The World Bank, HIV/AIDS and Sex in Sub-Saharan Africa: A Gendered Analysis

Abstract

This paper explores the relationship(s) between global governance, sex, and HIV/AIDS in sub-Saharan Africa (SSA), as embodied in the practices of such governance organisations as the World Bank, the African Development Bank (AfDB), and the Organization for Economic Cooperation and Development (OECD). ‘Neoliberal’ in their commitment to centralising the Western ‘free’ market and private capital in developing countries, these organisations trade in their success at instigating ‘effective’ (that is, profitable) policy-making. For governance organisations, and the ‘developing’ countries with which they work, HIV/AIDS is a subject to be taken very seriously, not only since the premature death of any adult population is a cause for concern, but also because HIV/AIDS is believed to impact particularly devastatingly on society's otherwise most economically productive participants. My focus on HIV/AIDS policy (in SSA because it is a region considered especially blighted) is, however, less focused on conventional accounts of ‘obstacles’ to economic development as measurable through gross domestic product (GDP). My concern is, rather, with the ways in which governance organisations' various approaches to HIV/AIDS in SSA provide examples of the ways in which global governance policy-making regulate and reproduce ‘appropriate’ human bodies through assumptions about who a person is and, therefore, what that person does (or is able to do).

Este artículo estudia las relaciones entre la gobernanza global, la sexualidad y el VIH/SIDA en el África sub-sahariano (SSA, por sus siglas en inglés) integradas a las prácticas de tales organizaciones de gobernanza como el Banco Mundial, el Banco de Desarrollo Africano (AfDB, por sus siglas en inglés), y la Organización para la Cooperación y el Desarrollo Económico (OECD, por sus siglas en inglés). Estas organizaciones ‘neoliberales’ comprometidas a centralizar el ‘libre’ mercado occidental y el capital privado en los países en desarrollo, intercambian sus éxitos promoviendo una ‘efectiva’ (es decir, rentable) toma de decisiones. Para las organizaciones de gobernanza y los países en ‘desarrollo’ con los cuales trabajan, el VIH/SIDA es un tema que debe tomarse muy seriamente, puesto que la muerte prematura de cualquier población adulta no solo es una causa de preocupación, sino que también se cree que el VIH/SIDA impacta de manera particularmente devastadora a la sociedad, que por el contrario, contaría con los participantes más productivos económicamente. Mi enfoque en la política del VIH/SIDA (en el SSA porque es una región considerada especialmente devastada) está sin embargo, menos centrado en los informes convencionales de los ‘obstáculos’ al desarrollo económico, mesurables a través del producto interior bruto (GDP, por sus siglas en inglés). Por el contrario, mi preocupación radica en la manera en que varios enfoques de las organizaciones de gobernanza ante el VIH/SIDA en el SSA, proveen ejemplos de formas en que la toma de decisiones de la gobernanza global regula y reproduce cuerpos humanos ‘apropiados’ a través de suposiciones sobre quién es la persona y por lo tanto, lo que esa persona hace (o es capaz de hacer).

本文探索了全球治理、性行为以及撒哈拉以南非洲艾滋病之间的关系，具体体现在诸如世界银行、非洲发展银行及经合组织这些治理组织的实践中。通过“新自由主义”地承诺在发展中国家整合西方“自由”市场和私人资本，这些组织成功地煽动了“有效的”（即，有利可图的）政策制订。对这些治理组织及其作用下的“发展中”国家来说，艾滋病成为一个受到严肃对待的问题，不仅是因为成年人口的过早死亡引起人们关注，还因为艾滋病被认为会对社会产生破坏性的影响，否则他们会是经济上产出最大的社会成员。不过，我对艾滋病政策（在撒哈拉以南的非洲，因这是一个被认为特别受摧残的地区）的关注，较少集中在以国内生产总值（GDP）衡量的经济发展“障碍”的惯常考察上。相反，我关注的是上述治理组织在撒哈拉以南非洲艾滋病问题上的一系列做法，将为全球治理的政策制订通过人是什么因而人做什么（或能做什么）来调节和复制“合适”人体的方式提供例证。

Keywords:

• governance
• HIV/AIDS
• sex
• sexuality
• World Bank

Notes

The World Bank is not easily identified as ‘one’ institution and is more accurately described by its group title (that is, the ‘World Bank Group’, a conglomerate of five component organisations). The Bank is most significant, as the author has elsewhere argued, as a source of contemporary global governance with inextricable links to the field and politics of ‘development’. The Bank is not monolithic, nor does it enjoy unrivalled precedence in the cultures and politics of every so-called ‘developing’ and ‘underdeveloped’ economy. It does, however, enjoy something of a monopoly of economic wisdom in practices of development that cannot be disarticulated from the institution's neoliberal doctrine (Griffin, 2009, p. 4).

This is most clearly achieved by the effecting in neoliberal discourse of gender as a ‘true’ expression of a fixed and binary notion of sex, centred on ideas of successful human behaviour modelled on an abstractly masculine identity (see Griffin, 2007, 2009). Gender in Bank discourse equates to a highly fixed and binary notion of sex, with ‘matters of gender equity’ pertaining to such issues as ‘women's’ and ‘girl's’ education, ‘women's’ health, and ‘women's’ productivity' (e.g. World Bank, 1999a, 1999b, 2001b, 2006). Where the Bank does speak of men in development, it refers to the ‘male side’ of gender in development, frequently reserving ‘productivity’ for men and also for boys (as soon-to-be-men). Women ‘produce’, but their productive role is viewed as a result of their essentially nurturing propensities, and their work concerned primarily with the well-being of family members (Griffin, 2007, p. 233).

Industrialised countries are estimated to contribute between US$9bn and US$10bn a year to efforts to combat HIV/AIDS. In 2008, according to the UK's Observer newspaper, developed countries contributed $13.2bn into efforts, chiefly for Africa. The same figure for 1996 totalled $480mn (Duval Smith, 2009).

According to UNAIDS, 25 million people have died of HIV-related causes globally (2008a, p. 15). In South Africa alone, ‘which has the largest number of HIV infections in the world (5.5 million), an estimated 1.8 million people have died of AIDS-related disease since the epidemic began’ (UNAIDS, 2008b, p. 4). Beyond Africa, since the signing of the United Nations Declaration of Commitment on HIV/AIDS (2001), the number of people living with HIV continues to increase. In Eastern Europe and Central Asia, for example, the increase has been by more than 150%. In Asia, between 2000 and 2005 the estimated number of people living with HIV in Vietnam more than doubled. Indonesia has the fastest growing epidemic (WHO, 2007). As UNAIDS reports, ‘some of the most worrisome increases in new infections’ are now occurring in ‘various high-income countries’ (2008a, p. 30, emphasis added). In Australia, for example, the number of new HIV diagnoses has been on the increase since 2001 (Sydney Morning Herald, 2006). That this has not resulted in a crisis of sorts for the West is a result of the ‘pronounced declines in AIDS-related deaths’ that have resulted from ‘advances in treatment’ in high-income countries (UNAIDS, 2009a, p. 16).

For its focus on the ways in which bodies are regulated in development policy-making and the global political economy more broadly, this article (as for my previous work) owes a particular debt to the vast gender and development literature that has proved so inspirational to development studies and political economy analyses. Far too diverse to possibly capture in any fair or meaningful way here, feminist and gender studies work in and on development has done much to problematise the continued, and often wilful, androcentrism of conventional development theory and practice (see, for example, Benería, 2003; Boserup, 1970; Elson, 1996; Ferber and Nelson, 1993, 2003; Hoskyns and Rai, 2007; Jolly, 2000; Kabeer, 2001; Tinker, 1990; Tinker and Bransom, 1976, among many others). With regards to my own work, feminist and gender scholarship has been most instructive for its commitment to building different kinds of knowledge about, but also beyond, what is considered conventionally acceptable in development today. Interdisciplinary and various in approach and methodology, such scholarship has traced the constitutive (and also causal) role that gender plays in the diverse forms, functions and impacts of the global political economy (GPE), while engaging with issues of terminology and methodology as much as economic analysis. An increasing commitment to gender analysis as a crucial means of analysing and understanding all socio-economic processes has thus thoroughly broadened gender's analytical reach, while also encouraging much-needed consideration of women and men's lived experiences of development processes.

It is also worth noting that the main method for collection of national HIV/AIDS trends is through anonymous surveillance at static clinics. Depending on a person's location, access to such clinics is by no means certain. Most frequently, antenatal clinic statistics are used to indicate HIV prevalence rates as apparently good estimates of young adult prevalence, although antenatal surveillance can often prove biased towards urban or wealthier areas and, of course, only targets women (men's attendance at antenatal clinics cannot be assumed).

According to the Bank, the private capital flows that had, in 2007, totalled $53 billion (‘financing much-needed infrastructure and commodity-based investments’) had in the second half of fiscal 2009 fallen by 40% (World Bank, 2009c).

The point worth emphasising here is, simply, that there is nothing fixed, monolithic, and/or predictable about African sexualities. As Ibhaze and Sholola (2008) note, colonialism and post-coloniality have created particularly muddied situations, for example, where ‘in the old African traditions same sex relationships existed and were tolerated if they were discreet and did not interfere with heterosexual marriage’ but where we now see modern African leaders denouncing such relationships as ‘un-African’. Thus those who, as the authors point out, believe they are ‘defending African culture from the so called perversions of the West’ are often instead defending a colonial, Christian construction ‘of what marriage ought to be’. Examples include former Namibian President Sam Nujoma's repressive castigation and stigmatisation of homosexuals in Namibia and his reported declaration (in December 1996) that ‘all necessary steps must be taken to combat [all that is] influencing us and our children in a negative way. Homosexuals must be condemned and rejected in our society’ (quoted in IGLHRC, 1997). Zimbabwean President Robert Mugabe's attack on homosexuality as ‘non-traditional’ and ‘un-African’ have become similarly infamous (Jolly, 2000, p. 82).

Like other disease hypotheses circulating in Western science at around the same time (the Ebola and Marburg viruses and also Lassa fever were also being posited as endemic in Africa), HIV/AIDS attracted a variety of misjudged and offensive comments. American scientist's Robert Gallo's identification, for example (in 1985 at the First International Conference on Virus-Related Cancers in Dakar, Senegal), of the AIDS-causing virus as ‘closely related’ to a virus isolated in African monkeys might easily be read as an assertion that Africans are in essence closer to monkeys than Westerners.

The more successful Ugandan slogans included references to ‘love faithfully’ and ‘zero grazing’ (which refers to the technique of tethering a cow or goat to a post, ensuring that it eats grass only in a circle). There was in the Ugandan campaign, however, little or no reference to condoms, which the Botswanans had found particularly offensive (2004, p. 1148). It should be noted, though, that the evidence for greater success with Ugandan initiatives is not uniform. Thus, Allen and Heald propose indications that HIV prevalence and rates of new infection in Uganda have been stable or in decline, while rates in Botswana during the same period have (despite its comparatively elevated standards of living, education and health care) significantly increased (2004, pp. 1141–1142). UNAIDS, however, offers some evidence to suggest that infections among ‘low-risk’ heterosexual couples in Uganda are increasing (UNAIDS, 2009a, p. 13). Certainly, Botswana has experienced a much higher prevalence of HIV/AIDS generally than Uganda, with estimates suggesting 25.2% in 2005 compared to Uganda's 6.4% (UNAIDS, 2009a, p. 19). Botswana also, however, reports the highest number of tests per 1000 population (UNAIDS, 2009a, p. 25) and no confirmed data is available for Uganda more recently than 2005, which may suggest that Uganda underreports HIV/AIDS prevalence. UNAIDS also notes that the declines in HIV prevalence reported in Uganda in the past decade ‘appear to have reached a plateau’, with reported increases in sexual risk behaviours in Uganda remaining ‘a source of concern’ (UNAIDS, 2009a, p. 28).

Bedford's analysis of Bank development policy-making in Ecuador is a particularly cogent articulation of the ways in which Bank discourse promulgates heterosexuality as the basis for a ‘two-partner model of love and labour wherein women work more and men care better’ (Bedford, 2005, p. 295).

Interestingly, in its 2008 report to UNGASS, St Vincent and the Grenadines states that, nationally ‘there is a reported number of 509 (2007) persons living with HIV, 265 (52%) being males and 230 (45.2%) being females; 14 (2.8%) were categorised as being of unknown sex’ (UNGASS, 2008). Being of ‘unknown sex’ is not, however, a common or typical occurrence in development policy-making and it is not clear from the St Vincent and the Grenadines' report exactly what is meant here (that is, whether the 2.8% of those classified as having HIV are intersex, or whether the government simply does not have this information).

Attention to the problematic relationship between HIV/AIDS and disability is rare, despite 10% of world population being disabled, ‘a percentage which is much higher amongst poorer people, and disabled persons are especially vulnerable to HIV infection’ (De Vries, 2004). Disability and HIV/AIDS are, notes De Vries, surrounded by ‘myths and misconceptions: by stigma and discrimination’ (2004). In relation to HIV/AIDS and disability, the World Bank suggests that ‘wrong assumptions’ (e.g. a misconception that disabled people are not sexually active) leads to the ‘exclusion from HIV/AIDS prevention and care services of a large group of individuals that face all known risk factors for HIV/AIDS at equal to [or] up to three times greater risk of infection than do non-disabled individuals’ (World Bank, 2008f). The Bank claims that a ‘detailed global picture on how gender and disability intersect is not yet possible’, since research has, according to the Bank ‘been quite limited and often clouded by factors that resist quantification’ (including ‘the feminisation of poverty, cultural concepts of gender roles and sexual and reproductive rights, violence, abuse and other means of exploitation, such as child labour’, see World Bank, 2008g).

Geeta Rao Gupta points specifically to the ‘Men as Partners’ or MAP project, conducted by the Planned Parenthood Association of South Africa (and also the Sonagachi sex worker project of West Bengal, India) as particularly transformative and empowering (2000, pp. 10–11). Barker and Ricardo's Bank-sponsored paper cites ‘promising’ approaches to gender-informed HIV/AIDS policy-making in Nigeria, Uganda, Botswana (they do not discuss the problems noted by Allen and Heald), and South Africa (2005, p. 46).