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How Data Drives Decisions at USAID

This post originally appeared on Impact magazine

Impact magazine interviews Ellen Starbird, Director of the Office of Population and Reproductive Health, USAID.

IMPACT: How does USAID assess the effectiveness of its health investments?

ELLEN STARBIRD: USAID assesses the effectiveness of its health interventions by looking at trend data in health indicators that are related to the programmatic interventions that we support. For our family planning and reproductive health programs, contraceptive prevalence, improvements in birth spacing and increasing age at marriage are all measured by surveys, including the Demographic and Health Survey. Changes in these indicators can be related to our investments. USAID uses evaluation findings to inform decisions, improve program effectiveness, be accountable to stakeholders, and support organizational learning. Research tests the effectiveness of possible interventions and is used to identify high-impact practices for our family planning and reproductive health programs. Pilot studies and introduction studies test the effectiveness of interventions in specific contexts or countries. Those interventions that best “fit” a particular context (i.e., level of program development, epidemiological context, resources available, etc.) are selected.

IMPACT: USAID has a long history of using a “logical framework of results” to monitor health programs. Could you describe this framework and how it is used to facilitate decision-making?

ES: The logical framework is an important part of project design, as it identifies and briefly describes the problem the project intends to address and the expected outcomes of the project. The framework includes inputs, outputs, outcomes and impact. USAID uses Project Monitoring Plans to monitor at each step in this process. These plans examine answers to questions such as: Are inputs being delivered as planned? Are inputs leading to the anticipated outputs? Are outputs leading to the desired outcomes? If not, is the problem failure to deliver the input, or is the problem that inputs are delivered but for some unanticipated reason are not leading to the expected outcome?

IMPACT: USAID recently conducted a thorough review of its evaluation practices and developed a new policy on evaluation to guide the organization. What does USAID want to learn through implementation of this policy, and what does this mean specifically for health programs?

ES: USAID conducted this review to ensure that effective evaluations were taking place and guiding programmatic decisions. There was a concern that over the last several years fewer evaluations were being done, and the agency wanted evaluations to play a more prominent role in program decision-making. By implementing the new policy, USAID hopes to get a better understanding of the success with which its programs are implemented (process evaluations) and the impact of those programs (impact evaluation). This means that our health programs will put more focus on the implementation and impact of its projects, and that this information will guide future programming decisions. Ultimately, this creates a quality-improvement process, capturing experience to develop increasingly effective programs.

IMPACT: Can you share a recent example of receiving surprising results from work our office has been supporting? How did these results shape the decisions you and your colleagues had to make?

ES: In recent years, results from the DHS, especially those from Africa, showed an unexpected level of interest in and demand for long-acting contraceptive methods. These findings led us to expand our efforts to make these methods more widely available in an acceptable, accessible and affordable ways. Another example is that survey and qualitative research have identified a substantial demand for contraceptive information and services among youth in developing countries. M-Health is providing access to information on methods and source of supply to youth via electronic communication. Information collected on these programs indicated that youth are interested in a wide variety of methods, including natural methods, injectables and longer-acting methods.

IMPACT: What are some challenges you anticipate in generating meaningful data for decision-making post-2015?

ES: As we continue to make progress, what and how we measure will also have to change. In the area of family planning and reproductive health, for example, we’ll need better measurement around costs, as well as better understanding of how to measure choice and rights. The current data collection mechanisms in place will need to be adapted for such advances, or new ones will need to be developed.

Webinar to Highlight How Extension, Technology, and Behavior Change Combine to Improve Agriculture and Nutrition

This blog post is by John Nicholson, SPRING Knowledge Management Manager, JSI Research and Training Institute, and Kristina Beall, SPRING SBCC Project Officer, The Manoff Group.  SPRING is funded by the United States Agency for International Development (USAID) and helps to strengthen country efforts to scale up high-impact nutrition practices and policies.

Leveraging the power of social capital and technology, Digital Green has pioneered the use of low-cost, community videos as an agriculture extension tool that allows farmers to record and share successful techniques with other farmers in their community. The work began as a part of Microsoft Research India’s Technology for Emerging Markets team in 2006, eventually spinning off into the non-governmental organization (NGO), Digital Green. This young, dynamic NGO has already helped produce over 2,600 videos that have been shared with more than 150,000 rural households across India, Ethiopia, Tanzania, and Ghana. Digital Green’s grassroots approach — producing context-specific videos by the community and for the community—improves the efficiency of existing agricultural development efforts by a factor of ten times, per dollar spent.

Example of Digital Green video production

Example of Digital Green video production

USAID’s global nutrition project, Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING), is partnering with Digital Green in Odisha, India, to test the feasibility of adapting this video-based methodology specifically to promote high-impact maternal, infant and young child nutrition, and hygiene practices. Under the SPRING/Digital Green model, a local NGO partner – VARRAT – has worked in Keonhjar District of Odisha to produce 10 videos that showcase key nutrition and hygiene behaviors, often celebrating early adopters of these important nutrition practices. Videos are shared among small community women’s groups on a weekly basis using portable, battery-operated pico projectors. A robust suite of analytic tools, coupled with feedback from community members, then provides Digital Green and its partners with timely data to better target both production and distribution of videos. The collection of 10 nutrition- and hygiene-specific videos produced under this collaboration can be viewed along with the corresponding adoption analytics on the Digital Green website.

On December 17th, SPRING will host a webinar examining the Digital Green work through a multispectral lens, focusing on their unique approach and the growing partnership to scale-up technology to improve both agricultural and nutrition outcomes. Visit the SPRING website for more information and to register for the webinar.

This webinar is part of SPRING’s continuing collaboration with the Bureau for Food Security and Bureau of Global Health to identify promising approaches to better link nutrition and agriculture.

Saving Lives of Children, Unburdening Economies & Shrinking the Malaria Map (for Good)

Global efforts to control and eliminate malaria have saved an estimated 3.3 million lives since 2000, reducing malaria mortality by half in sub-Saharan Africa, according to the World Malaria Report 2013 published by the World Health Organization (WHO).  Nearly 70% of these lives saved were in the 10 countries with the highest malaria burden, and among children under 5 years of age – the group most affected by the disease.

A girl is protected from malaria by an insecticide treated net.  Photo by Maggie Hallahan

A girl is protected from malaria by an insecticide treated net.
Photo by Maggie Hallahan

We celebrate the dramatic progress that has been made in reducing the burden of malaria in sub-Saharan Africa.  This progress is due to partnership — of national governments, international donors including the U.S. and U.K., The Global Fund, The World Bank, the private sector, non-governmental and faith-based organizations, local leaders, civil society, philanthropists, and many others.  But host country governments, the President’s Malaria Initiative (PMI), and The Global Fund deserve special praise for fueling this remarkable progress against malaria.

The United States malaria program through PMI continues to be a “game changer” in the global fight against malaria.  Launched in 2005 by former President George W. Bush, PMI has been embraced and expanded by the Obama administration. A collaborative interagency effort that is led by USAID and implemented together with the Centers for Disease Control and Prevention, PMI has supported malaria activities through more than 200 nonprofit organizations, approximately one-third of which are faith based. These groups often have strong and effective bases of operations in underserved rural areas where the burden of malaria is greatest.

In the eighth year of the initiative, the financial and technical contributions made by the USG are major catalysts in the remarkable progress that has been achieved in many countries to reduce the devastating burden of malaria on child mortality.

The Global Fund and PMI’s commitment to effective coordination maximizes our impact on the global malaria burden. Each program has its own unique strengths which contribute to the effectiveness of the partnership and significant success on the ground.

While we celebrate the good news revealed in the WHO World Malaria Report which states that the risk of malaria is declining and more children are surviving, the gains are fragile and could be reversed without continued support. More needs to be done. Millions of people with suspected malaria still do not receive a diagnostic test, and many people with confirmed infections do not receive appropriate treatment with a quality assured antimalarial drug.

Our goal must be to continue to shrink the malaria map and ensure our successes are not reversed, even as we continue to face challenges such as artemisinin-drug resistance and insecticide resistance. In malaria endemic countries, we must leverage higher domestic investments from the public and private sector. And we must engage regional banks to support investment for regional Global Malaria Action Plan needs.

We must continue to engage the private sector in endemic countries in sub-Saharan Africa to identify opportunities for corporate engagement in support of domestic malaria prevention, control, and elimination needs.  And we must continue to use smarter and more creative financing to maximize the impact of our investments and promote innovative approaches to address key bottlenecks in the development, introduction, and scale-up of global health technologies and interventions.

Investing in malaria has a powerful return on child survival. Healthy kids are at the heart of every nation’s prosperity and its sustainable development. Healthy children are more likely to live longer, stay in school, and be productive members of their society, generating benefits that reverberate through future generations.

In the Washington Post, Michael Gerson wrote, “In much of sub-Saharan Africa, the American image is now defined by the Peace Corps, PMI and by PEPFAR, the American AIDS relief plan. It is a form of influence that is hard to measure or weigh. But people remember when you help to save their children.” I can attest to this powerful truth.

Women are Women: Responding to the Health Needs of Female Sex Workers

From November 25th (International End Violence Against Women Day) through December 10th (International Human Rights Day), USAID joins the international community for 16 Days of Activism Against Gender Violence. During this time IMPACT will highlight USAID’s work to combat gender-based violence.

Mpiluka is a 29-year-old bar worker in Iringa, Tanzania. A single mother to an 11-year-old girl, she supplements her low monthly salary by selling charcoal and sex. Mpiluka fears the heightened risk of HIV, Sexually Transmitted Infections (STI), and unwanted pregnancy that she knows exists among female sex workers. But the harsh realities of sex work in this setting – the social, economic, and physical complexities of the negotiation of sex – make it difficult for her to use condoms as protection. Some men dislike condoms, offering double or triple the price for sex without. Others become violent if she insists. Recently, when Mpiluka confronted a client on condom use, she was beaten with a rock and robbed. The likelihood that Mpiluka has faced violence from her husband or boyfriend and that her daughter might also face violence in her life is significant.

Thank you for following our #16Days campaign.

Thank you for following our #16Days campaign.

Mpiluka’s story is not uncommon, and reveals the complex intersection of violence, reproductive health, and HIV faced by sex workers around the world. Historically, female sex workers of reproductive age have been considered a key population for HIV prevention, care, and treatment programs, and are 13.5 times more likely to be living with HIV than other women of reproductive age. While some prevention and treatment programs for sex workers do exist, they focus primarily on individual-level risk factors for HIV acquisition and transmission.  Unreliable access to contraception and reproductive health services remains a significant challenge for many sex workers, like Mpiluka, who face high levels of sexual and physical violence. Evidence has shown that these factors are related to increased risk of HIV.

Over the past five years, the Research to Prevention (R2P) project, funded by PEPFAR through USAID, has demonstrated a clear need for policies and programming that address the multiple levels of influence on HIV risk among female sex workers, including their risk of violence and need for comprehensive reproductive health services. One study of female sex workers in four West African countries revealed high levels of sexual and physical violence experienced across these settings, including 45 percent in Togo to over 70 percent in Burkina Faso. Fifty-one percent of female sex workers in Togo who did not want to become pregnant were not accessing a reliable method of contraception, often due to discrimination and fear experienced by the women seeking health services.

The recently launched WHO guidance on prevention of HIV and other sexually transmitted infections for sex workers in low-and middle-income countries is informed by evidence for interventions that address these broader needs. Interventions that address violence and empower sex workers are primary recommendations for sex worker programming, and reproductive health is a standard component of the clinical package outlined in global implementation guidance. The guidance harmonizes and strengthens a robust response for sex workers globally and forms the basis for USAID and PEPFAR programming.

As we mark the 16 Days of Activism Against Gender Violence, it is important that we remember women like Mpiluka. It is not enough for HIV programs to address individual-level factors in HIV transmission among female sex workers; they must also acknowledge the high risk of violence and varied reproductive needs of these populations around the globe.

Video of the Week: USAID and Nelson Mandela

This is a video of Nelson Mandela announcing a partnership with USAID on the AIDS Response Partnership in Durban, 2000. We continue to join with the world as it mourns the loss of Nelson Mandela.

Vice President of Ghana Oversees Launch of Online System to Fight HIV-Related Discrimination

On December 2 at World AIDS Day observations in Ghana, His Excellency Vice President Kwesi Bekoe Amissah-Arthur presided over the launch of a new web-based system for reporting HIV-related discrimination. The system will support people living with HIV and other key populations in upholding their rights and fighting discrimination.

In Ghana, as in many other countries, HIV-related discrimination remains an unfortunate reality. People living with or affected by HIV experience unfair and unjust treatment that affect many areas of their lives, from employment to travel to health, and often act as a barrier to accessing potentially life-saving HIV prevention, treatment, and care services.

The Commission on Human Rights and Administrative Justice's launch of Ghana's new discrimination reporting system. Photo credit: Health Policy Project/Futures Group

The Commission on Human Rights and Administrative Justice’s launch of Ghana’s new discrimination reporting system. Photo credit: Health Policy Project/Futures Group

Using the new discrimination reporting system, individuals and organizations will now be able to report such discriminatory treatment directly to Ghana’s Commission on Human Rights and Administrative Justice (CHRAJ). Cases of HIV-related discrimination can be reported online at http://drsystem.chrajghana.com/ or via SMS. Following case submission, a CHRAJ point of contact receives the complaint and has ten days to respond to the person who submitted the complaint. While mediation is the preferred method of handling complaints, CHRAJ also has investigation and litigation authority as well.

The creation of the system reflects a growing appreciation that discrimination faced by people living with HIV and key populations — including men who have sex with men, sex workers, and people who inject drugs — undermines human rights and quality of life.

Managed by CHRAJ, the discrimination reporting system is the product of a partnership among CHRAJ, the Ghana AIDS Commission, and governmental and non-governmental stakeholders, with support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Agency for International Development (USAID) through the Health Policy Project. Reflecting this partnership, Vice President Amissah-Arthur was joined at the launch event by Commissioner of CHRAJ Lauretta Vivian Lamptey, Director-General of the Ghana AIDS Commission Dr. Angela El-Adas, U.S. Ambassador to Ghana Gene A. Cretz, and other dignitaries.

In his remarks, Ambassador Cretz noted: “the U.S. government is proud to work with the Commission on Human Rights and Administrative Justice and the Ghana AIDS Commission in building systems that ensure that those affected by HIV-related stigma and discrimination have legal recourse in seeking support in protection of their rights.”

The reporting system improves accountability by fostering greater collaboration among CHRAJ, the Ghana AIDS Commission, and civil society organizations. In addition to serving as a reporting mechanism, features of the system such as case tracking enable registered organizations to monitor the progress of complaints. This will not only help those who have experienced discrimination gain access to redress if their complaints are legally actionable; it will also help link them with relevant social services.

More broadly, capturing cases of discrimination will provide an important source of data on discrimination for policymakers and advocates alike, arming them with information to take further action to fight HIV-related discrimination in the future.

Transforming Gender Norms and Ending Child Marriage: The Role of Boys

From November 25th (International End Violence Against Women Day) through December 10th (International Human Rights Day), USAID joins the international community for 16 Days of Activism Against Gender Violence. During this time IMPACT will highlight USAID’s work to combat gender-based violence.

Child marriage has recently gained heightened attention by donors, researchers, activists, program implementers, and policymakers. The international community has increasingly recognized child marriage as a violation of girls’ rights, health, and well-being, and efforts to prevent and respond to child marriage have prioritized critical “hot spots” where the practice is particularly grave and widespread. Yet, it is also crucial to shed light on a current “blind spot” in these efforts: the role of boys in ending child marriage.

When males are included in strategies and interventions to address child marriage, the focus is mostly on the key role that men play as powerful gatekeepers: fathers and religious and community leaders, whose support must be galvanized to intervene on behalf of girls. The forward-looking USAID Vision for Action on Child Marriage, for example, includes engaging men as an important part of mobilizing communities to shift norms that perpetuate child marriage. But the Vision does not stop there; it further states that, “equally important is reaching out to boys at a young age to encourage equitable gender attitudes and norms so that they can be allies in preventing child marriage and change agents within their communities.” This aspect of male engagement is usually not highlighted in child marriage discussions, yet raises a vital question: What needs to happen to create a generation of boys that resists and rejects child marriage for themselves in the future?

A young girl.  Photo Credit: Kendra Helmer/USAID

The international community has increasingly recognized child marriage as a violation of girls’ rights, health, and well-being, and efforts to prevent and respond to child marriage have prioritized critical “hot spots” where the practice is particularly grave and widespread. Yet, it is also crucial to shed light on a current “blind spot” in these efforts: the role of boys in ending child marriage. Photo Credit: Kendra Helmer/USAID

This “demand-side” orientation requires long-term investments aimed at changing the social and behavioral gender norms that drive child marriage. What if all future men refused to marry a child bride? Though directly addressing this side of the equation is seldom mentioned, there are promising interventions with young girls and boys that seek to transform gender attitudes and behaviors with the goal of promoting gender equality more broadly. One example is the USAID-funded Gender Roles, Equality, and Transformation (GREAT) project.

Although GREAT does not directly address child marriage, it works with adolescents (ages 10-19) and their communities to reduce gender-based violence and improve reproductive health in Uganda. Building on the CHOICES project in Nepal, GREAT recognizes early adolescence as a window of opportunity—a time when the formation of gender norms and identities is taking place. The project utilizes participatory activities to engage young girls and boys in gender equality discussions. For example, project staff ask young girls and boys to pile-sort cards representing various household and community tasks, to show who is responsible for them. Girls and boys (including sisters and brothers) see the pile of tasks assigned to girls steadily grow larger than the boys’ pile. The activity prompts conversations about fairness, as boys remark on the larger burden carried by their sisters.

These types of “a-ha” moments are crucial entryways to deeper critical reflections that can begin a journey towards gender equality. By tapping into young boys’ sense of justice at a very young age, interventions such as these, which seek to transform gender norms early in the process of childhood development, hold the promise of shaping a future generation of men as allies in wiping out child marriage globally.

To Win the Fight Against AIDS, We Must First Defeat TB

This week, tremendous and unprecedented progress in the fight against HIV/AIDS is being celebrated around the world by the HIV and AIDS community. The world has definitely made crushing AIDS a top priority and we’ve been able to accomplish what many would have said 15 years ago was impossible. But let’s not forget that if the dream of making this the generation that defeats AIDS is to become reality, we must also tackle the leading killer of people with HIV – tuberculosis (TB).

The overlap of TB and HIV is a deadly combination with tragic consequences. TB is the leading killer of people with HIV, accounting for one in four HIV-related deaths. Globally, one-third of the 34 million people living with HIV is infected with TB, and if left unchecked and untreated, TB can kill a person with HIV/AIDS in a matter of weeks. Furthermore, the alarming increase in multi-drug resistant TB (MDR-TB) threatens to reverse progress made against HIV/AIDS despite our efforts to achieve the 2015 Millennium Development Goals related to TB.

To mark World TB Day 2013 in Ethiopia the Minister of Health, joined by USAID and partners in the fight against TB, watch a role play created to raise public awareness about getting tested and fishing the prescribed course of treatment. Photo by Karen Ottoni/USAID Ethiopia

To mark World TB Day 2013 in Ethiopia the Minister of Health, joined by USAID and partners in the fight against TB, watch a role play created to raise public awareness about getting tested and fishing the prescribed course of treatment.
Photo by Karen Ottoni/USAID Ethiopia

Pressing public health challenges like this demand our collective and immediate attention. Today, the Global Fund is on the second and final day of its fourth Replenishment Conference in Washington D.C. Hosted by the United States government, this meeting is a pivotal opportunity for donor countries to increase their pledges over the next three years to bring treatment and hope for HIV, TB and malaria to some of the world’s most underserved and heavily disease-burdened populations.

In his remarks at the Global Fund Partnership Symposium yesterday, Secretary Kerry reminded global leaders that the goal of eliminating TB deaths in our lifetime is achievable if we make the commitment and stay the course – “TB is curable, and make no mistake: With the right effort and the right focus, the right energy, we can eliminate it.”

Bold steps of commitment by the global community will indeed strengthen our fight against TB and will give countries the tools, particularly life-saving commodities, to reduce the spread of TB, cure people suffering with TB, and prevent the further development of MDR-TB.  We need new drugs and tools that are safe and effective for people with TB, MDR-TB, and those co-infected with TB and HIV.  The U.S. Government has worked together across agencies in the introduction and implementation of the new Xpert diagnostic.  The Xpert MTB/RIF assay can detect TB more accurately than current methods, particularly among people co-infected with TB/HIV and can be a reliable proxy for MDR-TB.  USAID is also working with partners to improve the currently toxic and lengthy MDR-TB treatment regimen as well as the availability and price of existing second line drugs.  Most importantly, USAID and others are working together to prevent the spread of TB within communities and improve access to curable treatment for the most vulnerable and poor populations.

Simply put, we have a historic opportunity to turn the tide on an age-old killer that has plagued mankind for generations. By the global community banding together with resources and endorsements to meet the challenge, the goal of ending TB deaths in our lifetime is within our reach.

Video of the Week: Gift’s Last 10 Years

USAID is observing World AIDS Day this year by celebrating ten years of our HIV and AIDS work under PEPFAR.

Meet Gift. Today is her 10th birthday and she is celebrating the past decade of her life free of HIV. Thanks to life-saving antiretroviral (ARV) drugs funded by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development (USAID), Gift’s mom – who has been living with HIV – was able to protect Gift from the virus when she was born 10 years ago. Gift's 10th Birthday

Thanks to ARVs, support and care from their local community, and access to other preventive health services, such as voluntary medical male circumcision, Gift and her family have been empowered to live healthy and happy lives.

VIDEO: World AIDS Day 2013: Gift’s Last 10 Years

Note: Gift is a fictional character representing families and communities around the world affected by HIV and AIDS.

Follow @USAIDGH on Twitter through World AIDS Day, observed on December 2, for key facts, resources, and photos from our programs and partners and join the conversation using the hashtag #WAD2013.

Ancestors and Antiretrovirals: The Biopolitics of HIV/AIDS in Post-Apartheid South Africa

 USAID is observing World AIDS Day this year by celebrating ten years of our HIV and AIDS work under PEPFAR.

Book Review: “Ancestors and Antiretrovirals: The Biopolitics of HIV/AIDS in Post-Apartheid South Africa” by Claire Laurier DeCoteau

 

Introduction

In her most recent book, Dr. Laurier Decoteau eloquently traces the politics of HIV and AIDS from 1994 through 2010 in Post-Apartheid South Africa. She describes important shifts in health policy and nestles them in real-life stories of people living with HIV and dying from AIDS. Her ethnographic data, collected over ten years, highlights several key issues including the changing relationship between indigenous and biomedical health care and the complex and often contradictory way that the South African government failed to balance a neoliberal existence (i.e., political movement beginning in the 1960s that blends traditional liberal concerns for social justice with an emphasis on economic growth.) with the health needs of its citizens. A major theme throughout the book is that AIDS continues to be terrain upon which many post-colonial paradoxes are played out in South Africa.

South Africa is heralded for adopting one of the most progressive constitutions in the world. It is one of the wealthiest countries on the African continent. And yet, South Africa still maintains the ….distinction of having the highest rates of HIV prevalence in the world, and ranks among the most unequal countries in the world in ….wealth and income distribution (Page 7)

Summary

The book has five chapters, each with its own major theme. Chapter one describes the ethnographic setting for the book and introduces the reader to the challenges of living in townships and squatter camps and dealing with the effects that HIV and AIDS can have on a person, family and community.  We are introduced to the author’s method of presenting her arguments and raising important issues though the use of interviewee quotes.  One quote captures the essence of this chapter. “Many people think that HIV might kill them in ten years, but poverty or violence will kill them first, so why worry about it?” (Page 49)

Chapter two describes President Thabo Mbeki’s reign as President and his “AIDS Denialism”. We learn how this denialism affects people living with and affected by HIV and AIDS. President Mbeki’s main premise was that that biomedical science was couched in an imperialist paradigm and ignored the cultural and racial identity of Africans. The chapter outlines how his infusion of AIDS denialism promoted indigenous healing as an alternative to biomedical approaches, going as far as delaying the rollout of antiretroviral therapy and life-saving medication to thousands of people.  The author makes the case that his neoliberal economic policies required the state to cut social services, in essence, undermining ARV rollout. We also are shown ethnographic evidence that national discourses of self-responsibility became particularly prevalent during his tenure as well as a national environment that supported the individualization of blame for the spread of HIV. Ancestors and Antiretrovirals

Chapter three describes the efforts of the Treatment Action Campaign (TAC), a community-based advocacy group that took on the international pharmaceutical industry and ultimately brought free ARVs to South Africa. It also reinforces how structural obstacles often impede impoverished South Africans to participate in biomedical technologies.  The term “Biomedical Citizenship” is introduced and explained as we see examples of people who only have citizen rights if they have disciplined behavior to adhere to ARV medication.

Chapter four, titled “The Politicization of Sexuality” describes President Jacob Zuma’s reign and his ability to speak to poor South Africans.  Because he has been described as symbolizing many traditional aspects of an African Man, this identity is used to highlight several key issues.  The author argues that during this time period, deindustrialization and AIDS challenged idealized and traditional notions of masculinity and increased informalized sex.  This chapter illustrates how shifts in the political economy impacted gender ideologies and sexual practices in post-apartheid South Africa.

Chapter five analyzes the relationship between indigenous and biomedical healing in South Africa. We are provided an in depth analysis of indigenous forms of healing and how they have waxed and waned during the national discourse of AIDS over time.  We learn that “indigenous healing helps situate illnesses and recognizes them as composites of cultural, social, environmental, historical, economic and biological factors.” (Page 225) The book closes with a short critique by the author of “the ways in which biomedical solutions have failed to address some of the underlying, fundamental causes of the epidemic” (Page 23).  She argues that her research shows how an individualized, commodified approach to treating people, without regard for safety, sanitation and sustainability, might do more harm than good.

Critique

Having lived in South Africa between 2003 until 2007, this book was a trip down memory lane.  Many of the author’s arguments and many of the ethnographic anecdotes spoke to me personally.  At times I felt like a professor reviewing a doctoral dissertation and wanted to pull out the dictionary for words that I had never seen.  At other times, I found myself nodding in agreement of the points she made.  I regularly appreciated how she challenged core assumptions of Western social science. For example, she regularly offers evidence that the international epidemiological approach and a focus on individualized biomedical interventions decontextualize behavior and ignore the structural factors that create conditions of vulnerability to disease.

The book nicely captures the nuances of government policy choices and how these policy choices affect people’s lives.  I lived in South Africa during AIDS denialism; a period where drugs were available yet hindered from entering the country.  I fostered an HIV positive infant and worked through the systemic obstacles to get her on treatment.  It was a horrible and life-changing event.  I witnessed TAC marching at the international AIDS conference in 2000 advocating for ARVs on the continent.  I appreciated the author’s detailed account of TAC and although controversial, a critical organization in the fight to get services to people.  I saw an entire industry develop around the production of death and was maddened that people were denied ARVs.  I lived through the government fiascos that labeled the President and Minister of Health as unreasonable.  I remember the reshuffling of the Department of Health in 2006 after then Minister of Health Manta Tshabalala-Msimang displayed beetroot and lemon as a replacement for ARVs at the International HIV/AIDS Conference in Toronto.

Importantly, this book serves as a reminder that ethnographic methods are an essential tool for exploring the ways in which health and disease are experienced and understood by those most affected.  My friends and colleagues shared their stories of the stigma and shame that surrounds this disease.  In my opinion, donors and national governments have not paid enough attention to the power of stigma and discrimination. “With all of the obvious attention paid to the genocidal level of deaths the epidemic has produced, the words of HIV and AIDS are never mentioned at funerals. The bodies are piling up, but their significance is cloaked in silence.” (Page 76).  I appreciated that the author used interviewee quotes to bring important issues to the surface; no amount of epidemiologic data can capture the nuanced social and cultural issues that have an impact on HIV and AIDS.

I found myself wondering if I would appreciate the book as much as I did had I not lived the experience of working in the AIDS field in South Africa at the time.  I do, however, think that this book is artfully presented and an unusual read for those working in the public health arena.  It consistently connects the macro and micro levels and highlights the often complex and contradictory relationships between global processes, national policies and local practices. The emphasis on the broader system, relevant to health and disease, is critical when dealing with complex health issues such as HIV and AIDS.  Professionals and decision makers working on HIV and AIDS issues could learn lessons from disciplines such as sociology and anthropology, and would greatly benefit from a broader perspective than the strictly biomedical view of the world.

 

Follow @USAIDGH on Twitter through World AIDS Day, observed on December 2, for key facts, resources, and photos from our programs and partners and join the conversation using the hashtag #WAD2013.

 

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