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Journalist, Author, AIDS activist, Community Educator,
and Filmmaker
 AIDS:
A crime against women
Moving Mountains: The Race to Treat Global AIDS
by Anne-christine d'Adesky.
New York: Verso, 2004, 487 pp.
Reviewed by Karen Kahn
I WAS SHOCKED OUT OF COMPLACENCY recently
when I encountered a stunning figure in my morning newspaper.
The average lifespan in some African countries is spiraling
down so rapidly as a result of HIV infection that it is predicted
to be no more than 35 years in the near future. Though I had
known that AIDS is spreading rapidly in many parts of the
world, bringing with it increased poverty, despair, and death,
I had not stopped to consider the devastating toll of this
disease on entire populations. AIDS has become the bubonic
plague of the 21st century.
Since 1981, 20 million people have died of AIDS worldwide.
Today, over 40 million people are infected with HIV; of these,
the World Health Organization predicts 6 million will die
in the next two years, if they are not provided with antiretroviral
treatment. For Anne-christine d'Adesky, this is a crime against
humanity. In her new book, Moving Mountains,
she argues forcefully that "AIDS [is] not just a
medical or public health issue, but fundamentally a social
and political one." Though treatment could be made
available to the 6 million people who need it today, d'Adesky
contends, we do not have the political will. It takes only
one quick look at the resources going to the "global
war on terror" versus worldwide AIDS prevention and treatment
to confirm that d'Adesky's righteous anger is justified.
Moving Mountains is a challenging book--intellectually
and emotionally. D'Adesky pushes her readers to embrace their
responsibility for this human tragedy and join the struggle
to make treatment accessible around the world--and she grounds
her argument in detailed field reports from the Caribbean,
Latin America, Africa, and Russia. Her interest is in the
myriad challenges--political, social, medical, technical,
cultural--to delivering therapy, and to issues related to
disease control and the capacity of nations to mobilize their
civil societies and health sectors to deliver accelerated
access to AIDS medicines. (p. 9)
These are complex issues. For readers unfamiliar with the
technical aspects of AIDS treatment, global trade agreements
and their impact on the manufacturing and distribution of
inexpensive generic drugs, and the international agencies
involved in delivering prevention and treatment programs,
it may take some fortitude to keep going. But there is much
to learn here, making the effort worthwhile.
HIV infection may be the most important issue facing feminists
today. As Stephen Lewis, UN Special Envoy for HIV/AIDS in
Africa, told Ms. magazine this fall, HIV "has targeted
women with a raging, Darwinian ferocity." Gender
inequality leaves women vulnerable to sexual transmission
from husbands who abuse them or hide their HIV status. Often
men refuse to use condoms, but in many circumstances, the
family's desire for children simply outweighs other considerations.
In war-torn areas of Africa, rape by soldiers is commonplace,
leaving women stigmatized, pregnant, and ill.
Today, half of all HIV infections are among women--in Africa,
the rate is 58 percent. Among 15 to 24 year olds, 75 percent
of those infected are female. In Uganda, d'Adesky notes, girls
aged 15 to 19 are four to six times more likely to be infected
than boys of the same age. Many of these girls are infected
by older men who use them for sexual pleasure.
These high rates of infection among girls and women have
accelerated promotion of AZT and nevirapine to prevent mother-to-child
transmission of HIV. Such treatment programs have been highly
successful but often do not include treatment for the mothers
themselves. D'Adesky found women in Uganda "furious and
desperate" about the lack of treatment for themselves,
their husbands, and other members of their communities. Rather
than succumbing to despair, however, they were organizing.
If HIV infection has any up side at all, d'Adesky saw it here:
"I realized that a positive offshoot of the AIDS
crisis in Africa is the global attention it focuses on women's
issues, which is helping African women to fight against long-standing
legal, political, social and cultural inequities".
(p.143)
Still, many Ugandan women fear revealing their HIV-status,
as they may be beaten by husbands, kicked out of their homes,
and abandoned. Domestic abuse is common in Uganda, where male
privilege is deeply ingrained. A 2001 survey revealed that
40 percent of the women respondents had experienced domestic
abuse; some women were beaten for refusing sex, and others
were forced into sex as a marital obligation. As one activist
with Women's Treatment Action Group (WTAG) noted:
"The husbands are a real problem.... Many husbands
have two wives, and sometimes these wives do not even talk
to each other about HIV, even if one of them is HIV-positive.
They cannot afford to tell their husbands. That is the reality
we are going to have to confront". (p.152)
Uganda has been touted by the Bush administration as one
of the great success stories for HIV prevention. Using an
approach called ABC--abstinence, betrothal, and condoms--Uganda
has reduced its seroprevalence rate from 30 percent two decades
ago to less than ten percent today. However, suggesting that
the decrease in transmission may be the result of high mortality
rates, d'Adesky worries that, in a culture in which male privilege
leaves women few options, the ABCs may be doing more harm
than good. In Uganda, many married women have followed these
rules, abstaining from sex before marriage, only to find themselves
infected by unfaithful husbands. With little power in their
relationships, these women cannot negotiate condom use to
protect themselves.
Nor does the emphasis on abstinence and betrothal help marginalized
communities of sex workers, drug users, or men who have sex
with men. As the Bush administration pushes its conservative
agenda, HIV continues to spread through these stigmatized
but common activities. As AIDS activists in the US warned
in the early '80s, "Silence = Death."
The refusal to acknowledge the realities of nonmarital sex
and intravenous drug use and to provide easy access to condoms
and clean needles continues to leave countries vulnerable
to widespread infection.
IN THE LAST DECADE, the face of AIDS in
the West has changed dramatically. Today, the great majority
of the 1.6 million people living with HIV have access to antiretroviral
treatment; HIV has become a disease to be managed, rather
than a death sentence. In the developing world, however, only
seven percent of those in need of treatment--400,000 people--have
access to effective drug therapies. D'Adesky acknowledges
that providing treatment to all who need it is a tremendous
challenge, but she contends it is one that the world community
can meet. She is encouraged by the World Health Organization's
commitment to its "3x5 plan" to provide treatment
to 3 million people by 2005. Though politics and bureaucracy
have slowed the process, WHO is providing important leadership
in helping poor countries to acquire medications at prices
they can afford.
The United States has not been an ally in that effort. The
Bush administration, while widely publicizing its $15 billion
commitment to stopping the spread of AIDS, has blocked the
most important strategy for saving lives. Allying itself with
the world's major pharmaceutical companies, the administration
has used worldwide trade agreements to limit the ability of
poor countries to import cheap generic drugs. According to
d'Adesky, the cost of treating HIV-infected patients today
could be as low as 38 cents per day. The struggle for worldwide
access to antiretrovirals once again reveals the big lie about
the high cost of medical care--these drugs are not nearly
as expensive to manufacture and market as the pharmaceutical
companies insist.
Making these drugs available to developing countries is
not the only challenge in the battle against AIDS. Some claim
that treatment protocols are too complex for poor, illiterate
people to follow; d'Adesky insists that they are simply looking
for excuses to do nothing. Her field reports demonstrate that
even in the poorest communities in the world, treatment works.
Widespread use of generics combined with prevention education
have brought a runaway epidemic in Brazil under control in
just six years. In rural Haiti, Dr. Paul Farmer's Partners
in Health organization is saving lives through a community
mobilization model that "views patients as equal
allies in this effort."
Farmer's team relies on Directly Observed Therapy (DOT),
a somewhat controversial treatment protocol that has often
been used in prisons, mental health institutions, and drug
clinics to ensure that the patients take their medicines.
Partners in Health has adapted DOT as a public health strategy
by training members of the community to provide the support
patients need to comply with difficult treatment protocols:
"In Cange, [Haiti,] the ones giving out pills and
supervising patient behavior... are not doctors, but peers
and community members who go to patients' homes....[These]
community health workers are called "accompagnateurs"--those
who accompany. They don't just hand over pills; they listen,
they talk, they help individuals and their families cope with
a range of daily, personal needs". (pp. 107-108)
Farmer's success with DOT provides hope for communities
around the world. But other challenges remain. In many developing
countries, the public health infrastructure is practically
nonexistent. Lack of food and clean water undermines efforts
to fight both HIV and the many opportunistic infections that
attack those with compromised immune systems.
An optimist, d'Adesky sees these challenges as opportunities.
As countries take on the fight against AIDS, of necessity
they are building up public health systems and addressing
long-standing health issues such as tuberculosis, the number-one
killer of HIV-infected individuals in poor countries. In Africa,
AIDS has focused greater attention on a host of long-standing,
complex problems, including warfare, widespread famine, lack
of access to clean water, and gender inequality. Addressing
the AIDS crisis will necessitate finding solutions for these
threats to health and stability.
Moving Mountains is densely packed with
information and infused with the author's deep commitment
to AIDS activism; the book, however, suffers from some unfortunate
flaws. As a compilation of previously published essays, the
flow of information and argument is disjointed and sometimes
difficult to follow. I wished for a single chapter explaining
the manufacture and marketing of generic drugs and the impact
of world trade agreements, since this information was so central
to many of d'Adesky's most powerful political arguments. I
was also disheartened by the poor editing that left the text
littered with contradictory facts and figures that may have
been the result of error--or simply of the essays having been
written during different years. The author, along with her
editors at Verso, unfortunately failed to turn this thought-provoking
collection of essays into the kind of coherent and incisive
treatise that might have engaged a broader audience in addressing
one of the greatest challenges we face as a global community.
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