Sustainability of Hope

“Hope” has been the word of the hour since Obama’s campaign adopted it
as a key concept in his concept. While generally in the aid world, we
tend to focus more on the tangible resources, I think that hope has a
great deal of influence on the allocation of funding and attention.
I’m beginning a project focused on large-scale HIV prevention efforts
around the world. With the advent of antiretroviral therapy, access
to treatment has become the rallying cry for the AIDS community. And
indeed, millions of HIV-positive people have received access to
treatment, and often very good, comprehensive services, through the
programs made possible through PEPFAR and Global Fund monies.
Nonetheless, without bringing down the incidence rate significantly,
in a sense all we’re doing in bailing water out of a sinking ship
without addresses the structural problems. That’s easy to say, but
prevention remains an elusive concept—it’s difficult to measure,
difficult to define, and difficult to see, sometimes. As a result,
some narrow interventions, including condom distribution and
counseling have received disproportionate amount of funding without
producing results, while broader-based interventions, such as poverty
reduction, promotion of women’s rights, and increased access to
education, which may not be proximate causes but undoubtedly relate to
vulnerability, struggle to find resources. I am always struck by
this, because I feel that those prevention activities are just another
form of bailing water. Attacking the fundamental causes will require
us to really understand the societal context and dynamics, implement
long-term programs, and be patient as population-level change doesn’t
occur overnight.
I’m sure as I delve into this project, I’ll have more informed
thoughts on these issues and want to share them. Actually, this week
my mind has been in an entirely different realm, that’s elucidated
these issues very clearly. For the past four years, I’ve worked with
Harvard’s Office of Sexual Assault Prevention and Response to educate
freshman women about sexual assault, risk reduction, and resources on
campus. All freshmen are required to attend a presentation that
attempts to use humor to talk about gender norms and how they relate
to sexual assault, and then participate in a one-hour facilitated
discussion. In those discussions, we always share the tragic
statistic that 20-25% of college women will be the victim of an
attempted or completed rape. This number is unbelieveably high—what
would people say if we classified these as hate crimes: the idea that
1 in every five women will suffer a hate crime during college for some
reason may sound much more compelling.
While I was familiar with that statistic, what I did not realize that
is the department of justice has been conducting this survey for over
20 years. And guess what—that statistic has, in their language,
“remained remarkably consistent”. In other words, nothing that has
been done in the past twenty years has improved women’s control of
their sexuality on campus. What has been done is create resources for
victims. At Harvard in particular, the response team, composed of
passionate individuals possessing huge amounts of compassion and
empathy (though not institutional resources), victims who come forward
for support can be expect to met with some of the highest quality
services available anywhere. But I have twenty years worth of data in
front of me now to say that in terms of prevention, we are failing
young women. And no one should be satisfied by simply knowing that
victims now have places to go, because most victims still don’t seek
out services and even though many victims are able lead happy,
productive lives, the road to that recovery is often laden with
disruption and pain. Why do we ignore this issue? Has it been
classified as “hopeless”? I would believe that changing the dynamics
of what goes on in the bedroom would be extremely difficult—in the
critical moments, individuals are making decisions independently and
with no one to exercise any sort of social pressure over them. Which
inherently means that one would have to fundamentally shift the
paradigm of sexual dynamics to reduce or eliminate the incidence of
sexual assault.
You can see the connections to HIV prevention—at the end of the day,
what fuels HIV transmission is inextricably linked to what causes
sexual assault. Perhaps an extreme example of this comes from Rwanda,
where during the genocide, Hutu men with HIV were often encouraged to
rape Tutsi women.
Does is make sense to think about HIV prevention in a separate silo
than sexual assault prevention? Or should it be framed in a positive
way—promotion of safe, healthy sexual practices? How we define the
problem will determine the modes of intervention, and no doubt we’ll
start with the areas where we think (i.e. hope) we’ll have the biggest
impact. I’m not disagreeing with this strategy in principal, but I do
think it’s dangerous to get so focused at piece of puzzle that we lose
sight of the full context. Let’s not let another twenty years pass us
by and have people remarking about how incredibly consistent HIV
and/or sexual assault rates have been.