Plagues in World History (34 page)

Women in Africa are also disproportionately burdened in terms of nursing and caring for AIDS patients, which can further restrict their economic and educational opportunities. Particularly heartbreaking has been the psychological and 166 y Chapter 6

economic stress upon older women, such as grandmothers, who must care for their grandchildren orphaned by the disease at the same time that they mourn their children.56 When familial networks prove unequal to the task of caring for Africa’s numerous “AIDS orphans,” their upbringing poses a challenge to state institutions, and there is a danger that, due to stigma or poverty, these children will then grow up to become alienated from their societies. Still, there is hope for women and children in Africa in the age of AIDS: greater access to antiretroviral treatments is allowing AIDS parents to live longer, while the disease is also driving various cultural changes and opportunities that can benefit women. For example, in Tanzania it is anecdotally reported that the AIDS epidemic has strengthened family bonds and partner fidelity, increased acceptance of condoms, improved women’s access to education and legal ability to inherit, facilitated formation of women’s clubs and other female-oriented community groups and organizations, and generally made society more aware of the special issues faced by women as a result of the disease.57 In South Africa, a grassroots feminism movement seems to have been galvanized by the 2005 rape trial of the current president, Jacob Zuma, who was acquitted but whose testimony during the trial underscored some of the larger issues at stake in oppressive attitudes toward women that make them particularly vulnerable to AIDS. Zuma testified that he felt himself “obligated” to have sex with his alleged victim by her pro-vocative dress and demeanor (his further claim that denying an aroused women is “tantamount to rape” defies logic), and that he was not concerned about contracting AIDS despite his alleged victim’s HIV-positive status because he had showered afterward. Above all, the case demonstrated a need to address gender inequalities and sexual violence, even in a country with the most liberal democratic constitution in Africa, which nonetheless is reputed to have the highest incidence of rape in the world.58

Within the Caribbean, AIDS scholarship has naturally focused on Haiti and Cuba, even though AIDS has established a presence throughout the region. Because the epidemic here is primarily driven by heterosexual transmission, it has been classified as among Pattern II countries, along with those in sub-Saharan Africa. But there are other reasons for linking the Caribbean with Africa in terms of AIDS incidence: poverty, malnutrition, lack of safe drinking water, STDs, and other coexistent diseases are likewise prevalent throughout the region and are important cofactors of AIDS. Many Caribbean countries are also plagued by low ratios of doctors and poor availability of health services among the general population, and, as in Africa, commercial sex workers and migrant laborers are among the leading members of the “high-risk” population for AIDS. For instance, UNAIDS reports that, as of 2008, 27 percent of commercial sex workers in Guyana are infected, and in the Dominican Republic, the
bateye
migrants AIDS y 167

from neighboring Haiti who work on the country’s sugarcane plantations are particularly vulnerable. Compared to other regions except for Africa, the Caribbean also has a high AIDS incidence among women, who currently make up about half of all infections, and as in Africa HIV prevalence is especially high among younger women; the Caribbean also ranks just behind Africa in terms of its overall seroprevalence rate, which currently stands at 1 percent of its general population, even though this is still a fifth of Africa’s.59 The spread of and response to AIDS in the Caribbean is heavily impacted by its long legacy of having been subjected to imperialist domination, which during the twentieth century prior to the epidemic came from the United States, just as Africa was likewise emerging from under European rule in the decades leading up to AIDS.

There are, however, circumstances that are unique to the Caribbean’s experience with AIDS, which are best illustrated by the oft-cited case studies of Haiti and Cuba. Owing to its international sex tourism trade, including child prostitution (which is also prevalent throughout Latin America), the Caribbean, and Haiti in particular, is thought by many observers to have served as the key nexus, or Bermuda triangle if you will, of the global AIDS pandemic. It is possible, for example, that AIDS was imported to Haiti by French-speaking guest workers in the Belgian Congo or Zaire, as it was known then, during the 1960s and 1970s; the virus would then, in this scenario, have been imported to the United States and Europe through the gay sex tours that had long operated in impoverished Haiti.60 Others point out, however, that AIDS did not emerge in Haiti until after 1980, at exactly the same time as in the United States, so that it is just as likely that the United States
exported
the disease to Haiti. (The five Caribbean basin nations with the most AIDS cases in 1986—Haiti, the Dominican Republic, the Bahamas, Trinidad/Tobago, and Mexico—also happen to be those most economically linked to the United States in terms of tourism and trade.)61 In any case, because the CDC in the United States early on in the epidemic identified Haitians as one of its four “high-risk” groups for AIDS, in spite of the fact that they allegedly did not admit to engaging in gay sex or IV drug use, Haitian immigrants in the United States suffered terrible discrimination throughout much of the 1980s. Stories were told of taxi drivers hiding their identities, schoolchil-dren abused and beaten up, employees fired or refused work, and so on. This was most unjust, as subsequent research and reinterviewing of subjects revealed that, early on at least, HIV transmission in Haiti closely paralleled that in Pattern I countries such as the United States, namely, that the vast majority of victims were men having sex with men or who were bisexual, with the disease gradually spreading into the heterosexual population. (High HIV prevalence rates among men who have sex with men are stil found in Trinidad/Tobago and Jamaica.) Outside the capital of Port-au-Prince, seroprevalence in Haiti was actually quite low in 168 y Chapter 6

comparison with elsewhere in Latin America and even compared with some American cities, such as New York. Racial prejudice and misunderstandings abounded on both sides, in the United States and Haiti. Americans took seriously ridiculous rumors of exotic voodoo blood rituals and cannibalistic practices that al egedly spread AIDS in Haiti, while Haitians were wil ing to believe conspiracy theories that their powerful neighbor to the north had deliberately devised and exported the disease in an effort to further subjugate them.62 Even though the Catholic culture prevalent throughout Latin America since the time of Columbus has impeded preventative efforts such as increasing condom use, HIV infection rates in Haiti have declined dramatically since the late 1980s, when they peaked at around 12 percent of some sampled populations; next door in the Dominican Republic, UNAIDS reports that recent reductions in HIV infections are due to sexual behavioral modifications, such as increased condom use and reduced partner exchange. Nonetheless, Haiti remains the region’s epicenter for the epidemic.

Haiti has by far the most people living with AIDS in the region, currently numbering 120,000, which represents half of the entire AIDS population in the Caribbean, and its seroprevalence rate is double that of the neighboring Dominican Republic.63 Haiti’s tourism economy has also taken a beating from AIDS. When the disease first became known in 1981–1983, the number of visitors to Haiti dropped by as much as 75 percent, and discrimination against Haitians has also been slow to die, since as late as 1990 they were still forbidden to donate blood in the United States.64 And even though the Caribbean has benefited from the fifteen billion dollars in Emergency AIDS Relief pledged by the United States under former president George W. Bush, this has come at the price of enforced emphasis upon abstinence-only programs instead of more proven prevention techniques, such as condom distribution and education.65

The other anomaly in the Caribbean AIDS epidemic is, of course, Cuba. Owing to a decades-long trade embargo imposed by the United States against the Communist regime of Fidel Castro, some might think that Cuba’s low incidence of AIDS might be due to its diplomatic isolation, but that is not actually the case. (To date, there are just over six thousand people living with AIDS in Cuba, for a seroprevalence rate of 0.1 percent, six times lower than that of the United States.) The first AIDS cases in Cuba are thought to have occurred among the hundreds of thousands who served as soldiers on military duty in Africa, such as Ethiopia and Angola, or those who participated in cultural exchange programs abroad. Rather, most scholars agree that Cuba’s success in containing AIDS has been chiefly due to its mass testing program, which was first applied to high-risk groups such as expatriates and tourism industry workers but which was gradually extended to almost the entire population, and to its policy of quarantining all HIV-positive persons in special “sanatoriums” distributed throughout every AIDS y 169

province of Cuba.66 Although Cuba’s approach was unique in all the world, it was not developed in isolation, as its main motivating factor seems to have been a propagandistic desire to outperform the United States in terms of health care, for which AIDS provided a golden opportunity from the Cuban point of view, since it seemed to be a product of American “decadent” behaviors, such as homosexuality—nor was the Cuban response without historical precedent, as the sanatorium system was obviously pioneered during the era of tuberculosis in the nineteenth century, and quarantine was indeed adopted on a small scale during New York City’s tuberculosis epidemic during the 1990s. But Cuba’s policy was a direct contradiction of the privileging of individual rights over society’s welfare, for which AIDS proved to be a turning point in the United States, and human rights organizations criticized Cuba’s sanatoriums on the grounds that quarantine detention was for an indefinite period, despite the fact that its victims were otherwise healthy and could only infect others through conscious, intimate behaviors, and for inhumanely separating couples or even separating parents from their children if only one family member tested HIV-positive. While the Los Cocos sanatorium just outside Havana, which had originally been a rest and recreation center for military officers and therefore was easily transitioned into a facility servicing returning HIV-positive soldiers, showcased the apparent humanity of the system, with medical and housing facilities that, it was pointed out to visitors, were superior to those available to most Cubans on the outside, some inmates told a different tale that included homophobic beatings by guards, attempted suicides, and prisonlike surroundings.67 By the early 1990s, Cuba began modifying its sanatorium regime, at the same time as placing greater emphasis on AIDS education, which some argue it should have done from the very beginning. These changes were partly in response to international pressure; partly in response to a growing economic crisis caused by the collapse of Cuba’s leading economic and political partner, the Soviet Union, in 1991; and finally in response to a home-grown protest movement, known as the
roqueros
or “rockers,”

a music subculture of young people who self-injected themselves with HIV-tainted blood as an act of political defiance but whose numbers were also swelled by spouses who wished to join their loved ones sequestered in the sanatoriums.

Though their numbers were relatively small, about two hundred by 1992, the roqueros grabbed some international media attention even if Cuban Americans in the United States were loath to embrace such a bizarre, some would say almost perverse, method of protest. At the present time, it is reported that most AIDS

patients in Cuba reside in their local communities and receive care at outpatient clinics, while the sanatoriums now function as educational or training centers for an initial three-month period or else as a home base for those who otherwise live and work on the outside. Cuba has also stepped up its antiretroviral program, 170 y Chapter 6

whose drugs are manufactured internally due to the embargo and which Cuba offers at low prices to other Caribbean nations.68 In contrast to elsewhere in the region, homosexual intercourse, long a taboo subject in the country, may now be driving a rising incidence of AIDS in Cuba. One other territory that is bucking the trend in the Caribbean is Puerto Rico, where most HIV transmissions are due to intravenous drug use, accounting for 40 percent of new infections among men and 27 percent among women as of 2006.69

In Central and South America, AIDS has generally followed the transmission patterns that have also held true in the United States and other Pattern I countries, namely, being largely driven by homosexual intercourse and IV drug use, although there are exceptions, such as Honduras, which early on became the epicenter of the AIDS epidemic in Central America and where infections were attributed to heterosexual behaviors, especially among commercial sex workers.70

As in the United States, men outnumber women in terms of those infected and living with AIDS, but again this may change due, it is said, to the possibility that bisexual behaviors may be underreported owing to the different ways in which gay sexuality is defined and understood in Latin America, where only transves-tites and receptive partners are perceived as actually engaging in homosexual sex.

Latin America also mirrors the United States in terms of its low seroprevalence rate, currently at 0.6 percent, almost exactly that of the United States, and in its higher than average provision of antiretroviral treatment to its HIV-positive population, which was 54 percent as of 2008. And yet, Latin America has many of the same disadvantages and cofactors for AIDS that we have seen operating in Africa and the Caribbean, namely, widespread poverty and income disparities; malnutrition; predisposing disease environments, such as malaria; a large migrant labor population; and, associated with that, a high incidence of sexual exploitation and prostitution.71 Some countries in Central America, particularly Nicaragua, El Salvador, Guatemala, and Panama, have also known recent military intervention from the United States or else civil unrest just prior to and during the AIDS epidemic, while in South America numerous countries have until quite recently experienced brutal dictatorial regimes or domestic violence from drug cartels and guerrilla groups, such as in Colombia and Peru.72 How, then, do we explain the region’s relative success in combating AIDS?