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How could it be that people still knowingly engage in sexual behaviour that puts them at risk of a slow and painful premature death? Moreover, why do the best-intentioned and elaborately-funded HIV/AIDS prevention programmes fail to stem the tide of the epidemic? After “seven years of collaborative research and thinking,” Catherine Campbell attempts to answer these questions in her book Letting them die. How HIV/AIDS prevention programmes often fail.
Since 1997 Campbell has been engaged in research in a community called Summertown (not the town’s real name), which consists of a formerly white apartheid mining town and a black residential township about ten kilometres away. The Summertown Project “sought to mobilise the local mining community to address a problem that threatens to kill up to six out of ten of its young women, and six out of ten of its young men.” Campbell’s research sought to provide explanations for this conundrum, and in the end Campbell concludes that the seemingly reckless sexual behaviour of Summertown’s miners, sex workers and young people are not due simply to ignorance.
Prevention programmes, maintains Campbell, are often hampered by their assumption that sexual behaviour is shaped only by the conscious decisions of rational individuals. Letting them die, however, states emphatically that “the forces shaping sexual behaviour and sexual health are far more complex than individual rational decisions based on simple factual knowledge about health risks, and the availability of medical services.” Sadly, for failing to appreciate this significant procedure ‘HIV/AIDS prevention programmes often fail.’ For Campbell, however, Letting them die seeks to comprehend the transmission and prevention of HIV as a social issue located at “the interfaces of a range of constituencies with competing actions and interests.”
The Summertown Project was initiated in the early 1990s by a group of black African residents from a township in the gold mining region of the area. The residents were alarmed by the threat posed by HIV/AIDS to their community, and managed to involve a group of academics in the Project. The academics, amongst whom was Catherine Campbell, approached overseas funders and after a lengthy spell of negotiation a NGO with full-time employees was set up in 1997. Thus Campbell was afforded the opportunity of doing in-depth research in Summertown, and Letting them die is the culmination of her research in Summertown for the period 1997-2000.
In the first three chapters of the book Campbell tells the story of the history and goals of the Summertown Project. The activities of Summertown’s migrant labourers are also discussed in these chapters. Chapters four, five and six highlight certain case studies of the prevention and transmission of HIV among commercial sex workers, and chapters seven and eight deals with prevention and transmission amongst the youth of Summertown. The Summertown Project sought to limit HIV transmission through three activities: sexually transmitted infections control; community-led peer education and condom distribution; and local multi-stakeholder collaborative project management. Thus chapters nine and ten discuss the role of these multi-stakeholder partnerships (involving local government, the mining industries, trade unions and others) in project management in Summertown. “A key aim of this book,” writes Campbell, “is to highlight the importance of – and complexities of – mobilising a wide variety of stakeholder groups in developing new health and systems that might contribute to addressing the complexity of the HIV/AIDS phenomenon.”
After conducting her research in Summertown, Campbell concludes in Letting them die that people’s sexual behaviour are often shaped by a “complex intersection of intra-psychic and social forces,” and the likelihood of safe sex are often undermined by people’s living and working conditions. Thus HIV/AIDS information campaigns – which only target the rational decisions of individuals – are doomed to failure. “The extent,” claims Campbell, “to which people have the ability to adopt new sexual behaviours and to safeguard their health is dramatically constrained by the degree to which social circumstances support or enable them in these challenges.” This reinforces the sober truth that the fight against HIV/AIDS in South Africa is a battle against poverty and inequality, and thus the struggle against AIDS is by definition a long-term programme.
In her assessment of the HIV/AIDS epidemic in South Africa, Campbell believes that epidemics are peculiar events: “They arise because existing understandings of health and illness, and existing public health systems and institutions, are inappropriate for addressing the particular form the epidemic takes, and for stemming the particular mechanisms by which it spreads.” After her experiences in Summertown, one might ask, what kind of intervention programmes would Campbell recommend to be launched in South Africa to effectively combat the HIV/AIDS epidemic? “There is a need,” Campbell concludes, “to forge links between traditionally diverse groups, with very different levels of access to material and symbolic power but united through a common commitment to the reduction of HIV/AIDS.” As an understated warning in this process, however, Campbell adds that “the extent to which the efforts of grassroots communities can result in the development of new and more health-enhancing sexual norms, and in the empowerment of people to act on these norms, is strongly influenced by the willingness of more powerful local, national and international constituencies to work with them in this task.”
Letting them die has, if anything, illuminated a complex web of factors contributing to sexual behaviour in South Africa. Campbell has provided credible explanations for questions hitherto often considered inexplicable. What Letting them die has unearthed is the complex scenario that people are not often fully in control of their sexual behaviour, and hence to appeal to their rational decision-making will not necessarily inhibit the transmission of HIV. Thus, prevention programmes with such a focus have more often than not ended as failures. Sombrely, Letting them die has again underlined the fact that HIV/AIDS in South Africa is a long-term phenomenon: as long as there is large-scale poverty and inequality in South Africa there will in all likelihood be AIDS as well.
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