HIV and AIDS

HISTORICAL RACISM, SOCIAL AND HEALTH INEQUITIES, AND HIV/AIDS

RACE, CULTURAL IDENTITY, AND GLOBAL RESPONSES TO HIV/AIDS

BIBLIOGRAPHY

During 2005, around 4.1 million adults and children became infected with the human immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS). By the end of the year, an estimated 38.6 million people worldwide were living with HIV, according to the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS 2006) report. Since the beginning of the epidemic in the 1980s, 32 million people have died from AIDS, but it is increasingly clear that this global health crisis has not impacted populations equally. Rather, patterns of social and economic inequality are evident in the hardest-hit AIDS epicenters around the world.

Of those living with HIV globally, 95 percent live in developing countries. In contrast to western and central Europe and North America where the number of people living with HIV is estimated to be 720,000 and 1.2 million, respectively, in Asia, 930,000 people were newly infected in 2005, bringing the total number of people living with HIV in the region to 8.3 million, with more than two-thirds of them living in India.

However, sub-Saharan Africa is by far the worst-hit region, with 24.5 million people estimated to be HIV infected. This region is home to just over 10 percent of the world’s population, but almost two-thirds of all people living with HIV reside there. Across sub-Saharan Africa, HIV prevalence rates (proportion of people living with HIV) vary significantly between and within sub-regions and countries. While several southern African countries have HIV prevalence rates above 17 percent (with Botswana and Swaziland having the highest prevalence rates of 24% and 33%, respectively), prevalence rates in West African countries are much lower (with adult HIV prevalence rates lower that 2% in most countries). More serious epidemics are in Central and East Africa where HIV prevalence rates range from 4 to13 percent.

In the Caribbean region—which is the second most affected region—prevalence rates in the Bahamas (3.3%) and Haiti (3.8%) are the highest outside of the African continent. An estimated 330,000 people were living with the virus in 2005. In the same year, Latin America reported around 104,000 new HIV infection cases, and an estimated total of 1.6 million people living with HIV, about one-third are residing in Brazil.

In the United States, of the estimated 1.2 million people reported to be living with HIV in 2005, historically oppressed African American and Latino populations accounted for more than 73% of new HIV infections, although they represented only 12 and 11 percent, respectively, of the U.S. population (Centers for Disease Control 2003). Thus, in both resource-poor and resource-rich countries, HIV/AIDS has increasingly been concentrated in the poorest, most marginalized sectors of society (Parker 2002).

Three general factors have influenced the overlapping crises and the distinct dynamics of the epidemic: (1) poverty and economic underdevelopment; (2) mobility and patterns of community instability, including migration and social disruption due to war and political or community marginalization; and (3) gender inequalities (Parker, Easton, and Klein 2000). These structural factors are at work across all countries and also help elucidate how HIV and AIDS disproportionately impact indigenous people of color, particularly people of African descent, for whom larger health and social welfare inequities are tied to the enduring legacy of racism. Accordingly, this discussion situates the disease within a sociocultural context and delineates the ways in which racism underlies the alarming rates of HIV-infection among African descent populations that have historically been the targets of inequity and racism on a global scale.

HISTORICAL RACISM, SOCIAL AND HEALTH INEQUITIES, AND HIV/AIDS

Globally, racism plays a role in vulnerability to health disparities, including HIV/AIDS. Long before AIDS, many of the issues that place people at risk for HIV/AIDS occurred along the contours of racial oppression for marginalized indigenous populations, specifically among people of African descent. In discussing global health disparities, Raymond Cox contends that “systematic and widespread discrimination over centuries has manifested itself in poor living conditions and poor health of indigenous peoples and people of African descent all over the world” (Cox 2004, p. 548). The experience of sub-Sahara Africa sets the stage for examining historical conquest, violence, and oppression as a backdrop to socio-political conditions which have enabled the rapid spread of HIV/AIDS across the African Diaspora.

European colonialism and imperialism, and the artificial boundaries these systems imposed on Africa, exacerbated sociopolitical upheaval. The disintegration of traditional socioeconomic structures led to conflicts, poverty, and family and community disruption; forced migration; and involuntary displacements. South Africa, a country whose racist apartheid system deprived blacks of education and access to health care, is home to the second largest number of AIDS cases. Apartheid pervaded South African culture and supported the treatment of nonwhite South Africans as second-class citizens. During the 1960s and1970s, the government implemented a policy of “resettlement” that forced nonwhites to move to government-specified areas, or “homelands,” where blacks rarely had plumbing or electricity, and where access to transport, hospitals, and health-care facilities was sharply curtailed. Highly developed white hospitals were off limits to blacks, whose few hospitals were seriously understaffed and underfunded. Further, within the tragic pattern of forced removal of blacks to “resettlement zones” and the destruction of indigenous family life, black South African miners and other laborers worked long periods away from home and family. This became an underlying factor in increases in sex worker services and a major factor contributing to the HIV/AIDS epidemic (Sachs 2000, Robins 2005). Within this entrenched migrant-labor dynamic, it is estimated that AIDS may have been spreading at the explosive rate of more than 0 new cases per day. In 1982 the first recorded death from HIV occurred in the country, and by the mid-1990s the death toll had reached 10,000. In the United States, meanwhile, HIV/AIDS was ballooning into a health crisis, most notably for historically oppressed ethnic minority populations, African Americans and Hispanics. The U.S. epidemic ostensibly began as an epidemic of gay white males; however, the changing face of AIDS became evident in the mid-1990s as the percentages of AIDS cases among whites declined but grew disproportionately among people of color, especially African Americans. In 1985 blacks accounted for 25 percent of diagnosed AIDS cases but this figure rose to percent by 2005 according to the Centers for Disease Control (CDC 2006). In 2003 the rate of AIDS diagnoses for African Americans was almost ten times the rate for whites and almost three times the rate for Hispanics. African-American men had AIDS rates eight times that of white men, while the rate of AIDS diagnoses for African American women was 25 times the rate for white women. In 2002 AIDS was the number one cause of death for African-American women between twenty-five and thirty-four years of age, and AIDS ranks in the top three causes of death for African Americans aged twenty-five to thirty-four (CDC 2006).

The AIDS epidemic among African Americans has been shaped by poverty, chemical dependency, lack of accessible health care, mistrust of medical and other institutions, isolation, institutionalized racism, and internalized oppression (Gilbert 2003). It unfolded parallel to a rise in intravenous drug use and crack cocaine use, a situation only worsened by biased law enforcement practices and the increased arrests associated with the 1980s “war on drugs,” forcing a disproportionate number of black men to enter the penal system. Nearly half of all prisoners in state and federal jurisdictions and almost 40 percent of juveniles in legal custody are African Americans; and in 2003, the AIDS prevalence in state and federal prisons (0.51%) was more than 3 times higher than in the general U.S. population (0.15%) (Maruschak 2005).

Similar to people of African descent around the world, black Americans already suffered from serious health and standard of living disparities predating AIDS. The death rate for African Americans is higher than non-Hispanic Whites for heart diseases, stroke, cancer, chronic lower respiratory diseases, influenza and pneumonia, diabetes, and homicide. African Americans make up 40 percent of the homeless population; and infant mortality rates among U.S. blacks outpace those of some developing countries. Depression among African American women is almost percent higher than that of white women. Not surprising, the U.S. Institute of Medicine released a report in 2002 that documented increasing evidence that, even after such differences as income, insurance status, and medical need are accounted for, race and ethnicity remained significant predictors of the quality of health care received by African Americans (Smedley, Stith, and Nelson 2003). The report confirmed racial and ethnic bias in the U.S. health care system, and that people of African descent suffer poorer health, use fewer health services, and are less satisfied with health-services encounters than almost any other ethnic group. Thus, issues such as providers’ attitudes, communication with persons of color, and lack of cultural competence are factors in not only maintaining these disparities, but also in exacerbating them. Such patterns of health and HIV infection disparities are found in other countries where people of African descent are disproportionately poor and disenfranchised. In Brazil, which has the largest population of African descent outside the African continent, black and brown children are twice as likely as white children to die before the age of one (Cox 2004). Although the country has always boasted of its lack of racial problems, recent developments have highlighted racial disparities and pushed Brazilians to come to terms with how race affects virtually all aspects in their lives, from education to employment to justice. Around 47 percent of Brazil’s 185 million people are black, and half of them live in poverty. Blacks in Brazil are twice as likely as whites to be poor and to receive less schooling, and they are more likely to die at a younger age than whites. These statistics underscore how HIV infection rates parallel color lines in Brazil. Brazilian blacks are nearly twice as likely as whites not to know how HIV is transmitted and, thus, to not know how to protect themselves from the virus (Hay 2005). Further, between 2000 and 2004, new cases of AIDS among people who declared themselves black or brown rose from 33.4 percent to 37.2 percent for men and from 35.6 percent to 42.4 percent for women (Hay 2005).

Even in countries such as the United Kingdom, Canada, Australia, New Zealand, and Columbia, where advanced risk-sharing systems of health care should protect its residents equally, people of color are not in fact protected as well as others. In Canada, for example, disparities among the indigenous population and among people of African descent exist, and cultural incompetence among healthcare workers has been acknowledged as a cause for these disparities. Poverty rates among persons of color in Canada are unacceptably high, reaching as high as percent for some groups, such as recent black immigrants (Jackson 2001). As a result, blacks are highly overrepresented among those suffering from HIV/AIDS. In the 2001 census, black people accounted for 2.2 percent of Canada’s population but represented 15.1 percent of AIDS cases with known ethnicity. At the same time, the proportion of cases among white Canadians declined from 87.5 percent in 1993 to 64.1 percent in the first half of 2002 (CDC 2003). In sum, across continents and within countries, the patterns of HIV infection rates underscore the reality of health vulnerabilities grounded in inequitable access and treatment.

RACE, CULTURAL IDENTITY, AND GLOBAL RESPONSES TO HIV/AIDS

Sociopolitical constructions frame society’s responses to any epidemic, and people with HIV/AIDS have frequently been blamed for their condition, rather than being viewed in the contexts of marginalization and inequity. For example, the initial categories of “high risk” groups (i.e., gay men, Haitians, Africans, sex workers) obscured the sociopolitical constructions of HIV. Early responses to AIDS were crippled by a lack of knowledge about the sociocultural context of the lives of historically oppressed people, including an understanding of how structural impediments rooted in institutionalized racism often place people in “high risk situations” (Zwi and Cabral 1992) and limit the options people can choose as a means of survival. Among these impediments are poverty, sociopolitical inequity, under-development of education, disparities in health and healthcare, and marginalized and inadequate living conditions. Life choices to avoid HIV infection typically depend on the extent to which individuals have access to, and personal agency to obtain, crucial societal resources such as food, shelter, safety, money, education, and appropriate mental and physical health care.

Further, negative stereotyping and devaluing one’s group can lead to a weakening of self-regard and group pride, and can express itself in depression, despair, and self-abuse. Substance abuse, for instance, has been linked to deteriorating communities and hopelessness. In addition, in-group horizontal oppression often translates into the imposition of stigma, sexism, heterosexism, and oppression against less-empowered members, such as women and children, homosexuals, and other HIV infected persons. These internal group dynamics can, in turn, create added vulnerability to HIV infection. Further, the extent to which people of African descent are affected by a distrust of whites and the notion that Eurocentric health information is untrustworthy constitutes another hindrance. This distrust can foster conspiracy theories (i.e., AIDS is a manmade virus that is being

employed against blacks) as a way to make meaning of the disease and tragedy when accurate information is missing. Lack of information and educational disparities also remain a major barrier. For example, in Botswana where the HIV prevalence rate is 24.1 percent, only one in ten survey participant knew three ways of preventing sexual transmission of HIV (UNAIDS 2006).

HIV/AIDS researchers and policymakers have only recently acknowledged the ways in which early responses failed to adequately address the needs of people of African descent. Nowhere has the slow response to address HIV transmission and treatment been more controversial than in South Africa where President Mbeki persistently questioned, rather than taking action against, the startling HIV infection rates and projections. Steven Robins (2004) notes that while there is a need to avoid the construction of AIDS as a “black disease,” the government’s slow response along with popularly held AIDS myths, stigma, and shame created a sense of denial among the general population as well as policymakers and politicians. Former South African president Nelson Mandela’s 2005 announcement that his son died of AIDS sent a strong message about breaking down barriers surrounding the disease’s public stigma and putting pressure on the government to take prevention and treatment efforts seriously. At the 2006 International AIDS Conference in Toronto, the South African government faced severe criticism about its policies encouraging traditional remedies such as beetroot and garlic over antiretroviral drugs. While there has been some treatment progress, less than 20 percent of the almost one million South Africans in need of antiretroviral treatment were receiving it in 2005 (UNAIDS 2006).

Advances in tackling HIV/AIDS around the world can occur through culturally congruent programs that address structural and cultural forces and the daily realities of people who contend with racial oppression. For example, despite poverty, war, and social disruption, Uganda’s political leadership declared AIDS a national priority as early as 1986 and responded swiftly with educational programs backed by the participation of traditional religious and community leaders and prevention strategies that were integrated with media, popular culture, the arts, and school systems (Irwin, Millen, and Fallows 2003). As a result, while HIV infection rates rose sharply in late 1990s in many other African countries, Uganda saw a steep decline in HIV prevalence during the mid and late 1990s.

Brazil is noted for its universal free access to antiretroviral therapies that has nearly halved AIDS-related deaths. However, in 2005 leaders of Brazil’s AIDS Program acknowledged that racism is an additional factor in HIV vulnerability, pointing to new statistics that AIDS among people of African descent was on the rise. The ministry launched the “AIDS is RACISM” campaign to encourage more blacks to seek information on HIV/AIDS (Hay 2005). Similarly, in the United States, despite treatment advances in antiretroviral medications that can allow people to live with HIV as a chronic illness, blacks have not realized the same benefits. Black Americans account for more AIDS-related deaths than any other racial/ethnic group and blacks with HIV/AIDS face greater barriers to treatment, including lack of transportation and health insurance. In his noteworthy 1989 essay “AIDS in Blackface,” Harlon Dalton questioned how much whites would commit to sociopolitical action toward eradicating AIDS, a disease of the most politically weak and negatively socially constructed target population. Indeed, concern is mounting that as the disease has shifted away from whites to blacks, the general public has become less concerned and alarmed by the epidemic (Jaffe 2004).

Despite the fact that AIDS is a preventable and treatable disease, racism continues to play a strong force in structural impediments to effective prevention and intervention among African decent people worldwide. On a global scale, recent progress has been made through UNAIDS toward building a renewed international response to the HIV/AIDS epidemic; however, the path of progress remains unclear. Yet, it is clear that the health of people of African descent is inextricably tied to the broader struggles of equity and social justice in health, education, and social welfare. Therefore, organizations such as the Global AIDS Alliance, an organization dedicated to mobilizing the political will and financial resources needed to slow, and ultimately stop, the global AIDS crisis and reduce its impact on poor people and poor countries are of vital importance as a unified voice in continuing to focus attention on responsible and equitable treatment and global AIDS policies.

SEE ALSO Brazilian Racial Formations; Caribbean Racial Formations; Diseases, Racial; Haitian Racial Formations; Medical Racism; Social Problems; South African Racial Formations; Transnationalism; United Kingdom Racial Formations.

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Dorie J. Gilbert