Twenty Years of World AIDS Day

I was fourteen when I first heard about AIDS. I distinctly remember sitting in our living room watching the news and feeling a sense of fear settle in, as we learned more about this vicious, mysterious disease.

When AIDS (acquired immunodeficiency syndrome) first emerged in the early 1980s, it was clear that a serious new threat had surfaced: an infectious disease about which little was known other than that it was sexually transmitted and lethal, that it affected mostly gay men and that there was no medicine available to protect or cure.

This was particularly alarming in the age of modern medicine, when people had become accustomed to the idea that many dangerous diseases could either be kept at bay with vaccines or cured with antibiotics. Such illnesses were largely considered a thing of the past - especially in the developed world.

Fear took hold. The danger needed to be seized, singled out and destroyed. In response, people with AIDS -in its early days, often referred to by the press as GRID, Gay-Related Immune Deficiency - were shunned and avoided. Blame and marginalization followed suit. A public outcry for "effective measures" grew louder: "close the borders," "tattoo the infected," "shut them up". Governments were under increasing pressure to take urgent action.

The Swiss example: One government's response

Epidemiological data firmly established the link between HIV and AIDS, and it became clear that the only hope of halting the spread of the disease was to actively and systematically inform the general public and give clear and intelligible instructions as to how people could protect themselves from infection. No 'magic bullet' - no vaccine or medical cure - would immediately fix the problem.

As a result, like many governments in the western world in the late 1980s, Swiss health authorities launched an AIDS awareness campaign aimed at prevention. It was direct, frank, and for the times, quite shocking. The government did something unprecedented: it talked about sex, about sex between men, about condoms and how to use them and about the dangers of exchanging syringes when taking illicit drugs.

The campaign challenged the public to address topics that are often considered taboo or immoral and are at the very least private. In addition to adults, the government directed the campaign at children and adolescents, thus stirring even further controversy. The other challenge was to reach people mostly afflicted by the disease - the gay community and intravenous drug users - and get them actively involved in the urgently needed work of prevention.

This meant acknowledging people living on the fringe of society and seeking their collaboration to make prevention strategies work efficiently and effectively. Such efforts involved courage, tolerance and goodwill. After all, contracting HIV wasn't only about being infected with a lethal disease; it was also about being burdened with the stigma of having caught a disease associated by many with a reproachable lifestyle.

Needless to say, the Swiss government's plan, implemented with taxpayer's money, didn't always run smoothly and met with fierce political resistance. Public and parliamentary debates on the matter were often fierce and emotional. Political furor over the AIDS campaign and the media coverage that ensued was thus secured for years to come.

More than a medical challenge

The Swiss campaign demonstrates how the fight against AIDS was, and still is, far more than a medical challenge. Of course, the ongoing quest of medical research and the successful development of powerful drugs is an important element in the battle against AIDS, but so too is the story of how society began to cope with a highly complex phenomenon, for which there remains no medical cure.

The story of the AIDS campaign is one of complexity. It is about understanding nature and human nature in particular, questioning assumptions and beliefs, translating beliefs into actions, building community and moving forward together; there are interacting biological, social, economic, political, legal, and spiritual issues in play.

This integrated approach took shape in November 1986, when public health professionals and government officials met in Ottawa, Canada, under the auspices of the WHO, to proclaim a new public health movement, dubbed 'Health Promotion'. It challenged the prevailing idea that good health was largely the result of modern achievements in medicine. Indeed, the idea of Health Promotion posits that good health depends on much more than modern medicine alone or the mere absence of disease.

Instead, the Health Promotion approach stressed the maintenance of a general state of physical, emotional, mental and spiritual well-being and transformed it into a political program. In other words, the focus was placed on 'what generates health or keeps us healthy?' instead of 'how do we get to the bottom of an illness or injury?'. It articulated that health depends on many factors, such a shelter, food, education, clean water, economic stability, adequate income, security and justice, in addition to good medical care. In order to maintain and improve people's health, Health Promotion advocates argued, it was crucial to improve conditions that directly impacted on their well-being. It was not simply a call to improve the quality of healthcare but for a public leadership that makes strategic use of the knowledge that our welfare and well-being depend on the sound policy of all government branches.

Health Promotion offered a new conceptual scaffold that grew out of the necessity to cope with emerging challenges and threats. Indeed, AIDS clearly brought into focus the notion that modern medical advances alone could not secure health. A comprehensive approach that addressed education, prevention and socio-economic disparities, among many complex and intertwined issues, was critical to combat the ravages of the illness.

Health promotion has enlightened us to the many factors on which health depend. Many global health problems, including HIV/AIDS, are inextricably intertwined with huge inequities in basic living conditions - inequities that are closely related with other global phenomena affecting us all: global warming, migration, social disruption, depletion of natural resources and many more.

An unfinished battle

The HIV/AIDS prevention campaign has in many ways showcased how to address complex public health issues through influencing public opinion, attitudes and even behaviour.

As time has worn on, however, political and public attention to the issue has waned. Information on HIV/AIDS prevention must now compete for attention with emerging health issues. Also, information in the Internet age is distributed and accessed in more decentralized and individualized ways. As a result, generating focused attention for important public messages has become more challenging given the continuously available stream of information.

These new challenges come at a time when the latest UNAIDS report informs us that the AIDS epidemic is still far from over. Many of the issues linked with HIV/AIDS prevention must continue to be addressed: ignorance about its causes, routes of transmission and means of prevention, stigmatization and discrimination. It has also become evident that poverty and socioeconomic destabilization are aggravated by the disease, while they simultaneously facilitate its spread.

Much remains to be done. No ready solutions exist in an increasingly populous world that contains people with varied cultural instruction sets, social habits, attitudes and socioeconomic conditions, all moving at different speeds, yet communicating with increased velocity. Such diversity requires differentiated solutions that will only work when they make sense to the people affected.

Renewing our understanding of health

Indeed the world's health-related challenges are growing. They force us to reconsider our assumptions and ways of thinking. Many of our conceptions of health as developed 20 years ago must be challenged in light of evolving knowledge and reality.

When I listen to contemporary debates on health, I often perceive that health is being treated as a commodity, a kind of abstraction, only in need of enhancement by some technology or service. To me, however, health is an inherent property of life that emerges when things are right. Indeed, meaning is crucial to well-being and is at the root of Health Promotion. It is ancient wisdom that the WHO incorporated in its famous definition of health in 1946: a state of complete physical, mental and social well-being.

So what then does Health Promotion mean on the 20 year anniversary of World AIDS Day? To me, it has little to do with attaining some state of superlative well-being. It has far more to do with deriving meaning from engaging life fully and helping others realize their potential and lead complete lives.

This is something AIDS activists and campaigners continue to strive for in their battle against the disease: Coaching people to adopt lifestyles that prevent the illness from spreading and encouraging those with AIDS to find and lead self-directed, purposeful lives.