This book explains how, and why, economics has been applied to a terrible pandemic, using a range of examples mostly drawn from the region most affected, sub-Saharan Africa. Author Deborah Johnston argues that a political economy approach can bring meaningful insights to our understanding of the spread and impact of HIV/AIDS where both microeconomic and traditional mainstream macroeconomics approaches have failed. Sally Brown finds that this is an important and useful for read.

Economics and HIV: The Sickness of Economics. Deborah Johnston. Routledge. May 2013.

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Three million people died from AIDS in 2001, making it the world’s fourth biggest cause of death. Sub-Saharan Africa remains most heavily affected by HIV and AIDS, accounting for 67% of all people living with HIV and for 72% of AIDS deaths in 2007. Besides the human costs of the pandemic, HIV/AIDS is having profound effects on Africa’s economic development and hence its ability to cope. A thorough and in depth analysis of economics and its ability, or otherwise, to assist in understanding the impacts of a major illness, is clearly timely.

Deborah Johnston is a Senior Lecturer in Development Economics at the School of Oriental and African Studies, University of London. She has published widely on HIV, food politics, and economic development and agriculture, and as someone who teaches on growth and economic development in Africa, is well placed to write this detailed analysis and critique of economics as a discipline, which she claims has largely failed to provide insights into the HIV/AIDS pandemic despite the immense social and economic effects of HIV/AIDS worldwide.

Approaching this book as a non-economist, I was interested to note that in the first few pages Johnston mentions the language used in the book. As a sociologist with an interest in health and illness, I am much more familiar with the ethnographic accounts of experiencing illness that she mentions, and the depersonalised language used by economists does indeed conceal individual suffering and dying. She sets out the need to use the language of mainstream economics, with its “representative individuals making rational choices to optimizing behaviour in anonymous markets” in order to present scientific, analytical arguments, arguments which she then goes on to skewer most effectively throughout the book.

The book focuses on the impact of HIV/AIDS in sub-Saharan Africa, the region of the world most affected by the pandemic. It is divided into two parts, Part I discussing microeconomic approaches and how they relate to public health approaches to HIV/AIDS, especially where individual choices and behaviours are blamed for HIV transmission, and Part II considering the economic impact of AIDS, in particular why economists cannot agree if epidemic disease is a good or bad thing for economic development. This argument in itself seems quite shocking to me; the idea that a disease, particularly one as devastating as HIV/AIDS, could possibly be seen as a good thing, seems appalling, and shows why Johnston was correct to point out early on in the book that the language of economics depersonalises and hides great suffering.

President Obama, 2009. Credit: TED Conference CC BY-NC 2.0

The chapters follow a clear structure; each one sets out an introduction to the topic of that chapter, outlines key economic approaches and arguments, then critiques and effectively deconstructs them. For example, Chapter 3 considers the relationship between individuals and HIV transmission, in particular the choices individuals make (or the constraints on their ability to make choices). Outlining public health approaches to the relationship between health and individual behaviours, Johnston summarises debates on health inequalities, including disparities between the wealthy and the poor, access to health services, health seeking behaviours and wider social factors. She then presents a number of microeconomic approaches modelling behaviours such as demand for safe sex, and beliefs about utility and benefit of risky sex, condom use, and likelihood of being infected, which aim to reduce individual behaviours to mathematical formulae. The fundamental problem with such models is that they are predicated on the same notions that Johnston critiqued in her discussion of language at the beginning of her book, where rational individuals are in a position to make free choices: the reality of sexual interactions for many people, mainly women, is that they are not always freely chosen, either because of coercion, dependence, or lack of information. Her questioning of the basis of these models focusses on problems with theories of consumer choice, the rationality of decision making with regard to sex, perceptions of risk, and choice and compulsion. This critique is important because so much policy around HIV/AIDS prevention is based on assumptions about individual behaviours and choices. As she argues, choice-theoretical models fail partly because of the weaknesses of models based on self-reported data, which is known to be subject to error, and because of over-simplification in the models themselves.

Part II of the book considers problems in understanding the economic impact of AIDS, beginning by setting out early arguments about the relationship between health and wealth. It was assumed for many years that health was a by-product of growth, i.e. as countries increased their GDP, their populations would become healthier. This changed with the WHO report on macroeconomics and health which suggested that health was a factor in determining economic growth, not just a result of growth. Again, Johnston takes a meticulous approach to detailing the complexities of understanding how HIV/AIDS impacts on, for example, farming, individuals and households, and how this relates to economic growth.

The book ends by arguing that a political economy approach can bring meaningful insights to our understanding of the spread and impact of HIV/AIDS where both microeconomic and traditional mainstream macroeconomics approaches have failed. In particular, I would argue that one of the strengths of the book is in its unpicking of the complexities of HIV/AIDS in sub-Saharan Africa. Too often, countries, genders, social classes –  however we care to classify people – have been lumped together as “sub-Saharan Africa” when talking about HIV/AIDS. Johnston’s detailed and thorough unpicking of data, analyses and theories in this book shows how inaccurate that is, and how complex the problem is.

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Sally Brown is a Research Fellow in the School of Medicine, Pharmacy and Health at Durham University. Her research interests include young people and sexual health, men’s health, and lay knowledge and understanding about diagnosis, risk and decision-making. Read more reviews by Sally.

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