Bad Medicine: AIDS, Culture, and Women's Health

Article excerpt

WHEN FACED WITH A GLOBAL CRIsis, decision makers tend to search for a single, universally applicable solution. Often, this type of simple answer does not exist, making it necessary to develop more complicated strategies to address the problem. In some cases, however, officials will continue trying to apply a seemingly logical universal policy even after it initially fails. Misguided intervention of this sort can actually exacerbate the problem. This was what occured during early attempts to address the HIV / AIDS epidemic. It was believed that the best way to prevent the spread of the disease was to educate people about the risks of infection so that they would make informed, and thus less dangerous, decisions. These policies failed, however, because of cultural factors that play an important role in determining a population's vulnerability to HIV infection. Regardless of the way in which HIV infection first enters a society, after a time the epidemic has a tendency to affect the most marginalized and impoverished groups within the population.

Members of marginalized groups are more constained by cultural and economic factors than other individuals. Despite this, public health officials tried to address the spread of HIV in these marginalized groups through education, just as they did for other segments of society. These solutions only compounded the problem because they targeted the individual independent of social status and did not recognize the importance of cultural and social factors in vulnerability to disease. In order to best control AIDS, health policy must take into account the differences in the structures of societies around the world. The disproportionate risk of HIV infection among women is one of the best illustrations of the way in which solutions that do not address social factors actually harm the populations they are supposed to help.

Rational Models

In the last decade of response to the HIV / AIDS epidemic, the traditional public health approach was based on the "rational health belief model." This model assumes that if an individual understands the details of HIV infection and transmission, he or she would logically always use condoms when available, or else abstain from sex. In accordance with these beliefs, public health officials around the world have attempted to instruct women about condom usage and reduction of the number of sexual partners. Yet these programs have failed to reduce HIV infection rates considerably because people, especially women, are not always free to make the seemingly logical choices predicted by the rational belief model.

In East Africa, for example, even if a woman is fully aware that her husband is infected with HIV, she cannot protect herself against infection because of her lack of social and economic power. She cannot refuse unprotected intercourse with him for fear of a beating. In addition, her refusal may result in divorce, which would be equally dangerous because of the way marriage and inheritance laws are structured in the region. In other countries, the consequences of a woman's insistence on condom use may not be as severe, but even in the United States, where information about preventing HIV infection abounds and condoms are readily available and relatively inexpensive, women are still reluctant to insist on condom use. One recent study found that an alarming 40 percent of Haitian and Hispanic women, 15 percent of white women, and 20 percent of African American women said they would have sex without a condom with a partner who was HIV infected. Clearly, these women are not acting as the rational health belief model would predict.

Besides encouraging condom use, health officials have been attempting to get women to reduce the number of sexual partners they have. Once again, however, this logical and reasoned attempt at controlling the disease has failed. In much of the world, a woman's risk for HIV is not necessarily dependent on the number of her sexual partners. …