Product Details

• Amazon Sales Rank: #142675 in Books
• Published on: 2003-09
• Number of items: 1
• Binding: Paperback
• 224 pages

From the New England Journal of Medicine, May 13, 2004
Victorian euphemism had its uses. What we in our clinically literal era refer to as sexually transmitted infections once carried a more evocative label: "social diseases." On the evidence adduced in social psychologist Catherine Campbell's remarkable book, that seemingly evasive name was actually closer to the mark. The title of this book comes from a line by South African satirist Pieter-Dirk Uys: "In the old South Africa we killed people. Now we're just letting them die." Regarding the deadly role that social factors have played in the AIDS epidemic, the book poses two questions of burning importance. Why do people in AIDS-ravaged countries continue to engage in unsafe sex, which they know could kill them? And why do programs designed to prevent this practice so often fail? Campbell's answer is that sexual behavior is determined as much by its social and economic context as it is by individual will. What people understand about the human immunodeficiency virus (HIV), believe about themselves, and do in their sexual lives is not entirely of their own choosing but, rather, is profoundly shaped by a complex interplay of social norms, opportunities, expectations, and constraints. Past efforts to combat HIV and AIDS have failed because they have overlooked this fact and relied on narrow biomedical and behavioral interventions, efforts that target individuals but neglect to promote the supportive social processes that empower people to protect themselves. Unless people at risk are involved in nurturing their own "health-enabling community," Campbell writes, information and motivation alone will be insufficient to ensure behavioral change. (Figure) The book reports the outcomes of Campbell's multiyear evaluation of an HIV project in a South African mining town. The town is an archetype of the sort of environment in which the epidemic has thrived; it has 100,000 permanent residents, 70,000 migrants who work in the mines, and 2000 commercial sex workers. At the project's outset, 69 percent of the sex workers, 22 percent of the miners, and 8 percent of the town's 15-year-old girls were HIV-positive. Designed to address both medical and social issues, the project aimed to reach these key groups by promoting peer education, which was a program to train members of a given community to motivate their peers to change the collective norms that endangered their health. The project never worked as hoped. Among sex workers, peer education succeeded in raising HIV awareness and in increasing the women's willingness to practice safer sex. But this progress was of little use to the women if their clients continued to resist using condoms. As one sex worker remarked, "We don't have the power to enforce such decisions." Those who had more power -- mainly miners -- remained trapped in a mind-set of fatalism and machismo because both their managers and their union declined to put any effort into peer education. Although young people embraced peer education more readily, their efforts were stymied by the repressive rules of their schools and community, where few adults were willing to tolerate an open discussion of sex. As a result, pernicious peer pressure went unchecked, notably among boys who ridiculed one another both for abstinence and for condom use. In other words, a genuine attempt at change by some groups was thwarted by larger social strictures. It is telling that the anarchic environment of sex work proved to be a more congenial context for change than did the regulated settings of mines and schools, in which a rigid conception of roles blocked new ways of thinking from taking root. Leaders in industry and education largely saw the problem as one of personal behavior and failed to take responsibility for the role that their own institutions could play in enabling or obstructing individual change. This patronizing approach was mirrored in the project's management, which was led by a remote committee of medical and mining professionals, who did little to encourage the participation of sex workers, young people, or miners. This is symptomatic of a wider tendency among those involved in AIDS projects and other projects to treat people as discrete targets for intervention rather than as agents of their own development. Through this close study, Campbell demonstrates persuasively that programs to prevent HIV infection and AIDS must cultivate change among separate groups and not just within them -- especially in situations in which the social and economic forces dividing people are precisely the same forces that increase their shared risk of HIV infection. This means that all members of the relevant community must have a meaningful role in designing and executing the project since they have the fullest understanding of local conditions and constraints. "Letting Them Die" offers a signal example of why Campbell is considered one of the foremost researchers on HIV and AIDS. It is trenchant, troubling, meticulously reasoned, and compellingly written -- the forthright account of sex workers' lives rivals the most harrowing war memoir. The book also offers vital lessons that, unfortunately, will prove to be increasingly relevant far beyond Africa as the tide of the epidemic swells. Keith E. Hansen, M.P.A., J.D.
Copyright © 2004 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

New England Journal of Medicine
"A remarkable book.....a signal example of why Campbell is considered one of the foremost researchers on HIV and AIDS."

Customer Reviews

Superd
Superb study of an HIV/AIDS prevention programme in a South African township. Focussing on mineworkers, sexworkers, young people and (political)stakeholders.
Using several concepts of the social sciences, like empowerment, critical consciousness and social capital, she describes and analyses behaviour of the aforementioned groups in relation to the HIV epidemic in South Africa.
Making use of findings from 'The Summertown Project' she comes to a clear and lively story of the choices people from a marginalized community make.

I used this book for my final thesis on a research I did at an AIDS project in South Africa. It helped me to prepare myself on the things I was going to experience and to put my research in a broader perspective.

Not only for HIV education efforts!
This is an exceptional and courageously written book. It is a'must read' for anyone involved in efforts to get groups of people to change their behavior. Limitations of public education efforts identified in this book can be applied to numerous public health endeavors. Without the insights of this author, we will continue to make attempts to apply programs that will fail because we have failed to understand the context in which the undesirable behavior patterns occur. This is a tough, sobering and realistic piece of work.
I also found it a pleasure to read, profoundly interesting, although often tragically so.

Damocles Sword
There are few books about AIDS that are worth reading, let alone reviewing. The vast majority remain constrained by the rigid confines of their conceptualisation, almost none daring to suggest that their conceptualisation might be wrong. The author of this book is one of the very few who dare do this and as a result has produced a book which is not only outstanding intellectually but should also be mandatory reading for anyone who has an interest in programmes that attempt to have an impact on any one of the multitude of epidemics of HIV infection. In fact it should be mandatory reading for anyone who has an interest in programmes that attempt to change the way people are in relation to what are called the development problems of today.

The book describes the author's experiences with a project that started out by trying to reduce the risk of infection by HIV amongst three groups in a mining town in South Africa - female sex workers, male miners, and young people. There were two approaches to doing this: peer education and the "promotion of partnerships between a diverse array of community groupings of stakeholders to coordinate and support the variety of local HIV-prevention efforts in such a way that maximized their overall cumulative effectiveness". The interventions chosen were all invested with the glowing approbation of the international `AIDS project' community as prime examples of what should be done in such situations. In terms of having any impact on the epidemic or on the sexual culture of the area the project has so far been a failure. The author analyses the reasons for this failure in a number of analytical contexts.

The author is very well placed to analyse the history of the project. She herself as a social psychologist had been involved in the township in 1995 in trying to understand the reasons why there is such a high prevalence of HIV infection amongst the miners and sex workers despite their obvious knowledge of the existence of HIV and the ways in which it is transmitted. The studies themselves form part of the opening chapters, and provide very good insight into the conditions of these people's lives and the enormous social factors that influence their lives and decision-making. The following chapters describe the way the project grew as a result of a drive from some local people for work that would affect the growing numbers of people with AIDS and from a group of scientists and professionals (including the author) who had an interest in the area. One chapter provides the initial theoretical justification for the various actions that were taken, with heavy leaning on the writings of Paulo Freire on the conscientisation side, Pierre Bourdieu for social capital, and on the experiences of peer education with sex workers in Zimbabwe of David Wilson and others.

The book will be invaluable for the discussion of the importance of the social context for behaviour, and indeed will be read by many for that alone. It also details the very many ways in which the project's ideals fell by the wayside (the rates of sexually transmitted infection in miners actually rose during the period of the project, there were many difficulties with the peer education approach for young people in school, the stakeholders were far from unified in their vision or even interest) or were partially successful (there were several changes amongst the sex workers), and again these experiences will be as interesting as they are familiar to many who work with such projects.

However this book goes far beyond such a discussion. She points to the inadequacies of our current theoretical and modelling frameworks for such interventions; to the fact that the stakeholders who were involved did not see themselves as part of the epidemic or as people whose behaviour had to change; to the fact that the designers and researchers of the project had much discord and competition amongst themselves; to the great mistrust that developed between the researchers and much of the `community'. In fact, although the author tries to scotch the problem with the definition of `community' by stating that in this case the term `community' refers to the people in a geographic area, the tension behind this definition continues throughout the book as it is acknowledged that only a few of the many individuals and groups in the area were in fact being requested to change their ways - the paternalism and continued power of the `senior' stakeholders continuing throughout.

The value of the book is still more. The lessons drawn in the concluding chapter smack of a level of desperation in the author to find lessons, and this may perhaps be the only weakness of the book. In these lessons the author still struggles to keep the idea going that somehow in a better world the interventions could have had an impact if only people had carried them through according to the wishes of the project designers. The deep question the author raises in the mind of the reader is whether such approaches can ever work in relation to an epidemic (as opposed to being valuable for a few individuals or groups). This question is not actually present in the book (although there are numerous hints of the author's disquiet concerning the mismatch between the daily reality of people's lives and the wishes and interests of the project managers) but it hangs over ever sentence as did the sword over Damocles. As for Dionysius in relation to those who wield power, it is a question hanging over all those who praise mindlessly the black art of development.