Global Health and Foreign Policy Blog

During my stay in Zambia I have been visiting many schools to interview teachers, community members and students for my internship. My main purpose is to collect information about activities related to HIV/AIDS. In interviewing the students, I mostly ask about their learning environment when it comes to lessons on HIV/AIDS. Are they able to speak freely about topics such as sex or do their teachers try to suppress them from learning more? Talking with the students can be very difficult because some are shy and don’t want to talk. I try to break the ice with a greeting in their local language followed by simple questions such as what is your favorite subject and why? Based on these answers I can tell how difficult the interview will be. I recently had an interview where students gave rather lengthy answers to the introductory questions. I knew that a good interview would follow.

Usually after the interview is complete I let the students ask me a few questions. It is no surprise that after being questioned on the way they learn about HIV/AIDS, that the students have questions on the same topic. I have been asked questions such as “What are American students taught about HIV/AIDS;” “In America, how does a person feel if they find out they are HIV positive;” and “How long can a person with HIV or AIDS live?” Stranger questions such as “If a girl has large breasts, does that mean that she is having sex” and “Does the viral load increase in an HIV positive person when they have the urge to have sex” have also crossed my path. However, on the day that I met with the talkative students, I found myself in a very interesting conversation.

I told the students that they could ask me a couple questions before I left, but as soon as I answered one question they would shoot out another one. “How is it possible for a razor blade to transfer the disease even if you let it sit for a couple of days?” “How is it that a mother’s breast milk can transmit the disease to her baby…does her blood mix in it? Every time I asked if I could go, the students said they had another question. I didn’t realize that my interview was going to turn into a mini health education class. “I heard that someone in

America made a cure. Is that true?” “Where did HIV come from?” “I heard that ARVs make people more sick, how is that?” Then there was the question that sparked a debate: “Do you think the people who make ARVs are good or bad?” At first I thought we were about to get into a deep discussion about pharma companies making lots of money from charging extremely high prices for life-saving drugs, but I was wrong.

I asked the boy what he meant and he flat out said “I think they should stop making ARVs.” He told me that people get sick, take the drugs to get better, but keep spreading the disease. Don’t make the drugs so that they will die and can’t spread HIV anymore. I asked him if he thought that all people who contract the disease will not be responsible and spread it further. He said “Let them die.” I asked what if it was his brother. He just waved his hand in the air and said “Let him die.” Then I asked him about young children who do nothing to contract HIV, but are born with it because it is transmitted from their mothers. He responded that they should be killed. Harsh words for a 9^th grader. At the time I didn’t think to ask him what would we do with all the many more orphans there would be if we just let the HIV positive people die, but I’m almost afraid of what his answer would be.

Another boy, one of the most talkative of the bunch, agreed with his friend. Both boys are members of the school’s anti-AIDS club, but apparently they are also anti-AIDS treatment. I was surprised to hear this from these students because in other schools kids told me how they are taught about stigma and to not discriminate against those who are positive. Their teachers tell them that they should be accepting and embrace those who have the disease. So the question remains: Is the treatment of people with a deadly disease and no cure in sight further promulgating this epidemic? It is definitely one way to look at this dilemma. Whether you agree with these boys or not, what I find most important is that they are seriously thinking and talking about HIV/AIDS.

This frightening image is from Lael Brainard’s “Security by Other Means: Foreign
Assistance, Global Poverty and American Leadership.” Brainard and Steve Radelet from the Center for Global Development testified at the Senate Foreign Relations Committee last week on the need to reform U.S. foreign aid. While the above picture should be sufficient to convey their main message, the testimonies are also worth reading. Both call for major reforms including the creation of one integrated agency to manage U.S. foreign aid (akin to the UK’s DFID), and a complete overhaul of the 1961 Foreign Assistance Act. Interestingly, both cite preventing and managing infectious disease epidemics as a key part of advancing U.S. national security and national values. This is a good sign that the links between global health and foreign policy are recognized and accepted, at least within Washington DC. Their testimonies, available here, are a good overview of the problems and potential reforms to our foreign aid system.

This just in: White House interferes with public health and science. In case there is anyone reading who doubts that public health is a political activity, and I assume there are not many among our readers, this Washington Post article on White House interference with the Surgeon General is required reading. And it’s not just this administration; politicizing public health is a bipartisan sport. Note that all three previous Surgeons General, under Regan, Clinton and G.W. Bush, reported political pressure to modify or stop their speaking out on important public health issues.

Rather than issuing lamentations pleading for the political independence of public health, (see Waxman’s quote in the article,) we might try accepting that public health policies that determine whether or not people become sick and die are inherently political. Maybe then the public health community will be more successful in designing political strategies that build support for needle exchange programs, sex education, and other controversial interventions for which there is abundant scientific evidence but little political support.

The good news about the HIV epidemic among India’s general population, most recently reported here, was accompanied with bad news about the epidemic for India’s armed forces and their families. In an unusual announcement, Yogendra Singh, director general of the Armed Forces Medical Services, is urging wives of military personnel to protect themselves from HIV as the epidemic spreads among the armed forces. The government is “alarmed” at the spread of HIV in the military and Singh says “the youthful, exuberant and aggressive attitude of our troops, combined with the long separation from families and high mobility has compounded the risks faced by [wives].” One might add to this list of causes the rapid growth of brothels surrounding military bases in areas where soldiers often have higher incomes than the local population. The spread of HIV in India’s huge armed forces, (with 1.3 million active military personnel, 535,000 reserve force members, and another 1.3 million in paramilitary forces,) is occurring despite force-wide HIV screening introduced in 2006.

A major driver of this problem is the large number of Indian troops stationed in the insurgency-plagued Northeast, where heroin trafficking and use has contributed to high HIV prevalence in the area, especially in Nagaland and Manipur. Lieutenant General Bhopinder Singh, Director General of Assam Rifles (one of the paramilitary forces involved in counterinsurgency in the Northeast) recently said: “Now we find more soldiers dying to HIV-AIDS than to bullets fired by militants.” I have written here about how the overlap of insurgencies, sex workers, and heroin trafficking will create black holes in India, Russia and China’s efforts to fight HIV/AIDS. India’s Northeast, China’s Xinjiang and Yunnan provinces, and Russia’s North Caucasus region (which is also seeing a rapid rise in HIV prevalence) are major internal security issues for these states, and host large numbers of government troops. These troops are at high risk for infection, and will spread the disease when they are redeployed elsewhere or demobilized. I fear these troubled regions will become drivers of the epidemic in Russia, India and China, exporting HIV, TB and narcotics to neighboring areas and undermining efforts to fight the disease in these critical states.

The better news here is the recognition that HIV/AIDS can be a greater threat to troops than combat will push militaries to expand and improve their efforts to prevent transmission of the disease. The Assam Rifles seem to have realized this, as has the Indonesian military, which saw more of its peacekeepers in the UNTAC mission dying of AIDS than combat. The U.S. Navy runs an excellent military to military HIV/AIDS training program that addresses this issue by helping foreign militaries prevent and treat HIV/AIDS in their armed forces. These military efforts should be welcomed and might help limit the spread of HIV in the troubled areas where insurgencies, drug trafficking and commercial sex overlap.