AIDS versus development: Victim-blame continues

The cause of AIDS is underdevelopment. The best prevention is development My argument is that the causes of AIDS risk behaviours are structural, social, economic and political in addition to individual, familial and cultural in origin. The communication component of a solution needs to address these complex root causes that are invariably relational and therefore involve relational situational analyses.

To illustrate, why a male rural migrant is unwilling to use a condom in spite of his multiple sexual partners is not merely a function of his preference for ‘skin-to-skin’ sex but his adolescent introduction into sex and the expectations he acquired in his past relationships with his mother, father, initiation peers, religious leaders, teachers, early partners, marital preconceptions and the like.

The article starts by explaining why AIDS is a disease of poor people in poor countries. It then explains why communication alone cannot be a lifeguard for AIDS or a panacea for any development problem as this policy error continues to be repeated at the highest levels. The next section briefly reviews researcher advice on AIDS communication in developing countries before ending with a recommendation that media selection and message design address the relational roots of risky practices over the lifecycle (peers, family, church, school, sub-cultural events, health centre, state) and their contextual manifestations over space (economic, political, cultural).

No work, no wages

The virus finds easy entry into the bloodstream through genital sores that are untreated for lack of money for antibiotics. The virus infects rural migrants who are forced to leave their homes in search of work for pay, moving from a construction site to a mine to a factory town. The virus infects sex workers, migrants from the village themselves who provide human contact to other migrants.

The virus infects wives who stay behind in the village with the children when the husband returns at festivals or harvest time. The virus passes from the infected mother to her infant who she cannot afford to not breast-feed. The virus infects unemployed youth who sell drugs and start injecting themselves because there is no work. Clearly the proximal cause of AIDS is a virus, but the real causes go to the lack of jobs, the lack of economic development and the lack of public health facilities.

Media as lifeguard

I have shown how physical migration enables HIV infection earlier. Appadurai considers migration and media are characteristics of our present ‘globalized’ times.1 Peter Piot, head of UNAIDS, has frequently pointed out that communication media have the power to save more lives than doctors. Can one be a solution for the problems caused by the other? Given the state’s inability to generate rural employment where people live, and the need for them to migrate to cities to make a living, how can words and images presented through communication media help address these adults and adolescents to be resocialized into new family, sex and work contexts they have not been prepared for?

In the late 1950s, well intentioned US journalists and World War II propagandists convinced the young UNESCO and USAID that media could create a climate for social change and development in newly independent countries. The Development Decade of the 1960s resulted in very little development by any standard and provoked examination of why media had not performed better.

By the mid-1970s, this writer and many others presented common sense logic in academic tomes: states must make social structural changes and provide development opportunities; media are only providers of information about such redistribution of life chances, information must be tailored to the needs and preferences of particular users in terms of their education, gender, class, region, language and needs; the provision of comprehensible credible useful timely information needs to be followed up by peer group discussion to be internalized and considered for action; for behaviour change and action, information provision (e.g. on agriculture, health) needs accompanying inputs such as medicines, credit, fertilizer and water supply; media must be stimuli and sites for dialogue rather than tools of diffusion.

In summary: media campaigns must be preceded by state initiatives on changes in opportunities for action, provision of information about these changes needs to be integrated with provision of supplies and inputs to act on the information. Inspired by the large audiences that telenovelas attracted in Mexico in the 1980s, Population Communication International and Everett M Rogers focused on information provision, making it less preachy and more entertaining. Thirty years later, the mid-1970s academic consensus merits repetition as we continue to grasp for quick single solutions to complex multidimensional development problems.

The Communication Initiative web site and associated electronic newsletters funded by UN agencies, bilateral aid agencies and foundations presents case studies and news of the many uses of communication media. A large number of scholarly books have focused on how to harness media better, now in the service of AIDS. In January 2004, the UN Secretary General and the US Kaiser Family Foundation launched the Global Media AIDS Initiative to get profit-making corporate firms who now owned media since the 1980s state divestment to integrate AIDS messages across their commercial entertainment programming.

MTV took the lead, with state and private media corporations from Russia, South Africa, the UK India and Brazil as members of the Leadership Committee. The World Bank and UNAIDS have included the mass media in their collections of ‘best practices’. UNAIDS December 2005 report showcases three projects from South Africa: Soul City, Community Health Media Trust, and Takalani Sesame.

What does media research say?

Recommendations on how to improve media influence on AIDS comes from scholars in industrialized countries and scholar-practitioners from developing countries.

Leading the researchers from the North are Robert Hornik2 at the Annenberg School at the University of Pennsylvania, who has generated a systematic list of recommendations based on excellent action-research and experiments over forty years: they await the political will of governments to act on them. A younger group of researchers (e.g. Thomas Tufte of Denmark) continue to write about applications of media for development, emphasizing the neglect of advances in current communication theory from fields such as cultural theory, qualitative methods, and cultural globalization.

Epitomizing practitioner-action researchers from the South is Warren Parker, Director of the Center for AIDS, Development, Research and Evaluation (CADRE) that has pioneered with the production of Tsha Tsha, a dramatic TV series that features rural youth. It is followed up by a radio talk show to encourage peer group discussion. Writing in 2004, Parker pointed out the need to go beyond individual-focused risk prevention strategies to a range of public health approaches and contexts of risks. Risk reduction strategies focused on the individual need to bear in mind that there are differences in power that overwhelm individual intent, e.g. one faithful partner is infected by the other unfaithful partner, a young person is coerced into sex by a culturally-determined superior who is older than her, food and shelter may be exchanged for sex. Risks come from multiple levels too: the school, the church, the police, and the justice system.

Consistent with recommendations since the 1970s, Parker also stresses the need to differentiate and fine-tune recommendations to the situations of social groups on the ground, e.g. media messages need to endorse the abstinence and fidelity-oriented practices of the many rather than broad-based entreaties to change risky behaviour that is characteristic of only a few groups. In mid-2006, protests have risen against the across-the-board standardized application of the ABC (abstain, be faithful, use condoms) strategy by US agencies where the A and B have got more attention than the C (see ‘The ABC Disaster’, Drum Beat, Issue 345 May 1, 2006).

Continuing victim-blame in development communication

Analysis of the errors of development and development communication in the 1960s pointed out victim-blame: the claim was that developing countries had not advanced because their citizens were apathetic irrational unscientific peasants without the motivation to achieve. Current media campaigns against AIDS target present-day victims of state inaction and the virus: unskilled villagers looking for work in the cities because there is none in villages.

Media can stimulate dialogue at the grassroots level about what information citizens need, when, and in what form, to educate their governments – this is quintessentially bottom-up communication. Communication media can also share knowledge of opportunities created by the state, to enable their utilization. This would constitute conscionable top-down development communication. But what honest role is there for communicators where there is no development? An advertiser does not start running a media campaign to encourage adoption of a service before it comes to market. When the product is available, the media campaign may become more intensive: repetition may increase. Similarly, one would expect a functioning state to create opportunities for development and then communicate knowledge about them.

UNDP’s Human Development Report for 2003 reported that the 1990s were a decade of despair for many countries. Over 50 countries were poorer in the early 21st century than they were in 1990. Twenty are from sub-Saharan Africa, 17 are from Eastern Europe and the former Soviet Union, 6 from Latin America and the Caribbean, 6 from East Asia and the Pacific, and 5 from the Arab States. The after-effects of colonization persist, in addition to limited foreign aid and market access. UNDP stresses that wealthy nations can materially shape development in the poor world and that their efforts to do so should consist largely of providing resources to and trading opportunities for poor countries.

The Center for Global Development3 also points to the need for wealthy nations to lift the burdens that they place on poor countries (e.g. WTO’s intellectual property agreement) and provide them with enough space to craft their own economic policies. They pointedly ask: would China have been better off implementing a garden-variety World Bank structural adjustment programme in 1978 instead of its own brand of heterodox gradualism? They highlight the experiences of Eastern Asia (e.g. Vietnam), China and India in creating business opportunities for domestic investors, including the poor, through institutional innovations that are tailored to local political and institutional realities.

The 54 countries in the UNDP listing are for the most part featured in the 2005 and 2006 Failing States Index prepared by Foreign Policy magazine and the Fund for Peace. For the purposes of this index, a failing state is one in which the government does not have effective control of its territory, is not perceived as legitimate by a significant portion of its population, does not provide domestic security or basic public services, and lacks a monopoly on the use of force. A failing state may experience active violence or be simply vulnerable to violence. Nevertheless, basic governance has to be an internal affair. The consequences of outside intervention are illustrated by the situation in Iraq and Afghanistan.

Rather than targeting migrant workers in developing countries who leave their families in the village to make a living because of state inaction, communication planners need to also put the blame where it belongs: on post-colonial states that have not got their development policies and AIDS plans right even fifty years after independence.

Embedding AIDS communication in multiple relationships

Given the tragic circumstances that have led to the spread of AIDS in states that are failing their citizens, three suggestions follow on how to cautiously use media selection and content to design communication interventions as one complementary input.

(1) Focus on those most at risk: Since the sale of state-owned media to private entities and the commercialization of all media, irrespective of their ownership, AIDS campaign designers have to buy media time and space just like toothpaste advertisers in most countries. Toothpaste advertisers know the importance of frequent repetition and attention to different stages of message development (e.g. awareness, interest, evaluation details, trial, adoption, reminders); they build the costs of such media buying and elaborated attention in to the price of the toothpaste. They also ‘sell’ the same product through different media, characters and sets to different markets, based on the needs and sub-culture of the focal group.

Given the reality of a range of risky AIDS behaviours (injecting drug use, blood transfusions, unprotected sex with multiple partners) practiced differentially by different income groups and discussed by them in different terms and tones of voice, AIDS campaign design has to be differentiated too. AIDS messages are clustered on cable TV and in elite magazines in some countries when their poor have access only to radio and over-the-air TV media messages.

Design of messages in participation with distinct economic and cultural social groups can address differences in how to communicate, just like ad agencies custom-design their commercial campaigns for different market segments. When budgets are tight, attention needs to go to groups with the most need. Billboards welcoming Kofi Annan to town courtesy of the state AIDS organization are unconscionable when there is no money to pay for billboards in the shanty towns where migrant workers live.

(2) Integrate AIDS communication interventions with the efforts of other agencies responsible for other aspects of AIDS prevention, treatment and support, e.g. testing, counselling, condom distribution. Communication is one intervention and complementary to those who deliver goods and services. Creating awareness of the protective power of condoms when they are not available in that part of town makes no sense. Scaling up of AIDS efforts to cover large groups at risk must conceptualize prevention in terms of job creation, public health, gender counselling and medical-technical interventions. Communication interventions cannot be a substitute for job creation in rural areas.

(3) The content of communication campaigns must aim at ‘resocialization’ since adolescent and adult socialization that supplied the skills for life in the village cannot suffice for life in city slums or mining towns far from the family. Rather than presenting use of sex workers, re-use of needles or sale of blood at unlicensed sanitary facilities as deviant, these behaviours must be grounded in situational comparisons with the old, i.e. why there was no need to use a condom for sex with his wife in the village as distinct from paying for sex in the slum.

Personal changes take place in the context of group relationships. Counsellors and media campaign designers need to compare the old and new situations in terms of group contexts such as the family, friends, teachers, religious leaders, public health venues and employment locations. Institutions of involuntary resocialization (e.g. prisons) frequently fail more than half their populations who return to prison. The point being emphasized is that risky behaviours are formed in and sustained in relationship with other individuals and groups over the lifecycle and also over social and political space.

Illustrations of the possibility of change must surely be rooted in the context of realistic illustrative analyses of these causal and sustaining situations. Why an unemployed migrant unskilled labourer in a shanty town has unprotected sex with a sex worker is a function of many causes that may need to be addressed systematically, contextually and vicariously in several episodes of dramatic radio and TV series.

This article has illustrated why AIDS has become a disease of poor people in poor countries. It has refuted the notion of communication as a lifeguard that relieves the pressure on governments to address the neglect of employment generation in rural areas and their poor public health infrastructures that are the primary causes of the disease. It focuses on the need to address causal and sustaining contexts of risky behaviours (multiple sex partners, selling blood, using unsterilised needles) for those at highest risk to improve effectiveness of media campaigns.

Notes

1. Appadurai, A. (2001) (ed.). Globalization. Durham N.C: Duke University Press.
2. Hornik, Robert C. (1988). Development Communication. New York: Longman.
3. Birdsall, N, Rodrik, D and Arvind Subramanian (2005). How to Help Poor Countries. Foreign Affairs. July/August.

Bella Mody is the deCastro Professor of Global Media in the School of Journalism and Mass Communication at the University of Colorado in Boulder, USA. She specializes in the political economy of media in developing countries and in design research on public service applications of communication media. Her research team is presently completing a book on how the world’s media represented the genocide in Darfur. Dr Mody coordinated the graduate programme in international development communication at Stanford University (Assistant Professor 1978-83) and taught at San Francisco State University (Associate Professor 1983-85). She was a professor and administrator at Michigan State University for 19 years prior to moving to the University of Colorado.