The justifiable grim preoccupation of the caring public concerning the threat of global plagues needs to be moderated and re-oriented towards a critical reappraisal of the link between poverty and disease, and a re-emphasis on addressing the social roots of disease. The lurid attention to AIDS is a graphic example. Progressives have lost their reason over this phenomenon, and we need desperately to reclaim our balance. The world depends on it.

Long ago it was discovered that the best way to care for the sick is to prevent illness in the first place. And the best way to prevent illness is to promote health: the wholeness of the person, the security of the person, and a full active life in a caring community. The most profound predictor of health status is a secure livelihood in a cohesive, safe and dynamic social environment.

Conversely, the factors that erode the conditions of health and vitality are also clear: poverty, war, domestic squalor, environmental pollution, and hazardous work conditions. Put another way, the most pervasive causes of illness and premature death are injustice, violence, and corporate crime; the most profound factors in health are justice, peace, and citizen and consumer rights.

So why do health programs - and particularly AIDS programs - not focus more on promoting economic and social justice, human rights, and corporate responsibility? Why do we not emphasize the fundamental causes of poverty and chronic ill-health among the more than two billion absolutely poor, and develop policies and programs with the potential to transform these causes permanently? Why are we moved by the need to care for the dying, but unmoved to promote measures that will transform the conditions that kill?

In matters of health we are often constrained by politics from developing programs that emphasize these universally-understood root causes. The elements upon which we are willing to campaign - microbes and viruses, ignorance and individual behaviour - are almost entirely based in program prescriptions that are consistent with dominant economic ideology and interests. And these prescriptions almost always are technical and technological, rather than social and political. As such, they are never sufficient to confront fundamentally the realities of poverty and ill-health.

This can be seen in some of the major health and development issues of our time. It is a reason why, for example, the population control bias of international aid persists in spite of the evidence that far more can be achieved through programs that promote reproductive health, human rights, education, and economic opportunities for women.

It also underlies the controversy that President Mbeki of South Africa has unleashed in questioning the descriptions and prescriptions concerning AIDS in Africa.

The conventional definition of AIDS emerges from the policies available within international institutions to deal with it. These are primarily medical interventions, and programs of "behaviour modification", rather than innovations in social and economic policy that focus on issues of inequity and exclusion. We define the effects of immunodeficiency in terms of "disease" rather than "deprivation", because we have policies to deal with the first, while we do not have the political will to deal with the latter.

Of course, every person should have - as a human right - access to appropriate medical treatment and therapeutic health care. We need to continue the political struggle to achieve this universal access in every country in the world, including our own. At the same time, we need to be cautious about the medicalization of poverty and injustice which increasingly obscures the day-to-day reality of ill-health, misery and death that is the common lot among the poor.

The vulnerability of the poor to chronic ill-health and life-threatening disease are an inevitable by-product of the material conditions they experience. In the long run these are social problems, not medical problems, and require political and social interventions. And without such interventions it will not be possible to promote health globally, let alone to create the prospect of a viable universal health care infrastructure.

Nowhere is this more evident than in the issue of AIDS. No health issue has so galvanized the world and public attention as has the acquired immune deficiency syndrome. At the same time controversy persists and is growing about the nature of AIDS and the best way to respond to it.

In reaction to this debate, many progressives feel that we have no choice but to rely on mainstream medical explanations, and reject alternative explanations posed by other scientists and practitioners. But given the apocalypse that is being predicted in Africa and other parts of the world, it is important to scrutinize the lines of this debate and what we are seeing in the world. The starting point for such an examination is the middle ground of common understanding among mainstream and alternative practitioners, those areas where there is clear consensus.

What does such an examination tell us? The acquired immune deficiency syndrome is a condition in which a person's immune system is severely compromised and left vulnerable to a broad range of heterogeneous infections and diseases that debilitate and can lead to death. It is a medical construct that captures many disease phenomena in one basket for purposes of investigation, diagnosis and treatment. Within this complex syndrome, there are many factors; none of them - including the various viruses associated with immunodeficiency - in and of themselves is sufficient to bring on the onset of a chronic critical immune deficiency. The most determinant predictors of immune suppression and associated disease - in the north and the south - are factors directly related to social and economic status, or medical treatment itself. Not surprisingly, therefore, the front line in the "fight" against acquired immune deficiency increasingly is in the area of basic health promotion, even as the world focuses on the question of access to drugs.

Closely read, the in-house literature of the international health institutions and multilateral development agencies explain all of this. Fact: acquired immune deficiency syndrome is multifactoral, and social factors predominate. Yet there has been a tendency among progressives and AIDS support groups to obscure this fundamental understandings for fear of "confusing" people, undermining prevention programs, and eroding political support for program and research funding. It is far easier to mobilize support to fight disease than to fight poverty and injustice. Extensive resources are available for those who develop their programs within the conventional medical framework, and most programs and public education campaigns are built on the "HIV/AIDS" metaphor and image.

Those opposed to this emphasis and advocating a more balanced approach in health programming and in public education do not insist that poverty is the sole cause of extreme and chronic immune suppression, nor that viruses and other microbes can be declared with certainty to have absolutely no role in all cases. Most resist precisely the notion that what is called acquired immune deficiency syndrome is a single phenomenon or that it has a single and solitary cause. They do say that the factors and conditions that lead to such immune suppression are dominant among poor populations, that the poor are the most vulnerable, and that it is on poverty and its roots that we should focus.

A virus is a convenient and simple "target" to rationalize medical responses, but it also obscures other factors that would focus responses on long-term, substantive social and economic transformation of the conditions that make people vulnerable to the diseases that take advantage of chronic immune deficiency. The role of "medicine" - that is drugs - in resolving the crisis can only be very limited, and there is serious concern and controversy about the negative effects as well as the benefits of pharmaceutical approaches.

Many progressives have concluded that although prevailing medical theory is not accurate or complete, or even very helpful in the long run, it is what we have to go with until something better comes along. We can never do away with poverty so we had better make medicine work. Controversy about the nature and cause of acquired immune deficiency syndrome, they believe, undermines the good that medical science and humanitarian aid can accomplish. Scientific issues are matters for scientists to resolve, and not for politicians, or ordinary citizens, to debate. Debate only leads to public confusion and "politicization" of the issues. And it plays into the hands of cynical elements who use HIV/AIDS to spread messages of hate, bigotry, and paranoia. Therefore, controversy needs to be contained, and a consensus created to fight a "war" against the disease.

While perhaps understandable, this approach to knowledge is undemocratic and relies on coercion as much as education; it has always failed in the long run, and cannot succeed in this case.

Fundamental social change is the only hope for those most vulnerable to this and other conditions. To actually overcome AIDS requires that we build a broad public consensus towards a campaign against global poverty itself. It requires a relentless focus on the social and economic conditions that make people vulnerable to the conditions that lead to the chronic immune deficiency which threatens poor people the world round.

This struggle cannot ignore those presently enduring the deadly effects of immune deficiency. It will, of necessity, have to include building the legal and physical infrastructure to ensure universal access to effective medical remedies and health treatments - including stringent regulation of the research and marketing practices of pharmaceutical companies. But to be successful, the emphasis - the humanitarian and political goal - has to be the transformation of the political, social and economic structures that make the lives of the poor a permanent emergency in the first place.

Brian Murphy works with Inter Pares, the Canadian international social justice organization, where he is senior policy analyst in support of Inter Pares' humanitarian assistance, capacity-building and advocacy in Asia, Africa, Latin America and Canada. He is the author of Transforming Ourselves, Transforming the World: An Open Conspiracy for Social Change, ZED Books ( London and New York), 1999.]