"Behaviour Change" programmes are the primary response to many public health problems: smoking, obesity, HIV. They make health the responsibility of individuals. Heed the advice, change your behaviour, stay well or, if you are ill, get better. Current fashion is for government to give you a "nudge", financial, cultural, political, and so help you on the path to more healthy behaviour. Simple isn't it? If you become ill or die, it's even simpler - it's largely your own fault! You know it makes sense, you know it's true. Or do you? Well - it's not so simple, and the behaviour change advice is, in most cases, an ideological fashion rather than a scientific truth.
How far responses to HIV/AIDS should focus on changing individual behaviour or social conditions has always been problematic: the former appears both feasible and often claims to be cost effective whereas the latter seems far more challenging and costly because it requires social protection measures. Social protection is defined by the UNRISD as concerned with preventing, managing, and overcoming situations that adversely affect people's well-being. For example policies and programmes to reduce poverty and vulnerability, thus diminishing people's exposure to risks and enhancing their capacity to manage risks such as unemployment, exclusion, sickness, disability and old age.
Looking back over four decades of the HIV/AIDS epidemic, the visionary leaders in the fight against HIV/AIDS - people like Jonathan Mann, Daniel Tarantola, Peter Piot - recognised that medical training alone was insufficient to confront this global pandemic. Each society, with its specific social and cultural milieu, had an epidemic peculiar to local conditions; each person contracted their own infection, but not according to conditions of their own choosing.
Nineteenth-century scientist Claude Bernard drew attention to the role of the "terrain" in the genesis and progression of infectious diseases. Jacques Pepin's recent book, The Origin of AIDS", describes in plausible detail how the "terrain" of 20th-century colonial capitalism in central Africa, well-meaning but unintentionally lethal colonial medical practice, the 1970s trade in blood products, ideological and political struggles for gay rights and human rights more generally, global medication with anti-retrovirals - were part of the "terrains" of sub-Saharan epidemics.
There is no simple way to describe how the "social terrain" influenced HIV/AIDS epidemics; neither is there one form of social protection guaranteeing successful intervention to slow down transmission. Each of the many epidemics originates in a unique constellation of factors. However, a recurring factor has been the role of different forms of inequality: wealth, income, gender, class, caste. Poverty has often been cited as a "cause" of HIV epidemics, and poverty associated poor health may be a proximal factor in the initial infection and in the progress of the disease. But in some places and times, being rich was more associated with being infected than was poverty. A more likely factor is the social relationships of inequality which often put sexual partners in unequal relationships. Careful research by Richard Wilkinson and Kate Pickett, summarised in their book The Spirit Level, shows many health and social problems we know to be more common in the most deprived places are in fact very much more common in more unequal societies. More unequal societies have worse health and lower life expectancy. A 1997 study by the World Bank showed that globally, higher national rates of inequality correlated closely with higher national rates of HIV prevalence. And most generally, Michael Marmot's decades of work shows clearly the degree to which health and well-being are socially determined.
There is no single form of social protection which will stop all HIV epidemics. But one feature is common in some degree to all situations of inequality: lack of hope. Those living at the bottom of the heap see the heap rearing high above them every day, and very often seek short term solutions for survival at the expense of their long term well-being. They may even adjust to their situation by believing that it is right, ordained by "tradition", "biology" (as in the case of gender inequality), or even religion. Or they may do things which make them feel better in the very short term: smoke tobacco, inject drugs, gamble, eat sugar. If people can be assisted to hope realistically, to see a way forward to a better tomorrow, then they might just be able to take individual steps in the present to protect their long-term health. Realistic hope in the foreseeable future of a lifetime (rather than the non-specific hope of winning a lottery, or a very long term hope in eternity) is what effective social protection programmes offer. Thus social protection changes the "terrain" in which people can make their decisions and may create circumstances making it possible for individual decisions to improve the future. It moves people from the unrealistic world of hoping to win a lottery to the real world where they can hope to send their children to school or have enough money to pay for medical care.
An important study in South Africa by Pronyk et al, "Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial" (Lancet, 2006) showed that giving women small loans to establish businesses created social and economic conditions which altered their exposure to intimate partner violence, made them more assertive and therefore more likely to be able to plan for the future or themselves and their children. Introduction of an old age pension scheme in South Africa has had similar effects on a much larger scale, empowering older women and thus improving conditions and longer term decision making for young children and adolescents.
Social protection alters the "terrain" in which the human immunodeficiency virus can be transmitted. When done properly - enabling people to hope realistically, not in some vague way, but in ways that enable them to visualise a way out from under the heap of social, economic and cultural inequality - it goes some way to reducing the experience of inequality. I have written more fully about these questions in several places (see for example: Tony Barnett and Mark Weston, "Health, Wealth, HIV and the Economics of Hope", AIDS, August 2008, 22 Suppl 2:S27-S34).
It is ironic that the HIV/AIDS epidemic exploded in the early 1980s, at a time when equity was going out of fashion, when Reaganomics and the "Chicago Boys", with their emphasis on market solutions took over management of the world economy, and when "social protection" became stigmatised. Nobel prize winner Joseph Stiglitz has recently pointed out that inequality has costs and that "Paying attention to everyone else's self-interest - in other words to the common welfare - is in fact a precondition for one's own ultimate wellbeing - it isn't just good for the soul; it's good for business." Effective social protection - often dismissed with the abusive label "welfare" - does just this. And, by enabling people at the bottom of the pile to hope, it alters the "terrain", reducing their chances of contracting HIV/AIDS and a whole range of other communicable and non-communicable diseases. It is only with social protection that it is rational to expect people to have the capability to alter their behaviour.
The views expressed in Research Watch commentaries are those of the authors and do not necessarily reflect the view of UNICEF
Tony Barnett is Professorial Research Fellow at the London School of Economics and Political Science and Honorary Professor of the Social Sciences of Infectious Diseases at the London School of Hygiene and Tropical Medicine. He is co-author of AIDS in the 21st Century: disease and globalisation. His website is at: http://www2.lse.ac.uk/researchAndExpertise/Expertsfirstname.lastname@example.org