Harry Critchley argues that laws and policies can contribute to the spread or reduction of HIV infections.
The International AIDS Conference has returned to Durban, South Africa for the first time in nearly two decades. When the conference was last held there in 2000, President Thabo Mbeki shocked attendees by publicly questioning the causal link between HIV and AIDS and walking out during an impassioned keynote address by a young boy born with HIV. In a recent op-ed, South Africa’s health minister, Aaron Motsoaledi, noted that the conference in 2000 marked a low point in the country’s official attitude towards HIV/AIDS—a failure on the government’s part that is estimated to have led to nearly 330,000 premature deaths between 2000 and 2005.
In the intervening years, however, South Africa has experienced a sea change in its approach to HIV, in large part because of greater synergy between government policy makers and the scientific community. The country now operates the world’s largest drug treatment initiative and has seen significant improvements in its life expectancy and newborn infection rates. South Africa is also at the forefront of new prevention, testing, and treatment programs for HIV. The country still faces steep challenges, however. It has the largest population with HIV in the world and struggles with high rates of infection amongst young women aged 15 to 24. Nonetheless, the ambitious ’90-90-90’ UNAIDS global targets for 2020—90% of persons with HIV diagnosed, 90% of those diagnosed receiving treatment, and 90% of those receiving treatment virally suppressed—appear for the first time to be within reach.What this experience can teach us is that it is important to account for the complicated ways in which politics can influence health. Joseph Amon has stressed the need for epidemiologists to be attuned to the political dimensions of HIV. Epidemiology studies the distribution and determinants of health and uses this knowledge to promote public health. Amon’s claim, then, is that epidemiologists need to look more closely at the political determinants of health in order to encourage health-promoting action in line with the human rights obligations of governments.
If we take this kind of politically minded approach to epidemiology seriously, then we have to acknowledge that the downstream health effects of politics are not confined to low- and middle-income countries. We must be willing to cast a critical eye at high-income countries as well and consider how discriminatory policies negatively impact those at highest risk of contracting HIV, including transgendered people, sex workers, and prisoners.
A report released earlier this year by the Johns Hopkins University-Lancet Commission on Public Health and International Drug Policy does precisely this. It argues that ‘zero-tolerance’ policies that use incarceration as a drug-control measure inadvertently play a significant role in encouraging the transmission of infectious diseases both within prisons and in society more generally. The report recommends a shift away from such policies towards ‘harm reduction’ strategies that prioritize public health over criminalization.
In Canada, this recommendation is echoed in a recent statement signed by nearly 250 criminal justice and public health organizations across the country. The statement calls for the implementation of prison-based needle and syringe programs in federal and provincial correctional facilities. A strong case for such programs can be made on the basis of Canada’s commitment to upholding the human rights of prisoners as dictated by the Charter of Rights and Freedoms and UN guidelines, as well as their demonstrated public health benefits and cost-effectiveness.
The Correctional Service of Canada spends millions annually to eradicate drugs in prisons—for example, $120 million in 2008 on a large-scale anti-drug strategy—and yet research suggests that drug use is widespread, with 17% of men and 14% of women self-reporting injecting drugs while incarcerated. Studies show that people who inject drugs in prison are likely to share needles, significantly increasing their likelihood of contracting infectious diseases. A 2007 survey found rates of HIV in federal prisons 15 times the estimated prevalence in the general population, with highest rates amongst Aboriginal women. Where prison based needle and syringe programs have been implemented, results have been overwhelmingly positive. In Switzerland, for instance, over the course of a one year pilot no new cases of HIV were detected, and initial fears that the program would encourage increased drug consumption were deemed unfounded.
Harm reduction strategies are an apt focus for political epidemiology given that such strategies draw support equally from the principles that inform our constitution—the equality and intrinsic dignity of every person—and a pragmatic realpolitik that recognizes that politics only ever occurs under ‘non-ideal’ conditions. Whether in South Africa or here in Canada, a political system that makes health and well-being the central pillars of policy making will better reflect the ideals and values to which we as a society aim to hold ourselves.
Harry Critchley is a summer Research Assistant at Novel Tech Ethics, Dalhousie University.