As we saw in Unit 2, global changes in population mobility, climate, or land use have the potential to change the geographic distribution of populations and diseases and even to move some infections rapidly into global circulation. In this unit, we use the global epidemic of HIV/AIDS to illustrate (1) how health and disease are embedded within a complex web of social, economic, political, and cultural factors that can produce inequities in access to health care or in an individual’s health, and (2) how global changes can quickly bring a disease to epidemic proportions.

 

HIV and AIDS

 
    Acquired immune deficiency syndrome (AIDS) is a disease caused by the human immunodeficiency virus (HIV). In the nearly two decades since its first appearance in the US, the virus has spread worldwide. HIV is transmitted by the exchange of bodily fluids (i.e., semen, vaginal fluids, breast milk, and blood) from one person to another, especially through sexual intercourse, but also through intravenous drug use, and less frequently through blood transfusions. Babies can also be infected with the virus in the womb, but not all children born to parents with HIV develop the virus. HIV is actually a retrovirus; it cannot multiply on its own, but rather infiltrates healthy cells and takes over their reproduction processes. Specifically, HIV uses T₄ cells -- white blood cells essential to the human immune system. HIV devastates the immune system because, in using the T₄ cell to reproduce new virus, it destroys the cell in the process. With significantly reduced T₄ cell counts, the body is essentially defenseless against a number of opportunistic infections, including certain forms of pneumonia and cancer, as well as other viruses. At this stage, an individual is considered to have AIDS.

    There are currently an estimated 22.6 million people worldwide with HIV and an additional 6.4 million people have already died as a result of AIDS (Purvis 1996). Sub-Saharan Africa accounts for nearly 60% of the people currently living with HIV. In North America an estimated 750,000 people have the virus. There is neither a cure for HIV, nor a vaccine to prevent its transmission. There are, however, treatments that can extend the life and health of individuals living with HIV/AIDS. For example, antiviral drugs like AZT slow the replication of the virus in some people. In addition, a number of combination therapies or drug "cocktails" combine agents known as protease inhibitors with drugs such as AZT to fight HIV during its life cycle within cells. Treatments are extremely expensive and can cost as much as $20,000 per year, putting them out of reach of almost 90% of the people living with the virus. For example, the average Kenyan would exhaust his annual income in less than a week on the combination therapy treatments available in the US (Purvis 1996).

Government Responses

 
    HIV/AIDS first appeared in the US in predominantly white, homosexual male communities and as a consequence, the disease has been a highly charged issue, subject to emotional, moral, and religious debates. Because of this early connection to homosexuality, people with AIDS and their families were ostracized, and responses to the crisis by politicians and public health officials were inexcusably delayed, resulting in the infection of thousands of people before sufficient resources were allocated to identify the virus and its mode of transmission. While it is now known that all groups of people are susceptible to the virus, the stigma still exists. Outdated notions about who is at risk for acquiring the virus and ignorance of the ways in which the virus is transmitted have kept many people from taking necessary steps to protect themselves and others.

    After years of struggle, protest, and intense political pressure, HIV/AIDS is no longer ignored by the American government as it was during the early 1980s -- the critical, early years of the epidemic. Delays in action, however, were not confined to the US. Governments in other parts of the world have also refused to acknowledge that a problem existed or that their citizens were at risk. Thailand and India both provide important examples of how government action or inaction can directly affect the health of its citizens.

    HIV was introduced to Thailand through intravenous drug use in the ports of Bangkok and quickly spread to commercial sex workers. From the build-up of a commercial sex industry to service GIs during the Vietnam War to the current marketing of sex tourism to Japanese businessmen, the potential for introduction of HIV into commercial sex workers in Bangkok and dissemination throughout the country was enormous. In 1991, a military regime came to power in Thailand, and all AIDS programs came to a halt (Garrett 1994). The government in 1991 officially reported only a few hundred cases of AIDS, although several thousand commercial sex workers had already tested positive. The authorities and parliament (dominated by the military regime) suppressed the information in order to protect one of Thailand’s main sources of foreign exchange -- its general tourist industry.

    Student and civilian agitation in that same year led to new elections and a new government. The new prime minister installed Mechai Viravaidhya, the leader of the national family planning movement and condom promoter, to head the AIDS information campaign. The campaign has been quite successful, and the dissemination of information, tighter control of the sex industry, increased testing, and the promotion of condom use has led to a recent stabilization of the epidemic. But the loss of those first five years of the epidemic, however, has cost the country dearly. The disease has spread to the clients of sex workers and from the clients to their spouses, partners, and eventually their children. In less than a decade, more than 840,000 people in Thailand have been infected with HIV (Brown and Sittitrai 1995). Currently, more than 2% of women attending prenatal care clinics in Thailand are testing HIV positive (Brown and Sittitrai 1995).

    In India, the situation could be even more disastrous. HIV was introduced into South Asia in the mid-1980s, and already there are five million infected adults (Purvis 1996). It is predicted that within ten years, more people will be living with AIDS in India than in all of sub-Saharan Africa (Garrett 1994). Although these numbers seem large, getting government bureaucrats or physicians to take the epidemic seriously has proven difficult because the numbers are actually relatively small compared to other health needs in India. For example, efforts to increase surveillance and blood testing or to launch major educational efforts on HIV/AIDS are hard to justify when money is not available for testing blood for malaria, or screening it for TB or lead, all of which presently affect hundreds of millions. The difficult choices that India faces are clear.

    By underestimating or ignoring the risks of HIV infection, governments in effect deny their citizens access to life-saving information and set them up to be hard hit by HIV/AIDS. In places where governments have acknowledged the potential risks of HIV/AIDS, political and legislative reactions to people with HIV/AIDS have sometimes been extreme. Restrictions on travel and employment, lifetime quarantines, and mandatory testing of people considered to be at risk are all actions that have been taken in response to the epidemic. Fears of such actions may prevent many people who are at risk of infection from being tested.

Stopping the Epidemic: Treatment and Prevention

 
    If we consider for a moment the global diffusion of the HIV virus, it is easy to see how technological advancements and increased mobility have made its spread easier and its containment more difficult. In Africa, the spread of HIV along truck routes used by rural-to-urban migrants is well documented. With improvements in road networks and increased availability of transcontinental travel, it is virtually impossible to contain the virus. Borders are more porous today than ever, and quarantine doesn’t appear to present an acceptable alternative.

    One approach to curbing the spread of HIV/AIDS is to focus on the conditions that put people at risk and to educate them about how their actions can be modified to reduce their risk of infection. Efforts of this type inevitably face several barriers to success. As mentioned earlier, cultural factors such as religion, morals, values, and traditions can be difficult obstacles in the fight against the disease. Economic conditions are another barrier to effective prevention efforts. Poverty, in the US and worldwide, is inextricably linked to poor health and affliction with disease. Living in conditions of poverty with limited or no access to health care, clean water, adequate food supplies, or quality educational materials puts people at a greater risk for contracting HIV/AIDS. Intravenous drug use and prostitution, both closely tied to conditions of poverty and/or social oppression, often produce the same effect. Dealing with the immediate consequences and daily concerns of a life in poverty often outweigh any concern for the potential for future illness.

    As mentioned above, once an individual has contracted HIV, treatment of the many conditions associated with HIV/AIDS is extremely costly. In some countries, medications cost more per treatment than the annual per capita health care budget expenditure. Loss of life from HIV/AIDS can also have severe economic effects on families and entire communities. In many African countries a generation is being lost. In rural areas where condoms are unknown or unavailable, young children are frequently orphaned and left without grandparents to help them maintain their farms and their livelihoods. Beyond the impacts to families, a Zimbabwean businessman addressed the inevitable worker shortage his industry will face when he stated that, "more apprentices should be recruited by the printing industry in Zimbabwe to replace those workers who die from AIDS in the coming years" (South 1991).

    Differences in perception also pose problems in implementing effective educational and preventative campaigns. In the US where the first cases of AIDS were diagnosed in gay men, HIV/AIDS was originally thought of as a "gay disease," making it difficult to communicate the risk to all groups of people. Comparatively, in some parts of Africa where entire families and villages have been stricken by the virus, AIDS is considered a "family disease." In Yugoslavia the disease is spread foremost through intravenous drug use while in Romania most of the HIV/AIDS infected people are children who received contaminated blood products (South 1991).

    Perspectives on appropriate prevention methods differ as well. In the scientific community, it is known that condoms provide highly effective protection against the sexual transmission of the virus. In the US, campaigns have been instituted to promote the use of condoms, but not without years of intense struggle and debate. Americans were forced to confront their cultural taboos and religious and moral beliefs surrounding notions of sex and homosexuality. Consider for a moment the intense public debates that continue to surface over condom advertisements on television, sex and sexuality education in public schools, and the distribution of condoms. Other parts of the world face similar problems. In areas of the Middle East, suggesting the use of condoms goes against firm religious beliefs that preclude discussion of any sexual practices -- heterosexual or homosexual. Programs sponsored by the World Health Organization in such parts of the world promote condom use as a family planning method as opposed to an AIDS prevention method in order to work around these limitations. Such culturally sensitive approaches are important worldwide. In the US community outreach groups often employ diverse approaches in campaigns for different target groups. Hispanic populations, significantly hard hit by intravenous drug use, are now being targeted by curricula specifically designed for drug users in the Hispanic community (AIDS Reference Guide 1996).

    This unit has focused on how impacts from global changes will be experienced differently across populations, and specifically, how human health issues and responses to health crises are embedded in a number of social, cultural, and economic contexts that shape perceptions, impacts, and responses. In Unit 4, we turn to a case study of plague in India to explore the processes through which a disease, like bubonic plague, is spread.