I’ve just returned from a drumming ceremony commemorating World AIDS Day 2010. In my more jaded moments, it’s easy to dismiss these sorts of days as attempts by silos of the public health community to get their share of the limelight. But for those living with HIV and on the front lines of the fight, there is a poignancy in taking a day each year to reflect on where we are in the fight against a pernicious and deadly disease.
If drums are used to signal both celebration and preparation for the coming battle, then bring on the drums please.
Let me start here: I do think we’re winning this fight. The recent debates (sparked, in part, by the seminal NYTimes article on ART treatment in Uganda) raging about decreased funding and flatlining of ART enrollments are, to my mind, symptomatic of our success. The recent naval-gazing by HIV programmers in general is a sort of collective psycho-analysis. In many ways, those in HIV are like trained sprinters who mistakenly set off on a marathon. Several miles and three decades in, many feel that they’ve run well, run far, run fast – but the journey hasn’t come anywhere close to the finish line.
I think there is reason to take heart. The Wall Street Journal recently published two essays by Bill Gates and Matt Ridley debating Ridley’s new book “The Rational Optimist”. John Maudlin emailed the essays yesterday, with some fun commentary as well. The essays debated Ridley’s position that, to put it (very) simply, things really do seem to work out in the long-run. Gates’ posits that it’s our global focus and, well, pessimism, that allows to socially innovate and find solutions.
But the reason I found this debate so exhilerating is that we’re at this crossroads now with HIV/AIDS. There is a general sense of relief that people are living long and healthy lives with HIV. We’ve reduced pediatric infections by a commendable level, and the research for prevention measures has had a few tentative “light-at-the-end-of-the-tunnel” moments, even just in the last year (see the South Africa microbicide trials and the Truvado study). These are cause for celebration and optimism. At the same time, the HIV community is rightfully nervous when signs of success become trumpeted around the world. The fear becomes: what will happen if the focus and funding of the global community turns toward something else, when people start to believe that the solutions are at hand?
Do we need to be worried and fearful in order to stick to the fight? Can we be optimistic that we will win, celebrate the successes, and still garner the resources and the attention needed to see the fight through?
Gates poses that the optimist/pessimist debate obscures the bigger picture. Global financial resources are slim, institutional and individual attention spans are short, and the gravy train for HIV/AIDS funding is clearly waning. But while the tidal wave of resources devoted to HIV may be turning, I think that the receding tide will uncover resources that have been hidden in the deluge. Gates writes: “Pessimism is often wrong because people assume a world where there is no change or innovation. They simply extrapolate from what is going on today, failing to recognize the new developments and insights that might alter current trends. “
Two ideas:
First, it’s more complex than we think: I think the HIV/AIDS community needs to realize that they are but one series of episodes in a far bigger drama. NAM/AidsMap recently called this the false dichotomy of horizontal versus targeted systems in their article about how HIV programming can contribute to health systems strengthening. I enjoyed this substantive article, and I couldn’t help but think (heretically) – aren’t we (the HIV community) being a bit narcissistic? Is it really all about us? The task of re-integrating programs, organizations, theories and even the health of people and communities back into the larger context of society has the allure of stretching limited resources far beyond their current capacity. It’s a huge task, and stepping down from our HIV bandwagons could be a first step.
Second, it’s more simple than we think: In our fervor to “cure” and to “prevent”, we’ve forgotten that the power to heal resides within. Ok, that’s not a bunch of mumbo jumbo. In HIV, as with all chronic illness, the power to take preventative measures and adhere to treatment – essentially to keep ourselves well – rests on our own ability to make decisions about our lives and influence our families and communities to positively do the same. The greatest gains in HIV prevention have been made when communities come together to share information and support each other (see Helen Epstein’s work). These are not fancy interventions or expensive programs – but they require diligent attention and personal investment in the people around us. In our religious belief in “the system”, we’ve forgotten about the original system – our humanity. Let’s go back to our roots. Let’s tell people around us what is happening and enlist their compassion. Let’s educate each other and be open with our fears. And then let’s mobilize our communities around us – in New York, in Kigali, in Bangkok – to do the same. It’s simple and it’s healthy and it can make a profound difference.
To some degree, I feel that Gates and Ridley are both circling around the same conclusion. As humans, we’ve had a pretty strong success record of solving seemingly intractible problems. We’ve had a general upward curve on life, liberty and (mostly) social justice. But let’s give credit where credit is due. Fear and worry may ignite the fire, but the power to imagine and the instinct to help one another will take us across the finish line.
