Anthropology and the Study of AIDS-stages

FOUR PERSPECTIVES OF ANTHROPOLOGY & AIDS: (Ramin 2018)

1.       Anthropologists as Handmaidens: The Biomedical Paradigm;

2.       Anthropologists as Cultural Experts: The Community Paradigm;

3.       Anthropologists as Political Economists: The Structural Violence Paradigm;

4.       The Future: An Anthropological Synthesis.

During the Handmaiden period, anthropologists supported biomedical research without challenging the traditional public health approach. This early paradigm was characterized by a heavily biomedical emphasis and a largely individualistic bias in understanding HIV/AIDS.

In the Cultural Expert phase, there was a move away from individual-centric understandings of the epidemic. By the late 1980s it had become clear that a far more complex set of social, structural, and cultural factors mediate the structure of risk in every population group, and that the dynamics of individual psychology could not be expected to fully explain changes in sexual conduct without taking these broader issues into account. During the early 1990s, there was a growing focus on the interpretation of cultural meanings as central to a fuller understanding of both the sexual transmission of HIV/AIDS in different social settings and the potential to respond to HIV/AIDS through the design of more culturally appropriate prevention programs.

In the Political Economist phase, anthropological literature on HIV/AIDS began to increasingly focus on the linkages between local sociocultural processes that create risk of infection and global political economy. Farmer, a central figure in the structural violence school, is vituperatively critical of the earlier anthropological emphasis on cultural phenomena at the expense of political economy. He attributes these omissions of the structural and economic causes of HIV/AIDS transmission to “the ways in which anthropology ‘makes it object’”. Farmer recounts that

Animal sacrifice, zoophilia, ritualized homosexuality, scarification, and ritual beliefs all figure prominently in the early anthropology of AIDS. The only problem was that none of this had any demonstrable relevance to HIV transmission or AIDS outcomes and claims to the contrary were eventually revealed to be mistaken.

The HIV/AIDS epidemic, Farmer argues, requires broad biosocial approaches emphasizing structural forces such as racism, sexism and inequality, of which structural violence is the pre-eminent model.

·         societies are shaped by large-scale social forces such as racism, sexism, political violence, poverty, and other social inequalities that are rooted in historical and economic processes.

·         These forces “sculpt the distribution and outcome of HIV/AIDS”.

o   consider Schoepf’s observation that one consequence of the economic crisis of the 1980s was a proliferation of multiple partner strategies, as poverty forced women to exchange sexual favors for financial support. With the onset of AIDS, “what once appeared to be a survival strategy has been transformed into a death strategy” as “[m]acrolevel crisis generates conditions for microlevel dislocation”  

·         “fundamentally social forces and processes come to be embodied as biological events” (Farmer).

·         Problem it is “commonplace for HIV/AIDS program managers to acknowledge poverty as a causative factor, but to then say that ‘poverty’ is beyond the scope of their programs” (Castro).

·         Policy proposal: poverty reduction should be our central goal.

·         Weakness in perspective: The whole of anthropology, however, cannot focus on poverty reduction, as that would be poor use of anthropology’s comparative advantage.

SEXUALITY AND HIV/AIDS

At the outset of the epidemic and even into the 1990s, the non-anthropological literature on HIV/AIDS contained sweeping statements about a special ‘African sexuality,’ A common theme in early HIV/AIDS literature posited that the spread of the AIDS epidemic in sub-Saharan Africa was related to multi-partner sexual relations.

·         Anthropologists were employed to explain this hypothesis. Some early studies reported that sexuality outside of marriage is not disapproved of strongly in certain African societies.

·         Emphasis of studies was on individual agency, the notion that individuals are able to make free and unconstrained decisions regarding their sexual behavior.

·         With the rise of the structural violence paradigm, it has become more widely espoused that, as with all behavior, not just cultural, but also structural, political, and economic factors shape sexual experience to a far greater extent than has previously been understood.

CONCEPTUALIZATIONS OF RISK GROUPS

World Development Report 1993 expressed mainstream public health thinking by arguing that “high-risk groups may include sex workers, migrants, members of the military, truck drivers, and drug users who share needles” (Collins).

·         Epidemiological research was criticized for creating “scapegoated ‘risk groups’”.

·         Critique: over-emphasizing symptoms, with depersonalized ‘seropositives’ which are seen to be typically ‘prostitutes’ or ‘promiscuous people’, members of so-called ‘high risk groups,’ or ‘core transmitters,’ or ‘control populations,’ all epidemiological equivalents, linked to ‘reservoirs of infection’”.

·         Schoepf and others argue that “there are no empirically bounded ‘risk groups’”, it is instead the behavior of unprotected sex. shifting the debate to the more useful concepts of ‘vulnerable groups’ and ‘risk behaviors,’

·         everyone is vulnerable to infection.

·         UNAIDS argues that “HIV/AIDS epidemics in many countries are concentrated in specific populations that are often marginalized and vulnerable to a broad range of health and psychosocial difficulties apart from, or in addition to, HIV/AIDS”.

·         implication for prevention strategies: “AIDS thrives on exclusion … including vulnerable people in all available responses is a way of increasing society’s total resistance to the epidemic” (UNAIDS).

GENDER AND HIV/AIDS

As with all ‘high risk groups,’ women were implicitly blamed by the traditional understanding of the epidemic for spreading the disease:

·         In Costa Rica, prostitutes are “portrayed as the vectors, rather than agents/subjects/victims of disease”.

·         In Northern Tanzania, (Dilger)it is believed that women, whether married or unmarried, are ‘greedy’ for money and, therefore, have fast-changing sexual relations that can result in disease transmission.

·         Both the ‘promiscuity’ and ‘vulnerability’ of female sex workers have been singled out.

·         Anthropological studies indicate that women, in general, are relatively powerless in sexual negotiations with men.

·         Risk situations are omnipresent for women. In cultures where AIDS is a heterosexual problem, the risks for young women increased as AIDS consciousness spread and men began to seek very young partners whom they assumed to be free of infection (ironically).

·         Rather than seeing women as vectors, a structural violence perspective allowed us to further understand their deep vulnerability due to economic, social and physical factors.

·         Women often lack the agency to escape their vulnerability, predominantly because they are poor. It is poor women who are most susceptible to HIV infections, for gender alone does not define risk (UNAIDS).

BEHAVIOR CHANGES AND STRATEGIES

Prevention/education programs need to take account of traditional belief and value systems, as well as popular mythologies that circulate amongst the population. Anthropologists have helped ensure that education campaigns are, as far as possible, culturally appropriate

·         However, two major behavior-change strategies which had little regard for local cultures have been employed: advocating abstinence/monogamy and promoting condom use.

Knowledge of risk does not necessarily translate into behavior change.

·         In the realm of behavior change, few changes have faced more socio-cultural, economic, political and religious barriers than condom use. UNAIDS declares that “[c]ondoms are key to preventing the spread of HIV/AIDS” (34).

·         Issues of how sexual relations and condom use are negotiated within contexts of poverty, age and gender inequality, and other configurations of power that influence people’s priorities and constrain their choices.

o   Lyons identified attitudes towards condom use in Uganda as ranging from ‘condoms are not African,’ ‘condoms will promote promiscuity and moral lassitude,’ ‘condoms are a ploy to control our population size,’ ‘condoms kill women,’ ‘condoms are evil’ to ‘condoms will hinder the reconstruction of Uganda’”.

o   Setel observed that in many cultures, for many men and women, “the very definition of sex was to ejaculate into a women or to receive a man’s sperm; using a condom was said to be ‘dirtying oneself’”.

o   great importance to the notion of flesh-to-flesh sex, citing condoms for removing intimacy.

o   (Smith) “[m]any young people told me that suggesting condom use as protection from HIV/AIDS would be very difficult because it would imply either that one suspected one’s partner was a carrier (or the kind of immoral person who could be a carrier) or that one’s own sexual behavior was sordid and risky”.

·         Risk-taking behavior is not solely an individual matter: it is caused ultimately by social and economic factors, and “influencing the underlying causes of the epidemic will do much more to control the spread of HIV infection than the best education or counselling programs”.

·         A number of anthropologists have recognized that the ultimate barrier to condom use is poverty. This is the case not only because of the direct costs of condoms, but because of the broader culture of education, risk-taking and self-preservation.