This Is Why We Can’t Have Nice Things

As you probably know, the World Health Organisation is the agency of the United Nations charged with improving international public health. It has its fair share of critics and has been involved in a few controversies (allegations that it greatly exaggerated the ‘swine flu’ epidemic being the most prominent, recent, example) but it can claim quite significant victories too (it led the eradication of smallpox, for example). The Organisation lists its responsibilities as:

…providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends.

That ‘evidence-based policy’ bit is pretty crucial – it’s not just a bunch of UN politicians pushing whatever pet obsession they may have but doctors, scientists, researchers and more looking at what’s happening and how best to address it. Again, I’m sure there are legitimate criticisms to be made here but that’s for another time.

It’s for another time because last week the WHO released their updated guidelines on the treatment, diagnosis and prevention of HIV. This document “brings together all existing guidance relevant to five key populations – men who have sex with men, people who inject drugs, people in prisons and other closed settings, sex workers and transgender people – and updates selected guidance and recommendations.” The report itself states that this approach was necessary because the previous approach of issuing separate guidelines for these populations “has not adequately addressed issues common to all these key populations nor has it addressed countries’ needs for a coherent approach informed by situational analysis”. It includes a section devoted to explaining the methodology and process, wherein we’re told about the range of expertise and experience which fed into the guidelines “including appropriate geographical, gender and key population representation.” The report then explains how it reviewed and assessed current evidence and how this was fed into the resulting guidelines, which were then assessed by “73 peer reviewers from academia, policy and research.”

So how was this report of over 180 pages, covering the entire world and every group affected by HIV, reported in the press? Like this:

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Pretty much every report of the new guidelines fixated on one, new, guideline concerning pre-exposure prophylaxis (PrEP). As explained in the WHO report, this guideline came from reviews of hundreds of research outputs and looked at the effectiveness of PrEP, the possible side-effects, the feasibility of it as a treatment, the cost-effectiveness and the openness of people to using it (amongst other things). They ended up with the guideline as follows:

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You may have already noticed that this guideline mentions ‘gay men’ absolutely nowhere. ‘Men who have sex with men’ is a term common to the research and treatment of sexually-transmitted infections and one of the main reasons for that, in short, is that it avoids all issues of identification. Gay, bi, queer, trans, straight-who-dabbles, you have no fucking idea, you don’t care – if you identify as male and you have sex with other men, you’re in. So already we can see how shit and how homophobic the reporting of this was – reporters skim a document, see ‘men who have sex with men’ and think ‘GAYS!’ because if a guy touches another guy ‘that way’ he’s gay and that’s all there is to it, right? It’s embarrassing.

The second big thing to notice – the recommendation that PrEP is available as part of a ‘comprehensive HIV prevention package’. This isn’t saying to stop everything else. It’s not saying PrEP should replace condoms. In fact, here’s the FIRST guideline:

UntitledPretty categorical, right? There are other guidelines, and whole sections of the report, devoted to HIV education, testing and counselling.

This brings us to the big thing to notice in the guideline: the use of ‘choice‘. To read that guideline and take away from it ‘WHO SAYS ALL GAY MEN MUST TAKE PREP’ is not only wrong, it’s wrong to the point of being deliberately distorting and downright dangerous. It’s sensationalising for the sake of a story and fuck the consequences.

Unfortunately, some of us in the gay community are so wedded to playing the victim that, rather than heading off to the report to find out what was going on, we had instant outrage based on these egregiously incorrect reports. Patrick McAleenan in The Telegraph knocked out a piece complaining that the WHO were ‘perpetuating gay stereotypes’. His piece is a litany of complaints which expose his complete ignorance as to what the WHO actually wrote: why don’t they recommend education instead? Why don’t they recommend condoms? Most appallingly, he complains that “The report will encourage straight people to believe that HIV is simply a gay problem”. Well, not really, since it a) hardly mentions the word ‘gay’ and b) devotes scores of pages to key populations other than msm. In fact, there are other guidelines explictly relating to PrEP:

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But it didn’t matter. The outrage was well out of the traps by now:

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As the sensationalist stories make their way around social media and various sites, each day has seen new people jumping on them and complaining about how homophobic the WHO are. Apparently no-one actually bothers to go have a look at the actual guidelines. As a community we kinda have form for not bothering to check stories when there’s a good sense of victimisation to be had.

It’s all so fucking depressing. And what’s most depressing it how inevitable it feels. The WHO report found that “epidemics of HIV in men who have sex with men continue to expand in most countries” and that “in major urban areas HIV prevalence among men who have sex with men is on average 13 times greater than in the general population”. I can see no moral judgement of this fact in the report, and in fact it states:

Discriminatory legislation, stigma (including by health workers) and homophobic violence in many countries pose major barriers to providing HIV services for men who have sex with men and limit their use of what services do exist. Many countries criminalize sex with the same gender (either male–male only or both male–male and female–female). As of December 2011 same-sex practices were criminalized in 38 of 53 countries in Africa (9). In the Americas, Asia, Africa and the Middle East, 83 countries have laws that make sex between men illegal (10). The range of legal sanctions and the extent to which criminal law is enforced differs among countries.

This sounds pretty sympathetic to me. If anything, it’s the responses which have been screeching ‘BUT NOT ALL GAY MEN ARE UNSAFE/PROMISCUOUS’ that are problematic, as they cannot help but imply that the men who do engage in that behaviour almost deserve their fate. The safe ones, though, the ones who don’t sleep around – those nice guys don’t deserve to be treated like this by the nasty WHO! Zero self-reflection, zero sense of agency and responsibility – just instant, facile outrage and a rush to assert victimhood. It’s ironic to say the least that last year several UK HIV charities, including GMFA and the Terrence Higgins Trust, issued a statement supportive of PrEP “so that more gay men are able to reduce their HIV risk.” Presumably they are vile homophobes too?

It’s embarrassing. It helps no-one. It’s downright dangerous. Grow the fuck up.

18-07-2014 edit:

This morning I saw this in my Twitter feed:

Sure enough, this is in the report:

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It continues:

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Calling for the decriminalisation of drug use, of sex work, of same-sex behaviours and also calling for revision of age of consent laws are pretty big stories: much bigger than the non-story which the media led with. It’s also explicitly opposing homophobia. Unfortunately it would have meant actually bothering to properly look at the report before rushing to knock off a dramatic-sounding story.

The Next Four

 “The first five patients were white,” remembered Gottlieb. “The next two were black. The sixth patient was a Haitian man. The 7th patient was a gay African-American man, here in Los Angeles.”

It is accepted now that HIV originated in Africa and first made the leap to humans (from primates) in the 1930s. One of earliest known cases of human infection appears to be a man in the Democratic Republic of the Congo in 1959. It’s suggested that the DRC was, in the 1970s, the location of the first AIDS epidemic – one that was largely heterosexually-spread. HIV and AIDS then spread throughout the African continent from where, researchers suggest, it travelled to Haiti and then entered the ‘northern’ countries such as the USA. Dr Jacques Pépin has argued (read this link – it’s truly fascinating) that the global spread of HIV owes much to colonial rule in Africa.

The first ‘official’ case of HIV/AIDS in the USA has been retrospectively claimed as Robert Rayford, an African-American teenager from Missouri who died in 1969. It’s also been suggested that Ardouin Antonio, a Haitian man who died in Manhattan in 1959, could have been one of the first cases in the northern hemisphere. By 1981, when Dr Michael Gottlieb and his team identified what would soon come to be known as AIDS, there were already many thousands infected in the USA.

You will notice in the quote at the start that Dr Gottlieb recalls the first five cases he identified were in white men, while the next four consisted of people of colour. HIV/AIDS, of course, primarily affected men who had sex with men in countries like the USA (although doctors also reported the condition as present in intravenous drug users and their children in 1981.) What’s relevant here is that over 40% of the people reported as having AIDS in the initial period (1981-1987) of what we now know as the AIDS crisis were non-white.

As you may have gathered by the picture at the top, I was caused to think about and revisit this history by the broadcast (in the USA) of The Normal Heart, HBO’s Ryan Murphy-directed adaptation of the Larry Kramer play which was one of the first works to directly address the crisis. There has been a fair bit of advance publicity for this movie, due in large part to the veritable galaxy of stars appearing in it (and of course Murphy’s Glee/American Horror Story successes). I don’t think it’s being overly cynical to say that it has ‘award season’ written all over it, and the critical response has been predictably positive. I thought it was alright: it felt overlong and Murphy’s direction was all over the place but it’s fairly efficient as the polemic it’s clearly intended to be. It was impossible for me not to notice, however, that in the decades since the 1985 play was written much of its scenes have passed into the realm of cliche. You can’t fault Kramer for that, of course, but if you’ve seen any major drama or film about AIDS (almost always set in America) you’ll find much of this film very familiar.

This in turn, then, led to the observation that these dramas keep telling the same stories: those of white gay men. The gimmick of the recent, much-acclaimed Dallas Buyers Club was that the main character was straight but even that felt the need to throw in Jared Leto as a white Jiminy Cricket-esque transexual sidekick (to ‘represent’ the LGBT community, apparently). During The Normal Heart I started to notice that, amongst the cast of implausibly attractive, uncommonly famous actors there was barely a non-white face to be found and only one significant female character. A black man sometimes pops up in the background of what is supposed to be Gay Men’s Health Crisis but I don’t recall him having any lines, while a woman who is heavily implied to be lesbian shows up to volunteer and then is quickly forgotten.

Kramer was clearly writing from his own perspective here and GMHC was indeed set up by six white men. It’s churlish to complain about that, especially when these men definitely deserve to be remembered. Yet I feel uneasy at the narrative the film pushes, one which fits neatly into that already told in most of the famous AIDS dramas you can think of. It’s a narrative where HIV/AIDS and the activism surrounding it is seen to belong almost entirely to white men (who don’t even have non-white lovers, despite living in cities like New York) in rich countries. It’s also one where the radicalism offered is of a peculiarly blinkered kind.

There’s no better way to explain what I mean by that last comment than to link to the words of Sarah Schulman and Roberto Vazquez-Pacheo. Both former members of the radical group ACT-UP, they provide some valuable context which is almost entirely missing not only from aforementioned AIDS dramas but even most of the documentaries I’ve seen about the period. Schulman writes here about the make-up of the group:

There were all different kinds of people who joined ACT UP. Most of the women were already politically active because they’d been trained in the feminist movement. There were some men who came from the gay liberation movement, who also were radicals and had experience. There were people who came from the left. There were people who had been in the Black Panther party, but they had been in the closet. There was a guy who’d been in the Nicaraguan revolution, he had been in the closet as well. Jeff Gates. He died.

But the vast majority were gay men who had never been politicized. Some of them were everything from wall street brokers, to party boys, to quiet men living at home… they didn’t know anything about politics.

The clear picture here is that queer politics existed prior to AIDS activism and it intersected with other political movements which fought for liberation and against power. For his part Vazquez-Pacheco speaks not only of the tensions raised by being a man of colour in a group dominated by white people but of class. The ‘professional middle-class’ white guys felt betrayed by the system they had ‘grew up with’ but felt it could be ‘repaired’, having to be educated as to how that system had never served many of the non-white, non-male, non-professional groups affected by HIV/AIDS.

You can see this all over films such as The Normal Heart and Dallas Buyers Club, which present the awakening political conscious of men affected by HIV/AIDs but don’t really go any further than that. It remains a single-issue cause dominated by said men seeking to wrest some concessions from the white men in power. The politics of Dallas Buyers Club is particularly dubious in that it presents a straight white man unleashing the entreprenurial power of capitalism to combat lumbering, inefficent vested interests (healthcare and government) and helping the simpering queers while he’s at it – there is a single scene which acknowledges the radical activism which was taking place at the time. We’re presented with the veneer of radicalism (pretty much the sole reason for Jared Leto’s character existing, aside from providing some tragedy) when the story actually tells us that the system works if you make enough noise for long enough.

There is certainly no consideration of global politics, poverty and power structures. In all of these stories Africa is an irrelevant abstraction and AIDS has descended upon its northern victims like a sudden plague from God. It’s no surprise, then, that while the dramas/documentaries will usually draw attention to global HIV/AIDS figures there will be little to no attempts made to present the wider reality of the situation. Even in the USA, non-white people made up a majority of HIV/AIDS cases by the early 90s and today black/African-Americans make up the vast majority of new diagnoses. Factors like poverty and access to health care have been clearly linked to HIV rates while Against Equality have documented how (for example) these issues intersect with race in the prison industrial complex. Worldwide, almost 70% of HIV/AIDS cases are found in Africa while North America/Western Europe, which all of the portrayals focus on, accounts for less than 7%.

So what, some people will say – most of these depictions are made in North America/Western Europe and these stories deserve to be told. It’s inevitable that some will take this blog as an attempt to downplay the carnage caused by HIV/AIDS to men who have sex with men in the north. This isn’t intended at all. Rather, I think these depictions matter in framing HIV/AIDS as a currently existing problem and how we approach it. For example, Dallas Buyers Club is premised upon a man illegally buying drugs to treat HIV – a situation which not only is hugely relevant to healthcare access in so-called ‘privileged’ countries but which clearly parallels the issues surrounding big pharma monopolies on drugs in Africa. The Normal Heart, meanwhile, pushes the buttons of a certain audience (HBO is a premium cable channel) and keeps alive the idea of HIV/AIDS as a disease of white gay professional men. It’s not disrespectful to those who have died or to those who have fought to acknowledge that the fight isn’t the same. It’s largely not about us any more, even when numbers of us continue to be infected and even when we need to organise and fight against the austerity which cuts HIV/AIDS treatments.

That’s why I think it’s important to present the reality of HIV/AIDS and stop the erasure of non-white men from its story – it’s perhaps the most powerful way to build solidarity with those afflicted elsewhere in the world (and our own countries) and make us begin to realise that their situation is intricately connected with our own. HIV/AIDS is not so much an individual problem which can be solved by a noble men or men obtaining concessions from those in power as a systemic one. I think understanding it on that level fundamentally alters our response to it.

Beginning to question these connections and even how countries like the USA may benefit from them is part of a real modern-day radicalism, not getting dewy-eyed over a rose-tinted period of activism performed by actors who will reap not only awards but the plaudits of a world which continues to see these portrayals as terribly ‘brave’ (in itself a homophobic response).

The main character of The Normal Heart says early on “I hate that we play victim when many of us, most of us, don’t have to.” It’s a complacency which is quickly shattered and becoming a real victim fills him with an incandescent rage. You can never fake such a rage because you can never fake experiencing horrific oppression and nor should we ever try to. We shouldn’t and cannot downplay the fights which need to be fought but these have never been solely about sexuality and we cannot forget that. We cannot forget that our liberation is always to be found linked in feminism, anti-racism, anti-poverty, anti-colonialism.  It’s for this reason that it’s so desperately important that the stories of ‘The Next Four’, and all they can be seen to represent who came before and since, are told.

AIDS ribbons and poppy-watching

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This image did the rounds on social media yesterday. At first I paid little attention to it but by the fourth or fifth posting I was curious as to what it was about. I read and re-read the two captions about the Work Programme, assuming that there was some glaring misrepresentation of the figures tailored to each leader. Unable to see any, I felt a little dumb. Then someone shared it explicitly pointing out what we were supposed to be looking at – the AIDS ribbons.

The ribbons are, of course, a way of both raising awareness and of remembering those affected. Reading some of the comments, however, it is pretty clear that the ribbon has become an expected accessory around this time of year – much like the poppy in late October/early November. I did buy a poppy this year but it fell off within ten minutes and (having made my donation) I didn’t feel the need to replace it. I understand that many have a problem with the poppy as a political symbol; I also understand that it simply doesn’t cross the mind of many to buy one. I have zero problem with these positions (and zero problem with the teenager who posted a burning poppy on his Facebook) – it’s what freedom of conscience and freedom of expression are about. Yet ‘poppy-watching’ has become a feature of the period, with twitter accounts and countless topics of forums devoted to discussing who is and (more frequently) who isn’t wearing one. Presumably the proponents of this believe that they are ensuring due respect is paid to those who ‘died that we might live’ – I think that while such respect is important in human terms, it shouldn’t be reified. It’s something we should personally reflect on – why did these people fight, why did they die, what was at stake? This reflection undoubtedly leads to innumerable different conclusions and many of them do not fit nicely with the mystification of the armed forces which is such a core tenet of poppy-watching. It’s easy to stick a poppy on because you’re supposed to; it’s far more difficult to separate respect for human life and human sacrifice from a sceptical approach to authority and war. For me, part of my respect for men like Harry Patch is to attempt in my own small way to understand the function played by the armed forces in modern society and to question (and oppose, if necessary) it. This includes opposing the uncritical, unengaged stance which the ‘respect’ is supposed to take for many. So while I understand and appreciate the importance of the poppy for many, I am wary of the symbol becoming the object of discussion rather than what it is supposed to symbolise.

Much the same can be said of the AIDS ribbon. In this image, the implicit (but barely so) assumption we’re supposed to make is that the evil coalition don’t care about AIDS while noble Labour does. I’m not even sure of the ‘rules’ around AIDS ribbons myself – I’ve not worn one so far this year and I’ve barely seen anyone else doing so. This hasn’t stopped the point-scoring. Yet I would wonder how many people sharing it pay any attention to Government policies and funding regarding HIV and AIDS, not only here but around the world (it’s the third-biggest killer in low-income countries but not in the top ten in the so-called ‘First World’). Tackling HIV/AIDS involves political choices regarding austerity, taxation, developmental aid, poverty, culture and more. None of these are things which can be summed up by whacking on a ribbon for a week each year.

Now, one very interesting aspect of this was that it was overwhelmingly gay men who seemed to be sharing the image. Some of the responses I saw believed Labour’s mass adoption of the ribbon to be a cynical response to the Government’s reported plans to rush through legislation on gay marriage. This is how quickly identity politics gets absolutely absurd. At PMQs yesterday they ‘discussed’ (in the facile, braying manner typical of PMQs) the flooding hitting the country, the Leveson enquiry, unemployment, welfare, the rail system, tax avoidance, the Middle East and the 40th anniversary of the expulsion of Asians from Uganda. As a gay man, however, I’m reduced in the eyes of many to being impressed by the coalition’s policy on gay marriage but liking Labour’s red ribbons. All of the other stuff, much of which has a far more tangible impact on my daily life, is unworthy of comment. It’s supremely facile and patronising. It also fails to understand the global reality of HIV/AIDS today, which is that it is far from being a ‘gay disease’ and disproportionately affects women in Sub-Saharan Africa. Of course the gay community has a unique, tragic history with HIV/AIDS but in viewing the red ribbon as an identification with ‘us’ we ultimately do the cause (and ourselves) a disservice. Indeed, many of the people sharing this image would undoubtedly be outraged if HIV/AIDS was referred to as a ‘gay disease’. Whatever the history, the disease is not ‘ours’ to be used as a weapon deployed to curry our favour. As a gay man in the UK you’re far more likely to die of circulatory disease, cancer and respiratory disease than of HIV/AIDS and just as the former three unite everyone to ‘stand up’ against them, we should hope for the same response to the latter, free of our own rush to offence.

We’ve come a long way when AIDS ribbons are seen as signifiers of being ‘good’ but what ultimately matters are actions and understanding. Going down the path of ‘ribbon-watching’ does nothing to help these things and if we find ourselves doing that we should pause and think about why. What does the ribbon mean to us? Why is it so important that we see people wearing it? What do we do in our own lives to further the aspects we value so much? This seems to me to be a far more thoughtful and respectful response to the symbol, which should never ever become the point of the discussion.