tend to promote ‘traditional family values', prohibiting sex before and out of marriage as the principal means of turning the epidemic around. A similar pattern is present in Islamic communities in Africa, though there can be a tendency there to see HIV/AIDS as a disease of Christian societies. At the same time, western trained medical professionals seek extra funding for clinical research and treatment while, as in the Western industrial complex, representatives of local business–those who wish to manufacture, import or sell drugs and other medical aids to counteract the effect of HIV in all its manifestations–press their interests on national governments.
International capital & ARVs
The various points discussed above, which are the constituents of a political economy of HIV/AIDS, come together again in the example of the provision and availability of antiretroviral (ARV) drugs to control the growth of the HIV virus within the human body, and in particular the combination of three drugs known as HAART (highly active antiretroviral treatment). Here we have, at one end, the consumer, victim or patient, and at the other, a series of strands leading to different suppliers, which include the major international pharmaceutical companies. Between these, and intercepting according to how their remit is defined and interpreted, there are the international trade institutions such as the WTO and national governments representing the interests of consumers and producers (sometimes both within the same country). Consumers, or patients, may not be the same as the purchasers who are likely to be Ministries of Health, while suppliers will also include generic producers who are not tied to brand names and who may be located in Brazil, India, Thailand or South Africa. The usual questions then arise of who gains and who loses; who are the principal suppliers and who the main consumers, and how and why is the pattern as it is?
Antiretroviral drugs can have a dramatic effect on sufferers from HIV, not only in creating the conditions for substantially prolonging life but also, if accompanied by appropriate diet, enabling life to be fully active and therefore economically productive. It is for this reason that many larger corporations have programmes to supply ARVs to their core workforces where the cost of drugs and ancillary support are less than those of recurring recruitment and training. For peripheral workers and others less fortunate, including peasant farmers and virtually all who struggle in the vast informal sector of most African countries, the cost of effective drug treatment for HIV is totally prohibitive. For governments too, the cost of any meaningful subsidised provision to their citizens is similarly proscribing, especially in a context of often (IMF imposed) public expenditure constraint. At the time of writing, this remains so despite the fact that the drug component of treatment for HIV has fallen from $10-12,000 per annum in 2000 to around $300 in 2004 (UNAIDSb, 2004), a sum which is still out of reach of the vast majority of households in the least developed countries and elsewhere where the per capita cash income for many is no more than the equivalent of a few dollars a week.
The context for this scenario provides a revealing illustration of how 'globalisation’ may be both a useful and a limiting concept. Continued dependency of transnational corporations on the state, where it suits them and where they have been able to exercise control, is epitomised in national patent laws which protect the right to produce and sell those drugs which any given company has created. The limited time monopoly which this provides is intended to allow the inventing company to recoup its research and development costs. Given the ubiquity of the nation state, it is the national laws of each country which provide patent protection for operations within its geographic boundaries and although the WTO is often regarded as the epitome of a global organisation operating in the interests of capital, transcending the nation state in its powers, for the actual implementation of its policies it still requires national legislation. An illuminating example is found in WTO agreements on Trade Related Intellectual Property Rights (TRIPS) in which all but the least developed countries must have patent legislation in place by 2005 and the least developed themselves by 2016. With this in place transnational pharmaceutical companies can patent, for sale or production, their brand named drugs in those countries. The principal reason driving this internationalisation of common legislation is the difficulty corporations have in protecting their new products from plagiarism. Drugs formulae seldom remain secret for long (otherwise the need for patent protection would disappear) and competitor companies, often in middle-income countries, are able to produce ‘generic’ versions under different brand names to be sold at considerably lower cost. These competitive market forces, which proponents of the market system proclaim as so beneficial, do not in this case suit the large pharmaceuticals, and it is the purpose of the TRIPS agreements when they are fully in place to control generic production (Subramanian, 2004; Shadlen, 2004; Correa, 2004; Ford, 2004).
However, although the international TRIPS agreements have been promoted and driven through by the governments of industrially advanced countries representing the interests of the major pharmaceuticals, they do not leave institutional purchasers in developing countries totally powerless: by issuing, or threatening to issue, a ‘compulsory licence’ to allow either local manufacture or importation of generic alternatives to branded drugs, a third world government can exert pressure on suppliers to reduce prices. Of course, the transnational pharmaceuticals may get around this, partially, by establishing or acquiring their own subsidiaries for the local manufacture of generics or, as in the cases of Brazil and South Africa, pressure the US Government to threaten trade and aid sanctions unless the restrictions are removed (O'Manique, 2004; Gray & Smit, 2000). Sometimes public concern (expressed for example, through campaigning groups such as TRAC in South Africa) over the severity of the AIDS problem in certain countries, such as South Africa allows a series of compromises, albeit tightly controlled, between the pharmaceutical transnationals and governments of developing countries, negotiated partially in the Doha meeting in December 2001 and clarified to some extent in the subsequent 2003 Geneva statement whereby least developed countries without their own manufacturing facility and others in a crisis situation with HIV/AIDS may continue to import generics from countries like India or Brazil (World Trade Organisation, 2004). This particular struggle is ongoing. In May 2005, the US Government announced a ‘fast track’ registration process for foreign generics to be approved by the US Food and Drug administration (USFDA), prompting a collaborative response from Bristol Myers Squibb, Gilead and Merck to counteract with their own cheap combination ARV drug ( The Guardian, 18 May 2004). What is given with one hand is, however, taken away with the other: At the July 2004 International AIDS Conference in Bangkok both President Chirac and Oxfam accused the US of introducing stricter patent laws into the terms of bi-lateral trade agreements with a number of developing countries which were capable of producing generic ARVs ( The Guardian, 14 July 2004). If, therefore, cheap anti-HIV drugs are seen as an inevitable concession, then the pharmaceuticals will make sure that it is they who either control or produce and profit from them, though it is interesting that the site of legal challenge includes not only the WTO but national courts with notable examples particularly in South Africa and China (The Guardian,18 August 2004 and 21 August 2004a).
The debates and negotiations over ARVs at the WTO arise automatically from the way in which the provision of health care through the market favours those who can pay most. Thus, most research is into diseases which affect the affluent consumer market in the West such as ageing, heart disease, and various cancers, while those which are most pressing in many poor communities, especially in the tropics, such as malaria, TB, dysentery, cholera, receive relatively little attention by comparison. One may argue that the very existence of effective ARVs is as a response to the initial fears about HIV and AIDS in the West and to powerful lobbying by well-organised interest groups, though the counterpart is their high cost. The outcome of providing branded varieties to poor communities elsewhere in the world at reduced prices, as a result of public pressure, is for prices in the industrialised West to remain high. This is only possible if arbitrage between markets is prohibited and can be monitored–hence the regulations which have to be in place in all countries by the deadline of 2016. It is thus the consumers of the high-income countries who are subsidising the provision of cheap ARVs in low-income countries. In somewhat old-fashioned terminology, it is the labour aristocracy of the West which, through its various medical insurance programmes, is allowing pharmaceutical capital to recapture sufficient economic surplus to be able to offer low price drugs to poor countries, and hence to soften its public image. To recap on an earlier point, it is an alliance between nation state and international capital, which facilitates and sustains such market discrimination. Such observations remind us that our understanding of the social reproduction of labour depends not upon debates between ‘the West’ and ‘the rest', or America and Islam, but between capital and labour in a complex local-global nexus. Signs of this are evident, for instance, in attempts by the state of Illinois (US) to import cheaper drugs from Canada in contravention of local US regulations (Guardian, 21 August 2004b).
Cures, culture & commodification
Even at the vastly reduced prices at which generic production of anti-HIV drugs are now available, the cost of 'rolling these out’ to the large and diverse community infected with HIV in many African countries–including the associated administrative, testing, follow-up, and monitoring costs–remains prohibitive for both governments and the majority of individuals, except amongst the better off in a few countries such as South Africa or Botswana. This, of course, is not a new phenomenon having been the situation regarding treatment and prevention of many other diseases for many years–but the additional costs of HIV related medication vastly intensify the pressure on existing resources. A pressure, which once again is being squeezed on one side by international forces, this time those of the International Financial Institutions as they impose fiscal discipline on conditions for debt relief and official aid. It may be argued that some attempt is made to soften the impact by linking the former with Poverty Reduction Strategy Programmes (PRSP) to ensure that economic efficiency gains will benefit the poor, but in a context of externally determined public expenditure limitations this is window dressing of what is essentially Structural Adjustment continuing under another name in which the patient is forced to dance to the piper's tune. Moreover, governments are locked in not only to the rules of official lenders and donors but also, by virtue of subsequently depending upon private charity, to the values, objectives, fads and fashions of NGOs from the West; and while many of these are honourable, open minded and sympathetic in their dealings with host governments, others carry a set of beliefs and values which promote and perpetuate a longer term agenda of religious or neoliberal right-wing ideology, and which as a result will support only a strictly defined range of assistance to HIV/AIDS problems which ignore historical and structural factors.
The absence of effective biomedical treatment, even for many in the middle class in most African countries, either for reasons of cost or because of a focus on preventative behavioural change means a dependence on other more readily available, but less effective, forms of medication. At the local and personal level a variety of often overlapping networks of traditional and civil society organisations come into play–each offering a sanctuary to those many thousands of infected and affected individuals and household members who feel helpless in facing up to the implications of the disease when they cannot afford sustainable treatment. Amongst the most important of these, organisationally and politically in many countries, are the religious communities, particularly those with continuing links to international parent bodies, such as the Roman Catholic, Anglican and Seventh Day Adventist churches. Others are independent offshoots of these, many of which also claim to provide miracle cures, which have mushroomed to such an extent in Nigeria that the government has banned television channels devoted to their promotion ( The Post, 11 June 2004). In so far as communicants pay financially to their church, there is considerable commodification of belief which therefore incorporates the possibility of cures for HIV/AIDS and other diseases into its domain. For many people living with HIV/AIDS, their faith also extends to the skills of traditional doctors and herbalists, while for others their religious faith overlaps with non-Christian or non-Muslim belief in traditional cosmology and the spirit world as expressed through witchdoctors.
This extensive informal array of traditional, religious and spiritual practices plays an important role in many societies in providing explanations for the appearance and transmission of HIV, in interpreting the official messages regarding its prevention, and in offering alternative cures and palliatives. In one sense, the strength and pervasiveness of these institutions may be regarded as a response to exclusion from Western scientific bio-medical treatments: an exclusion determined by political and economic structures often with global tentacles as outlined above, but in another, they also reflect the depth and institutional complexity of ‘traditional’ societies in their negotiation with externally introduced change. To the extent that a parallel ‘market’ in medicines, palliatives and ‘cures’ (including ‘miracles') remains separate from the formal health sector, there are similarities with the argument of Heald (2002) that such organisations represent a local reclamation of the power inherent in knowledge that appears to have been appropriated by Western medicine
Conclusion
The observation was made above that the appearance and rapid spread of HIV/AIDS in many parts of the African continent has coincided with major changes in the structure and dynamics of international capitalism, and has impacted on land use and the composition of the labour market, affecting both extra-household and intra-household relationships. In a sense, one might say that the coincidence of the HIV/AIDS pandemic with the various manifestations of capitalist adjustment is no more than that–a happenstance or conjuncture of a disease-related disaster and the impact of certain international trends at a particular stage in their development. This would be too simple, however, and not only because of the links between vulnerability and social disruption, structural adjustment and changes to international markets. These have been present in other continents where the impact and prevalence of HIV/AIDS has, at least to date, been less severe. The questions to ask are–why Africa, and why so soon in Africa?
To point, as many Afro-pessimists do, to such factors as corruption, political instability, civil war, or long-term economic mismanagement, is only to beg the further question of what lies behind these direct causes were we to accept their validity. Although the answer to that question is elusive and complex, by taking the longer view we can approach some form of understanding which goes beyond mere conjuncture, an approach which begins by returning to my opening paragraph where reference was made to the impact of the slave trade. Although almost impossible to quantify, the long-term costs of that episode in terms of state formation and economic development have been assessed as critical, most notably by Walter Rodney writing in 1972, some two years before the first edition of this Review. The intergenerational impact on stunted institutional development and transfer of skills, knowledge and experience created by the trade in slaves extended into the later expansion of colonial penetration (with important variations in the settler colonies of east and Southern Africa), which, as has been well documented, at its best in various forms of 'benign neglect’ did little to lay the foundations of any sustainable form of ‘economic take-off’ during the immediate period of independence in the 1950s and 1960s. At the same time, the advanced capitalist nations, building in great part on their colonial assets, experienced continual expansion, especially during the second half of the 20th century, to metamorphose into their globalised character by the later decades of that century–just at the time when the HIV virus was entering the human chain and ready to take off at its weakest points, many of which were to be found in the legacy of exploitation, neglect and structural dislocation in Africa, especially Southern Africa. The consequence, if unchecked, will amount virtually to a repetition of the impact of the slave trade with considerable threat once again of extended intergenerational negative consequences (substantiated even by mainstream economic projections (Bell 2003)–and by FAO field studies (UNFAO, 2004b).
The point, however, as readers of this Review will appreciate, is not only to understand society but to change it and hence to pre-empt the dire outcome predicted at the end of the previous paragraph. For this it is not sufficient to join calls for changes of attitude amongst young people or for governments to provide more publicity and education. The challenge presented by HIV/AIDS is a challenge against the established order and its historical legacy, it is a call for intensified struggle to remove exploitation that creates poverty, to provide free medical treatment at point of delivery, to divert resources to the improvement of public health services such as clean water and efficient sewerage, to equalise male and female legal rights and facilitate access to their benefits, to eliminate protectionism by private business interests whether in the form of patent laws or farm subsidies, and to create an effective general educational base for both sexes. And finally, to remove religious and ethnic bigotry and stigma. The social and economic factors which lie behind the spread and depressingly high levels of HIV/AIDS in so many African countries today are the product of the same international capitalistically driven forces which were so relevant at the foundation of this Review in 1974, and the human tragedy of its impact underlines the continued relevance of the Review in providing a channel for oppositional debate, awareness raising and the intellectual and moral support that is essential for those among us who are activists in the field and behind the scenes.