Communication Currents

Communication scholars interrogate the inherent meanings, assumptions and implications of global health policies. While global health interventions claim to be based on principles of participation, co-operation and empowerment, we argue that such interventions perpetuate unequal power relationships between the developed and developing world. Our study interrogates the assumptions guiding one such policy intervention that is conceptualized in the West and implemented in developing countries.

This essay explores the meanings and assumptions undergirding an intervention targeted at the eradication of HIV/AIDS in African and Asian countries. Over the last two decades, the HIV/AIDS epidemic has had a dramatic, if disproportionate impact on developing countries across the globe. In response, resource-rich governments and national associations in the West have introduced health interventions like the United States President's Emergency Relief Fund (PEPFAR). PEPFAR has been heralded as the largest commitment by any nation to combat a single disease in history. Signed into law on May 27, 2003, PEPFAR is involved in bilateral AIDS relief programs with 87 countries. In 2008, the Congress sanctioned up to $48 billion over the next five years to combat global HIV/AIDS, malaria, and tuberculosis.

While PEPFAR-funded programs may be well-intentioned, our analysis questions their inherent altruism by demonstrating certain common features and priorities across such programs. This unquestioned, taken for granted "common sense" of PEPFAR programs, is that of neoliberalism. As a political-economic philosophy, neoliberalism favors unfettered free markets, deregulation and entrepreneurial individuals over public infrastructure and governments. Moreover, neoliberal ideals are not merely economic arrangements, but are steeped into our cultural, social, and political lives today, to the point where neoliberalism forms a "common sense" of its own.  No surprise, then, that public health interventions are -implicitly or explicitly -shaped by this neoliberal common sense. 

A good example of the neoliberal influence on public health is the pervasive idea that health is foremost an individual and private responsibility, to be achieved by enterprising individuals who can make the most efficient health choices from a range of market-based solutions. Increasingly, health interventions in the developing world suggest individual-level solutions to the problem of HIV/AIDS (such as condom use, increased screening and preventive behavior, entrepreneurial ventures for financial stability, etc.) Policies that consider HIV/AIDS solely at the individual level represent neoliberal common sense in several ways. At their simplest, they fail to consider the important role played by governments and broad societal structures in providing health services for all. At their most insidious, individual-level health policies obfuscate the damning fact that much of the devastation of HIV/AIDS in developing countries is the result of strong-handed neoliberal policies enforced onto these countries in a top-down manner. (Some detailed commentaries on the relationship of structural adjustment policies and their impact on public health can be found here and here.)

Our analysis demonstrates the ways in which PEPFAR programs function within a neoliberal "common sense.” As data, we used a corpus of 78 documents from the universe of materials available from the PEPFAR website that represented five years of PEPFAR programming. This corpus included annual reports to Congress, press releases, fact sheets and operation plans for individual countries. Through a textual analysis of these documents, we identified three ways through which a neoliberal vision was apparent in PEPFAR-funded programs.

First, PEPFAR-funded programs talk about HIV/AIDS as primarily a threat to a productive labor force. In reference to programs in sub-Saharan Africa, the impact of HIV/AIDS is calculated in terms of the "hours of productivity" lost. The use of concepts like DALY: (disability-adjusted-life years) to measure the burden of disease emphasizes its economic cost as its primary social cost, giving weight to the neoliberal idea that HIV/AIDS is a problem because it interrupts the smooth functioning of markets. HIV/AIDS is seen as a problem because it weakens national economies. Consequently, health interventions are co-mingled with "peacekeeping and protection" (of national security) in countries like Uganda, Malawi, and South Africa, through the intervention of the Western militaries. The US Department of Defense, as well as military sub-units like AFRICOM, are strategic implementation partners of PEPFAR programs. 

Second, we argue that even as PEPFAR programs note the greater vulnerability of Southern women to poverty, inequality and HIV, they locate the problem of HIV/AIDS exclusively within "backward" gender and cultural norms of these countries. Consequently, interventions focus on promoting gender norms consistent with Western Judeo-Christian ideas of sexuality. Consider this excerpt from a PEPFAR report on gender violence in Sub-Saharan Africa:

"Men and boys are encouraged to equate risky behavior with manliness and to regard health-seeking behaviors as ‘‘unmanly.’’ Some traditional gender roles limit men’s options regarding how they can behave, encourage early sexual activity and multiple sexual partners..." 

In this example, like many others, the locus of change lies in traditional “cultural practices” (such as early sexual activity). No mention is made of any structural factors like poverty, large-scale unemployment, and inequitable global agro policies that are a direct consequence of neoliberal structural adjustment programs. In fact, by emphasizing the individual level focus on "changing gender norms," PEPFAR programs systematically conceal the structural role of neoliberal policies in the diffusion of HIV/AIDS in the Third World.

Finally, we explore how the language of partnership and co-operation is depicted in the corpus. PEPFAR is considered to be a departure from traditional top-down, donor-recipient programs through its emphasis on partnerships. One of the ways in which this is done is by focusing on PEPFAR as a development effort not just limited to health. By fusing the language of health and development, we argue that the agendas and locus of decision-making is in fact diverted from recipient nation-states to the transnational partners. (See our full article for examples.) While our corpus abounds with data about the number of partner organizations, NGOs, and agencies that work with PEPFAR, there is no way of knowing the nature of these relationships. Working with local grassroots organizations comes across as a departure from traditional top-down relationships, but absent from the corpus are questions such as "Who sets the agendas for these partnerships?" The lack of specificity in the nature of partnerships raises critical questions from the perspective of global health campaigns: is this just another way in which local NGOs toe the line of the transnational conglomerations and associations that fund them? Or do these partnerships really function as a way to "talk back" from the grassroots?

Our purpose in this essay was to raise questions and conversations around the seemingly altruistic and participatory nature of PEPFAR. Through the identification of a "neoliberal common sense" running through these programs, we argue for a greater scrutiny of the participatory intent and "grassroots" claim of transnational health interventions. Research from across the globe shows that the most effective decisions and agendas in health campaigns are the ones articulated by those that are the targets of such interventions. A scrutiny of the neoliberal logic inherent to PEPFAR helps us ask who benefits from these campaigns: the targets of the intervention, or the transnational elite that is invested in the promise of Third world labor and emerging markets.