HIV and AIDS: The Global Inter-Connection

SELF-ESTEEM IS ESSENTIAL

Dr. Patricia Burke
Interviewed by Berl Francis

My first contact with HIV in Jamaica was totally unexpected. For several months during 1987, my colleagues and I had been investigating the cause of a three-year-old child's persistent cough, her enlarged liver, spleen, and lymph nodes, and her general failure to thrive. We conducted a battery of tests but the source of her illness remained a mystery until I attended a lecture by Dr. Celia Christie, a Jamaican recently returned from studying infectious diseases in the United States. Then I realized the child had AIDS. That was the first case of pediatric AIDS in Jamaica and, within a few months, we identified four more.

HIV is viewed by most Jamaicans not as a virus which will cause chronic illness with remissions and exacerbations but as an acute plague, a scourge, a moral blight. The society regards itself as highly religious and morally upright. Thus HIV is viewed as a disease of homosexuals and commercial sex workers as they were the first people to be publicly associated with the disease. The conclusion many people draw is that people who contract the virus deserve their lot. Our homophobic society is quick to point out that in the Bible, the punishment for sodomy is death.

Although Government studies indicate that the majority of Jamaicans place more credence on advice from a physician than from any other health-care professional, to date there has been little concerted effort from that quarter to educate the public. The majority of the doctors are male, and I suspect that their reluctance to speak out is because many fear being labelled as homosexuals.

In this atmosphere of ignorance and prejudice, rejection of those living with HIV is almost automatic. Stigmatization is the last thing that HIV-infected persons and those diagnosed with AIDS either want or need. The fear of discovery, stigmatization, and censure has sent many infected and affected people underground as people go to any lengths to protect themselves. They would rather be dead than rejected.

People diagnosed as being HIV-positive react like anyone faced with grief and loss. They show the classic responses of denial, anger, bargaining, depression, and acceptance. But in light of society's strong censure, they also show tremendous paranoia. Because this is a small country, their first and foremost reaction is that no one should know.

Are Intensive Information Programmes Enough?

For the sake of those who are infected and also for the good of our entire society, a much more intensive information programme should be launched immediately. We must educate the public about the reality of the disease and the necessity of treating people living with HIV and AIDS with compassion and understanding. Current information programmes are helpful but HIV cannot be controlled through mass media alone. With the media one is simply transmitting a message. Information is disseminated but you may not be changing attitudes and concepts, hence behaviour will not change. The basic concepts affecting self-esteem, sexuality, and disease prevention must be addressed before behaviour change can occur.

Our country desperately needs a national education programme that focuses on teenagers and younger children. Classes that teach human sexuality in the context of awareness and responsibility, provide information on sexually transmitted infections, and destroy myths that encourage unsafe practices must be developed.

Targeting this younger age group is especially important because early sexual activity is a distinct aspect of the Jamaican social and cultural pattern. Nearly 25 per cent of all births on the island are to girls ranging in age from ten to nineteen. It is expected that by age eighteen, the average young woman will already given birth to two children. Currently, young adults between the ages of twenty and thirty-nine constitute the most highly HIV-infected segment of society. Given the incubation period of HIV, it is clear that many became infected as teenagers.

Attitudes and behaviours within a society are so deep-rooted they are extremely difficult to change. Counselling sessions structured to address issues that put people at risk of contracting HIV along with other self-esteem building programmes are needed for both men and women of all ages and socioeconomic groups. For example, among middle- and upper-class Jamaican women, there are many whose sense of self and social status is tied to their marriage. If a woman, regardless of her economic class, can be encouraged not to barter sexual favours for money and status, then she may feel more secure in telling a man to wear a condom.

In our society, men's self-esteem is closely linked to their sexual prowess and to the number of women that they can financially support. Men are also taught that sexual experience and control of women are valuable male characteristics. Mothers and fathers alike encourage that sort of behaviour as their sons grow into manhood. The more financially successful a man is, the greater his sense of entitlement. If men can be encouraged to value sexual responsibility and restraint, rather than excess, we will have gone along way toward reducing the risk.

We at the Family Centre have watched self-esteem building approaches work with family members of teenagers living with HIV. When the Centre first opened, we recognized the need to involve these adolescents in various activities.

Unfortunately, many young girls living in poverty believe that their only means of escape from poverty is the commercial sex industry. Girls who come to the Family Centre are being shown that there are other options through unstructured, ongoing interaction with the programme staff. Gradually the girls begin to adopt new attitudes toward themselves and as a result new behaviours evolve. When interacting with males, the girls now tend to be more assertive and self confident.

People attending the Centre are drawn exclusively from poor economic groups which are hardest hit by HIV. Illiteracy and the absence of marketable skills heighten their vulnerability. But there are also a number of other factors at work that contribute to the problem.

Male response to economic hardship may well be a contributing factor to the instability of so many relationships. For most men, unemployment and underemployment are the norm and their wages often provide only the basics. In the rural areas many choose to become migrant workers. They work on farms in the United States and Canada or in the cane fields in their own or neighboring countries. They tend to establish relationships with women wherever they go. As a result of this migratory lifestyle, serial relationships often become a way of life for low-income Jamaican men and women.

Other factors are involved though, one of the most important being socialization. Girls are taught from an early age to develop strategies for survival, which usually revolve around their ability to work, to be caretakers, to market sex, and to bear children. The latter is very important, because men place a high value on proven virility. As a result, women who do not bear children risk being labeled "mules" and being abandoned. They are not seriously considered for marriage.

At the same time, girls are also taught that it is extremely important to have a male partner, that men are dominant, and that a woman is not free to do what she wants but must "take telling" from her man. So girls are socialized to be economically and socially dependent on men.

Boys are not taught to be caregivers and they are not taught to be fathers. Too often they are encouraged to believe that their sexuality and promiscuous sexual behaviour are a measure of their manhood. Boys are not taught survival skills the way girls are. In the absence of this training, they depend heavily on the women in their lives, but they are unhappy about it. While they have internalized the ideology of male dominance, they resent their dependence on women.

Unemployed men are economically dependent on women. Their feelings of depression and inferiority in this situation are manifested in repeated abuse of the women in their lives. This abuse can be both physical and psychological. He may beat or rape her; he may constrain her freedom; and he may develop relationships with a number of women.

It is significant that in Jamaica there are more heterosexual men with HIV than any other seropositive group. This situation has serious implications for women who engage in unprotected sex. Currently, the number of women infected with HIV is rapidly increasing.

Although pregnant women are not being routinely tested, those whose behaviour or clinical history suggests possible exposure to HIV are usually tested when they visit an antenatal clinic. If a woman is found to be HIV-positive, counsellors will inform her of the risk to her health and the risk that her child will be born with the virus. She is allowed, but not coerced, to make a decision about continuing the pregnancy if it is in the very early stages.

Jamaican women who live in poverty tend to be malnourished. In a family where food is limited, the male head of household traditionally receives the lion's share, children the next-largest share, and the mother takes what is left. The effect of such poor nourishment on infected women, who are responsible for the care and nurturing of their families, is that they tend to die faster than men. This may also be exacerbated by the fact that infected women often put their own health needs behind those of their family and they may not seek medical help until the disease is more advanced.

What of Tomorrow

Historically, Jamaican women have been unable to depend on their mates for their family's financial needs. Thus, female heads of households are a dominant fact of life in Caribbean societies. As a result of the HIV epidemic, trends strongly indicate an increase in deaths among women who are heads of households.

They will leave behind infected as well as uninfected children. And an increasingly heavy burden will be placed on relatives and friends who will be called on to care for surviving children. We have tried to tackle this serious problem by initiating a fostering programme, but our resources are limited. We are experiencing difficulty in raising funds to feed parentless children and adults who are without a source of support.

I look ten years down the line, and frankly, I am terribly concerned. My worst fear is that Jamaica's already fragile family structure will unravel. We will have more parentless children, an increasing number of homeless, an increase in commercial sex work born of the desperate need to survive, and the consequential and continued spread of the virus.

This is particularly worrying because many of the infected people that I work with can repeat information verbatim about how the virus is transmitted yet continue to have unprotected sex. The reason for this is their fear of the consequence of disclosure of their HIV status, or at the point of actual sexual contact they become intimidated by the mechanics of safe sex. Unless one has practiced putting on a condom, doing so for the first time at the point of arousal can be difficult and frustrating. Many women have never even touched condoms. And despite the efforts of our healthcare professionals to educate them, many men do not know how to use condoms either.

If nothing is done to change the attitudes and behaviours that perpetuate HIV, we will have a nation populated with impoverished young and old people. We have already seen evidence of this in parts of Africa. I do not want to give the impression that HIV and AIDS are problems only of the poor. The "haves" in our society are also stricken. For the more affluent, the consequences are likely to be as devastating. Those who can afford available medication are spending more than U.S. $25,000 a year. These treatments may prolong their lives but they will eventually die and the money that might have gone to educate their children will have been consumed by medication.

HIV seems to be spreading faster in the poorer nations of the world than in the rich but there is only one world. Events and developments that take place in any one part inevitably affect the whole. Countries that have more resources should help stem the disease's spread in poorer nations by contributing financial support and expertise.

Countries like Jamaica must recognize that HIV is not to be trifled with. The disease must be treated as a national concern, not a government, health-sector problem. In Uganda HIV is no longer viewed as strictly a health problem. The government has taken a very aggressive stance toward the disease and all government ministries are involved. Here in Jamaica, the private sector is already getting involved, albeit to a limited extent. Our National AIDS Committee, which has a heavy representation of private-sector interests, is responsible for advising the government on HIV-related issues but the programme has very few resources.

People are creating programmes to fight HIV, but efforts are fragmented and I fear there is much duplication of effort and a subsequent waste of limited financial resources. We need to delegate responsibilities to various agencies, acting under the direction of a central government agency that would also coordinate the procurement of funding assistance.

In spite of the gravity of the situation, there are positive aspects to this challenge. The public health sector is doing a valiant job in the face of daunting odds. We have an excellent blood bank system, and no infections through the use of blood or blood products have been reported since 1985.

If the collective will is mobilized and we pull together, we can eliminate some of the conditions that enable HIV to flourish in our country. The old saying "United we stand, divided we fall" has taken on a very special meaning for me as Jamaica confronts HIV.

Biographical note

Dr. Patricia Burke was programme director of the Family Centre of the University Hospital of the West Indies. The Centre, a nonprofit organization, provides care for persons living with HIV and AIDS and their families. Services offered by the Centre include medical and pharmaceutical attention provided free of charge or at minimal cost, psycho-social support for patients and dependents, spiritual counselling, and education on prevention and safe sexual practices. The Family Centre also offers job placement services, provides seed money for income-generating projects, and provides financial assistance for a wide range of needs such as funeral expenses and transportation costs. Infant formula and food supplements are also available, as is legal assistance. As a member of the National AIDS Committee of Jamaica, Dr. Burke has been responsible for the development of national HIV/AIDS policy guidelines.

Berl Francis is a Jamaican communications specialist with more than twenty-five years of experience in the fields of public relations and jurnalism.