HIV and AIDS: The Global Inter-Connection

ON THE EVE OF DESTRUCTION

By Marie St. Cyr-Delpe

HIV, which knows no social or economic barriers, no political ideology, and recognizes no skin colour, is planting seeds of destruction in communities, nations, and continents throughout the world. Yet each nation must face the challenge in the context of its own historical, cultural, economic, social, and political realities.

The realities that shape the course of HIV in Haiti are devastating. The Haitian people have endured five decades of autocratic rule, disastrous economic policies, environmental decay, and social neglect. For much of this period, Haiti has been in the midst of the most destructive political upheavals of its history. Just as the forests that once blanketed her hillsides have been depleted, so too have the ranks of her citizens. Death claims many as a result of the endemic poverty, hunger, disease, and political violence. Woefully inadequate health care has left Haiti with one of the world's highest rates of infant and maternal mortality, and an average life expectancy of fifty-five years of age. Seventy-eight per cent of the population live in poverty.

It is not surprising, given this situation, that Haitians in ever increasing numbers have fled the country. Beginning in 1957, with the advent of the Duvalier regime, Haiti began to experience a marked surge in emigration to other countries. It was the literate, educated, and skilled who began the exodus, but by the end of the Duvaliers' thirty-year reign, rural farmers, who had once migrated to the coastal cities, were leaving the country in ever growing numbers. Although many Haitians settled in other Caribbean nations, Canada and Europe, the United States was their prime destination. As a result there are more Haitian physicians in New York City than in Port-au-Prince.

The last ten years of the Duvalier regime and its aftermath, a period plagued by ever changing civil-military governments, unfortunately coincided with the accelerated global spread of HIV. Throughout the 1980s, there was persistent denial of the dimensions of the HIV epidemic first by government leaders and then by the people. Thus the changes needed to prevent the epidemic's spread were never addressed.

This denial was linked to the country's need to preserve its tourism industry, which was already suffering because of the deteriorating political climate. It was also fueled by the ruling elite's blatant disregard for the well-being of the majority of the Haitian people. But the level of denial among Haitians living at home and abroad was greatly increased by the stigmatizing linkage of Haiti with HIV globally, most notably in the United States. Therefore, HIV and AIDS were added to the list of taboos and family secrets, and the struggle for national dignity and personal pride overrode the need to develop prevention programmes.

Haiti is the only country once classified by the United States' Centers for Disease Control in their "4H" categorization of groups at high risk of contracting and spreading the infection (Homosexuals, Heroin Addicts, Hemophiliacs, and Haitians). Thus, in 1982, Haitians who had emigrated to the United States after 1977 were automatically barred from donating blood. By the time this classification was rescinded in 1990, Haitians had been irrevocably linked with HIV in the minds of many people. This stigma was also was exacerbated by sensationalized stories in the global media that attempted to place the disease's origin in Haiti.

The nation's denial of its HIV problem, along with the country's rapid economic, political, and social deterioration, all combined to set the stage for the current catastrophic health crisis. In mid-1991, Daniel Henrys who was then Haiti's Minister of Health, while acknowledging the need to integrate HIV into the country's health programme, said that HIV and AIDS fell last on the list of the nation's priorities, after malnutrition, tuberculosis, leprosy, diarrhoea, and and infant/maternal mortality. He admitted that due to the government's lack of attention, the overall impact of HIV in Haiti will result in greater losses.

To better understand the potential impact of HIV on development in Haiti, consider the following. It has been estimated that 1 million Haitians now live abroad, and the numbers continue to grow. The majority of those departing are adults in the most productive stage of life, the age group most vulnerable to HIV. Those whom the society does not lose to emigration may be lost to HIV. Thus emigration and HIV are interwoven, as both are critical factors in the skilled-resource crisis that confronts Haiti today. Given the nation's low literacy rate and life expectancy, this crisis would worsen even if HIV were to be stopped in its tracks today.

As a result of the migration of rural people to coastal cities, lifestyles and sexual behaviour have changed. The majority of rural migrants were single. As such, in overcrowded, poor, urban communities, serial monogamy and sex with different partners, practices frowned upon in rural communities, frequently became a way of life. The intensifying economic hardship during the last decade has led to an increase in male and female commercial sex work.

Many studies have shown that a significant number of women are infected with HIV. This is of particular importance to the economy because young, unmarried women constitute the overwhelming majority of employees who work on the assembly lines in Haiti's factories.

The private sector reinvests very little in Haiti and most Haitian wealth is in foreign banks. The HIV epidemic is fostering a situation where both the private and public sector must share the responsibility of curbing the spread of this virus. The government's failure to respond to the epidemic has already compelled many employers to sponsor their own HIV and AIDS education programmes. These efforts are extremely important, but unfortunately their agenda is often set by people who have neither the expertise in HIV prevention nor, in the case of many foreign employers, any actual knowledge of or abiding interest in the people.

It does not appear that current employer involvement is comprehensive enough to offset the spread of HIV and that information on the disease is being passed on by the workers to their families. I hope that when employers begin to lose increasing numbers of their workers and experience a marked decline in productivity, they will not consider coercive policies such as mandatory testing prior to hiring or investing in employee training. Efforts must be made to ensure that such drastic policies are not implemented. At the same time employers need to be provided with models for effective prevention programmes.

The Impact of Culture

Given that the majority of people who are infected with HIV may not know their serostatus or may not have changed their behaviour, Haiti's future is already being shaped by HIV. The social significance of the numbers of infected persons is profound. How many children will be left parentless and without care? How many families will be wiped out? How many thousands of people will be left destitute? What of the psychological impact on the survivors? Because Haiti's population is young, and because the disease affects those at the height of their reproductive and productive work years, the impact will be felt as support, purchasing power, and access to health care diminish.

This scenario, however, must not undermine our ability to creatively search for alternatives which can defray the epidemic's impact on the future of our nation. Granted we are starting this search late but, even if a vaccine were developed now, it would not necessarily eliminate HIV's presence in our midst. Therefore, we must develop strategies that will positively impact on the future.

Culture is at the core of our struggle against HIV in Haiti and the rest of the world, because our hopes for the future are anchored on changing attitudes and sexual behaviour. Personal, religious and social beliefs must be taken into account. In Haiti, major change can occur only if prevention is integrated with traditional culture and values. The hougans (highest-ranking voodoo priests), the bokos (voodoo priests associated with spells and curses), Catholic priests, teachers, the press, and our political leaders must all be incorporated into this effort.

Urban and rural Haiti are as different as separate countries: their world views, cognitive processes, value judgements, and perceptions of government are not the same. Those involved in HIV education must create programmes designed specifically for each of these two differing existences. In the rural areas, these programmes must be linked to the workplace, farm and market square. They should also involve major institutions, places of worship, community leaders, and the neighborhood lakou and katie (housing organized according to family hierarchy and religious rituals). For the urban areas, programmes should utilize advertising and promotion from other countries (Haitians are enamored of imported goods), mass media, and prominent citizens or government representatives.

The need to reach rural people effectively is especially important given that they represent the overwhelming majority of the population and because they feed the nation. As HIV travels from urban to rural areas, consideration should be given to a reverse-trend strategy for education in an effort to stave off the epidemic's spread.

In order to devise effective prevention programmes, one must carefully address socially sanctioned gender-based attitudes and behaviour. One must bear in mind that in Haiti women are perceived as the vector of the disease. This perception is not limited to women who are commercial sex workers, but applies to all sexually active women. Those who are known to be infected with HIV or living with AIDS are hardest hit by ostracism, hatred, and victimization. Along with women's low status in society and their culturally mandated social and sexual passivity, this stigmatization makes it virtually impossible for most Haitian women to initiate safer sex practices for fear of public censure and male reprisal. For many single women, sex with multiple partners and serial monogamous relationships have become necessary strategies for economic survival. This also leaves them particularly vulnerable to HIV infection. Regardless of marital status, a woman's ability to choose or demand their needs is inevitably linked to poverty and a culturally prescribed subservient role in society.

Despite the fact that economic realities and culturally sanctioned attitudes combine to prevent the empowerment of Haitian women when negotiating the terms of sexual conduct, HIV prevention is being focused on them. However, by failing to make the education of Haitian males the priority, prevention policies essentially absolve men of responsibility while reinforcing the belief that HIV is a woman's disease. Placing the burden of responsibility on women for preventing transmission is almost guaranteed to fail.

Prevention efforts in their current form are merely catering to prevailing beliefs. The failure of educators to rid themselves of these notions, and their limited expertise present some of the gravest problems in HIV prevention. The unwillingness of officials to address the disease in a positive way exacerbates the situation. By continuing to downplay or deny the seriousness of the epidemic, they fail to provide the people with leadership in promoting behaviour change. If prevention is to succeed, educators should demonstrate greater awareness and devise relevant programmes that address traditional beliefs and values. They must focus their efforts on reaching men.

The other aspect of Haitian culture that impacts on education, prevention, and care is the interweaving of religious and ritual values with concepts of health and illness. Let us briefly examine voodoo and healing practices. Integral to the concept of illness and healing is the notion of the supernatural and of recourse to folk medicine for treatment. Healing and surviving illness is a collective activity among Haitians. When a person is ill, family and community are in continuous attendance, providing care, preparing strong food like bouillon Pie bef or ji Kawot and appealing to religion for healing. Fear of HIV is now eroding this psychological and physical support system. In its absence, patients tend to die sooner and alone. Their children are avoided, and instead of the acclamation that traditionally follows a death, there is only silence.

Change Is Inevitable

Because HIV challenges the accepted notion of healing, in Haiti the epidemic undermines the deification of doctors, as well as the traditional health providers. Long-held traditions and the underlying economic exploitation by healers will be questioned. Traditional healing may be redefined in a way that merges traditional approaches with Western medicine to enhance people's knowledge, while diminishing the competition between the two methods and providing validation for both. Hopefully there will be an integration of family involvement in the medical care of patients with HIV-related illnesses, because the country's healthcare institutions are ill equipped to manage the increasing numbers of these patients.

Inevitably HIV creates fear that impacts on sexuality. The administration of President Aristide (assuming that he returns to head the government), which reflects the morality of the Catholic Church and preaches the need to respect and protect families, may provide leadership in advocating behaviour change. While I do not believe that Haitians will ever return to the staid social sexual patterns of the past, more responsible sexual behaviour can occur. To achieve this, the government and private sector must make special efforts.

Students and educators should be trained and must spend time in the provinces sharing information with youngsters. Haitians living abroad with skills in counselling or medicine should be recruited as volunteers to train others and to work in the field. Specific programmes geared to the education of the unemployed and those living in poverty should also be priorities. Neighborhood teach-ins should utilize and include people from within the community as educators.

I am often reminded of a statement made by Zambia's former president, Kenneth Kaunda: "The most important thing is not to know where the disease comes from but to discover where it is going." We must acknowledge and confront the reality of our situations. By honestly evaluating what the outcome may be, we can move decisively to reduce the negative impact using strategies based on traditions and values that shape our lives.

HIV mirrors the inequities of the world. Inevitably, the epidemic's true impact on developing nations can be offset only if the crisis compels world leaders to respond with compassionate programmes that hold life more dear than the strategic economic and political manifestations of power. A comprehensive global approach, one that fully marshals the world's material and intellectual resources to fight HIV, is the only method through which we all truly stand a chance of reducing the destructive impact of the epidemic.

Biographical note

Marie St. Cyr-Delpe is a Director of Iris House, an organization in New York servicing women infected with HIV. Previously, she was a deputy commissioner for community relations at the New York City Commission on Human Rights. She has been the director of the Haitian Coalition on AIDS, executive director of Women and AIDS Resource Network (WARN), and a consultant to the American Foundation for AIDS Research.