The other evening my university's School of Public Health, which is happily intertwined with the CDC next door, honored my old friend Robert C. Bailey for his HIV/AIDS research in East Africa. The key was that he had been brought into global health in the mid-90s after a distinguished career in anthropology, in an Emory/CDC program designed to apply behavioral science expertise in the worldwide fight against disease.
Bob's introduction, by James Curran-longtime dean of the school and a leader in the fight against AIDS since 1981-reminded me that behavioral research did not always get the respect it now has in public health. It was the baffling emergence of that grave threat that made it clear that the future of health and illness would depend on behavior, and that global health warriors had to first of all win the fight for hearts and minds.
Of course, the Just-Say-No crowd were comfortable with one approach to behavior, and they gave AIDS sufferers the brush-off for years, blaming the victims. If only you were heterosexual and monogamous, they said, and didn't inject any illicit substance... Of course there was the matter of blood transfusions, and the occasional innocent, even Republican wife whose bad-acting husband brought it home to her.
But then there was Africa, where HIV was spreading fastest, heterosexually. Here right-wing values cost countless lives, because the culturally accepted patterns of sexuality were not about to change overnight. It was hard enough to change the behavior of men who did not want to use condoms and who basically got to decide, but when funding for family planning programs was compromised and lies were spread about the value of condoms, all in the name of abstinence, many more people died.
Bob Bailey had long done anthropological research in Africa and was one of the people who noticed that ethnic groups with traditional, ritual male circumcision had lower HIV rates than those without the practice. Years of carefully designed studies, culminating in two randomized controlled trials, enabled Bob and his colleagues to show that even adult male circumcision reduces HIV transmission by over 50 percent.
And, using a wide range of behavioral measures, they also showed that circumcision does not increase compensatory risk-taking, and they found out a lot about how cultural and social factors affect condom use and how to increase it.
The Wisdom of Whores is a great book about the epidemic by Elizabeth Pisani, a courageous journalist who became a Ph.D. epidemiologist and brought all her investigative skills, qualitative and quantitative, to the worldwide fight against the virus. She spent much of her time in Indonesia, where she took an anthropologist's approach to participant observation but brought to bear the statistical tools she had mastered and reported the results with compelling writerly gifts.
But "results" has to be understood properly. She knew that in the ‘90s there were epidemiological studies and models that were not worth the journal paper they were printed on, and that many misleading ideas about the epidemic and its future were held and spread. This resulted in needless panic in some places, and a lot of wasted funds.
Pisani immersed herself in the Indonesian culture of sex and sex work, which included male-on-male, transvestite, transgendered, and ordinary commercial heterosexual contact all intertwined with each other, with noncommercial longer-term relationships and, of course, with drug injection. These complex intersecting behavioral worlds turned could be understood only in terms of the local cultures and subcultures as subjectively experienced.
The result was a far deeper understanding of the multiplicities of the epidemic, who was at greatest risk and why, what behavioral measures could be most successful in harm reduction, and how ill-advised attempts at behavioral eradication by governments simply led to displacement, dispersal, increased distance from health and prevention services, and in the end more illness and death.
But one of the things we know makes a huge difference not only in AIDS prevention and harm reduction but in all aspects of global health is the empowerment of women and girls, and that's where The Girl Effect comes in. Nicholas Kristof wrote about it recently in the New York Times, and called attention to a stunning short video and a follow-up under that title.
These powerful clips drive home what global health and development leaders have long known: that in the long run the way to make the greatest impact on communities in the developing world is to educate girls. This behavioral intervention results in greater health for them, their children, and even their husbands; lower rates of infection; safer births with better infant outcomes; smaller families; greater lifetime earnings; and better educated children of their own, especially girls.
But perhaps the key is that educated girls and women are at least partly inoculated against exploitation by men. Evolutionary psychology predicts that when men have too much power over women they will abuse that power. Decency, ethics, and the goal of a better life for all demand that more aid dollars be used to curb that abuse of power. Behavioral problem. Behavioral insight. Behavioral intervention. Behavioral solution.
Some day their sons too will thank them and those who have empowered them.