Kimberly Vrudny

Archive for the ‘Public Health’ Category

AIDS Denialism

In AIDS Denialism, HIV/AIDS, Public Health, South Africa, Structural Drivers of the Pandemic on August 11, 2010 at 3:00 am

Denialists and Conspiracists

AIDS denialists deny that the human immunodeficiency virus (HIV) is the cause of acquired immune deficiency syndrome (AIDS). While some reject the very existence of HIV by perpetuating the myth that the virus has never been isolated, others promulgate the idea, following Peter Duesberg, a professor of Molecular and Cell Biology at the University of California, Berkeley, that HIV exists but is a harmless passenger virus rather than the cause of AIDS. Another group believes that researchers created HIV in a laboratory with the aim of using it as a biological weapon against people of African descent. Still another group claims that pharmaceutical companies created AIDS hysteria in order to turn a profit. That these views are opposed to scientific consensus is of marginal consequence; each view has acquired a following. Although the effectiveness of the anti-retroviral treatments has caused a large number of former dissidents and denialists to change their opinion, myths about HIV/AIDS continue to spread, mostly online, but also by means of misleading films.

The fact that HIV causes AIDS is considered scientifically conclusive. Fulfilling all three of Koch’s postulates, which serve as kind of a “litmus test” for determining the cause of any epidemic disease since the nineteenth century, HIV has been shown conclusively to be the cause of AIDS. According to a helpful article published by the National Institute of Allergy and Infectious Diseases, these postulates pertain to epidemiological association, isolation, and transmission pathogenesis. “With regard to postulate #1, numerous studies from around the world show that virtually all AIDS patients are HIV-seropositive; that is they carry antibodies that indicate HIV infection. With regard to postulate #2, modern culture techniques have allowed the isolation of HIV in virtually all AIDS patients, as well as in almost all HIV-seropositive individuals with both early- and late-stage disease. In addition, the polymerase chain (PCR) and other sophisticated molecular techniques have enabled researchers to document the presence of HIV genes in virtually all patients with AIDS, as well as in individuals in earlier stages of HIV disease. Postulate #3 has been fulfilled in tragic incidents involving three laboratory workers with no other risk factors who have developed AIDS or severe immunosuppression after accidental exposure to concentrated, cloned HIV in the laboratory. In all three cases, HIV was isolated from the infected individual, sequenced and shown to be the infecting strain of virus” (niaid.nih.gov).

Despite scientific evidence that has been supported by medications that have produced something of a “Lazarus effect,” bringing people even with CD4 counts of zero back to health, perpetuation of AIDS denialism is conducted mostly online, though two films have also been created to twist the facts and to mislead people into believing falsely that HIV is not the cause of AIDS. The Other Side of AIDS, a 2004 film by Robin Scoville (the spouse of Christine Maggiore, a prominent AIDS denialist who followed her infant daughter into death in 2008 after contracting several AIDS-related conditions), is predominantly a collection of interviews with people who have refused to take drugs, believing the opinion promulgated by Maggiore and others that drug companies were attempting to make profits off of common illnesses that have afflicted humans for centuries.

More recently, the 2009 film House of Numbers by Brent Leung has been criticized by a review for the New York Times as “willfully ignorant.” It resurrects the denialist’s claims by interviewing legitimate scientists, but then editing their words to promote Leung’s denialist agenda. According to Jeanne Bergman, writing for AIDStruth.org, “Leung in fact got the information he sought from the legitimate scientists, doctors, and advocates he interviewed, but he then edited it out of the film to deceive and confuse viewers. The audience is manipulated to reach the wrong answers.” More poignantly, Bergman goes on to articulate the implications of Leung’s willful ignorance and manipulative technique. “Since Leung leaves his own positions unstated, he dodges accountability for the film’s potential impact—namely, that people might decide that they don’t need to protect themselves or others from being infected with HIV, or that people living with HIV might reject medical care and the medications that could keep them healthy.” AIDSTruth.org has published an article to counter the untruths spread by the film.

To be sure, the history of AIDS denialism is a fascinating case study about how easily and effectively a body of information can be manipulated, challenged, and discredited in the minds of those so predisposed, often in this case by homophobic and racist viewpoints. Tragically, however, its impact has been extremely harmful. In South Africa, for example, people whose lives could have been prolonged by obtaining the medications that were available elsewhere were denied access under the ill-informed presidency of Thabo Mbeki, who subscribed to the denialist position, as did his appointed minister of public health. A Harvard University study recently estimated that 330,000 lives were unnecessarily lost between 2000 and 2005 as a direct result of that country’s government and its position on AIDS.

In agreement with a statement by AIDSTruth.org, my intention here is not to debate denialist claims. “Debating denialists would dignify their dangerous position in a way that is unjustified by the facts about HIV/AIDS. The appropriate way for dissenting scientists to try to persuade other scientists of their views on any scientific subject is by publishing research in the peer-reviewed scientific literature. For many years now, AIDS denialists have been unsuccessful in persuading credible peer-reviewed journals to accept their views on HIV/AIDS, because of their scientific implausibility and factual inaccuracies” (AIDSTruth.org). Such a refutation of denialist claims has been conducted well, and this work is widely available online.

Rather, here I would like simply to direct people to some websites that are useful when trying to grasp the harmful impact of AIDS denialism.

To contrast the two positions, visit: AIDSTruth.org (one site promoting sound scientific approaches to HIV/AIDS), and VirusMyth.com (one site promoting unsound and unscientific claims in relation to HIV/AIDS).

To read arguments against each claim, one by one, I recommend articles published by AIDSTruth.org, the Treatment Action Campaign, and Aegis. Nicoli Nattrass’s article “AIDS Denialism vs. Science” is also thorough and instructive.

To understand the emergence, biology, and history of HIV/AIDS, several sites are beneficial, including one from the National Institute of Allergy and Infectious Diseases, the AIDS Education and Global Information System, and Tibotec, a pharmaceutical research and development company specializing in antiretroviral therapies. NOVA and Frontline, too, have broadcast high-quality programs in relation to HIV/AIDS. The Body and Avert also publish reliable information about HIV/AIDS.

Inequitable Access to Healthcare

In Health Care, HIV/AIDS, Public Health, South Africa, Structural Drivers of the Pandemic on August 11, 2010 at 2:30 am

1400 a Day

Despite the election of a president who is more astute in relation to the HIV/AIDS epidemic in his own country of South Africa than his predecessor, global funding to make medicines to treat an HIV infection widely available, and a network of community health clinics and NGOs working to distribute information about prevention and treatment of HIV/AIDS, 1400 people daily become newly infected with HIV in South Africa. These account for nearly 20% of the estimated 7,400 new infections occurring daily worldwide. Likewise, the actual number of deaths related to HIV holds steady at about 1000 a day in South Africa, again accounting for about 20% of the 5,500 people dying daily worldwide from complications arising from an infection.

Although South Africa is among the most severely affected countries in the world by this pandemic, only about a third of those testing positive in South Africa are accessing the antiretroviral therapies (ARVs) that can prevent the virus from multiplying, thereby restoring the immune system to healthy levels. The reasons for this are complicated, as 30/30 is attempting to document. In addition to the social and structural complexities that have been mentioned in this collection of essays, there are a host of complications around access to healthcare in South Africa. During apartheid, for example, the government focused on the development of providing primary care to the public through a nationwide system of hospitals, leaving the masses living in townships with little access to a network of quality care. Under the new government, community health care centers like Inzame Zabantu are being built and are increasingly providing access to primary care in impoverished communities, but the patient load at these clinics is astoundingly high, and clinics are still inaccessible to tens of thousands of people. Government grants are making it possible for people to access ARVs, but the odds are still stacked against the poor. Drugs are accessible to those who do come forward to test, who live near a community health center, who test positive, who return to take a second test to find their CD4 counts, whose CD4 counts measure less than 200, who navigate the application for a government grant, who wait for a decision in relation to their application, and who qualify for assistance. Moreover, the effectiveness of treatment relies on consistency and good nutrition. The drugs are not effective if taken on an empty stomach. Since most people on the drugs are living on about $1.75 a day, hunger remains a serious issue. Finally, despite the work of NGOs to blanket the community with information about HIV/AIDS, even in the post-Mbeki situation, the stigmatizing effects of an HIV-positive diagnosis continue to prevent people from seeking medical attention.

To add yet another layer of complexity to this difficult situation, information about the virus is received tentatively by a culture that is torn between African tradition and European ways. The denialism of Thabo Mbeki only fueled an already latent distrust of Western medicine in many African minds. Rumors of the virus coming in the needles of the “white man,” promises of herbal cures by medicine men, and traditional ritual treatments continue to compete for the allegiance of those struggling to survive in communities where the unemployment rate often hovers around 70%. Medical aid workers widely note that, despite testimonies of people “coming back to life” once on ARV treatments, there is a continuing resistance, especially among men, to seek treatment and live.

These realities and their attending statistics are inherently alarming. In trying to process them himself, Jonny Steinberg, a South African journalist, attempted to understand the situation to a greater extent than the newspapers and academic papers were able to provide. For eighteen months, he periodically visited a village in the Eastern Cape Province of South Africa in an effort to understand the choices of a man he calls Sizwe Magadla. Despite a high risk of having been infected, when Steinberg met him, Sizwe adamantly refused to test for HIV. The result of Steinberg’s investigation is published in a masterwork of literary journalism entitled Siswe’s Test: A Young Man’s Journey through Africa’s AIDS Epidemic. In it, Steinberg explores with tremendous insight what is often at stake for men in still traditional villages as they confront this modern-day disaster, navigating his way through the “architecture of shame” that surrounds the illness, the struggle to lift oneself out of poverty and the reality of envy which threatens to pull the successful back in, and the constant push and pull of cultures as traditional African beliefs and practices encounter, accommodate, and resist European beliefs and practices. Indeed, it is Steinberg’s navigation of these competing beliefs, and what is at stake in concession, that is pertinent here, for they point to a terrible albeit unforeseen complication that is the legacy of colonization in Africa and apartheid law in South Africa: the understandable even if catastrophic mistrust of white “man” and “his” needles.

Steinberg recounts a telling conversation he had with Sizwe, who shares with him a “black people’s secret”: ‘Some people believe that the whites have developed a cure for AIDS,” Sizwe told Steinberg, ‘but that they are holding it back. They are waiting for enough black people to die so that when we all vote in an election the whites will win and F. W. de Klerk will be the president again’ (138). Sizwe’s own distrust of the medicine of white men was corroborated by Kate MaMarrandi, a community health-care worker also interviewed by Steinberg in the Eastern Cape. She told Steinberg,

‘In 2003, Dr. Hermann came. He started to tell us he has got help—ARVs. Nobody believed him. Some said this one has come to kill the people. Even the doctors didn’t believe him. People thought he had come to destroy the people with his needle and his blood test. They believed AIDS was caused by politics, by white people.’

Steinberg reflects on these disclosures, writing, “For all our talk on the causes of AIDS, it had taken this trip . . . to out [Sizwe’s] strongest suspicion about the origin of the epidemic. It was brewed, not by witches and their demons, but in the vividly imagined laboratories of Western science” (146). Steinberg’s book goes on to try to understand this mistrust of Western medicine. First, he turns to tales of the ordeals experienced by Dr. Hermann Reuter, the doctor for the MSF (Medicines Sans Frontieres / Doctors Without Borders) who set up a clinic to bring ARVs to Lusikisiki, the region of the Eastern Cape where Steinberg’s story about Sizwe unfolds. He was told,

‘When [Hermann] arrived, there was a big crowd outside the clinic. Many were not sick; they had come to see Hermann. They said they had heard that here is a doctor who has come to inject AIDS into people. They came to see what he looks like. When he came out, they all stared at him, but no one said anything.’ . . . . During his early days in Lusikisiki, he had on two occasions arrived to packed clinic waiting rooms; some of the people assembled there had not come to be tested but to ask him to explain what was in his needle. He had had to stand in front of his audience and convince them that he had not come there to kill them (147-148).

Ultimately, Hermann won the trust of many of Lusikisiki’s residents by treating patients with ARVS, which rapidly put life back into those whose immune systems were shutting down, and by offering scientific explanations for what was happening in the bodies of his patients in an attempt to override any association of the onset of illness with the needle that pierced the skin to draw blood. Hermann also allowed his own blood to be drawn publicly, in order to dispel fear (156).

The fears in the community about which Steinberg writes are fears to which I, too, have been witness in my work in relation to HIV/AIDS—both in Minneapolis, and in South Africa. In 2008, I attended a service-learning conference sponsored by the National Youth Leadership Council in Minneapolis. A luncheon discussion featured the work of Dr. James Hildreth, the Director of Meharry Medical College Center for AIDS Health Disparities Research and Professor in the Department of Internal Medicine, who was sharing advances in scientific understanding of how the virus was transmitted, and of how it might be stopped pharmacologically. I sat at a table where the pre-lecture discussion ultimately turned to the origin of HIV/AIDS, and several attendees at my table disclosed how they very much believed HIV was concocted in a laboratory in the bowels of the CIA. When asked about this during the Q&A after his talk, Dr. Hildreth, having credibility in the African American community, said in no uncertain terms that HIV predates the technology that would have been required to develop such a virus as HIV—and that this is indeed a vicious rumor that must be stopped for the health of the disproportionately high number of people in the African American community now testing positive for the virus. It is a rumor that persists, nonetheless, both in America and in Africa. This became evident to me again in 2009. While facilitating a refresher course in systematic theology for pastors working in the townships outside of Cape Town, South Africa, we welcomed a guest from the ministry of health. She quite openly admitted that she believed that “white men” had devised HIV in order to bring harm to Africans.

Although it is easy to dismiss the persistence of the rumors about HIV coming with malicious intent from the laboratories of Western science as superstitious and ignorant, it is important to acknowledge episodes in history that contribute to the perpetuation of such “dis-ease.” In South Africa, such episodes are not in the historical annals that students study as some remote lesson from the past, illustrated by pictures of murky liquids percolating in glass flasks and printed on glossy textbook pages in sepia tone, but rather these are stories that occupy the modern-day press. Wouter Basson was on trial in 1999 for allegedly developing biological weapons, including pathogens, for the apartheid government. Although amnesty and an acquittal prevented his arrest, he was also widely believed to have provided lethal toxins to be used against African National Congress (ANC) activists whose resistance the apartheid government so feared. He continues to face legal proceedings for crimes against humanity.

Of course, South Africa is not alone in its history of mistreatment of people with dark skin pigmentation. The Tuskegee syphilis experiment is perhaps the most infamous example in the United States, when researchers, between 1932 and 1972, undertook to study the progression of syphilis in people of African descent. Penicillin had become the standard treatment for syphilis by 1947, but in order to continue their observations, the scientists for the U.S. Public Health Service prevented nearly 400 African American subjects from gaining access to the drug that could have treated their illness. In addition to this notorious example, Harriet Washington has provided many other episodes in her book, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. Among them are these:

In 1945, Ebb Cade, an African American trucker being treated for injuries received in an accident in Tennessee, was surreptitiously placed without his consent into a radiation experiment sponsored by the U.S. Atomic Energy Commission. Black Floridians were deliberately exposed to swarms of mosquitoes carrying yellow fever and other diseases in experiments conducted by the Army and the CIA in the early 1950s. Throughout the 1950s and ’60s, black inmates at Philadelphia’s Holmesburg Prison were used as research subjects by a University of Pennsylvania dermatologist testing pharmaceuticals and personal hygiene products; some of these subjects report pain and disfiguration even now. During the 1960s and ’70s, black boys were subjected to sometimes paralyzing neurosurgery by a University of Mississippi researcher who believed brain pathology to be the root of the children’s supposed hyperactive behavior. In the 1990s, African American youths in New York were injected with Fenfluramine—half of the deadly, discontinued weight loss drug Fen-Phen—by Columbia researchers investigating a hypothesis about the genetic origins of violence (Nelson).

In the long and winding path that has been the history of public response to HIV/AIDS, both in South Africa and globally, the world community faces another fork in the road. In one direction, there is death. In his recent presentation to South Africa’s parliament, the health minister spoke of his fear that the population of South Africa would soon begin to decrease as the numbers of deaths in his country threaten to surpass the rate at which South African babies are born (Kgosana). In the other direction, there is life. The situation truly is this stark. The reversal of the trend toward a decreasing population largely attributable to HIV/AIDS depends on a successful campaign to make drugs accessible to the two-thirds of the positive population still going without treatment. The issues that attend access to these life-saving and life-prolonging medications, as this essay has shown, are complicated to be sure, for in this multiply wounded society there are reservoirs of resistance that betray the naïveté of even the most benevolent attempts to provide treatment. According to projections through 2012, the lives of 1.2 million people in South Africa hang in the balance, dependent upon the rate at which the government is able to scale up access to ARV treatment (Walensky, et. al.).

Such a campaign in the direction of life is going to require the unified effort of government, academic, and religious sectors to shift the paradigm in which response to HIV/AIDS is conceived and conducted. This shifting of paradigm is a service to which 30/30 attempts to contribute, such that the direction we take at this critical juncture, rather than in favor of death, celebrates life.

Mistreatment of Vulnerable Persons

In Elderly, HIV/AIDS, Orphans, Public Health, South Africa, Structural Drivers of the Pandemic on August 11, 2010 at 2:15 am

Elders and Orphans

In 1993, the Henan provincial health council in China decided to establish blood collection networks in order to supply blood plasma to biomedical companies, who used it in the manufacture of medicine. More than 200 stations were established throughout the province. However, an unknown number of illegal stations also operated throughout much of the rest of the decade. Peasants were paid the equivalent of $5.00 (U.S.) for 400cc of blood. The Japan Times reported that illegal stations “collected at one time from a number of donors who share[d] the same blood type. Afterward, the blood [was] pooled, the components needed for medical use [were] separated and the remaining blood [was] divided up and re-infused into the original donors. This unsafe procedure expose[d] people to the blood of six to 12 other donors every time they donate[d], facilitating the spread of not only HIV but hepatitis and other serious diseases” (Chan). The practice was banned in 1998, but official action came too late. In villages like Wenlou and Donghu, infection prevalence rates were measured at one time to be as high as 65% and 80% respectively. According to Xie Yan, a woman who tested positive for HIV and who was interviewed by The New York Times in 2002, “‘I try not to think about myself since I know I won’t be cured,’ she said. ‘But at night I can’t sleep—I have nightmares and wild thoughts—worrying about what will happen to the [children]” (Rosenthal).

Xie Yan’s question is one that has haunted leaders in HIV/AIDS response for over a generation. What happens when parents die, leaving behind millions of orphans?

According to The Orphan Foundation, there are more than 143 million orphans in the world today—a number that far surpasses the expectation announced a decade ago that there would be 100 million orphans in the world by 2010. When combined with 20 million children who have been “displaced” in the world, the number of orphaned and displaced children number more than the entire population of Russia. Fewer than 50% of these will live to see their twentieth birthday, and half of those that do will end up working in organized crime or sex work, or will become addicted to drugs. In many countries of the world, orphaned and homeless children are recruited as child soldiers to fight in wars and in militia movements.

It is not an overstatement therefore to say that the impact of HIV/AIDS on children has been profound. In 2004, the United Nations published a volume called The Impact of AIDS. The volume dedicates chapters to the impact of AIDS on demographics, households, firms, agriculture, education, the health sector and economic growth. Taken collectively, the report paints a sobering picture about the impact of a pandemic that has to date directly affected 58 million people, .008% of the world’s current population of 6.8 billion, with ripples that emanate outward, affecting a range of enterprises, from the world’s ability to conduct business to its production of the food supply.

Because the numbers are so large, it is difficult to process the staggering statistics that fill page after page of the booklet. Unlike most of the chapters, however, the article on the impact of AIDS on households is immediately jarring, so basic are its observations. The authors write, “The HIV/AIDS epidemic threatens the social fabric of the most affected countries. . . . The evidence shows that the AIDS epidemic is having severe effects on households” (39). The report goes on to outline “three kinds of economic impacts,” as well as four social implications (39). The economic impacts include loss of income, higher household medical expenditures, and indirect costs related to caregiving:

The first is the loss of the income of the family member, in particular if he or she is the breadwinner. The second impact is the increase in household expenditures to cover the medical costs. The third impact is the indirect cost resulting from the absenteeism of members of the family from work or school to care for the AIDS patient. . . . If a household member dies from the disease, the funeral, mourning and other costs may also add to the burden of the household (39).

There are also four social implications that the book outlines, including “change in household composition, with the gradual disappearance of the parental generation and children being cared for by grandparents and other relatives . . . [or] an increase in one-generation households headed by the older children” (39). In addition, the book outlines how many children withdraw from school as the result of an infection in the household, how many households enter into poverty, and how welfare is correlated to the willingness of the community toward helping households in need (39-40).

All of these implications of high HIV/AIDS prevalence rates are painfully evident today in South Africa, among other places. Grandparents—grandmothers, in particular—are caring for their grandchildren, even in the midst of mourning over the loss of their own children. Participants 19, 20, and 21 in “30 Years / 30 Lives” all share stories of children acquiring an infection, leaving grandchildren behind for them to look after. Others, like “Participant 04” in “30 Years / 30 Lives” who opened her shack to twelve children not biologically her own, are stepping up to care for children without family to look after them. She recognized an enormous need in her community, and she refused to turn away.

The UN document on The Impact of AIDS on households goes on to discuss this impact of AIDS on older persons. “Recent survey data . . . confirm that orphaned children are more likely to reside with grandparents than with other relatives or non-relatives” (45):

[O]ne effect of the disease is to change the structure and composition of households. In many affected regions in developing countries, more and more older persons are taking care of AIDS orphans. Older parents may also provide end-stage care to their adult children afflicted with AIDS. A study conducted in Zimbabwe showed that older caregivers were under serious financial, physical, and emotional stress owing to their care-giving responsibilities. . . . The AIDS epidemic not only puts more stress on older persons, but it also impoverishes them at the very same time they themselves may need to be taken care of. . . . [S]urvey data confirm that substantial proportions of the older population of many countries are living in skipped-generation households and that such households tend to score lower than average on an index measuring quality of housing and household amenities (45).

The three stories that participants in “30 Years / 30 Lives” shared with me upon meeting them at Ikamva Labantu, an organization providing integrated care for seniors and orphans, confirm these findings. On a tear-filled morning in Cape Town, I sat down with all three. One by one, they wrote their stories into the journal, reading their own entry aloud to us at the table when they were finished. We wept for the daughters they had lost and for whom they were providing care—and they spoke of caring for the little ones their daughters left behind.

But the stories grow more complex even still.

In 2006, I visited with a director of a senior center in one of the townships outside of Cape Town. When I asked her about the impact of AIDS in her community, she explained how senior citizens, in the post-apartheid situation, often live off of a governmental pension check equivalent to about $100/month. She spoke especially poignantly about how many young adults in their late teens and twenties, experiencing hopelessness from grinding poverty, inadequate education, and joblessness, are becoming addicted to drugs. And then she spoke about how these two disparate observations about seniors and their pension checks and young adults and their drug addictions are connected. One of her seniors, she told us, leaning in and speaking softly, had been locked into the public toilet facility in her community. After she stole her mother’s monthly pension check, the drug-addicted daughter used the money to buy drugs.

Jonny Steinberg, in his book Sizwe’s Test, recounts a similar story. Sizwe, the young man from the Eastern Cape Province in South Africa who Steinberg shadows for a period of eighteen months, approaches an elderly woman on a late Sunday afternoon. The woman is negotiating with a taxi driver to take her out of the village of Ithanga, and Sizwe bids her farewell, insisting she come back often.

‘Who is the old woman,’ [Steinberg] ask[s].

‘She is a customer of mine,’ [Sizwe answers]. ‘She has been coming to drink since the day I opened.’

‘Why is she leaving?’

‘Because of the gangsters. She has been robbed twice.’

He points to a hilltop on our right. It is among the highest in the village and is particularly steep. A solitary round hut sits incongruously near the summit. It appears as if its inhabitants might open their front door, step outside, and roll down the hill.

‘That is her home. It is very isolated at night. Twice, on the night after pension day, very late, maybe one in the morning, they have knocked on her door, and when she opened they pointed a gun at her. After the second time, she said enough is enough. She has gone to live with relatives. . . .’

To be sure, the HIV/AIDS pandemic has focused the spotlight on complexities of social safety nets. Monthly pension checks, intended to provide food and shelter for the elderly, do not necessarily secure the future, but endanger it. Access to antiretroviral therapy, intended to prolong lives so as to limit the number of vulnerable children left without parents, is threatened by constriction of the global economy, drying up the financial wells from which the treatments have been funded. When access to the drugs that enabled a Lazarus-effect that encouraged more and more to be tested and to be enrolled for treatment is reversed, more and more lives will be lost. Children will again be made vulnerable. Seniors will be expected to care for them. And not everyone throughout the world was able to afford access in the first place.

“Perplexity is the beginning of knowledge.” —Kahlil Gibran

“To know and not to do is not to know.” —Ancient Proverb

Poverty and Hunger

In HIV/AIDS, Poverty, Public Health, Structural Drivers of the Pandemic, United States on August 11, 2010 at 1:45 am

Interruptive 96%

If epidemiologists are correct, 33 million people throughout the world are living with an HIV/AIDS infection today. 96% of these live in the “developing” world. This is a stunning statistic. 96% is a number that ought to interrupt those of us with financial means to question how it is that the vast majority of those contracting this disease are living in conditions of poverty. 96% means that about 31,680,000 people are living in places with challenged economic, educational, and health care systems. In other words, presumably only about 4% have some (even if modest) access to decent care, while the rest presumably do not—at least, not without governmental assistance. Another 25 million people have already died from the virus’s devastating impact on the body’s immune system. Why has this virus traveled to the poorest parts of the world?

The statistics are shallow. Like all statistics, they conceal as much as, if not more than, they reveal. Behind each of these numbers is a man, a woman, a child, a daughter, a son, a mother, a father, a spouse, a partner, a friend. Each one has a name, a heritage, a history. Each one has a story.

But their stories often go without attention, or are left entirely untold, supplanted by an overpowering narrative that edits their own. The dominant story line unfolds to express the view that HIV/AIDS is about individual behaviors. These behaviors, mainly drug use, promiscuous sex, and homosexual relations, mean that the infection (so goes the narrative) is in some way merited, the logical consequence of a foolish choice. The madness of this kind of reasoning needs to be interrupted.

No one deserves HIV/AIDS.

They are called “voiceless.” But people living with HIV/AIDS have voices. It is just that louder, more powerful ones have drowned them out, rendering them silent. These are the voices that shush neighbors in clinic waiting rooms when frightened patients whisper news of an infection, stigmatizing those testing positive. These voices shame those testing positive for having acquired the virus. These voices attempt to justify turning away to other, more “worthy” recipients of dollars.

But the narrative is more involved than we’ve been led to believe, its characters more complex, its plot not so linear. Certainly, individual behaviors play a part in the plot line. But when 96% of those living with the virus are concentrated in the poorest regions of the world, it is insufficient to point only to the individual, and to call for a higher morality. Reducing the rates of HIV/AIDS in the world is also going to require moral accountability in the so called “developed” world that gives shape to world economies. Reducing the numbers of people infected with and affected by HIV/AIDS is going to require dedication to the task of making resources accessible to all, rather than to the advantage of some and to the distinct disadvantage of the rest.

This revised narrative is evident, for example, in a story about a young woman in Thailand by the name of Lek, told by filmmaker Rory Kennedy in her documentary Pandemic: Facing AIDS. When she was raped as a young girl, Lek left her family’s rice farm in order to prevent shame from falling on her father’s name. She later married, but was abandoned after she had given birth to a son. She sent her baby to her parents so that she could go into the city to try to earn a living wage to assist her parents in supporting him. Without an education, her options were limited. She tried tending bar, and ultimately sold sex for money. By the time she was in her mid-twenties, she had contracted HIV/AIDS. Medicines were out of reach financially. The film documents the wasting away of her body, and the agony of her final days without medications even to alleviate the pain.

Paul Farmer, a medical anthropologist who teaches half of the year at Harvard and spends the other half practicing medicine in Haiti, all the while writing books and leading Partners in Health, indicates that this kind of story is more common than most of privilege dare to imagine. People become desperate when resources become more and more scarce, and resources are becoming increasingly scarce in many places throughout the world. Men feel forced to travel hundreds of miles away from home in order to work for months on end. Relatively few, it seems, return home having had no other encounters with women. In some communities in stories that Farmer tells, fathers who accrue high debts are stalked by dealers in the sex trade. Some sell their daughters to pay off debtors, or to feed the younger ones. Women coming of age know the way to financial security in the world is to marry, so they look for available men, not all of whom have been chaste. Uneducated women, also desperate to earn money to buy food to stave off hunger for themselves and for their children, often are vulnerable to human trafficking, or resort to trading sex for money.

In many ways, Farmer confirms, Lek is like the majority of people today contracting HIV/AIDS—people whose choices in life are measured by the degrees of jeopardy they carry according to their social location in relation to gender, ethnic background, economic class, age, orientation, accessibility of healthcare, accessibility of education, immigration status, and so on. However, when people have hope that they will find gainful employment that honors them as human beings, fewer become addicted to drugs. When people have access to an education that promises a place in the work force, fewer are made vulnerable to an infection by traveling hundreds of miles from home, or by trading sex for money. When people form cultures that do not tolerate human trafficking, rates of HIV/AIDS infection drop.

Such stories are often hard to hear. They involve violence far too often, and hopelessness some of the time. In encountering them, a seething but righteous anger begins to boil against the circumstances, not at all accidental, that have led us to the interruptive 96%.

Nevertheless, we must listen to these stories. We must hear them. Because in these stories is the potential to reverse the trajectory of one narrative, and the empowerment of another. In them is the possibility for a new story to unfold,  where fewer and fewer are made vulnerable, because more and more recognize the wisdom of “ubuntu,” that where one is diminished, all are diminished; where one is nurtured, all are nurtured.

“30 Years / 30 Lives” offers another opportunity to listen to stories that otherwise might go unheard—including the voices of those affiliated with Open Arms of Minnesota.

Religious Fundamentalism

In HIV/AIDS, Public Health, Religious Fundamentalism, Shame, South Africa, Stigma, Structural Drivers of the Pandemic on August 11, 2010 at 1:30 am

Deconstructing the Architecture of Shame

South African journalist Jonny Steinberg has been acclaimed for his book Sizwe’s Test: A Young Man’s Journey Through Africa’s AIDS Epidemic, not least of which for insights he provides into the “architecture of shame” that frequently accompanies an HIV/AIDS infection. In order to understand the limits of efforts to make ARVs accessible widely in the country of Steinberg’s birth, over a period of eighteen months Steinberg accompanied Sizwe, a young adult man in his twenties who lives in the Eastern Cape Province of South Africa. Steinberg is curious about why so many South Africans, like Sizwe, refuse to be tested for HIV. In the process of writing the book, Steinberg discloses how the pandemic brought into sharper relief in his own mind a parallel that existed between his privileged white South African upbringing and Sizwe’s own marginalized upbringing within a rural village in the same country. Both men faced the culture’s stigma in relation to HIV/AIDS. After considering the ramifications a positive diagnosis would have on Sizwe’s livelihood even beyond the infection, and after listening to Sizwe’s rationales for so opting, Steinberg dug deeper into his own experience for a framework in which to make sense of Sizwe’s decision. By sharing indiscretions of receptionists and of medical personnel who failed to protect Steinberg’s privacy and who then passed him off to another clinic under the guise of concern, Steinberg constructed in his book what he calls the “architecture of shame,” and the scrutiny under which those who agree to be tested live, regardless of the outcome of the test. Shame is internally present, stigma its external driver. Knowledge of shame is what he shared with Sizwe, along with its accompanying and requisite fear of social ostracization.

At [shame’s] root lie myriad watching, judging eyes that look at one and see a disgusting and gluttonous figure. They are the eyes of others, but one has internalized them. They are strangers’ eyes whose watchfulness is nonetheless experienced in secret on the inside. When one stands in a crowded room and a person shouts ‘HIV,’ the very name and embodiment of one’s shame, the secret opprobrium expressed by the strangers inside heads for the real strangers on the outside like electrons in a force field. You are suddenly struck with the sickening feeling that the contemptuous eyes have always been on the outside; that is their natural home (Steinberg, 293).

In a conversation with Edwin Cameron, a judge in South Africa’s Supreme Court of Appeal, among the first public officials to disclose his status and to advocate for nation-wide accessibility of pharmaceutical treatment, Steinberg records the judge’s reflections in relation to self-contempt and, as such, to shame. “‘I knew my status for eleven years before I started treatment,’ [Cameron] said. ‘During that time, I did not realize that this virus inside me represented an enormous contamination, a sense of self-rejection. I only began to understand these things when I realized that the drugs were working. Once the viral activity had been stopped in my body, I stopped feeling contaminated. . . . There’s a liberation from a sense of self-disentitlement which successful treatment brings’” (Steinberg, 181-182). The tragedy of this statement is that, by shadowing Sizwe for all of those months, Steinberg was studying the limits of the reach of ARVs on a population that, for many reasons, continues to resist white “men” and their needles.

Steinberg and Cameron’s reflections provide three-dimensionality to the concept of stigma, shame’s more public companion. Ervin Goffman, a Canadian sociologist, defined stigma as the process by which the reaction of others spoils normal identity (Erving Goffman, Stigma: Notes on the Management of Spoiled Identity [Prentice-Hall, 1963]). By definition, stigma is “a mark of disgrace associated with a particular circumstance, quality, or person.” Scholars differentiate individual stigma from social stigma, the latter of which is “severe disapproval of personal characteristics or beliefs that are perceived to be against cultural norms.” According to AVERT.com, “AIDS-related stigma and discrimination refers to prejudice, negative attitudes, abuse and maltreatment directed at people living with HIV and AIDS. [This] can result in being shunned by family, peers and the wider community; poor treatment in healthcare and education settings; an erosion of rights; psychological damage; and can negatively affect the success of testing and treatment.” (See the article in full for an excellent overview of the stigma associated with an HIV/AIDS infection athttp://www.avert.org/aidsstigma.htm.)

Although different contexts will express the phenomenon differently, stigma has trailed the virus everywhere it has spread. The nuances in which it is expressed in a culture like ours in Minnesota, at a Catholic University where I teach courses in Christian doctrine, are instructive, for these stigmatizing forces are prevalent even in a climate where it is most uncomely to speak of them. They come to the surface, however, when I require students to participate in service projects related to HIV and AIDS. In doctrine classes, for example, students are required to work several shifts at Open Arms of Minnesota, an organization in the Twin Cities that prepares meals for and delivers meals to people living with HIV/AIDS, ALS, MS, and breast cancer. For some of my students, perhaps a quarter, the reluctance to engage is both rigid and immediate. Even once orientation to the project is complete, when fears about contracting the virus by paper cuts or whatever other ridiculous stories they’ve heard are dispelled, many of my students would prefer to engage in projects for other, it is revealed in class, more “worthy” recipients.

When we discuss this reaction, I ask, “In your mind, what makes people living with HIV/AIDS unworthy of the kind of care and concern we could offer by, say, delivering a meal through the work of Open Arms of Minnesota?” For these students, it always comes down to a judgment about very private behaviors they consider sinful—and which this virus makes public. These perceptions are the very root of the shame and stigma associated with HIV/AIDS and, as such, it is vitally important to investigate them, in order to overcome them. And so something like the following conversation ensues every semester. It is a compilation of numerous exchanges with students across years of teaching and, while the majority of students do not express verbally the attitude of the student depicted below, one cannot help but to sense that those who do speak up represent a fair number of students whose desire to be politically correct prevents them from uttering aloud similar thoughts.

“So,” I begin, “let me see if I am understanding this correctly. Firstly, you are making assumptions that the people to whom you are serving meals are HIV-positive when Open Arms delivers meals also to people who are living with breast cancer, ALS, and MS. Secondly, you are making assumptions about how the people acquired the virus, but regardless it automatically falls into the category of ‘sin.’ Thirdly, you are imposing your own religious views onto the person even though you don’t know if they share your view as their own and, moreover, you are making assumptions that the supposed sin has not been absolved. And, lastly, you are judging that person therefore to be unworthy of your own very valuable service hours. Am I tracking this correctly?”

“Well, basically—yes.”

“And if the people to whom we deliver meals have indeed committed an act that the church considers to be sinful—let’s say they’ve had intercourse outside of marriage—what if they have confessed their sins to a priest and have received absolution?” I go on: “They have received God’s forgiveness, but not yours? Does the recipient of care need to ask for your forgiveness, as well? And what about the person that delivers on Thursday? Shall they seek that care provider’s forgiveness, too? Do you expect them to confess to everyone who comes to the door?”

“I guess not. I never thought about it from their perspective before.”

“My suspicion, though, is that the mere idea of having sexual intercourse outside of marriage doesn’t offend you nearly as much when a sexually transmitted disease isn’t part of the equation.”

“I’m not sure what you mean.”

“The rumor in the quad is that lots of your classmates go to parties on the weekends. More than just a few are probably not going to their bedrooms alone afterwards. Do you shun them in the cafeteria?”

“I’m not the partying type, myself. I don’t shun them. I just hang out with a different crowd.”

“Fair enough.” Stopping for a minute to think about how to redirect the line of argument without losing the point, I say, “But what if one of your classmates were to get sick?”

“What are you asking?”

“If your dorm organized a food service, would you deliver him or her a meal?”

“Sure. Why not?”

“That’s all I’m asking you to do for the clients of Open Arms.”

“That was tricky,” my student says, defensively. “But my classmates aren’t like the people that Open Arms serves.”

“Now you’ve lost me,” I reply. “What do you mean they aren’t like the people that Open Arms serves?”

“C’mon Dr. Vrudny. You know what I mean.”

“I’m afraid I really don’t.”

“Most people who have AIDS in Minnesota are gay.”

“That is statistically true. What is your point?”

“That is my point.”

“Should we not deliver meals to people who are gay?”

My student was silent.

“Because that is what we’re doing. We’re contributing to the vision of Open Arms. They believe that no one who is sick ought to go hungry. Kevin Winge, the executive director of Open Arms always says: ‘It’s about food.’”

My student says nothing.

“Let me ask you this: Did you know that in Minnesota, epidemiologists are watching with great concern the numbers of people in between the ages of 16 and 24 who are becoming infected, because there is a disproportionately high number of new infections in young people, both homosexual and heterosexual?”

“I heard that during the orientation, but I’d forgotten.”

“And did you know that worldwide more than half of people living with HIV/AIDS are women?”

“No. I thought they were mostly gay men.”

“And do you know that many infants and children are living with HIV today, as a result of something they call ‘vertical transmission,’ or mother-to-child transmission?”

“Yes, I know about that. But I thought that was a small number.”

“Worldwide, more than 2 million children are living with HIV/AIDS today. That’s not exactly a small number.”

“Right. It isn’t.”

“There are also about 140 million orphans today, largely due to HIV/AIDS.”

“I can’t even get my head around that number.”

“I know. It is a particularly staggering statistic. That one keeps me up at night.”

“Hmmm,” my student acknowledges, nodding slowly.

“Do you know that many wives who have been loyal to their husbands are infected by the double standards in many cultures that tolerate married men having more than one sexual partner, but not married women?”

My student nods.

“And in places more numerous than I care to number, many people are poor and hungry. They are desperate for money. Women and children are often sold by families, often unaware, into human trafficking rings, or many women sell their bodies for money.”

“That can’t be too many.”

“I wish you were right. But I’m afraid you’re really in error . . . .” My mind trails off to memories of visiting a group of young children in a township in South Africa. The oldest was probably eleven. They told me they wanted to be engineers and doctors when they grew up. Then we drove up the road maybe a half-mile, and got out of the car to talk with a group of young women who were playing net ball. They were all sixteen to eighteen years of age. We asked them how HIV was affecting their community. They told us that they were playing net ball to build skills in sports. They thought maybe if they could make it athletically, they wouldn’t have to sell their bodies in order to survive. I emerge from the township again when I hear my student assert, “Still, if people would be responsible for themselves, infection rates would go down.”

“Yes, yes,” I say, holding my forehead for a minute. “And certainly no one is suggesting that we cease efforts to get information out there about how dangerous it is to have more than one sexual partner. But may I ask you a question?”

“I suppose.”

“Have you ever thought about what your responsibility is in relation to the pandemic? I mean, you’re talking a lot about responsibility. But the responsibility about which you speak seems to be ‘theirs.’ So I’m asking: what is yours?”

“What do you mean? I’m only twenty. I’ve not been infected, and I won’t infect anyone else. I’m a very responsible person.”

“Right, right,” I say, gathering my thoughts. “But I didn’t mean only your responsibility in sexual encounters. What I mean is: what is our collective responsibility as human beings toward people who have been impacted by this public health crisis of the modern day?”

“It isn’t my fault that so many people are getting sick.”

“I’m not suggesting it is your fault. Rather, I’m asking: what is our responsibility in the face of this illness?”

“I didn’t think I had any responsibility at all in relation to a pandemic impacting people half way around the world.”

“As well as here,” I quickly interject. Thinking it is time to share some of my own thinking about responsibility, I say, “I see the world as greatly interconnected. One country’s economy affects another’s. Some are winners in that contest. But the costs are high for the losers.”

“So? What’s your point?”

“So, as a human being, and as a Christian human being, I want to contribute to the creation of a world where the interconnectedness of humanity is honored, where we recognize that if one person goes hungry, we all are deprived.”

“I don’t get it. I’m rarely hungry.”

“How does that make you feel—that you rarely go hungry in a world filled with hunger?”

“Happy that I live here and not there. Grateful for my life. Blessed, even.”

Ignoring the projection of hunger to “over there,” when I know that there is too much hunger here, as well, I say, “‘Blessed’ is a theological word.”

“Yes. I am a Christian.”

“I see.”

“Catholic even.”

“Lovely. . . . So, when you say you are ‘blessed,’ does that mean that God does not bless, say, those who go hungry? So hungry that they are desperate for money? So desperate for money that they sell their body for money in order to buy food and contract HIV as a result? Are they forsaken by God, whereas you are blessed?”

“I never thought about it that way before.”

“I know. I know. It’s okay. I’m just trying to get us to think about all of this in relation to God. It is a theology class, after all.”

“Very clever.”

Pressing on, I say, “So what do you think God wants of us in this situation? To just shrug our shoulders, and to say: ‘too bad.’”

“I suppose not,” my student said, quietly. But I could see there was more. When pressed, my student relents in a whisper, “But my priest has said AIDS is a punishment from God.”

“Do you agree with him?”

“I’m not sure. I try not to think about it.”

“The idea that AIDS is a punishment from God is a fairly easy one to dismiss, you know,” I offer.

“Really?”

“Yes, really. We are taught to think of God as a Father, right?”

“Right.”

“Well, if your earthly Father intentionally exposed you to a virus in order to punish you for whatever you’d done wrong and it killed you, he would be tried for murder.”

“I follow you.”

“So, we arrest a human Father for murder for this kind of behavior, but we worship and praise God for the same behavior on a massive scale?”

“But he’s God.”

“Yes?”

“Nevermind.”

After stopping for a moment to let the previous analogy soak in, I continue. “The other side of the argument that often comes is that God sends HIV/AIDS in order to test us—to see if we’ll respond compassionately.”

“I’ve heard that, too.”

“Again, to use a parenting analogy: Let’s say that I have two kids. And let’s say that I shoot the first one to see if the second one will respond compassionately.”

“I see where you’re heading. You’re going to be carted off to jail, again.”

“Exactly.”

“I understand. But I still don’t know why God sends HIV/AIDS.”

“Are we sure that God sends HIV/AIDS into the world? Maybe it is just a natural thing—like a fungus that kills a beautiful tree, only this virus happens to kill humans?”

I was happy that my student was still hanging in there, and still listening. But it was time to bring it around to my main point, so I say, “Let me ask you something your generation seems to be asking yourselves quite often these days: What would Jesus do?”

“How am I supposed to know?”

“Fair enough. But what do you know about him?”

“He died on the cross to save us from our sins.”

“That’s a good start, and we’ll definitely be talking about all of that in due course. But I mean—what do you know about how he spent his time? What do you know about what he taught?”

“He called twelve disciples. And he went from place to place healing people. He taught people about how to inherit eternal life. And then he was crucified.”

“I see. And what did he say—I mean, when he taught about how to inherit eternal life? How do you inherit eternal life?”

“I dunno. I can’t remember.”

This time, I was silent.

Finally, my student answers, “You believe in him, maybe?”

“He talks about this rather directly. According to the Gospel of Matthew, in a rather forthright account providing a string of information about the kingdom of God, he talks about those who inherit eternal life. May I read it to you?”

“Is that a rhetorical question?”

Picking up my Bible, I read from the 25th chapter of Matthew, beginning with verse 34: “Then the king will say to those at his right hand, ‘Come, you that are blessed by my Father, inherit the kingdom prepared for you from the foundation of the world; for I was hungry and you gave me food, I was thirsty and you gave me something to drink, I was a stranger and you welcomed me, I was naked and you gave me clothing, I was sick and you took care of me, I was in prison and you visited me.’ Then the righteous will answer him, ‘Lord, when was it that we saw you hungry and gave you food, or thirsty and gave you something to drink? And when was it that we saw you a stranger and welcomed you, or naked and gave you clothing? And when was it that we saw you sick or in prison and visited you?’ And the king will answer them, ‘Truly I tell you, just as you did it to one of the least of these who are members of my family, you did it to me.’ He goes on to say that those who serve people in this way are welcomed into eternal life.”

“Are you trying to frighten me?”

“No, not at all. We are going to spend a great deal of time in class talking about the grace that makes it possible for us to feed the hungry, give drink to those who thirst, welcome the stranger, provide clothing to the poor, and care for the sick. In time, knowledge of grace should eliminate your fear. For now, I’m trying to get us to look at what God might expect of us according to a Christian understanding. . . . Does it make you think that maybe we have a responsibility in relation to the pandemic?”

“I’m beginning to understand what you’re saying.”

I smile. “May I say just one more thing about this?”

“If you must.”

“In my reading of Bible, Jesus doesn’t seem to think that anyone is unworthy of his time or attention. He reached out to all of the people who were excluded in his culture. All of the ‘untouchables’? He touched them. Lepers, menstruating women, Samaritans. He touched them all—even on the Sabbath, apparently. He befriended tax collectors and prostitutes, alike. The widows and orphans who had no one to care for them—he cared for them. So, if we were to take the question, ‘What would Jesus do?’ seriously, how might we respond?”

“I guess we should try to figure out who the untouchables are in our culture, and try to do likewise?”

“That is a really beautiful idea. Who are the untouchables in our culture? Who are the ones cast aside by our social systems?”

“Well, let me think for a minute. The homeless, maybe? Prostitutes, still? There are immigrants in my hometown. I’ve heard some pretty unkind things said about them. So they seem to be cast aside. And the uninsured, too.”

“That’s a great start. Anyone else?”

“Yes. I know where you are heading. You are wanting me to say: People living with HIV/AIDS. I suppose they’re like the lepers of Jesus’ day.”

“It’s been said.” Not exactly comfortable with the analogy given the cruelty of humans to those they perceive to be different, nevertheless I press on. “So. What am I saying? What is our responsibility in relation to the pandemic?”

“You’re saying that if I care for someone who has HIV/AIDS, I’m caring for Christ. And it is what God desires for me to do in this situation.”

“And what do you think about that?”

“It’s hard.”

“Is it? Lots of my students, by the end, talk about how ridiculously simple it was—to give an hour or two a week to pick up a cooler packed with food, and to get it to people who are not feeling well, but who need nutritious food to feel better.”

“Really?”

“Yes. Really. And you know what I hope?”

“What?”

“I hope that, one day, you might look back and think how meaningful it was—this experience, doing something that seemed so off-putting at first, doing something as simple as handing a person a bag of food across a threshold. Someday, perhaps years from now, you’ll hear something said about someone who is gay, or someone who has contracted HIV/AIDS, and maybe you’ll stomach will turn a little bit because you don’t like to hear such derogatory talk. I hope that this simple kindness you are offering this semester ignites a love in you that becomes your source of greatest joy.”

“That might be aiming kind of high.”

“I tend to do that.”

“I don’t get it,” my student persists.

“For now, that’s okay. You don’t need to get it. I just wanted us to have a straightforward conversation to get to the root of what troubled you about the assignment and in order to discuss what, in my mind, HIV/AIDS has to do with theology.”

“Quite a lot, as it turns out.”

“Yes,” I nodded, smiling. “Quite a lot. And we’ve only scratched the surface.”

Sighing, my student looks into the distance.

“Listen,” I say, pausing. “Give it a chance. Deliver a shift of meals at Open Arms of Minnesota, and we’ll talk again. And I promise: all of this will make more sense as we study theology this semester.”

“Do I have any choice?”

“Yes, of course you do. You can drop the course. There are lots of other sections in which you can enroll, even yet this semester.”

Thinking for another few seconds, I hear, “Okay. I’ll give it a shot.”

“Lovely! In the end, you may not agree with me. And that’s okay, too. But who knows?,” I suggest gently. “Maybe you’ll discover the face of God along the way.”

+  –  +  –  +  –  +

This imaginary yet all too realistic dialogue with a student demonstrates how deeply entrenched attitudes are about HIV/AIDS in our culture in Minnesota, if not nationwide, even still. Teenagers coming to college are under the impression that AIDS is only present among gay men and, given its presence in a population that engages in sexual activity the students consider to be offensive to God, they legitimize an unresponsive posture. Their immediate condemnation and judgment in relation to it all is the root cause of the shame and stigma that heap insult upon insult for someone living with the virus. There is something that we can do about these attitudes by analyzing them, addressing them, and working to eliminate them. In this case, we are able to do so within the context of a course in Christian theology, the very source of so much of the judgmental stance.

The service-learning project is intended to bring this kind of conversation into the open in the classroom, where we can reject ideas that marginalize, hoping ultimately to transform students’ lives into something more beautiful, even more Christ-like, by semester’s end. When we talk about human nature, which we call theological anthropology in systematic theology, students wrestle with prejudicial thoughts they may have had in relation to HIV/AIDS, thoughts that would otherwise remain unreflected upon if it were not for our engagement in the issue in the community through service learning. Students are forced to weigh that realization—that they themselves have had prejudicial thoughts—against their widely held belief in the essential goodness of humankind. And when we bring this recognition into conversation with the person and work of Jesus Christ, and contrast our own judgmental instincts with Christ’s wide embrace of humanity, we are able to talk about sin and redemption in a way that seems more relevant than it did before we engaged in service learning of this kind. And lastly, when we study the nature and mission of the Holy Spirit, we are able to get more deeply into the issue of altruism, and whether goodness is, indeed, naturally occurring or whether, just maybe, it is made possible by the gift of divine grace.

The issue of HIV/AIDS grounds our discussions in the real world and in the challenges that confront us, today, as a global community. The entire exercise points us to the vitally important issue of education in relation to HIV/AIDS—not only in terms of getting information into the public arena about what HIV/AIDS is and how it is transferred, and not only in terms of the ABCs of AIDS prevention, but also in terms of how we can shift the conversation about HIV/AIDS, especially within the churches, into a more constructive, even life affirming, pattern.

If our goal is the creation of a more just, a more forgiving, and a more beautiful global society, then this is our calling.

Violence Against Women

In HIV/AIDS, Public Health, South Africa, Structural Drivers of the Pandemic, Violence Against Women on August 11, 2010 at 1:10 am

“It is a fact that a woman born in South Africa has a greater chance of being raped than learning how to read.” —Carolyn Dempster, British Broadcasting Corporation

“When someone perpetrates an act of rape, it’s about reclaiming a sense of power.” —Kelly Hatfield, People Opposing Women Abuse

In 1973, Adrienne Rich published a collection of poems called Diving into the Wreck, including one called “Rape.” The poem explores how the survivor of rape is traumatized again by the male-dominated criminal justice system. This is evident from her first point of entry, when a male police officer records the woman’s account of the crime. His voyeuristic titillation by her disclosure implicates him in something of a gang that continues to perpetrate violence against her.

And you see his blue eyes, the blue eyes of all the family
whom you used to know, grow narrow and glisten,
his hand types out the details
and he wants them all
but the hysteria in your voice pleases him best.

The full text of the poem is available here.

Rich’s poem is an artistic observation about the banality of violence inflicted against women, so enmeshed is it with culture that it is scarcely recognized as out of order. Today, almost forty years since the poem’s publication, there has been little progress in addressing Rich’s critique, even while voyeuristic curiosity about violence committed against women is increasingly satisfied by online access.

Recognizing that the process of sharing painful memories can foster healing, but wishing to provide a space for storytelling beyond the criminal justice and psychological services sectors, many web pages have been launched to give survivors of rape a format by which to share their stories. While some sites have password protection so that visitors need to create accounts to gain access to the postings, others are accessible by nothing more than the click of a mouse, introducing the ambiguities of online access. Nonetheless, by sharing their stories, women who recount their experiences participate in a healing process by refusing to acquiesce to the culture’s desire that they bear their pain in silence.

Postings to web pages of this kind are numerous in South Africa, which has the highest ratio of reported rape cases per capita (per 100,00 people) in the world. Estimates suggest that a woman is raped every 26-36 seconds in South Africa, where a child is raped every 15 minutes. South Africa also has a high number of incidents of infant rape or “baby rape,” as it is more commonly called. Indeed, 41% of those raped in the country are under the age of 12, according to South African police reports. “A nine-year study by Cape Town’s Red Cross Children’s Hospital, published in the South Africa Medical Journal in December 2002, found that the average age of children raped was three. Research has shown that 40 percent of those raped in South Africa are at risk of becoming HIV-positive if they do not receive PEP [post-exposure prophylaxis].” (See Charlene Smith, “Rape has become a sickening way of life in our land,” Sunday Independent, 26 September 2004.) TIME magazine recently reported that more than a quarter of men in South Africa admitted to having raped. “46% of those said that they had raped more than once” (Lindow, TIME, 20 June 2009). As much as 75% of rape in South Africa is believed to be gang related.

In an effort to understand the underlying causes of the violence in South Africa, where democracy came only sixteen years ago after widespread brutality had been inflicted by the white government of apartheid against 80% of the population that was designated “black” or “coloured” (people of mixed ethnic heritage), scholars have articulated at least six theories that attempt to uncover the root causes of the violence directed against women in contemporary South Africa. These theories go beyond the obvious conclusion that individual men have made violent choices. The truth probably lies in an interweaving of theories that the individual choice to commit sexual assault against women is correlated to a combination of factors, including poverty, circulation of myth, persistence of cultural norms related to the subordination of women, male disempowerment, broken familial structures, and lack of legal deterrents.

1. Endemic Poverty. Most of the incidents of rape reported in South Africa occur in the poorest neighborhoods, including both township and rural types of communities, although according to Megan Lindow reporting for TIME Magazine, surveys have found that many of the men “most likely to rape . . . had attained some level of education and income.”[i] In a policy brief released by the South African Medical Research Council, its authors confirm, “the overwhelming majority of victims are found among the working classes and the poor.”[ii]

Poverty and unemployment are barriers to men and women accessing traditional sources of well-being, status and respect. Inequality in access to wealth and opportunity results in feelings of low self-esteem, which are channeled into anger and frustration, and violence is often used to gain the sought after respect and power, whether through violent robbery, rape, fighting between men, severe punishment of children or violence against partners.[iii]

Of course, there are many places in the world where there is a concentration of poverty without similarly alarming statistics pertaining to sexual assault. All the same, when perpetrators explain their behavior by saying that it was too expensive to pay for the services of a woman, the correlation between poverty and rape merits mention.[iv] When poverty is combined with additional factors described below, the situation foreseeably erupts, such that societies can expect to see increasing numbers of acts of aggression targeted against women when multiples of these factors coalesce.

2. Circulation of myth. As has been widely reported, there is a myth that has been circulated in South Africa, where HIV/AIDS rates are among the highest in the world, that it is possible to cure AIDS by having sex with a virgin. Although research has yielded mixed results in terms of evaluating the degree to which the myth is believed, it seems that the myth has greater tenability in some regions of the country than in others. The continuing circulation of the myth certainly does nothing to improve the number of incidents of rape in South Africa, though Helen Epstein, in The Invisible Cure: Why We are Losing the Fight Against AIDS in Africa, discusses how myths of another kind are playing a role in the spread of the epidemic in Africa. She writes, “In precolonial times, chiefs of the Sotho tribe would sometimes allow other men to have sex with their wives to secure the men’s loyalty. This was considered statesmanlike behavior and is celebrated in traditional myths and poems. Contemporary gang rape may be a violent reprise of this male-bonding tradition.”[v] Thus, mythic understandings of what it means to be male and cultural traditions practiced to secure alliances are implicated in violence against women in South Africa.

3. Persistence of cultural norms related to the subordination of women. Researchers have long recognized that male “domination is often so deeply embedded in social practices and the unconscious that the dominated scarcely perceive it as [dominance].”[vi] Research suggests male-inflicted violence against women is “pervasive yet largely unseen,” as it is “exercised through everyday practices in social life where political, educational, religious and economical macro structures are based in the ideology of gender differences.”[vii]

South Africa’s men from across the racial spectrum are raised to see themselves as superior to women and taught that men should be tough, brave, strong and respected. Heavy drinking, carrying weapons and a readiness to defend honor with a fight are often seen as markers of manhood. The violence that ensues between men often has very severe consequences. With most men perceiving that women should submit to control by men, physical and sexual violence are used against women to demonstrate male power, and thus teach women ‘their place,’ and to enforce it through punishment. Thus gender inequality legitimates male violence over women, as well as being accentuated by the use of such violence.[viii]

Gillian Paterson writes a concise synopsis about this normalization process in her book, Women in the Time of AIDS.[ix] “Physical violence against women . . . becomes accepted as part of the ‘normal’ way that things are.”[x] She goes beyond the description of the process, however, to suggest how HIV/AIDS is prompting a paradigm shift since survival itself is at stake. Throughout the book, she promotes a way forward through a participatory development model that wishes not to alienate men, but to involve them in the process so as to secure a lasting shift. Epstein, too, underscores how important it is to address male responsibility in programs aimed at reducing rape statistics in South Africa: “The epidemic of sexual violence in South Africa is part of a wider war between men and women that is as fierce and partisan as any other on the African continent, and it has been raging far longer. Empowering individual women without addressing the attitudes of men and society in general risks creating empowered women who antagonize men [thereby] playing right into the rapists’ hands.”[xi]

4. Male disempowerment. Sociologists have observed how men who are disempowered politically and culturally in colonized systems direct their power to spheres of influence that remain open to them. In a similar context of oppression as experienced by the indigenous peoples of Australia, Germaine Greer, for example, has argued in a book called On Rage that “the centuries of disempowerment, dispossession, discrimination, defamation, marginalization, murder,” and torture of Australian males has left a legacy of substance abuse and violence in Aboriginal communities that is directly traceable to oppression under an Australian version of apartheid policy.[xii] The pattern that Greer describes has parallels in many places, South Africa among them. According to Epstein,

[R]ape is an assertion of male power, not sexuality. [University of Pretoria anthropologist Isak] Niehaus speculates that men . . . found in acts of violence against women temporary relief from the humiliations of living in a society based on the presumption of white superiority. But these acts were not only misdirected expressions of racial anger. They were also ‘desperate protests against men’s loss of control’ over women. . . . The epidemic of rape may be a reaction to their perceived loss of status. In response they are reviving ‘scripts of male domination’ with deep historical resonance.[xiii]

5. Broken familial structures. In his book Spots of a Leopard, a collection of essays about male identity shaped by hundreds of interviews conducted with men throughout Africa, Aernout Zevenbergen asserts, “rape is a signal of a society that is sick to the core.”[xiv] Pointing to South Africa’s long history of migrant labor, Zevenbergen believes apartheid’s practice of migrant labor, of sending men to work hundreds of miles from home to work in mines, resulted in the breaking apart of families that “set the stage ‘for an epidemic of young men who, in the absence of positive male role models, are now consumed by a sense of anger and entitlement. What we have are the wounds of men creating wounds in women, creating wounds in children. . . . Who is going to stop the vicious circle?’”[xv] The South African Medical Research Council lends credence to Zevenbergen’s assertions:

South African families are highly unusual by global norms. In South Africa, growing up as a child in a home with two biological parents is unusual. A majority of children are born outside marriage and there is generally no expectation of fathers having a social involvement in the lives of these children. They often also provide no financial support. Frequently children are raised by family members who are not their biological parents. Without their parent’s protection, children are extremely vulnerable to abuse and neglect. Whilst this is a problem in its own right, it also gives rise to intergenerational cycling of violence. Girls exposed to physical, sexual and emotional trauma as children are at increased risk of re-victimization as adults. Exposure of boys to abuse, neglect or sexual violence in childhood greatly increases the chance of their being violent as adolescents and adults, and reduces their ability to form enduring emotional attachments. Trauma during childhood impacts on brain development, enhancing anti-social and psychopathic behavior and reducing the ability to empathize.[xvi]

Related to broken familial structure is widespread abuse of alcohol and drugs, for “South Africa has one of the highest per capita alcohol consumption levels per drinker in the world.” [xvii] The Medical Research Council again reports that many “acts of fatal and non-fatal violence occur after alcohol and drug abuse, especially fights, some types of homicide, and rape. Many victims of violence are also rendered vulnerable by alcohol.”[xviii] The report acknowledges the cycle of violence that alcohol and drug abuse perpetuates. “In a vicious cycle, victims of violence often start drinking heavily to deal with the trauma they have experienced, but their drinking makes it harder from them to escape from violence in their lives. Children are often left very vulnerable by their parents’ drinking.”[xix]

6. Lack of legal deterrents. It is estimated that less than 10% of reported rapes will result in a conviction in South Africa. The election of Jacob Zuma to the presidency in 2009 has not helped, for even he was accused of rape during his campaign, though he was later acquitted of the charges. In an interview with The Guardian, co-director of the Sonke Gender Justice Project, Dean Peacock is quoted as saying, “We’re at a complicated moment in South African history with revived traditionalism and there’s a danger of gender transformation being lost. We hear men saying, ‘If Jacob Zuma can have many wives, I can have many girlfriends.’ The hyper-masculine rhetoric of the Zuma campaign is going to set back our work in challenging the old model of masculinity.”[xx] Again, the Medical Research Council has stated,

With society accepting the use of violence in many circumstances, and the community very often protecting perpetrators, it is not surprising that law enforcement is generally very weak. Widespread corruption and general under-resourcing within the police force, as well as challenges of transformation and restructuring in the detective services, contributes to the problem. Few perpetrators are effectively punished, with the result that laws fail to provide deterrence and victims often have little faith in the system. / Despite the massive problem violence poses to the country, there has been a conspicuous lack of stewardship and leadership in the area of violence prevention from Government. The current policy of the Government which, simply put, is to ‘get tough’ on criminals, is unlikely to be a useful response to violence in the long term. Without widespread social and economic reforms, it fails to address the roots of violence and, equally problematically, it is both rooted in and serves to perpetuate many of the very ideas of manhood that underlie the problem of violence in society.[xxi]

All of this is to say that where poverty, myth of sexual cures for dreaded and prominent illnesses, cultural norms of male domination, male disempowerment, broken familial structures and lack of legal deterrents coalesce, risk is high for high incidents of rape and sexual violence to be committed against women. Where there are high incidents of rape and sexual violence committed against women, there is a high risk of HIV/AIDS infection.

Professor of medical anthropology at Harvard University Medical School and founder of Partners in Health, an organization devoted to provided high-quality medical services and pharmaceutical access to people living in the poorest communities throughout the world, Paul Famer has written extensively about gender inequality, poverty, and AIDS. Although his books tend to focus on his experiences in Haiti, the public health challenges he describes are relevant elsewhere, as the patterns to which he bears witness in Haiti have, in an age of globalization, replicated in many places throughout the world. In his book Women, Poverty, and AIDS: Sex, Drugs, and Structural Violence, Farmer explains how women are both biologically and socio-economically more vulnerable to an infection than men:

Certain studies suggest that per-exposure transmission from man to woman during genital-genital intercourse is two to five times more efficient than from woman to man. Other investigations have prompted researchers to argue that HIV is up to 20 times more efficiently transmitted from men to women than vice versa. HIV is more highly concentrated in seminal fluids than in vaginal secretions and may more easily enter the bloodstream through the extensive convoluted lining of the vagina and cervix. Vulnerable penile surface area is much smaller. . . . One recent study suggests that certain strains of HIV may grow better in a type of cell lining in the vaginal wall.[xxii]

Farmer also explains how female risk for HIV goes beyond biological risk factors alone.

[B]iological risk alone does not explain soaring infection rates among women. Women’s precarious social status, a direct result of gender inequality and amplified poverty, magnifies each of these biological predispositions. In addition to the gendered power differentials characterizing most sexual unions, women are denied equal access to economic resources, housing, health care, legal protections, land, schooling, inheritance, and employment in the formal sector of most societies. Wage-earning women may be obliged to supply sex to supervisors as a condition of employment. Domestic workers are particularly vulnerable to this kind of abuse. Women who work in the low-wage informal sector may also be forced to supplement meager earnings with sex work. Still others can find no employment in the informal sector except sex work. Male violence, whether threatened or actualized, is also all too commonly used to control women throughout their lives and increases their vulnerability to infection. In many cases, such violence is legally as well as socially sanctioned.[xxiii]

Any effort, therefore, to minimize the risk for replication of South Africa’s statistics pertaining both to sexual assault incidents as well as to HIV/AIDS prevalence rates must be multi-dimensional, addressing opportunities for income generation for both genders as well as financial independence for women, campaigns to distribute factual information about the biology of HIV/AIDS and its treatment, as well as information targeted to raise awareness about gender domination and its alternatives. South Africa has many NGOs working in these areas and their work is invaluable to the lives that are touched by their efforts and services. Also underway are governmental efforts to broaden the impact of endeavors aimed at eliminating poverty, ending the age of AIDS denialism, challenging a culture of female subordination, empowering males by creating meaningful work in every region of the country thereby also shielding familial structures from the harsh impacts of migrant labor, and enforcing laws already in place and revising unhelpful laws for the protection of women and children.

NOTES

[i] Megan Lindow, “South Africa’s Rape Crisis: 1 in 4 Men Say They’ve Done It,” TIME (20 June 2009; http://www.time.com/time/world/article/0,8599,1906000,00.html, accessed 30 August 2011).

[1] Ibid.

[ii] R. Jewkes, et. al, “Preventing Rape and Violence in South Africa: Call for Leadership in A New Agenda for Action,” MRC Policy Brief (November 2009), 1; http://www.mrc.ac.za/gender/prev_rapedd041209.pdf (accessed August 30, 2011).

[iii] Ibid.

[iv] Nicole Itano, “South Africa Begins Getting Tough on Rape, WENews (24 February 2003;http://www.womensenews.org/story/rape/030224/south-africa-begins-getting-tough-rape, accessed August 31, 2011).

[v] Helen Epstein, The Invisible Cure: Why We are Losing the Fight Against AIDS in Africa (New York: Picador, 2007), 228-238, esp. 234.

[vi] Diana Gibson, “Rethinking Domestic Violence: Case Studies from the Western Cape, South Africa,” in Amsterdam School for Social Science Research, Working Paper Series, October 2004.

[vii] Ibid, 3.

[viii] Jewkes, 1.

[ix] “His and Hers: A Note on Gender Analysis” in her book, Women in the Time of AIDS (Maryknoll: Orbis Books, 1996), 30-35.

[x] Ibid.

[xi] Epstein, 234-235.

[xii] Germaine Greer, On Rage, Melbourne University Publishing, 2010; see also Gideon Polya, “Book Review: On Rage by Germaine Greer,” MWC News, 27 June 2009.

[xiii] Epstein, 232-233; quoting Isak Niehaus, “‘Now Everyone Is Doing It’: Towards a Social History of Rape in the South Africa Lowveld,” research working paper presented at Sex and Secrecy, a conference of the International Association for the Study of Sexuality, Culture and Society, July 12, 2003.

[xiv] Aernout Zevenbergen, Spots of a Leopard: On Being a Man (Laughing Leopard Production, 2009); see also Lindow.

[xv] Lindow.

[xvi] Jewkes, 2.

[xvii] Ibid.

[xviii] Ibid.

[xix] Ibid.

[xx] David Smith, “Quarter of men in South Africa admit rape, survey finds,” in The Guardian (17 June 2009;http://www.guardian.co.uk/world/2009/jun/17/south-africa-rape-survey, accessed August 31, 2011).

[xxi] Jewkes, 2.

[xxii] Paul Farmer, Women, 47.

[xxiii] Ibid, 50-51.

Xenophobia / Xenophilia

In HIV/AIDS, Public Health, South Africa, Structural Drivers of the Pandemic, Xenophilia, Xenophobia on August 11, 2010 at 1:00 am

Last year, more than sixty people died as a result of xenophobia in South Africa. Typically, xenophobia refers to the unreasonable suspicion, distrust, or even hatred of foreigners. Although factors contributing to the xenophobic violence in South Africa are complex, it is clear in every report about it that tensions are running high because the country is experiencing unemployment rates nationwide of about 40%, a rate which soars above 70% in many so-called “coloured” and “black” townships established during apartheid, and in the informal settlements and shantytowns that continue to build up around them. Tensions erupted in 2008 when perceptions circulated that “foreigners” were taking jobs that could go to native-born citizens, creating a distrust that was fueled by accusations that drug trafficking was largely attributable to immigrants who, it was alleged, were bringing illegal substances across the border when they entered the country. These rumors caused immigrants in South Africa to become targets of attacks that captured the world’s attention in 2008.

In order to provide a sense of the scope and brutality of the attacks, consider an excerpt from this article published 19 May 2008 in the Mail & Guardian Online (Africa’s first internet-based news source begun in 1994, reputable internationally for quality reporting from inside Africa):

[P]olice recovered the hacked body parts of a Malawian national on a sandy road in Ramaphosa township and, near Primrose, one person with Mozambican identification papers in his pocket was found dead. Two other Mozambicans were seriously beaten.

In Zamimpilo, outside Riverlea on the West Rand, at least 50 shacks were burned. Foreign nationals in the area were taken to safety at a community centre.

In Kya Sands, an industrial area close to informal settlements, groups of people began throwing stones at each other after a community meeting, but the situation was brought under control, said police spokesperson Superintendent Lungelo Dlamini.

In the Jerusalem informal settlement, near Boksburg, police came under fire as they tried to stop a group of about 500 people from looting shops there.

Police in Cape Town were identifying possible flashpoints for xenophobic violence and would have units on standby, the city administration said on Monday.

These summary reflections by journalists for the Mail & Guardian about the week’s unrest, and the article in full, point to a further tragic dimension of the xenophobic violence in South Africa. The crimes are directed against those who are already suffering in townships and informal settlements where sometimes people are living in cardboard and tin-covered shacks built on nothing but dirt. An immigration status adds another degree of jeopardy to already jeopardized lives. Indeed, many of those who continue to flee here are leaving terrible and terrifying conditions, most arriving today from Zimbabwe and the DRC (Democratic Republic of Congo). They come here hopeful that they might find the refuge to which their designation as refugees attests—an illusion that is often broken swiftly when they enter a country with high rates of unemployment. On top of this, they too read the chilling words of those arrested for conducting the attacks, and the attempt of those involved to justify their activities. One unemployed man, for example, from his jail cell after he was arrested for destroying a few shacks in the Gauteng Province (in which Johannesburg and Soweto are located), is reported to have said, “We will keep on going; [the police] can’t stop us. . . . Foreigners are taking our jobs and our wives.”

Imagine, then, the increased anxiety felt by those immigrants who come with an HIV-positive status, or who acquire HIV once they have crossed the border. Their costume, accent, and location may already “target” them as “foreign.” To add fuel to the fire, in societies where all sexual subjects are taboo, word about an HIV infection present in the body of a refugee can fan the flame of violence all too ready to erupt.

Indeed, the issue of stigma was an omnipresent reality during my time at the Scalabrini Centre. The staff discussed with me how their clients often felt vulnerable, such that even coming to the HIV support group was difficult for them. When I presented the project to the members of the support group and invited each one to participate, two women made reference to the stigma of an infection when they politely and understandably declined the offer. Although two of my subjects permitted me to photograph their faces, one kept hers hidden for fear of being identified in her community. And all three asked that their names be kept absolutely confidential. Though one mindlessly wrote it nevertheless in the journal entry, I have used Photoshop to erase it from the subject’s journal page on the still life in order to honor the subject’s request for some degree of anonymity.

Of course, xenophobia is not the only option. Jesus himself drew on the ancient laws in his own Jewish tradition when Matthew records him to say, “I was hungry and you gave me food, I was thirsty and you gave me something to drink, I was a stranger and you welcomed me, I was naked and you gave me clothing, I was sick and you took care of me, I was in prison and you visited me” (Matthew 25:35-36). The tradition upon which he was drawing was written in the ancient Israelite Code of Law: “When an alien resides with you in your land, you shall not oppress the alien. The alien who resides with you shall be to you as the citizens among you; you shall love the alien as yourself, for you were aliens in the land of Egypt: I am the Lord your God” (Leviticus 19:35-36).

All of this is to say that the Judeo-Christian tradition advocates against xenophobia in preference for “xenophilia”—a love and a deep, abiding respect for the inherent dignity of the foreigner in our midst. Certainly political questions become rapidly complex as priorities are juggled with limited Rands, Dollars, and the rest to be allocated to relieve varying competing and significant needs—but as “People of the Book,” these verses should guide our deliberations. First and foremost, we are called to recognize the “strangers” in our presence as also created in the image of God (imago Dei), possessing by virtue of their very existence a dignity that is absolute—a dignity that is inviolable.