Beware the Blob
For World AIDS Day 2012 I post an edited excerpt of a speech I gave a decade ago to the Second Scholarly Conference on Women and Work: Health and Wellness held at the Center for Worker Education in New York City. I ask whether HIV can search for the most vulnerable populations.
Identifying trends in health and disease doesn’t mean we know how these patterns came about.
Why, for instance, is HIV/AIDS so prevalent in Africa? It’s where the virus first emerged, of course. Cases have had more time there to accumulate. But at 22 million HIV cases, initial conditions are hardly explanation enough. An array of interacting socioeconomic circumstances and cultural happenstance locks millions of people to precarious fates (and, in this case, greater risk of infection). Many of Africa’s countries are the poorest in the world and the workaday people live in are channeled in such a way that the term ‘choice’, at the heart of much public health commentary, loses its connotation of free will.
Here’s a characteristic scenario, variations of which have been repeatedly documented in the health literature: Structural adjustment programs imposed on an African country by the International Monetary Fund decimates the local agricultural sector forcing a young farmer to work for cheap in a mine hundreds of miles away from his home village for months on end. At the mining camp he patronizes prostitutes, who have also cycle-migrated to the camp.
The farmer returns home and infects his wife with HIV. She feels unable to ask him to wear a condom, if only by the sexist expectations underlying village life but also via the economic crisis that forces her to depend on his salary to feed her children. Asking her husband to wear a condom, in short supply as they are, would also imply—in his eyes—that she’s the one infected and should be abandoned. The farmer subsequently dies of AIDS and the woman is by custom betrothed to her husband’s brother, infecting him, and by extension, his other wife or wives. The epidemic marches on from there.
If by ignorance or corruption we failed to acknowledge IMF and World Bank policies that structure the epidemic, we would likely never grasp HIV’s disease ecology. We wouldn’t be able to propose interventions of any meaning or sustainability. We might, for instance, suggest more condoms be made available in Africa and think that enough. But even if we were to airdrop millions of condoms or even billions of antiretrovirals on Africa—our pith helmets painted a dashing baby blue—the epidemic would unlikely stop or, in some areas, even slow down.
So scale matters. What happens at the level of international finance and neoliberal expansion profoundly affects governments’ budgets, the services they offer their populations, and ultimately the choices individuals must make to survive, including knowingly exposing themselves to a virus that will ultimately kill them. Indeed, such pathways can be traced to the very origins of the virus. Colonial exploitation opened up Cameroonian SIV to greater spillover and a longer chain of preliminary transmission.
I believe other such scale effects can be found from the virus’s perspective.
Let’s take a look at HIV in New York City. A demographic transition characterizes the epidemic here and, by the City’s cornerstone status, the U.S. in its entirety. What was a disease that primarily affected communities of gay white males now appears entrenched in minority communities. Over 80% of new AIDS cases in New York City are of Black and Latino individuals. As a population, minority women bear a heavy burden. According to New York City’s Department of Health, Black and Latino women respectively account for 54% and 33% of all cumulative female AIDS cases.
How did the transition come about? There are myriad reasons deeply embedded in New York City’s political matrix (addressed in detail here). To make a long story short, minorities in New York are subjected to many of the same socioeconomic constraints, the same orders of racial and economic apartheid, as sub-Saharan Africans. And these, of course, are what really matter when we speak of causes and effects (and interventions). But for the point I wish to make today I’ll focus on two additional though not unrelated inputs.
First, while pathogens may be concentrated in certain populations, they are almost never contained there. From groups of white gays and intravenous drug users HIV spread to heterosexual minorities along shared sex and drug networks. Of course, we need acknowledge the intriguing caveat that the City’s Black, Latino and female populations were infected right from the start of the epidemic as well, if not at the rates of gay white males.
Secondly, affluent whites appear to have greater access to the new antiretroviral combination therapies first made available in 1996. AIDS incidences have since declined much more in New York City neighborhoods with large white populations than in minority neighborhoods, adding to the disparities of the epidemic.
I would like to offer here another if novel explanation, a spatial mechanism.
In the course of changing their spatial extents, epidemics change what geographers term their ‘characteristic area’, the area the epidemic generally occupies. In the early years here in the US the HIV epidemic occupied only a few blocks, growing into a neighborhood phenomenon, seeding other neighborhoods and, as we can see from Peter Gould’s maps, other cities. The public health implications are profound. The interventions that would have worked when HIV occupied a few blocks aren’t enough now that HIV attacks a larger extent. In spreading, HIV changes its very nature.
By expanding its characteristic area, HIV entrains a greater number of communities into the epidemic. In this case, it expanded into infecting in addition to gay and IDU communities the greater heterosexual population, particularly urban/suburban communities of color (although also now into meth-blitzed rural counties). The more groups are affected, the more likely the epidemic will find populations that provide a good epidemiological fit, of a greater prevalence of unsafe behaviors that power an outbreak.
In other words, a local HIV epidemic—which on a map appears at its peak like a big blob—embodies a geographic mechanism by which the virus, to risk an anthropomorphism, continually searches for the best susceptible populations presently available.
It is in these populations—with their supplies of potential new hosts—that HIV finds refuge from whatever subsequent contractions in the epidemic may occur. And in its recent expansion in New York City and beyond HIV apparently found its haven in socioeconomically targeted populations of Black and Latino heterosexuals, meanwhile multiplying the difficulty of public health intervention.
That HIV exhibits an albeit unconscious and epiphenomenal agency is indeed a scary thought. But it drives home a revelation. Because HIV displays an apparent capacity to look for populations of susceptibles, if only to maintain itself above the rate of replacement, we are all, infected or not, living with HIV/AIDS. This isn’t to take away the profound meaning embedded in any one person’s infection, but at the public health level the HIV epidemic—a searching, dynamic entity—hangs over all our heads like the Sword of Damocles, a threat pendulating above us all.
It follows, then, that, to turn scale back in our favor, our individual selves are very much tied up in the health of our communities. Our fates are inextricably intertwined. And as each other’s wealth and well-being we can act on that, even against the very histories that produced HIV.