Bangkok AIDS Conference
Dennis Altman Plenary (Transcript)
Plenary: Ensuring Access for Youth and Women
July 14, 2004 from Kaisernetworks
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NILS DAULAIRE: Good morning. Im Nils Daulaire, the
president of the Global Health Council. Its my privilege
today to introduce this years Jonathan Mann Memorial Lecture.
I know were running a few minutes behind schedule but when
youve heard our remarkable speaker, youll be glad you stayed.
Jonathan Mann was an AIDS pioneer, the founding director of the
Global Program of AIDS at the World Health Organization, the
founding director of the FXB Center for Human Rights at Harvard
University. He and his wife, Mary Lou Clemmenspan
[misspelled?] were killed in the crash of Swissair Flight 111.
But neither Jonathans positions nor his tragic death are the
basis for our memorializing him here today. Rather it was his
moral vision and intellectual clarity. The way in which he
brought together the linkage of health and human rights not as
rhetoric but as a discipline that make him an important force
in health for the 20th and the 21st century. Jonathan taught us
a health society is not possible without a respect for human
rights and that a health individual is not possible without a
respect for her basic human dignity. He helped to recognize
that when it comes to health there is no them, only us. And
he counseled us that we could not fulfill our role as healers
unless we were willing to speak truth to power. The Global
Health Council is honored to sponsor the Jonathan Mann Memorial
Lector and particularly pleased to welcome our speaker today,
Professor Dennis Altman.
Dennis is a widely published expert on politics and
sexuality. He is a professor of politics at LaTrobe University
in Melbourne, Australia, and president of the AIDS Society of
Asia and the Pacific. Next year Professor Altman will take up
a visiting professorship at Harvard University. His most
recent book, Global Sex, is being translated into five
languages. He also authored Power and Community as well as
AIDS and the New Puritanism, both directly relevant to HIV and
AIDS, and his 1971 text Homosexual: Oppression and Liberation
is now viewed as the definitive source for ideas that shape the
era of gay liberation.
In a recent newspaper article, professor Altman wrote:
Infections, illness and death dont provide the sort of
dramatic headlines that are provoked by war and bombings. But
if the AIDS pandemic continues to grow along current
projections, it poses a human and security disaster far greater
than either terrorism or rogue states. Please welcome Dennis Altman.
Thank you. My original invitation to deliver this address, specifically spoke of interventions of MSMs, IDUs and sex workers, to which one friend, a veteran activist, said I should call it the Perverts Plenary.
The very framing of this topic shows both the strengths and the limits of the current language of HIV prevention. Its highly important to recognize prevention and to recognize that some groups, because of particular behaviors are particularly vulnerable to HIV infection. But there are two problematic assumptions. One is we assume people can be neatly divided by behavior into discreet and identifiable groups. The second is that everyone has equal knowledge and resources to make free choices, whether they be the choices for sexual abstinence and refusal to use drugs or the choice to always use condoms and clean needles. And indeed both conservatives and liberals place great emphasis on choice. The advice to just say no, which we hear from the United States, is equivalent in som ways to the advice to always follow safer and injecting practices. Before we have choice, we need both knowledge and the resources to act on that knowledge. Yet estimates from most parts of the poor world suggest continuing ignorance about HIV and the basic measures to control it. One survey in eastern India suggested that 60% of women had never heard of AIDS.
Jonathan Mann consistently reminded us that we must protect human rights because we want to effectively control AIDS as well as protecting rights for their own sake. Jonathans work lives on through the journal, Health and Human Rights, through the [inaudible] Centre at Harvard University, and most importantly through leaders like Nelson Mandela and An San Soo Chi [misspelled?], an unfortunate absence here, who have taken up his call.
Jonathan was always willing to offend people when it was necessary to confront us with the consequences of action or indeed of inaction and that is a model I intend to follow. Our shared work here in HIV/AIDS grows out of respect for human life and dignity which is both a religious and secular tradition. It must be related to a basic understanding of human security and the worst excesses of the past decade. I think of Rwanda, Cambodia, of Bosnia, remind us without respect for human life, there is no security. In much of sub-Sahara [misspelled?] societies face the literal possibility of collapse and disintegration due to this epidemic. If unchecked, AIDS will undermine societies as surely will the bombs of terrorists. Yet the resources provided to check HIV/AIDS are miniscule to those now being put into fighting terror.
Let us be careful that outrage, justifiable outrage, at the treatment of large numbers of women does not lead us to forget that poverty, racism, war and oppression also limits choices for millions of men. Indeed let us remember the very term men is problematic as is clear if we think about the diverse forms in which gender is expressed. The rich transgender of groups such as Katouhy [misspelled?], Bachla [misspelled?], Hidra to take three examples of the part of the world we are in, reminds us that there are many different ways of acting out being a man. And men who deviate from the conventional assumptions of masculinity are often likely to be particularly vulnerable to HIV. But there is a parallel danger in assuming that women are equally and inevitably vulnerable.
We too easily then end up painting women as either Madonnas or whores, further stigmatizing the most vulnerable and increasin their vulnerability. In general, the more socially and economically marginalized a population, the greater its vulnerability to infection. And there are many groups we could be talking about this morning such as refugees, migrant workers, prisoners, indigenous and tribal populations, none of whom have been adequately represented in the plenary sessions.
Let us further be clear that when you do not choose between allocating sources to prevention rather than treatment, strengthening one can only strengthen the other. And this is an argument that will be developed in a paper the AIDS Society of Asia and the Pacific releases later today. Even poor countries such as Uganda and Cambodia remind us that it is possible to undertake effective prevention programs. And indeed the greatest tragedy of this epidemic is that we know how to stop it spreading and in most parts of the world we fail to do so.
Literature tends to emphasize immediate problems, lack of condoms and clean needles, safe sex fatigue, unwillingness to interfere with immediate gratification. There is far less emphasis on the political barriers that are accelerating transition, deliberate neglect by governments, the unwillingness to speak openly of HIV and its risks, the hypocrisies with which simple measures of prevention are prevented in the name of culture, religion and tradition.
Put simply, structural interventions of policies that recognize vulnerability to HIV goes far beyond individual choices and behaviors. Structural interventions can be as ambitious as reducing economic inequalities to provide better housing and clean water, but they can also describe specific programs such as needle exchanges or the provisions of condoms to sex workers and prisoners. In most cases they require governments either directly or through enabling programs undertaken by NGOs and communities. Imagine a child living on the streets of Rio or Dakar or Lagos or Kiev, surviving through prostitution and petty crime, often turning to drugs to numb the pain, the fear, the hunger, the cold of everyday survival.
Telling such a child to use condoms or not to share needles is meaningless. Imagine a young woman forced by family and community pressure to marry at 13 and to have sex with a man older than her father whom she had never met and then imagine the possibility of her insisting he use a condom, if indeed she even knows the danger of unprotected intercourse. Imagine a young man forced into an army or militia, perhaps in prison or a makeshift refugee camp, introduced to drugs as a means of short-term escape. And then imagine the chance he will have the mean or means of [inaudible] or may not be clean.
Unfortunately there still are many more examples of political action which hamper sensible HIV prevention than support them. Too many governments provide sanctions, punishment and repression, ignoring the reality that humans will seek both pleasure and survival in ways that often confront the traditional norms to which social, religious and political leaders pay lip service. There is a double vulnerability in HIV, both economic and social factors are crucial. Someone who sells sexual services to survive will be more vulnerable to HIV, both through the specific behavior but equally to the poverty and despair that leads them to that behavior. Now as Ive said, there is a problem in talking about vulnerable populations. Most people whose behavior Im discussing would not necessarily names themselves in these ways. There are times when we need to name groups and we need to empower groups. There are other times when we need to recognize that people will understand themselves in very different ways to the language of HIV prevention.
One example, the fear of stigmatizing homosexual men by linking them too closely to HIV has now been replaced by a frightening silence whereby most national and international organizations do not acknowledge homosexuality at all. In Japan for example there is much talk of the risk of young people. There is little public acknowledgement that the young people at risk of HIV infection in Japan are in fact young homosexual men. To always speak of HIV infection through heterosexual intercourse, without recognizing that many men engage with sex with each other is to send the very dangerous message that homosexual intercourse is without risk and in many parts of the world that is in effect what is happening. In western countries and in some developing countries, gay communities pioneered responses to this epidemic. Equally, as one Australian drug worker pointed out, it was us collectively and individually through our organizations who developed the educational messages, trained the peer educators, taught each other safe injecting techniques and passed on the equipment of information from person to person.
Now there is a political and conceptual in problem in lumping together very different groups in very different settings into the category of vulnerable populations. Yet where people can organize around particular identities, this is the most powerful force for prevention and action against stigma. We have seen this for gay men and hemophiliacs in western countries, for sex worker groups across the world, for people living with or close to those with HIV, through major social movements like TASSO [misspelled?] in Uganda and TAC in South Africa. Some of the greatest bravery has come from people who have confronted the double stigma of their marginalized identity and their serial positivity, and they have built the community organizations that has brought many of us to this conference.
As we were organizing the last regional conference in Melbourne in 2001, a conference in the shadow of September the 11th, we were inspired by brave young homosexual men in Lachnau [misspelled?] in India who were harassed and imprisoned by local authorities as they sought to provide basic information resources for safe sex in Utapradesh [misspelled?]. Also in India is the extraordinary sex worker cooperative, the Dobra Mahila Somonwaya [misspelled?] Committee, which has empowered sex workers to protect themselves and their dependents from HIV infection. There are other examples of great bravery from people who have set up needle exchanges and have done outreach for drug users on cities ranging from New York to Beijing, risking police persecution and intimidation.
Last Sunday a ministerial meeting took place in Bangkok on AIDS at which there was no representation of affected and infected communities. The lessons from countries as far apart as Brazil and Uganda, the policy work demands the full participation of affected and infected communities has been forgotten once again by our governments.
Good interventions include legal and social regulations that seek to improve the quality of life, health citizenship for all. Here Brazil stands out with a combination of programs aimed at linking treatment and prevention, its willingness to promote condoms and clean needles and the launching of a government plan called Brazil without Homophobia. Earlier Brazil proposed a resolution of the United Nations Commission on Human Rights, unfortunately postponed which would outlaw discrimination based on sexuality.
We know theres growing tension between evidence based public health and denial of that evidence, fueled by religious and ideological pressures, which often unites the United States and some of its most bitter enemies in their support of repressive legislation. Some countries such as my own contained IV use of the spread of HIV through the early introduction of needle exchange and harm reduction. Yet this lesson is still disputed by the United States and most Asian governments with the result that IV use continues to fuel the epidemic in alarming proportions.
The opening of this ceremony, the Thai prime minister appeared to acknowledge that he had made major mistakes. Let us hold him accountable to what he said and let us remind him that in Portugal, which has moved to remove users for the criminal justice system there has been a corresponding decline in needle related HIV infection.
In most countries there are restrictions on the discussion and promotion of condoms, on sex education in schools, on honest discussion that homosexuality and sex for money are realities in every complex human society. If the choice is between maintaining the demands of ancient superstition and the power of ancient clergy and providing the information and resources to protect young women and men from infection with a potentially lethal and painful virus, how can anyone who seriously believes in a just god or a system of ethical standards seriously doubt the answer?
Good interventions support genuine choice and protect people in their choices. In the case of sex work this means action against the enforced recruitment of women and children into prostitution often with the involvement of government, business and military. Sex workers need genuine alternatives to prostitution as means to livelihood, but they equally need real protection in their work. Extending workers rights as in some European countries and as recently proposed here might be the most significant structural intervention possible.
A hundred percent condom programs are attractive but only where they involve sex workers themselves at all levels. Good structural interventions will often provide safe space for those whose behaviors puts them at risk from police and from unofficial violence. Such policies include the provision of safe spaces for injectors as exists in Switzerland, safe street areas for prostitution or community drop-in centers for those who identify as homosexual as was recently established with city and state support by the Homsafar [misspelled?] Trust in Mumbai. Because these interventions empower and remove stigma, they also further human rights. By doing so they increase the likelihood that people will act to protect themselves. An empowered sex worker or user is more likely to find alternatives than one who is criminalized and stigmatized. Think imaginatively and boldly. In countries like United States and Russia, where prisons are incubators for HIV, reducing the number of people in jail might be the most effective way to reduce the spread of HIV.
In much of the world only a radical shift by organized religion, a willingness to accept that safeguarding life is more important than preserving antiquated moral rules will bring the resources and messages about safer sex to those who are most vulnerable. In most of Britains former colonies in south and Southeast Asia, in Africa and the Caribbean, homosexuality remains criminalized because of British laws which are kept by governments who boast to their opposition to colonialism. How more hypocritical can we get?
As Mary suggested, theoretical discussion is central to find empirical solutions. Not nearly enough attention is paid to these conferences to analyzing the barriers that religion, politics and human hypocrisy erect against effective programs of HIV prevention.
In the end, the great issues that demand research and action are political questions involving power, control and ideology. We are so unwilling to confront these issues often that we fall back on platitudes about leadership and communities of faith because we are scared to actually point out that they are often the problem and not the solution. As the world becomes more dangerous and uncertain and political attention increasingly focuses on war and terror, how we respond to this challenge is the central test we face of human decency and solidarity.
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