Gender, HIV and Risk

Navigating structural violence

E. Anderson

• Publisher: Palgrave Macmillan
• Year: 2015
• ISBN:
  9781137316127
• Topic: Politics & International Relations
• Subtopic: Social Policy
• Index: Politics & International Relations

This book examines the gender context of HIV and critiques the global policy response. Anderson contributes to the feminist task of de-invisibilising gender as structural violence and identifies how gendered power structures are responded to at the local level in Malawi.

1

Framing the Virus

The Policy Response to HIV

HIV has had a prominent place on the global health agenda as an ‘exceptional’ issue for global governance, attracting unprecedented levels of political commitment and resources as compared to other health concerns (see Smith and Whiteside, 2010; Nguyen, 2010, p. 13). The Global Fund to Fight AIDS, Tuberculosis and Malaria was established in 2001 and up to April 2010, US$19.3 billion had been committed in 144 countries. Seven grants were awarded to Malawi from October 2003 to 30 June 2010, totalling US$460 million ($343 million of which had been disbursed) (OIG, 2012, p. 1). In addition, the US President’s Emergency Plan for AIDS Relief (PEPFAR) was launched by former President, George W. Bush in 2003 and subsequently extended by President Obama. On 30 July 2008, the United States Global Leadership Against HIV, Tuberculosis, and Malaria Reauthorization Act was signed, authorising the commitment of up to US$48 billion over the ensuing five years. For the fiscal year 2008, President Bush requested US$5.4 billion to support treatment for 2 million HIV-infected people, prevention of 7 million new infections, and care for 10 million people infected or affected by HIV.

Crucial to understanding the rise of ‘AIDS exceptionalism’ is the ways in which the complex challenges the virus poses have been framed. As Elbe (2006, p. 125) argues, it is a political decision how to frame HIV and this serves to circumscribe the parameters for the response (see also Shiffman and Smith, 2007; Labonté and Gagnon, 2010, p. 14). This chapter is concerned with examining the implications of the ways in which HIV has been conceptualised and responded to for engaging with the gender dimensions of the pandemic. First, the analysis questions the ramifications of these frames for engaging with gender as a structural determinant of risk. As Butler (2009, pp. 9–10) considers in her work on the ‘frames of war’, these can be challenged by showing that the ‘frame’ never contained the reality it was supposed to depict. It is argued that the ways in which the pandemic is conceptualised invisibilises the gender dimensions of people’s lived experiences of insecurity and risk. Second, the dominant neoliberal responses that emphasise the medicalisation of risk and changing so-called ‘risky’ behaviour from the top down are critiqued. It is argued that, as is the case for neoliberalism more broadly, these serve to legitimise, manage, reinforce and even perpetuate the very structural inequalities and power relations that heighten risk rather than challenge them. In doing so, this chapter highlights the importance of context and provides the rationale for the subsequent analysis of the nuances of gender as a structural violence in Malawi.

Framing the global response

The analysis here focuses on examining the implications of the development and security frames for engaging with the gender dimensions of the pandemic. Since the mid-1990s HIV has been included within a global development framework (see Linking, 1996). In 1994 the International Conference on Population and Development highlighted in its Programme of Action the challenges HIV posed for population and development (UNFPA, 1995). Moreover, in 2000 combating HIV was included in goal six of the Millennium Development Goals, recognising that addressing the pandemic was critical to achieving ‘sustainable development’ (see Hulme, 2007). Ahead of the Millennium Summit, Kofi Annan (the then Secretary-General of the UN [United Nations]) highlighted in his report We the Peoples that, despite the multiple health challenges that are fundamental to development:

It is beyond the scope of this report to explore all of these challenges. I wish here to focus on a specific health crisis that threatens to reverse a generation of accomplishments in human development, and which is rapidly becoming a social crisis on a global scale: the spread of HIV/AIDS. (Annan, 2000, cited in Rushton, 2010a, p. 8)

Framing HIV in development terms is important for recognising the complex challenges that the virus poses for development at all levels, including global development, states, the private and public sector, communities, households and individuals (see UNAIDS, 2009, p. 21; Commission for Africa, 2005, p. 204; Hope, 2001, pp. 22–9). For the case of Malawi, the National HIV/AIDS Policy (GoM, 2003) highlighted how the virus is threatening development by undermining previous gains and changing the very nature of development. Labour productivity and economic growth were diminishing, families were losing their breadwinners and the burden on elderly family members and older siblings was heightened. In the health sector, HIV patients were occupying more than 50 per cent of hospital beds and the maternal mortality rate more than doubled, a large part of which was attributed to AIDS-related illnesses. Agricultural extension workers were dying at a faster rate than replacements could be trained and it was estimated that by 2020 the agricultural workforce would be 14 per cent smaller than it would have been without HIV. Chronic illness was reducing productivity with the result that land was being left fallow. Where adults were absent for long periods to nurse sick relatives they were unable guard their land and livestock against theft. Women were identified as being particularly at risk of property grabbing on the death of their spouse. The persistence of a short-term outlook meant that people invest in petty trading rather than agricultural enterprises and children left orphaned do not have the skills to perform agricultural activities. Furthermore, HIV impacts on the capacity of the political system to effectively and efficiently perform its mandates, and thereby respond to the multiplicity of challenges posed by the epidemic. It exacerbates the demand on the public services to respond to the plethora of challenges and yet it decreases the capacity of these services (see UNAIDS, 2006, ch. 4; GoM, 2003, 1.1–1.4; Ngwira et al., 2001, pp. 15–16). The Malawi Human Development Report in 2005 therefore propounds that ‘unless HIV and AIDS is placed at the centre of national planning processes Malawi’s chances of stimulating economic growth, reducing poverty and promoting human development are dramatically reduced’ (UNDP, 2005, p. 1).

And yet the dominant neoliberal ‘Development’ discourse (capitalised here to distinguish it from development more broadly defined) serves to manage and reinforce the structural inequalities that underscore HIV risk in the first place. There is a long history of ‘top-down’ neoliberal development in Malawi. Structural Adjustment Programmes (SAPs) were introduced from 1981 and, as was the case in other so-called ‘developing’ countries, these conditional loans were dictated by the ‘good governance’ prescriptions of the Bretton Woods Institutions (the World Bank and the International Monetary Fund). The underlying freemarket ideology required the rolling back of the state, efficiency cuts (with particular ramifications for health and education with the introduction of user fees) and export-orientated agriculture (see Chilowa and Chirwa, 1997; Lele, 1990; for the situation in general see Hay, 2004; Harvey, 2005). The SAPs did not include a systematic evaluation of the impact of adjustment on the poor, who are predominantly women (Kydd and Hewitt, 1986, p. 362). In the aftermath, facing growing criticisms, including the calls for adjustment with a ‘human face’ (UNICEF, 1987), the World Bank recognised that in countries with extreme poverty, such as Malawi, the SAPs compounded the adverse effects on the poor, highlighting the need for investment in broader agricultural development (Lele, 1990, pp. 1207–8). This led to the promotion of broader economic restructuring through the Enhanced Structural Adjustment Facility. Structural adjustment was replaced in 2001 by the Poverty Reduction Strategy Papers, following criticism of the limitations of the previous Poverty Action Plans and the Interim Poverty Reduction Strategy Plans of the 1990s. It stressed the importance of empowerment and creating an enabling environment ‘whereby the poor can reduce their own poverty’ (GoM, 2001, p. 90), but it remained vague in how this is to be achieved (Ellis et al., 2003, p. 1496).

Despite Malawi being hailed as one of the strictest adherers to neoliberal policies, at the end of the 1990s it was highlighted that increases in foreign direct investment and economic growth failed to materialise (Chilowa, 1998). The shift to export-orientated agriculture – most notably burley tobacco – has left the economy vulnerable to exogenous shocks in global trade prices. Agriculture accounted for 35 per cent of gross domestic product in 2008. For the period 2000 to 2010 there was an increase in the trade deficit to166 billion Malawi Kwacha (MK). Tobacco is the main export but there is an increase in nontraditional export commodities, including garments and cotton (NSO, 2011, p. 4). The government is still dependent on foreign aid for 40 per cent of national budget and the UK’s Department for International Development (DfID) provides the largest bilateral aid programme. Given the situation of dependency on the external environment there is a pressure to enact donor-driven policies, as is the case for gender mainstreaming, democratisation and the Farm Input Subsidy Programme (see Moser, 2005; Chinyamunyamu, 2014), a point I return to in chapter 5.

Neoliberalism focuses the attention of agencies, particularly the World Bank, on technocratic and universalising policy initiatives in poor countries such as Malawi. As J. Ferguson (1990) famously argues in The Anti-Politics Machine, the deeper issues of development that underscore poverty (including inequalities, dependency and gender) are left suspended in mid-air, rendered non-political and are not talked about on the ground. As Mowforth’s (2014) recent work considers, development is predicated on force and systemic violence, which permeates the policy response. The concern here is that the inherently political nature of many development problems, including inequality, discrimination and the local and national political processes, is obscured (see Hickey, 2009; Green, 2006). Hickey (2009) argues that, despite some lip-service paid to new forms of political analysis and efforts to support ‘pro-poor’ initiatives, these are limited and the agenda of liberalism – based on ideology rather than evidence – is entrenched. A stronger political perspective is therefore essential and this includes a gender perspective. These reforms have had a particularly negative impact on women, as chapters 3 and 4 explore. As Moser (1989) famously argues, women are a resource for development within neoliberal policies: their unpaid labour mitigates the negative impact of, for example, the SAPs and shocks to food production, including droughts and floods. Neoliberalism continues to be the dominant paradigm of international development today, which Bezner Kerr and Mkandawire (2012) argue includes the policies on HIV and gender. Despite the attention paid to the ‘female face’ of issues of development (including HIV), this is only at a superficial level, which invisibilises the deeper aspects of gender as structural violence, a point returned to in chapter 5, when I look at empowerment.

Since the turn of the twenty-first century there has been an emphasis on conceptualising HIV in international security terms and this has been extensively debated within the Global Health IR literature (see Rushton and McInnes, 2012; McInnes and Rushton, 2010; Rushton, 2010a, 2010b; Elbe, 2003, 2005, 2006, 2009; Ostergard, 2002, 2008; Barnett and Prins, 2006; McInnes, 2006; Whiteside, 2006; Garrett, 2005). In January 2000, the UN Security Council took the extraordinary step of highlighting the pandemic as ‘a threat to international peace and security’. The speed with which it has spread across Sub-Saharan Africa and the absence of an effective response has entrenched the perception that HIV is a crisis situation. The rapid increase in AIDS-related mortality brought about uncertainty about the magnitude of the risk, which is compounded by the time lag between infection and AIDS-related deaths a decade later; HIV is a ‘lentivirus’ – taking a long time to manifest itself (see Boesten and Poku, 2009, p. 3). The long-term impact of HIV is hard to measure, which impairs the response to HIV as a systemic condition (Poku and Whiteside, 2004, p. xvii). The combination of the uncertainty of the situation and the fact that healthy looking people can be infected exacerbates the sense of emergency (Anglewicz and Kohler, 2009, pp. 65–7). In April 2001, the Abuja Declaration and Framework for Action for the Fight Against HIV, Tuberculosis, and Other Related Infectious Diseases in Africa was created at a special summit of the Organization of African Unity, describing the AIDS situation as ‘a state of emergency facing the continent’ (OAU, 2001). The aim was to foster African leadership in the response to AIDS and African governments were required to commit at least 15 per cent of national budgets to the health sector to assist in the fight against HIV, tuberculosis and other infectious diseases. The UN General Assembly held a special session on AIDS at the end of June 2001, which represented ‘the most concerted, high level and comprehensive gathering of nations ever held to discuss AIDS’ (Piot and Seck, 2001, p. 1107) and a declaration of commitment was created.

This shift in how HIV is conceptualised was important because, as Labonté and Gagnon consider, the ‘high’ politics of security trumps the ‘low’ politics of human rights and development – allowing them to be taken more seriously in IR (2010, p. 14). Peter Piot (2005), founding Executive Director of UNAIDS and Under Secretary-General of the United Nations from 1995 until 2008, propounds how framing HIV as an ‘extraordinary security threat’ is advantageous: it engages with some of the complexities of the military, political and economic impact, appealing to material and strategic interests of states. The UN Political Declaration on HIV/AIDS (2 June 2006) recognised that ‘HIV/AIDS constitutes a global emergency and poses one of the most formidable challenges to the development, progress and stability of our respective societies and the world at large, and requires an exceptional and comprehensive global response’. Emphasis is laid on the alarming statistics to highlight the sheer scale of the pandemic and quantify risk. The UN Political Declaration on HIV/AIDS (UN, 2006) for example states that:

[We] [n]ote with alarm that we are facing an unprecedented human catastrophe; that a quarter of a century into the pandemic, AIDS has inflicted immense suffering on countries and communities throughout the world; and that more than 65 million people have been infected with HIV, more than 25 million people have died of AIDS, 15 million children have been orphaned by AIDS and millions more made vulnerable, and 40 million people are currently living with HIV, more than 95 percent of whom live in developing countries.

UNAIDS (2009, pp. 7, 21) reports that over the past three decades a total of almost 60 million people have been infected and there have been 25 million AIDS-related deaths. Sub-Saharan Africa is the area hardest hit by the pandemic, accounting for 67 per cent of the global population living with HIV and 72 per cent of all new HIV infections in 2008. Against this backdrop there has been a proliferation of global and regional treaties, conventions and organisations, particularly over the first decade of the twenty-first century, committing governments to respond (see for example UNAIDS, 2008a, 2009; UN, 2000, 2006; OAU, 2001).

However, the securitisation of HIV lays emphasis on the more traditional, state-centric concerns about the impact on military security, particularly through diminishing the capacity and effectiveness of armed forces (see discussion in Elbe, 2006, pp. 125–6; for the debate on pandemic influenza see Enemark, 2007, 2009; Lee, 2006). HIV emerges onto the agenda as a security concern because of the connections with national stability and conflict (see McInnes, 2011; de Waal, 2010; Singer, 2002, p. 145). Narrow national security interests lie in protecting a state’s territory, its population and its economic, social and political interests from the external threat of AIDS ‘the invader’ (Feldbaum et al., 2006a, p. 774; Elbe, 2006, pp. 120, 129). This rhetoric permeates even the United Nations discourse: when the former Secretary-General, Kofi Annan addressed the African Summit on HIV/AIDS, Tuberculosis and Other Infectious Diseases on 21 April 2001, he declared that ‘The war on AIDS will not be won without a war chest, of a size far beyond what is available so far’ (UN, 2001). Scarce resources target strategically important populations for national and international stability and security, in particular prioritising the elites and army. The virus is considered a threat to the operational capability of the military because it depletes highly trained human resources that are difficult to replace, interrupts training of new recruits, reduces the pool of new recruits and then there are the costs associated with treating infected soldiers. UN Resolution 1308 was formulated six months later, which mandated UNAIDS to take action with regard to the effect on peacekeeping missions. There was a dual concern to prevent diseases being spread to the civil population by peacekeepers and the peacekeepers becoming infected and introducing infections when they return home (Elbe, 2006, pp. 119–44; Barnett and Prins, 2006, pp. 367–8; Feldbaum et al., 2006a, p. 775). The US National Intelligence Council report Global Infectious Disease Threat and Its Implications for the United States drew attention to the impact of infectious diseases on national security: they ‘endanger US citizens at home and abroad, threaten US armed forces deployed overseas, and exacerbate social and political instability in key countries and regions in which the United States has significant interests’ (US National Intelligence Council, 2000, pp. 33–65). As recognised by the human security discourse introduced by the 1994 Human Development Report (UNDP, 1994), problematising HIV in narrow security terms ignores individual women, men and children who are infected or coping with the impact, and, more specifically, the ability of women to identify with and contribute to the creation of security (see also Hoogensen and Stuvøy, 2006, pp. 208, 210). Furthermore, feminist scholars highlight that security is a gendered term, dominated by masculine characteristics of war and violence (see Tickner, 1992; Enloe, 1989).

Seckinelgin et al. (2010), in their work on Burundi, argue that the narrow security frame does not effectively engage with the ways in which conflicts place people (and women in particular) at HIV risk. They expose how the security–HIV nexus fails account for the gendered vulnerabilities, how these are instrumentalised in conflict and post-conflict, and how they are also maintained and changed as a result of people’s experiences during conflict. The concern here is that it invisiblises gender as structural violence, which permeates even seemingly ‘peaceful’ contexts. Although Malawi is heavily affected by HIV, it does not have a history of conflict, and yet it is not a country at peace in the broadest sense of what Galtung (1969) defines as ‘positive peace’. HIV risk is part of a ‘continuum of violence’ (see Kelly, 1988; Cockburn, 2004) that is interlinked with broader experiences of under-development and insecurity that is entrenched in a long history of colonialism and neoliberal development. As de Bruijn and van Dijk (1999, pp. 115–16) consider in their research on insecurity and pastoral development in the Sahel, ‘crisis situations are not just calamities for an unhappy minority, but rather a dominant feature of life for millions of people in numerous societies throughout the world. . . . For them insecurity is a total experience not confined to one life sphere or another, but integrated in their lives and society.’ The linkages between HIV and (in)security have resonance, particularly in terms of poverty, under-development and poor health as a structural violence – and these are experienced in gendered ways. This brings to the fore questions of what we can learn about the complexities of structural inequalities of gender in ‘peaceful’ contexts such as Malawi.

The sense of a ‘crisis’ within the security discourse is at odds with people’s lived experiences of the normalisation of risk. Although it is over 30 years since the first clinical evidence of AIDS was reported in 1981, the pandemic is still treated as an emergency situation. Framing HIV as a ‘crisis’ is attractive because it fits the short-term view of the governments, non-governmental organisations (NGOs) and media, which respond to current events and emergency situations (Melesse, 2008). The virus has long been normalised and accepted as an inescapable fact of lif...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Acknowledgements
• Abbreviations
• Introduction: Gendered Risk as Structural Violence
• 1. Framing the Virus: The Policy Response to HIV
• 2. Methodology
• 3. Sex for Security: Gendered Poverty
• 4. Sex for Well-being: The Gendered Value of Life
• 5. Gender on the Agenda? Empowerment
• Conclusion: Gender Social Justice
• Appendix 1: Interviews, Consultations and Focus Groups
• Notes
• Bibliography
• Index