Nonviolent Change Journal

    Although a variety of therapies are available for the treatment of disorders related to Human Imuno-retrovirus infection, prevention of infection remains a primary focus of attention for public health officials and epidemiologist. Infection by the various strains of the virus begins a process that leads to compromise of the immune system in a majority of individuals, allowing opportunistic infections to overcome the natural defenses of the body. While medical or surgical intervention remains the most popular and prevalent stratagem for treatment in the armatorium of Western Medicine, in the case of HIV infection medical treatment is at present limited and not usually curative and surgical intervention has no demonstrable value. In addition, currently available medical treatments that address the problems that arise from HIV intervention are often prohibitively expensive for citizens of those nations most severely affected.

     Prevention remains the most effective strategy for control HIV. However, the methods and approaches required for effective disease prevention do not fit easily within the medical service models of many nations. Cultural factors within individual societies influence attitudes towards particular behaviors. Such attitudes may be discerned in both industrialized societies and in economical developing nations. This paper explores methodologies and strategies, which may be useful in assisting the process of large systems change, with special emphasis on applications to Sub-Saharan Africa. Its plan of development centers on a discussion of selected cultural and political realities in the region which favor the spread of HIV infection and AIDS, followed by presentation of a model for change based upon organization development (OD) technologies applied to large systems change. Conclusions and suggestions for applied research are also provided.

Non-violent large systems change techniques applied to the epidemiology of HIV infection
     Non-violent change strategies applied to large systems may address a variety of human behaviors. Most of these behaviors are closely identified with cultural issues relating to diverse populations of interest in applying change strategies to a large, diverse region such as sub-Saharan Africa. In particular, cultural aspects of African life make change in the way that members of the society perceive risk difficult. Application of large systems change technology will require assessment of cultural, political and economic factors, development of change strategies that are suitable to the environment, careful implementation of strategies together with formative evaluation of feedback, and evaluation of results at specific intervals in the change effort.

     Assessment of actual need in the light of cultural and political realities and the development of behavioral strategies for education individuals for improved prevention efforts must remain a prime focus. Whereas the preferred model of Western medical care is reactive, at present only preventative measures are truly effective in addressing the realities of HIV infection. In part, this may be true because of the inability of this model to address cultural as well as economic aspects of African and Western public Health behavior.

The role of economics in the epidemiology of HIV
     Because of the costs associated with treatment for HIV, economic realities pay a major part in the development of intervention strategies. Current approaches to treatment stress use of complex “cocktails” or combinations of drugs that aim at the retardation of viral growth and the strengthening of the individual immune system against opportunistic invasions. The mortality which eventually occurs as a result of HIV infection is usually the result of opportunistic infections by bacteria made possible by the degradation of the body’s immunological defenses. The principal role of treatment is slow the process of such infections. The combinations of medications required for such treatments are sophisticated an expensive, providing economic stress to industrialized nations. Currently, many of the available therapies are beyond the economic capabilities of developing nations, particularly those nations in Sub-Saharan Africa. Such regions remain among the most heavily impacted regions on the globe.

     The Western model of medical care is based upon profit motivation. As such, this model has arguably produced the most viable approach to providing health care to the majority of citizens within the industrialized democracies. Following the model, health care is seen as an economic good and a service, which may be quantified in terms of euros or dollars. While such an economic model produces significant stress for the wealthiest societies, it is clearly beyond the scope of the citizenry of many developing nations.

     The Western model of medical treatment assumes large numbers of citizens who have both the economic and educational resources to assume a significant degree of individual responsibility for their health care. Key to the model is the consumer as customer and the physician and her/his staff as provides of services in a business-oriented relationship. In brief, life is seen as individual property, and care becomes a commodity to be sold, traded and managed. This point of view underlies the health systems in even those democracies that operate on a modified capitalist mode, including Canada, Sweden and Japan. While basis health care in those societies is made available to the majority of citizens, advanced care is available to those who posses superior financial means. Although economically and technologically advanced, the societies, which are noted as examples above are in fact socially and economically dependent upon others within the Western model which, are based upon market-oriented economies. Following this model, private laboratories are motivated to spend significant amounts of money to develop pharmaceuticals in the expectation of limited monopolies on their sales for a period of years after development. The classic venture/risk vs. prospective reward model is clearly evident in this Western model. Such an approach provides incentive for private enterprise to spend funds on research and development, resulting in continuing discovery of new drugs and improvement of existing products. Companies are able to realize very significant profits in excess of production costs in order to make the developmental research possible and to also provide a return to their investors.

     Significant evidence points to the ineffectiveness of applying this Western model to the requirements of health promotion in Africa and other developing regions. A key matter of discussion has centered in recent months around the availability of generic pharmaceuticals for the treatment of AIDS-related conditions on the sub-Saharan African continent. Generics are less expensive, and therefor more available to individuals in developing nations. For this reason, international attention has beef focused upon recent agreements, which promise to make generic products available for application to AIDS treatment in Africa.

Generic anti-AIDS drugs for sub-Saharan Africa
     According to a recent report by the French journal Le Monde Diplomatique (Dec. 10, 2003), a recent agreement between the major pharmaceutical firms and African governments bodes well to improve the availability of anti-AIDS drugs in that area of the African continent. The article discusses the historic accord signed on December 9, 2003, by the government of South Africa and major global firms which produce anti-AIDS pharmaceuticals. This accord opens the way to similar agreements for application throughout the continent.

     GalaxoSmithKline (GSK) and Boehringer Ingelheim (BI) are the two major drug companies that were involved in the judgment. GSK holds the patent for AZT and lamivudine, while BI holds the patent on nevirapine. These are the three prescriptions most often utilized in Africa in respect to HIV infection. Their active ingredients are chemical molecules that are covered under international patent law.

     The terms of the agreement allow for the production of generic equivalents of the aforementioned drugs under significantly reduced royalties to the pharmaceutical companies which developed them. companies. The use of generics under the form of pills or set dosages will provide some limits to the risk of the development of resistant viruses. This represents a significant therapeutic advance for the African continent and will promote the availability of treatment in this region of the world. Additionally, the accord paves the way for the production and distribution of HIV-specific medications to other portions of the continent.

     From the point of view of large systems non-violent change, this accord represents a major breakthrough. Le Monde Diplomatique suggests that the accord may represent an armistice in a sort of “war of the patents” that had been raging since the 1966 conference held in Vancouver which highlighted major differences in approach between the Northern and Southern parts of the African continent in providing for the therapeutic interventions in the assisting AIDS victims and developing preventive strategies. The accord may be seen as a starting point from which behavioral change technologies might be applied to bring about non-violent change within national political structures for disease management and control.

     Treatment remains a second line of defense in the struggle against HIV infection. In order to realize positive outcomes, nonviolent change strategies targeting human behavior on the systemic and individual levels must be developed. These must take into consideration the cultures of the market-base economies that produce the relevant pharmacology, as well as the requirements of the emerging economies in which the products are so critically needed. In fact, the recent African accord may provide a model for provision of generic drugs produced in Canada to disadvantaged consumers in the United States.

Summary and conclusions
     Interventions targeting the reduction of the incidence of HIV infection and subsequent treatment of AIDS remain focused on change in human behavior, despite medical advances in treatment. While individual behavior change is the ultimate target of such efforts, large systems change is necessary for significant reductions in pathology to be possible. These changes may be framed as bilateral in scope. Western attitudes towards health as a market commodity must be modified to accommodate an additional view centering on the improvement of public health as a natural resource. For this change to take place, large systems OD strategies for non-violent change will continue to be necessary.

Reference
The International Registry of Organization Development Professionals and Organization Handbook (2004).   Chesterland, Ohio, The Organization Development Institute.

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