BioMed Analysis: Mixing medicine and morality

Moral crusades against HIV/AIDS may have good intentions, but there is no substitute for sound evidence on behaviour change, says Priya Shetty.

When it comes to health policies on sex and drugs, science has a hard time competing with morality. Policies on HIV/AIDS, for example, are often strongly moralistic, driven by personal judgements about how people such as sex workers and drug users should behave despite their high risk of infection.

So how will the Vienna Declaration, due to be signed this week (18–23 July) at the XVIII International AIDS Conference in Austria, be received? It will call for the introduction of evidence-based drug policies, such as treating drug addiction as a medical condition rather than demonising it as a crime.

Criminalising drug use, say the scientists behind the declaration, is fuelling the HIV epidemic because it does not tackle risky behaviour — such as sharing dirty needles — that can spread the virus.   

Moralistic health policies such as penalising drug users may be well intentioned. Indeed, a moral imperative to end human suffering probably lies at the heart of all efforts to fight disease in the developing world. But moral judgements — from any end of the political or religious spectrum — should not have a place in health policies. People should not be forced to choose different values as a precondition for receiving assistance.

It is not too strong to say that morality not rooted in evidence can play ideological games with public health.

Abstinence doesn't work…

Global morality-based HIV/AIDS policy undoubtedly reached its height during George W. Bush's administration in the United States, from 2001 to 2009, when the government strongly pushed the abstinence part of the 'ABC' (abstinence, be faithful, use condoms) model for tackling HIV/AIDS.  

Uganda is often heralded as a success story for ABC, and is cited by abstinence advocates as proof that their approach works.

But with HIV/AIDS now on the rise in Uganda, the reality seems to be different. It is true that the country saw HIV prevalence drop in the 1990s, when President Yoweri Museveni's government aggressively pursued ABC. But researchers and development workers say that back then, the campaign actually promoted all components of ABC, especially education about the virus and condom use.  

By 2006, UNAIDS reported that the gains against HIV/AIDS seemed to be receding, in part because the emphasis on condoms had given way to the ideology of abstinence until marriage.

…nor does stigma

An important consequence of a moral bias in HIV policy is that it influences who is treated or targeted for prevention. In the abstinence version of ABC, for example, it meant that condoms were not given to teenagers despite many having sex before marriage, not always with a condom.

While the United States may have been one of most prominent proponents of moral HIV/AIDS policies, it is by no means the only one.

In the early 1990s the state government of Maharashtra, India, established an HIV-prevention programme to stop the virus spreading in sex workers. But the goal was not to improve sex workers' health — instead it was to stop the virus spreading from sex workers via migrant workers to 'good' housewives.

If it had slowed the spread of HIV, moral advocates might have had a point. But such approaches have little chance of success.  

In this case, rather than tackling the stigma of being a sex worker and educating people to take care of their health, the government simply gave out condoms and told them to stop having unprotected sex.

Meena Seshu — from nongovernmental organisation SANGRAM, which was instrumental in challenging the government's approach — says that the programme did not work because the sex workers did not feel any ownership of the project.

It was only when SANGRAM created a rights-based approach grounded in the lives of the sex workers that the programme began to have an impact.

Understanding human behaviour

Moral programmes are flawed because they go against the grain of good policymaking — that any policy must be rooted in reality and have an understanding of human behaviour.

Policies based on judgements about what people should do rather than an understanding of what they are likely to do tend only to be workable when they are mandatory and punishable by severe penalties. But even then, as anti-drug policies show, the most stringent legislation is not always enough to change behaviour.

Policymakers in developed countries who have tried to promote healthy lifestyles by simplistic messages have learnt this lesson to their cost. Despite much advice on the dangers of an unhealthy diet, junk food is still consumed in vast quantities and obesity, especially in children, is still on the rise.

Morals and social values may well spur people in power to do good and improve people's lives, but we need science and robust evidence to tell us the best ways to change people's behaviour for the better.