Volume 10, Issue 4, Fall 2000

The Toughest Pill to Swallow

Amitai Etzioni

When millions are condemned to die a horrible death, it is a sin to mince words. Muted words, not to mention staying mum, make one an accomplice. The only way to battle the AIDS epidemic in Africa effectively is for African men to change their behavior. If they stop frequenting prostitutes, abstain from intercourse when they are young, and remain monogamous once they have girlfriends or wives, the rate of HIV transmission will drop fast. Indeed, in a few African countries, such as Uganda and Senegal, in which the prevailing taboos have not stopped public leaders from strongly advocating behavior changes, infection rates have dropped drastically. In Uganda, infection rates dropped from 14 percent in the early 1990s to 8 percent in 1998; in Senegal, rates are below 2 percent!

As a sociologist, I am painfully aware of how difficult it is to change culture, habits, and especially what is considered macho. But nothing less will do. Providing medical services and cheaper drugs to those already infected is decent and humane. However, the billions to be so spent will not stop one African from being newly infected.

Even at the lower costs some African leaders have demanded, antiviral drugs consume a large amount of resources. Furthermore, they must be taken properly or they will lead to drug-resistant mutations of HIV. At best it will take years before vaccines are developed, tested, mass-produced, and distributed. Behavioral changes can save lives now, and at very low cost.

What needs to be done? First, we need to overcome what remains of our own inner resistance to focusing on behavior. For too long in the United States, we faced powerful opposition to treating HIV like all other infectious diseases. Public health authorities were reluctant to promote testing and to advocate a moral obligation to inform one's past and prospective partners about one's HIV status. They claimed that once people's HIV status becomes known, they might be stigmatized or lose their job and health insurance. It was also argued that there was nothing a person could do with the information, so why bother? These arguments subsided as new laws better protected HIV patients and new drugs became available for them. As a result of these developments, our public authorities and several gay leaders have become more willing to speak up about the need to change behavior--to good effect. The more we can overcome our resistance to advocating behavioral changes, the more we will be ready to speak clearly as to what we expect from our own citizens, and the more ready we shall be to properly address those in Africa.

We must tell African leaders, intellectuals, clergy, and other opinion makers in no uncertain terms that their demands for cheaper drugs are fully understandable, but they must stop acting as if the heart of the problem is that the West has not so far provided such drugs on a large scale. Blaming the West deflects attention from what must be the first priority: keeping people from being infected in the first place. An ounce of prevention beats a ton of post-hoc treatment.

When I say we should "tell the Africans" what to do, I can practically hear objections of political correctness. We are repeatedly told that one culture is not to judge another. They engage in female circumcision? We practice male circumcision. They force young girls to marry old men? We are not respectful toward our elders. And so it goes. I will leave it for another day to sort out the ethical issues this position raises. All that needs to be said in this context is that when we can help save millions from a terrible disease and death, we are obligated to speak up.

Will speaking up make a difference? We tend to underestimate the impact of American culture on others, despite the potshots leveled at it from abroad. And speaking up should include sending to Africa a large number of our public health officials, a much increased Peace Corps contingent, and community leaders to help Africa develop the messages and social action that will lead to the needed behavioral changes.

As with other social problems we face, we have medicalized HIV rather than treating it principally as a behavioral problem. Most people who study HIV, attend conferences on it, and consult about it are medical researchers. Very few are social scientists. Medical researchers naturally are interested in the development of drugs and vaccines. They do not consider finding better ways to change sexual conduct to be their prime business. They ought to.

As a refugee from Nazi Germany, I am generally opposed to characterizing another event as a Holocaust, because I consider that an evil in a class all by itself. However, as millions die such unnecessary and horrible deaths, keeping silent now is akin to the silence of the early 1940s when the first news of concentration camps reached the West. The main difference this time around is that we know much better what is happening and what must be done. Anybody who does not focus on fostering behavioral change and who invests all hope in drugs or vaccines should consider himself an accomplice to the AIDS epidemic.

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