Aids As a Social Problem: The Creation of Social Pariahs in the Management of an Epidemic

Bronwen Lichtenstein * Definitions * Naming A New Disease and Its Icons * An Epidemic of Inequality * Aids Iconography in the Management of a Sexual Disease * HIV/AIDS in the Twenty-First Century * Conclusion * Note * ENTRY CITATION AIDS (acquired immune deficiency syndrome) was viewed as a social problem 1 as soon as epidemiologic reports about a gay plague appeared in the United States. Like other sexually transmitted diseases, AIDS was associated with people who had the misfortune to fit into rather distinct classes of outcasts and social pariahs (Shilts 1987). The first social pariah to be named in the AIDS epidemic was the white, gay man whose lifestyle was assumed to be an efficient conduit for HIV (human immunodeficiency virus) transmission. AIDS, in fact, was known as the gay white man's disease well past the time when the accuracy of this characterization should have been questioned, and certainly past the time when heterosexual citizens in developing countries were being infected at an alarming rate. This chapter will address the concept of AIDS as a social problem along two dimensions: first, in its creation of social pariahs through discourse about who was infected and, second, in the subsequent problems of this representation for responding to the epidemic. My approach to AIDS as a social problem will center on the understanding of disease as a socially constructed phenomenon. In this conceptualization, AIDS is not just a virus that afflicts hapless individuals at random but is the product of social and economic forces that help determine how, when, and where particular persons are infected. To para-phrase Robin Gorna (1996), AIDS has nothing to do with being an equal-opportunity virus, even though it has been presented as such in the media and in health promotion materials. Like many other infectious diseases, HIV/AIDS affects certain people more than others. In the United States, it affects minorities more than whites. Around the globe, HIV/AIDS affects those who are poor or disenfranchised. As stated by the late Jonathan Mann, former director of the World Health Organization's Global Program for HIV/AIDS, inequality through poverty, discrimination, or marginalization is the central societal lesion underlying AIDS and ill health worldwide (Mann 1993). Neither of the popularized conceptualizations (AIDS as a disease of socially deviant risk groups or AIDS as an equal opportunity disease) has explicitly acknowledged the structural factors underlying the HIV risk for disadvantaged or marginalized members of society. The social fault lines theory (Bateson and Goldsby 1988), however, underlies much of the current sociological literature on HIV/AIDS, although as Mann (1993) has noted, societies try hard to ignore it. My approach to AIDS as a social problem will illustrate how structural factors give rise to differential HIV infection patterns. I will present three archetypes (icons) of HIV/AIDS (the gay white man, the injection drug user, and the African prostitute) for analysis. These three perspectives will illustrate the links between stigmatizing iconography and the management of an epidemic.

Definitions HIV/AIDS HIV infection is a syndrome that takes the form of opportunistic diseases such as Kaposi's sarcoma, Pneumocystis carinii pneumonia (PCP), cytomegalovirus (CMV), toxoplasmosis, and the virulent forms of thrush, herpes, and hives. HIV infection can be transmitted through unprotected sexual intercourse, contaminated hypodermic needles, and untreated blood products. HIV infection has a latency period of 5 to 15 years but is usually fatal if an untreated infection has progressed to AIDS. Antiretroviral medicines developed for the treatment of HIV infection can significantly prolong the life of people with HIV (PWH). HIV infection may be deadly in societies in which lifesaving medicines are unavailable and chronic (manageable) in wealthy nations in which antiviral regimens are the standard of medical care. Iconography Iconography is the study of societal understandings about icons, that is, how groups of people are presented, created, and reproduced through pictorial, textual, or media representations. The formal definition of iconography stems from the concept of icons as images, statues, figures, pictures, or representations. In the HIV/AIDS epidemic, these icons are public images of those who become HIV-positive (Gilman 1988). This chapter will investigate the ways in which iconography serves to reveal compelling but rarely stated frameworks around which meanings and understandings are organized. Iconography may be thought of in this context as a study in attributions to images that are particularly relevant to HIV/AIDS on broad societal levels. Following Gilman (1988), this approach recognizes the extraordinary power the images have to reflect (and shape) society's responses to individuals suffering from disease. Naming A New Disease and Its Icons The first cases of HIV infection were documented in 1979 among gay men in the United States. AIDS was classified as a new disease as soon as scientists had determined its incidence and origins. The spread of HIV infection around the globe ended the complacency that had existed after the virtual elimination of such diseases as syphilis, smallpox, poliomyelitis, cholera, and yellow fever in their epidemic forms (Lichtenstein 1996a). The appearance of a deadly new disease renewed fears about human susceptibility and led to a search for viral and human culprits in an attempt to control the spread of infection. HIV/AIDS was dubbed the gay plague because the first people known to be afflicted were men from self-defined gay communities in San Francisco, Los Angeles, and New York (Altman 1986). The Centers for Disease Control and Prevention (CDC) specifically linked the homosexual lifestyle to an emerging epidemic of pneumonia, Kaposi's sarcoma, and wasting disease associated with gay men (Treichler 1988a). The association of an epidemic with a lifestyle set the scene for the way HIV/AIDS was perceived and managed in the United States. The scientific community initially labeled the new disease gay-related immune deficiency, or GRID. The syndrome was later and more neutrally renamed AIDS, but the link between male homosexuality and AIDS was firmly established as an epidemiologic entity (AIDS became HIV infection or HIV/AIDS once the difference between asymptomatic and symptomatic stages emerged). This first-world conceptualization of the new epidemic as a gay man's disease continued even after it was known that AIDS afflicted heterosexual populations in sub-Saharan Africa. Most Western literature about HIV/AIDS focused on the idea of male homosexuality as a locus of the epidemic, whether as an assumption or as a point of argument.

Concern about the sexual behavior of gay men was expressed through political vilification, media hyperbole, and sociobehavioral interventions. While moral concern centered on the nature of same-sex activity and the perceived threat to health and social order, sociobehavioral interventions were predicated on the notion that sexual behavior could (or should) be changed (Rushing 1995). Like syphilis before it, HIV/AIDS soon emerged as a sexual epidemic in terms of its politics and management. This meant that HIV/AIDS was viewed in terms of social deviance rather than as a public health threat that needed immediate attention (Shilts 1987). In the early days of the epidemic in the United States, this response was evident from the Reagan administration's refusal to address HIV/AIDS as an urgent public health issue (Perrow and Guillen 1990). The government's refusal meant that HIV prevention was given low priority in the public health sector. The management of AIDS focused on risk groups as a means of tracing, monitoring, and controlling the spread of disease. The initial investigation of HIV infection by epidemiologists meant that the new disease was constructed in terms of a risk group iconography of social or sexual deviance. The CDC initially used this construction in public health surveillance and case reports (Oppenheimer 1988). The epidemiologic emphasis was instrumental in HIV/AIDS becoming known as the epidemic of the 4 H's: Homosexuals, Haitians, Heroin addicts, and Hemophiliacs (Treichler 1988a). The use of risk groups as the explicit basis of surveillance reports ceased after 1993, but the data were still organized according to modes of transmission that are commonly associated with risky behavior. HIV/AIDS therefore continued to be associated with sexual and social deviance. An Epidemic of Inequality The United States In the United States, the demography of HIV/AIDS has undergone substantial change since the early days of the epidemic. While white middle-class men in major urban areas in the Northeast and Pacific West were among the first to be afflicted, HIV infection is now associated with ethnicity and poverty. African Americans and Hispanics account for 54 percent and 19 percent of new infections in the United States, respectively, even though they make up only 12 percent and 9 percent of the population (CDC 2002a; U.S. Census Bureau 2001). This epidemiologic pattern is similar to other sexually transmitted infections (STI) such as syphilis, gonorrhea, chlamydia, and genital herpes (CDC 2001a), all of which disproportionately affect minorities. Most new infections occur in the southeastern states. African Americans in particular are at risk of HIV transmission. In Alabama, for example, 72 percent of new cases occurs among African Americans, who represent 26 percent of the state population (Alabama Department of Public Health 2002). Similar patterns occur in Mississippi, Georgia, Florida, and South Carolina (CDC 2001b). The gap between the number of infected men and women is narrowing for African Americans, meaning that the AIDS iconography of the gay white man in the 1980s is no longer a primary referent in the 21st century. Women in the Southeast account for one-third to onehalf of new infections (CDC 2001b). This development suggests that HIV/AIDS among African Americans is developing a Type II (non-Western) demographic pattern that is often associated with HIV transmission in developing countries. The structural dimensions of HIV/AIDS in the United States are evident in social problems that afflict the poor and disenfranchised. In Brown and Wiesman's (1993) study of low-income women in the United States, for example, housing instability was a primary indicator of HIV risk, while other factors such as man sharing (partner concurrency) in communities where there is an imbalance in the ratio of men to women through death or imprisonment were

indicators of HIV risk for African Americans (Campbell 1999). Sexual relationships involving an element of financial exchange are also common and are linked to man sharing, drug use, and poverty (Lichtenstein 2000). Sexual networks involving partner concurrency and commodification are efficient conduits for STI because transmission can occur at multiple points in a community in a relatively short period of time (Laumann et al. 1994). African Americans are also vulnerable to HIV transmission because of homophily (black-on-black sexual relations), meaning that infection becomes pooled and therefore self-reproducing within members of a community (Pfingst 2002). Inequality Around the Globe The emergence of ethnic and poverty-related disparities outlined above is consistent with HIV transmission patterns across the globe. Bloor (1995) has noted that HIV/AIDS is socially patterned in terms of who is most at risk of HIV transmission, both locally and on a global scale (i.e., some societies or groups are more vulnerable than others). Mann's (1993) assessment of this social patterning is that it is characterized by poverty, political upheaval, and social systems in which women in particular lack equality. Many of the recent public health reports on HIV/AIDS are concerned with issues of discrimination and poverty (e.g., UNAIDS 2000). The following section addresses the social patterning of HIV/AIDS in terms of gender and poverty, the two main issues that appear in these reports. Women Women now outnumber men in HIV incidence. Biological factors, such as being the receptive partner, place women at greater risk of HIV infection than men (Caldwell and Caldwell 1993), as does their subordinate position in society (Mann 1993). The links between women's biology, social status, and HIV/AIDS are evident in the infection rates of girls who are sold into prostitution in Thailand and who exchange sex in Africa, India, and other countries in which women lack economic and social equality (UNAIDS 2000). Mann (1993) has argued that women who are unable to make life decisions with regard to marriage, property distribution, or income are often rendered powerless in their sexual lives; thus, they become susceptible to HIV and other diseases through the double jeopardy of biology and sex discrimination. Mann (1993) has further noted that reforms of laws governing property and divorce may be more important in helping to prevent HIV infection than increasing the distribution of brochures or condoms. Condoms may not be a useful HIV prevention tool for women for a variety of reasons, such as the fact that only men can use them or because men perceive them to be a threat to masculinity or as a sign of being unfaithful (Crosby et al. 2000). The prevalence of rape is also a potent factor in HIV risk for women (Epstein 2002), as is unequal access to education (UNAIDS 2000). Lichtenstein (2002) has documented the way in which domestic abuse victims are at risk of HIV transmission through nondisclosure and lack of condom use by infected men who use sexual coercion and violence to control their partners. The fact that women are becoming infected with HIV/AIDS at higher rates than men around the globe has prompted Mann (1993) to conclude that not only does gender discrimination play a role in health care for women but also that ipso facto, male-dominated societies are a threat to public health. Men Structural factors affect men's risk of HIV transmission as well. HIV transmission in subSaharan Africa has been fostered, in part, by the shift from agrarian to capitalist forms of economy, which has resulted in large-scale migration across regions of the African continent

and the disruption of traditional patterns of work and kinship. This development has separated men from their families and relocated them in industrial towns and cities in which prostitution or contingent relationships are common (Epstein 2002). War, famine, and poverty affect men's as well as women's HIV risk through the social dislocation caused by troop movements and recruitment (particularly of young boys) for military purposes. Hankins, Friedman, Zafar, and Strathdee (2002) have reported that ethnic patterns of recruitment into the Ugandan National Liberation Army after the overthrow of Idi Amin in 1979 correlated positively with geospatial patterns of HIV transmission and that infectious diseases (including HIV/AIDS) can spread quickly in battlefield medical settings. In parts of Europe (e.g., Edinburgh, Scotland) as well as in the United States, structural factors involving men's HIV risk include urban decay and postWorld War II changes that eliminated employment and housing opportunities. In one notable example, the geographical distribution of HIV infection associated with intravenous drug use in New York was linked to the slum clearance and forced relocation that concentrated poverty in overcrowded southern parts of the Bronx (Wallace 1988). In Russia, an increase in injection drugrelated HIV infection, particularly among men, has been associated with social upheaval and economic hardship in the post-Soviet era (UNAIDS 2001). The relationship between community disruption, risk behavior, and HIV transmission is located firmly within these sociostructural explanations of the epidemic. Poverty Structural factors play a critical role in HIV transmission. While in secular and relatively wellto-do countries (e.g., Britain, Canada, the Netherlands, Germany, Norway, Australia, and New Zealand) the epidemic is said to be contained by virtue of a well-funded and coordinated response (Davis and Lichtenstein 1996), heavily populated countries in which poverty is endemic or that are beset by wars and social dislocation (e.g., Bosnia, Russia, Bangladesh, Sri Lanka, and Ethiopia) have seen an exponential increase in HIV/AIDS that threatens these nations' ability to function (Epstein 2002; UNAIDS 2000). HIV/AIDS has also become a key indicator of social class. This factor is particularly salient in poor nations but also in industrialized countries where there is a considerable wealth gap between rich and poor, and whose health systems are similarly stratified (e.g., the United States) (Smith 1999). In the case of more egalitarian countries, especially those with national harm-reduction strategies such as needle exchange for injection drug users (e.g., in Europe, Canada, and Australasia), new cases of HIV infection in heterosexual populations often occur through immigration from countries with high rates of HIV infection or through the sex tourism associated with such countries (Gorna 1996; New Zealand Ministry of Health 2001). The citizens of sex trade countries (e.g., Thailand and Kampuchea) are often impoverished, indicating that the movement of populations through travel, immigration, and trade is also socially patterned and that international sex tourism (like other tourism) is part of the economic interface between rich and poor. Another factor relates to refugees from war-torn countries who may suffer from infectious and other diseases. In New Zealand, 40 percent of all new HIV infections over the past five years have occurred among immigrants, particularly those with refugee status (New Zealand Ministry of Health 2001). Table 19.1 lists the HIV/AIDS rates for 28 countries. The seroprevalence rate in each country is presented together with the main modes of HIV transmission: men who have sex with men (MSM), injection drug use (IDU), and heterosexual (HET). The countries were selected

because they are representative of their regions or because the HIV/AIDS data are available in published public health reports. The table has been organized into four main categories to represent the geospacial distribution of HIV/AIDS. First, there are the industrialized countries whose epidemics are stable or contained (e.g., in Europe, North America, and Australasia). Second, there are the countries that are characterized by a rapid increase in HIV transmission, poverty, political upheaval, and underfunded health systems (e.g., in sub-Saharan Africa, Southeast Asia, and some Caribbean nations). Third, there are the countries whose more recent epidemics began after the collapse of communism or through isolation from their neighbors (e.g., the former Soviet Republics and China, respectively). These countries are experiencing a rapid increase in HIV transmission. The fourth category consists of a small number of high-prevalence countries that have reduced HIV transmission through aggressive public health interventions (e.g., Uganda and Thailand). The table also shows that in general, heterosexual transmission is common in high-prevalence countries; same-sex activity (and to a lesser extent, IDU) is associated with HIV transmission in the West; and injection drug use is associated with HIV transmission in the former Soviet Republics. Table 19.1 is a beginning point for understanding how the course of the epidemic is shaped by political and socioeconomic factors. The highest HIV transmission rates are in developing countries, particularly in sub-Saharan Africa, the Caribbean, and Southeast Asia. HIV transmission has largely been confined to the group of origin (e.g., middle-class gay men) in wealthier countries, especially those with comprehensive HIV-prevention strategies where needle exchange and targeted funding have proven to be effective (Lichtenstein 1996b). In other countries, cultural disincentives for condom use (e.g., in pronatalist societies), gender discrimination (Mann 1993), and practices such as polygyny or child sex (Gould 1993) are examples of how sociocultural factors (practices) intersect with HIV transmission. For Crimp (1988), the point that social factors shape the course of HIV/AIDS and its outcomes is crucial to dispelling the myth of an equal-opportunity disease. In presenting the views of Delaporte (1986), Gould (1993), Mann (1993), Farmer (1999), and others, Crimp (1988) asserts that AIDS [like other diseases] does not exist apart from the practices that conceptualize it, represent it, and respond to it. We know AIDS only in and through those practices (p. 3). The following section will discuss how HIV/AIDS exists within a framework of social practices that have given rise to AIDS archetypes (iconography), with a corresponding effect on the management of a public health crisis. The discussion will center on the AIDS iconography of gay men, injection drug users, and African women as representative of the three main risk groups identified in the surveillance data in Table 19.1. Aids Iconography in the Management of a Sexual Disease Gay Men The Iconography HIV/AIDS is characterized by blame of the afflicted. Sander Gilman (1988) has argued that blame is meted out to the victims of disease in an attempt to isolate those we designate ill. In the case of the gay man, isolation came about, in the scientific sense, through nineteenthcentury medicalization in which the homosexual was cast as a subspecies, an abnormal sexual variant (Foucault 1978). The struggle for gay rights in the 1960s was in part a challenge to the medical-scientific discourse that had constructed gay men and women as mentally ill or deficient. The AIDS epidemic again presented homosexuality in terms of disease and as a societal threat. In effect, the categorization of the homosexual as a subspecies in the nineteenth

century (a notion captured by gays and reworked to become an identity in the 1970s) turned full circle once gay men were classified as AIDS patients and AIDS carriers. Even psychopathology was reintroduced, this time appearing as depression or dementia in the later stages of AIDS (Leibowitz 1985). In contrast to the nineteenth century, however, this iconography has had a unifying effect on the gay community in terms of political action. The restigmatization of gay men during the HIV/AIDS epidemic was in part the result of an epidemiology that linked high STI rates among gay men to HIV risk. Altman (1986) has noted that the success of the gay movement in claiming legitimacy for its lifestyle probably distorted early research on HIV/AIDS because researchers looked for lifestyle factors that could explain the outbreak of HIV infection instead of assuming that the culprit was a specific organism that could also infect heterosexuals. Words such as immune overload, immune fatigue, and life in the fast lane were used to describe the environment in which AIDS flourished (Treichler 1988a). Misleading perceptions about AIDS arose from the extravagant metaphors that eschewed reason and fanned public fear about other lifestyles. Leibowitz (1985) has noted, The homosexual lifestyle was so blatantly on display to the general public, so closely scrutinized, that it is likely that we will never have been informed with such technicphantasmal complacency as to how other people live their lives (p. 3). This negative publicity made the gay man the first AIDS icon and an example of how other icons would be constructed in terms of blame and otherness. The Response In the United States, the gay community mobilized in support of AIDS care for the afflicted and for HIV prevention programs. AIDS iconography (the AIDS patient as a special case) was used as a political tool by gay organizations such as the AIDS Coalition to Unleash Power (ACTUP) to demand health services for PWH (Kramer 1990). At the time, the U.S. government was suspected of refusing to respond to the epidemic because of what Shilts (1987), Altman (1986), and Kramer (1990) have described as a trenchant antagonism toward homosexuality and the inherent immorality of gays. Kramer (1990), for example, believed that a stigmatizing AIDS iconography was behind the U.S. government's torpid, fitful, fragmented [response, that was] riven with prejudice against those afflicted with the virus (p. 26). In further explaining the formal sector response, organizational analysts Perrow and Guillen (1990) have drawn attention to the fragmented nature of health care in the United States and to the nation's historic inability to respond quickly to a public health crisis. Panem (1988) has documented how large-scale federal funding was allocated in 1985 only after the epidemic had threatened the health of heterosexuals. By this time, the gay community's care and prevention programs had become a model for responding to HIV/AIDS. Gay activists had also turned their attention to the rapid development of medicines for HIV disease, using their status as AIDS icons to give weight to their demands (Burkett 1995). The antiviral medicines for treating HIV disease were fast-tracked through the Food and Drug Administration in the 1990s on the basis of this political activism. The self-help model of gay men and women in the United States has been adopted on a global scale. In Britain, for example, the Terrance Higgins Trust (THT; a London-based gay community group) provided help to PWH along the same lines as in the United States (Lichtenstein 1996a). This action took place against a backdrop of denial by the Thatcher government, which had made no secret of its disapproval of homosexuality and which initially offered little in the way of funds for prevention and care (Weeks 1989). Only after heterosexuals were thought to be at threat of infection did Mrs. Thatcher delegate the job of

AIDS policy to the deputy prime minister, who then created a period of wartime emergency in 1986 (Berridge and Strong 1992). The government's response built on the gay community model, eventually incorporating its principles and operations into the formal health sector. Britain's response to HIV/AIDS occurred in three stages. Weeks (1989) has called these stages (1) dawning awareness (19811985), (2) crisis management (19861987), and (3) normalization (1988 onward). During the first phase, gay organizations worked to meet the needs of infected persons on a voluntary basis. In the second stage, parliament underwrote Britain's response to HIV/AIDS by empowering certain individuals to direct policy or to allocate large sums of money to community agencies and existing health authorities. In the third stage, political control of AIDS policy reverted to government agencies for integration into the health system as described above (Street 1993). This integration of services occurred at the same time that AIDS was being reconceptualized as a chronic disease in terms of its clinical management (Berridge and Strong 1992). Britain's three-phase response is similar to that of Europe, Canada, and New Zealand and to some degree reflects the political and organizational structures of these countries (Australia's case was different in that the government took control of the epidemic in its early stages). These Western countries, with their focus on containment and favorable political structures, appear to have fared better than the United States with its plethora of competing, heterogeneous organizations and programs over which no one individual or voice has had effective control (Perrow and Guillen 1990). For example, Britain's HIV epidemic is still mostly confined to gay men, and the total seroprevalence rate remains relatively low at 0.11 percent of the population (compared with 0.61 percent for the United States). On a national basis, harm-reduction programs for IDU, among other measures, have been instrumental in HIV prevention in Britain (Henderson 1993). The iconography of AIDS in Britain, therefore, has been used with some success by the gay community and public health authorities as a rationale for targeted interventions and for limiting the spread of HIV/AIDS. Injection Drug Users (IDU) The Iconography In the United States, people labeled drug abusers have been the targets of a moral crusade since the early twentieth century (Kandall 1996). IDU in particular have been singled out for their presumed sociopathology. The image of the IDU is of the urban, high-risk male living a shadowy existence; he is also associated with crime and ethnicity in the popular imagination (Lichtenstein 1996c). IDU have been presented as a bridge to the heterosexual population for HIV transmission and are therefore viewed as sexually dangerous as well as criminal. This representation has placed IDU in an invidious position in relation to HIV prevention because they are often regarded as too unworthy or too unreliable for HIV prevention in the United States, even though harm-reduction programs for this population have worked in other countries (UNAIDS 2001). The iconography of the IDU intersects with ethnicity and race. Gilman (1988) has argued that this association stems from the iconography of syphilis and other STI in which disease is associated with minority status. The imagery is constructed around a stereotype that in the United States often centers on the hypersexuality of African Americans. An illustration of this imagery is the drug-addicted African American woman who engages in prostitution or who barters sex at crack houses (Kemp 2002; Murphy and Rosenbaum 1997). Kemp (2002) refers to this representation as a controlling image because it assumes that drug-using African American women are hypersexual disease-bearers. The iconography also involves African American men, for example, the HIV-positive sports icon Magic Johnson (a former superstar of U.S. basketball), who is said to have been infected by having sex with thousands of women (King 1993). The publicity surrounding Magic Johnson's confession about his HIV status

prompted King to argue that his hypermasculine stance helped to promote myths about African American hypersexuality and other constructions. Gilman (1988) writes that prior to the AIDS epidemic, the association between race and STI culminated in the Tuskegee experiment (19321972), where it was assumed that black men had greater immunity to syphilis and where they were observed without treatment, sometimes until they died. (Smith in King 1993) argued that the creation of images about hypersexual, drugaddicted African Americans allows the problem of HIV infection and its devastating effects on minority communities to be viewed and dismissed through the selective lens of bigotry. For Kemp (2002), the conflation of social deviance with HIV infection under the rubric of personal responsibility helps to conceal the class-based nature of HIV/AIDS in the United States. The focus on ethnicity and risk behavior (particularly illicit drug use) therefore reveals a modern form of stigmatization that can be justified in terms of beliefs about personal responsibility, even as it ignores the structural basis for disparities in HIV risk, particularly in communities of color. While this justification is understandable in terms of the personal havoc wreaked through addiction, imprisonment, and adverse familial effects, the stigmatizing iconography has relegated IDU to an illegal, shadowy existence outside the realm of proactive HIV prevention in which IDU themselves might become full participants. The Response America's War on Drugs has shaped the iconography of the IDU. This policy has portrayed injection drug use as a problem of blacks or Hispanics in large cities such as Miami or New York (Sills 1994). The imagery has not only hampered HIV prevention efforts, but those moral leaders and lawmakers in the United States who have responded to the War on Drugs have been particularly fierce in raising barriers to HIV prevention for IDU, their sexual partners, and their children (Cohen 1999; Gould 1993). This response includes some African American leaders who have also opposed needle exchange programs, believing them to be a genocidal plot to destroy black communities through accepting illicit drug use as fact (Cohen 1999). However, there is little doubt that the politicization of needle exchange and the refusal of the U.S. federal government to fund harm-reduction programs has increased HIV transmission in minority communities. The CDC estimates that IDU is now the direct or indirect cause of 33 percent of all new cases of HIV/AIDS in the United States, with most of these infections occurring among African Americans (CDC 2001b). The refusal to provide federal funding for needle exchange in the United States has resulted in programs being established in a piecemeal fashion in only 81 cities, mostly in the Pacific West and the Northeast (CDC 2001b). In a Washington Post article entitled Scarcely a Dent in the AIDS Menace, Rene Sanchez (1994) noted that the problems inherent in a lack of federal funding were reflected in one city-sponsored program in Washington, D.C., that was so restrictive as to be a complete flop. Other U.S. needle exchanges have been similarly hampered by moral, fiscal, and political concerns. Hurley and Jolley (1997) have documented that many of the 55 needle exchange programs established in U.S. cities by 1994 operated illegally, with tenuous funding, and on a limited scale. The authors concluded that needle exchange remains controversial in the United States despite sufficient evidence about its efficacy in HIV prevention. National needle exchange programs have been established in a number of other countries, especially in Europe (Hurley and Jolley 1997). Most of these programs were introduced without the moral furor that occurred in the United States. Britain is one nation where such programs were given official, if quiet, sanction once the government realized that the HIV/AIDS epidemic demanded a departure from the U.S.-style War on Drugs (Henderson 1993). The HIV prevalence in IDU in Britain has remained low (8 percent of the total infections), and other countries with needle exchange have reported similar success. These countries include Canada (11 percent of the total), the Netherlands (11 percent), Australia (3

percent), and New Zealand (2.4 percent) (Australian Annual Surveillance Report 2001; CDC 2001b; European Centre for the Epidemiological Monitoring of AIDS 1999; New Zealand Ministry of Health 2001). The CDC has noted the special case of Poland, where a national needle exchange program successfully limited the number of new infections in IDU and prevented HIV from gaining a foothold in the general population (CDC 2001b). HIV prevalence also remains low in countries such as the Czech Republic, Hungary, and Slovenia, where well-designed HIV/AIDS programs, including needle exchange, were established more recently on a national basis (CDC 2001b). The countries mounting a strong response to HIV prevention for IDU have several factors in common. First, they rejected the War on Drugs rhetoric that characterized the U.S. response. Second, they had a tradition of government intervention in public health crises. To illustrate, the Netherlands, an innovator in health reforms, established the world's first needle exchange program in 1984. This program provided a model for other countries (American Civil Liberties Union 2001). The British government followed the Netherlands' example by taking a U-turn in existing drug policy and by approaching harm reduction as a government responsibility rather than as a social problem to be criminalized (Henderson 1993). In New Zealand, Australia, and Canada, the iconography of IDU as a public health threat led the government to allocate funds to community groups, which then supplied clients with clean needles and HIV prevention materials, including condoms (Davis and Lichtenstein 1996). The AIDS iconography of the IDU as socially disreputable and criminal was tempered by this approach so that injection drug use became partially decriminalized in the interests of protecting the public health. The iconography of the IDU as criminal has masked the role of social change as an important element in promoting illicit drug use. The World Health Organization has noted the case of former Soviet countries (e.g., Belarus, Ukraine, Russia, Bulgaria, and Romania) as examples of the syndemic of social change, illicit drug use, and HIV/AIDS. The CDC has defined syndemic as two or more factors interacting synergistically and contributing to an excess burden of disease in a population (CDC 2002b). The transition to capitalism in these countries has been marked by a recent and rapid spread of drug trafficking, proximity to drug supply routes, widespread unemployment, economic dislocation, and political instability (UNAIDS 2001). There are also fewer government services, high inflation, endemic corruption, and widening disparities between the rich and poor. A particularly dramatic example of the effects of social change on HIV transmission has been in the Ukraine. There, 47 cases of HIV infection in 1994 had risen to 24,000 by 1998, with an estimated 79 percent of these infections occurring in IDU (see Table 19.1). This example underscores the importance of understanding how the effects of political change are often expressed synergistically through risk taking, ill health, criminality, and other social problems. The African Eve The Iconography Much of the scientific and public speculation about the origins of HIV/AIDS has centered on the African subcontinent. From the outset, Dr. Robert Gallo (codiscoverer of HIV) stated that he could not conceive of AIDS coming from anywhere else but Africa (Treichler 1988a). The Africa theory is now widely accepted in the scientific literature (Connor and Kingman 1988; Leibowitz 1985), especially after it was linked to a single species of African ape (see Feng et al. 1999). However, the idea of sexually transmitted disease as New World in origin predated this latest discovery. Gilman (1988) and Fee (1988) have noted that understandings about STI and Africa began during colonial times when syphilis was linked with African slavery. They also note that while the Europeans had infected colonized people with STI, blame was attributed to the non-Europeans in the racist ideology of the times. Gilman (1988) has argued that such attributions about STI are very much in line with Western notions that blacks are inherently different and have a fundamentally different relationship to disease. Blame has also

been attributed to women as natural reservoirs of such disease, particularly in colonized countries (Kehoe 1992). The AIDS epidemic in Africa has been defined as heterosexual, or Type II in epidemiologic terms (Smallman-Raynor, Cliff, and Haggett 1992). For this reason, and in the tradition of the STI epidemics, attributions of blame have again centered on women. Treichler (1988a) has noted that African women, whose exotic bodies, sexual practices, or who knows what, are seen to be so radically different from those of [other] women that anything could happen in them (p. 46). The African Eve icon has emerged from this conceptualization as sexually promiscuous and often a prostitute. This iconography is perpetuated in common lore, but also in HIV surveillance that focuses mainly on women as sentinel populations (i.e., pregnant women, female sex workers). This gendered approach has identified the problem of women's greater HIV risk, but the lack of surveillance data for men reinforces the notion of women being the locus of disease and perpetuates largely unexamined assumptions about heterosexuality being the only mode of HIV transmission in Africa. Most attributions about women as AIDS vectors center on prostitutes who have sex with migrant workers and truckers or women who engage in commodity or survival sex (see Barnett and Blaikie 1992; Gould 1993). African women have sometimes been labeled pervasive vectors and a major reservoir of the AIDS virus because of the literally hundreds of contacts they have a year (Packard and Epstein 1992; Treichler 1988b). Certain types of African women (notably those from the non-clitoridectomizing Haya tribe of Northwest Tanzania) are said to be so interested in sex that they constitute a disproportionate number of Nairobi's sex workers (Caldwell and Caldwell 1993). The African woman's alleged promiscuity and high-STI rates have helped cast her as the female, heterosexual equivalent of the gay male fast-laner. This focus on female promiscuity has proven a distraction from investigating the broader mechanisms of HIV/AIDS in Africa or men's roles in HIV transmission and thus provided little predictive power for understanding the scope of the epidemic. The Response Popular beliefs about the sexual dangerousness of women have had unfortunate results. These results include HIV-positive women in South Africa being kept in hospital against their will, ostensibly to protect their partners from infection (Raletsemo 1995). On a social level, women are perceived as vaginas waiting to infect men (Patton 1994). A particularly tragic outcome of the epidemic is that young female children who are orphaned by HIV/AIDS turn to prostitution as the only means of supporting themselves and their siblings (Gould 1993). At the same time, older infected men seek virgins or young girls for sexual intercourse as protection from disease, thus bringing the virus into the next generation (UNAIDS 2000). These practices not only expose women to HIV risk at an early age, but the sexual commodification of girls is being naturalized by the events surrounding maternal death and orphanhood. The emphasis on women's sexuality has given rise to extreme comments about female AIDS vectors. For example, a Zimbabwe MP, Chief Mutoko, is reported to have said, If a pregnant woman is found to have AIDS, she should be killed so that the AIDS ends there with her. You should not only terminate the pregnancy because the woman would still continue to spread the AIDS. (The Press 1994:4) Chief Mutoko made this statement despite belonging to a male elite that routinely has access to a retinue of femmes libres (tokens of esteem) as a class privilege (Gould 1993). In a similar vein, influential men in Mozambique resist the idea of issuing condoms to women because to do so would promote promiscuity and disrespect of men (Epstein 2002). These perspectives ignore the gendered hierarchy of HIV transmission and the fact that HIV infection has often passed from social elites (powerful men) to the lower classes (female consorts) in what Gould (1993) refers to as the hierarchical diffusion of the virus in Africa (p. 83).

The notion that African women are natural reservoirs of STI/HIV infection has also been promulgated through studies of female prostitution and other forms of sexual exchange. Packard and Epstein (1992) have argued that this first-world construction in the scientific literature reflects the Western tendency to look for deviance in an African setting. This conceptualization means that the behavior of African prostitutes has been described, quantified, and analyzed in a manner similar to that of gay men in the United States. To reiterate Leibowitz (1985), this focus illustrates how the sexuality of an AIDS icon provides a legitimized and often titillating insight into how other people live their lives. The heterosexual man (often the silent partner in the HIV/AIDS epidemic) avoids this scrutiny. Indeed, prevalence statistics for men are rarely listed in AIDS reports (see UNAIDS 2002). A social problems perspective on the female vector theory of AIDS in Africa is that cultural practices, poverty, and economic factors contribute to the high rates of HIV infection in the region. For example, polygamy, widow sharing (which requires a woman to marry her late husband's brother), and dry sex are considered to be important factors in HIV transmission. A lack of circumcision among sub-Saharan African men has been associated with higher HIV infection rates in the region, particularly in the presence of genital ulcer disease (GUD) (Caldwell and Caldwell 1993; Connor and Kingman 1988; Leibowitz 1985). The politics of gender inequality also mean that impoverished women are likely to be at risk by having sex with older, wealthier men (age mixing) in exchange for food or money (Epstein 2002). These sexual exchanges often occur in depopulated rural areas because of out-migration of men to industrial cities in South Africa, or in regions characterized by war and famine. Several recent studies and reports have suggested that violence against women has become a critical element of HIV risk in Africa (Epstein 2001; Hankins et al. 2002; UNAIDS 2000). This violence is part of greater problems relating to poverty as well as to war and civil unrest. Two examples of violence-related HIV risk include the jack rolling of women (seemingly random rape and robbery) by youth in urban slums in Johannesburg (Gould 1993) and the rape of female refugees in refugee camps in war-torn countries of Africa and elsewhere (Hankins et al. 2002). Violence has also been directed toward HIV-positive women because of assumptions about their promiscuity or because of a heightened stigma (UNAIDS 2000). The iconography of African women as AIDS vectors masks the power structures that give rise to discriminatory practices and differentials in HIV risk and offers a reminder of the synergy between inequality and disease. HIV/AIDS in the Twenty-First Century The Iconography The creation of social pariahs in the AIDS epidemic was an alarmist response to an emerging health crisis. This iconography emerged from existing ideas about the role of sexual deviance in the transmission of STI. AIDS as a social problem was first defined by its specificity (e.g., gay men and IDU in the developed world and the female prostitute in Africa). However, recent developments suggest that AIDS iconography is becoming more unified in the twentyfirst century. For example, ethnicity is now a defining feature of HIV risk across the globe, meaning that there is a conflation of race and risk behavior in understandings about HIV transmission. This conflation is evident in the focus on HIV transmission in developing countries, particularly in sub-Saharan Africa and Asia. In the United States and other countries with majority white populations, the trend toward conflation is evident in STI/HIV surveillance statistics and in HIV prevention funding that is increasingly targeted to minority populations. Delaporte's (1986) analysis of responses to the cholera epidemic in eighteenth-century France provides a model for further understanding the iconography of HIV/AIDS. Delaporte noted that cholera disproportionately afflicted working-class citizens in Paris, leading to the widespread belief that they were the source of contagion. Attributions of blame included accusing the poor of being thieves and revolutionaries who were spreading disease in a plot to overthrow the

French ruling classes. Public health responses included quarantine for the afflicted in hospitals outside city areas and marking the doors of victims who had died. At the heart of the problem were the overcrowding and unsanitary conditions that ensured that the poor had a higher susceptibility to disease. The newly coined germ theory of the nineteenth century later provided a scientific explanation for cholera as an infectious rather than iatrogenic agent (i.e., due to environmental factors rather than to sin or social inferiority). This explanation led to a revolution in public health in the development of modern-day sewers and treated drinking water that ended the outbreaks of cholera in industrialized nations. Attributions of blame for the poor as disease bearers in the cholera epidemic soon disappeared, suggesting that such blame motifs occur in the absence of a cure or adequate measures of control. Delaporte's theory that diseases are produced through harmful or discriminatory practices has been the basis of theorizing by Crimp (1988) and other community AIDS activists. For these activists, the public attitudes and laws that drive homosexuality underground, or that prevent the funding of needle exchange, have provided a fertile ground for HIV transmission. Two related factors are at work. Gilman (1988) has noted that the desire to create a cordon sanitaire between infected persons and others becomes a matter of urgency. A stigmatizing iconography is necessary in order to justify this distance on moral grounds. Furthermore, the iconography exists only for as long as it is useful or relevant. In the case of the STI epidemics, a stigmatizing iconography persisted in the interests of controlling sexuality and in the absence of a cure (Brandt 1988). This imagery, which focused on good-time girls and female prostitutes, largely vanished from public view in the United States and in other Western nations once a cure (penicillin) was found in 1943. The reemergence of a stigmatizing iconography in the HIV/AIDS epidemic indicates the persistence of STI-related images but also the concerns of moral entrepreneurs and the worried well during the time of plague (Lichtenstein 1996c). If the responses to other epidemics are any guide, the stigma of HIV/AIDS will diminish over time because there will no longer be a compelling need to flee from the specter of death (i.e., if a cure is found or as HIV infection becomes less fatal, as in the case of syphilis). HIV/AIDS may become just another STI, which, although stigmatized, can be managed by passing or concealing it from other people (Goffman 1963). This historical precedent suggests that the iconography of HIV/AIDS will change over time. I propose three discrete stages to take account of this type of development. A linear path may follow from Stage 1 to Stage 3 or may vary depending on international patterns in the epidemiology of HIV/AIDS. The stages are (1) personalization, in which the disease is viewed as a potential threat to everyone; (2) externalization, in which the sense of personal threat diminishes if the disease is seen to afflict a particular segment of society; and (3) habituation, in which HIV/AIDS becomes just another disease in terms of its treatment and perceptions about its normality. These stages are outlined below. In the first stage, personalization, explanations are urgently sought for the sudden appearance of the disease, its level of contagion, and the means by which it is spread (i.e., through ports of entry or immigration). In the case of HIV/AIDS, there was an immediate search for risk groups to determine the threat to society. The public gained a semblance of control over its panic, in part through a defining set of images about PWH. In terms of Gilman's (1988) concept of creating barriers to the threat of contagion, this iconography later resulted in the involuntary detention of HIVpositive Haitians who attempted to immigrate to the United States and in the segregation of PWH from other patients in U.S. hospitals. Other countries also followed this example, as in the case of the quarantine of PWH in Cuba and the compulsory hospital confinement of infected women in South Africa. In the second stage, externalization, AIDS is seen as more of an external threat to the majority, and iconography becomes less compelling as a mechanism for HIV control. In the United States, this stage occurred after HIV/AIDS was understood to afflict other types of people

and societies more clearly and after antiviral medicines transformed HIV/ AIDS into a more manageable disease. This second stage has been reached in most industrialized countries, where a diminishing sense of personal threat means that safer-sex guidelines are often being ignored, even by people deemed at high risk of infection (CDC 2001a). However, this externalization is not the case in developing countries, particularly those in sub-Saharan Africa, where the number of infections continues to escalate and where categories of HIV risk are being expanded to take account of the scale of the tragedy. The third stage, habituation, will relegate HIV/AIDS to a minor health concern if a vaccine is developed or a cure is found. In the West, this development will mean that HIV/AIDS will become part of the hidden epidemic of STI (Eng and Butler 1997) in which passing (Goffman 1963) is considered normative. Stage 3 may be reached by developed nations during the twentyfirst century. However, based on present projections in the global epidemiology of AIDS, developing countries may progress slowly, if at all. For example, Stage 2 may not be reached in some subSaharan countries in the foreseeable future if antiviral medicines remain unavailable to the public or if so many people are infected that it becomes impossible for overburdened and underfunded health systems to offer HIV prevention to reduce the level of infection in their societies. Nevertheless, the waxing and waning of all epidemics throughout human history (e.g., leprosy, bubonic plague, cholera, yellow fever, influenza) suggests that a staged response will eventually take place, even as it involves a catastrophic loss of life. The Epidemiology Further outbreaks of HIV/AIDS in the twentyfirst century depend upon sexual cultures, war, famine, drug routes, and political unrest, as well as access to antiretroviral medicines and treated blood supplies. Recent trends in HIV transmission indicate that large population centers (the former USSR, China, and India) will become epicenters of HIV infection in the twentyfirst century (Bogaarts 1996; UNAIDS 2001). China, for example, stands on the brink of an explosive AIDS epidemic, mainly through injection drug use and illegal schemes to sell untreated blood in rural areas (New York Times 2002b). Southeast Asian countries such as Indonesia and Kampuchea also face the rapid spread of HIV infections among heterosexuals, indicating a generalizing epidemic rather than one that is confined to sentinel populations engaging in injection drug use and same-sex activity. Table 19.2 depicts New Wave epidemics in Asia and the former Soviet republics based on twenty-first century projections in UNAIDS reports. The table also depicts Older Epidemics in non-Western regions that are continuing to grow. Table 19.2 shows that HIV prevalence is not only increasing in Africa and Asia but also across a large swath of the Northern Hemisphere once considered to be at minimal risk. For some countries, the AIDS epidemic is rising so fast that it is a threat to global stability (New York Times 2002a). HIV prevalence is expected to triple over the next eight years in the new-wave countries, which also account for more than 40 percent of the world's population. Experience has shown that the enormity of these newer epidemics depends on how quickly and effectively HIV prevention takes place among sentinel groups (Carael 2002) and how much access the newly infected have to antiviral medicines and other forms of treatment (Farmer 1999). Conclusion This chapter has indicated that HIV/AIDS is socially patterned and that marginality plays an important role in HIV transmission. HIV risk has been well documented in terms of individualized behavior (risk behaviors), but the view that disease is produced through structural inequality offers a broader view of the synergy between individual behavior, social structure, and disease. This structuralist perspective offers a unique opportunity for developing an impetus to change laws, attitudes, and practices in order to protect the public health. The countries that have changed or introduced legislation in the AIDS era to meet this public health threat have usually succeeded in limiting the spread of HIV/AIDS. Nations that have lacked the

political will or resources for HIV prevention may face economic and social ruin, particularly in AIDS-ravaged countries in sub-Saharan Africa. The path of HIV transmission around the globe will depend on whether societies perceive HIV/AIDS to be an intractable social problem, like poverty or crime, or whether AIDS as a special case will prevail in the interests of humanity. This question will be answered by how much AIDS is perceived as a threat in the twenty-first century and whether the disproportionate suffering of some citizens and countries will continue to be tolerated on a global scale. Note 1. The social inequality perspective of this chapter is offered as a counterpoint to popular stereotypes of HIVpositive people as irresponsible or deviant. This is not to suggest that personal factors have no role in becoming infected or that irresponsibility cannot play a role in infecting others. However, the personal responsibility mantra of modern times has created a geography of blame that has not occurred in nonsexual epidemics, such as influenza. I take the view of Farmer (1999), who argues that the idea of personal agency is highly exaggerated and is tantamount to blaming the victim. In this view, not only do individualistic notions of personal responsibility fail to acknowledge how AIDS has become an epidemic of powerlessness, ethnicity, and poverty, but they are flawed because the harmful effects of inequality on disease patterns remain unchallenged and intact. Further Readings Entry Citation: Lichtenstein, Bronwen. "Aids As a Social Problem: The Creation of Social Pariahs in the Management of an Epidemic ." Handbook of Social Problems. 2004. SAGE Publications. 14 May. 2010. <http://www.sage-ereference.com/hdbk_socproblems/Article_n19.html>.