Ann Lee
ANTH215 Final Paper
Quiz Section AH, Jessica Lozano
The
“AIDS epidemic” may be one of the most widely recognized and globally
concerning health issues to date. Contrary to its centrality in world health
forums and non-profit organizations today, being a key target of scrutiny for
the World Health Organization (WHO) and UNAIDS, a subgroup of the United
Nations focused on HIV/AIDS, the acquired immunodeficiency syndrome, which we
call “AIDS”, has only been named and known as a disease for close to thirty
years. In the United States, the first records of clinical observance of the
disease occurred in 1981 among populations of drug-injecting users and
homosexual men. During that time of limited knowledge, doctors were forced to
make logical assumptions based on early cases and what was most probable. Thus,
the earliest AIDS patients were diagnosed with “GRID”, an acronym for
gay-related immune deficiency, because of the belief that the disease was
associated with the gay community.
Ever since
its discovery, medical efforts in order to battle AIDS have persisted
consistently, resulting in countless research hours and some successful advances.
Consequentially, medical knowledge has expanded immensely within the last few
decades. Human immunodeficiency virus (HIV) is understood to be the root cause
of AIDS by slowly attacking white blood cells in the human immune system
resulting in the ultimate inability of the body to fight previously harmless
pathogens. The virus progresses in stages: a flu-like infection, an
asymptomatic period, and finally acquired immunodeficiency syndrome (AIDS), in
which the low blood count makes the individual especially susceptible to
infections. Transmission is through the
exchange of bodily fluids most commonly via unprotected sexual intercourse or
contaminated needles. Currently, no cure or vaccine exists. The most effective
prevention methods, safe sex and clean needles, are strongly emphasized. Beyond
prevention, the WHO also focuses on global availability of treatment. Antiretroviral
therapy coverage among people with advanced HIV infection was one of WHO’s
indicator for one of its 2012 millennium development goals (WHO page 26). Many
other goals exist, including elimination of new HIV infections among children,
prevention of HIV among drug users, reduction of sexual transmission, etc.
WHO’s 2012 Report lists ten categories
of “global health indicators”, each quantitatively analyzed through various
statistics. “Health service coverage indicators reflect the extent to which people
in need actually receive important health interventions,” one indicator being, “pregnant
women with HIV receiving antiretrovirals to prevent mother to child
transmission” (WHO page 96). This shows that the WHO acknowledges the
importance of preventing HIV/AIDS from HIV-positive women via mother to child
transmission (MTCT).
MTCT can
occur during pregnancy, labor, delivery, or breastfeeding, so transmission can
be prevented in various ways. According to the WHO website: “In the absence of any interventions transmission rates range
from 15-45%. This rate can be reduced to levels below 5% with effective
interventions.” Prevention of mother to child transmission
(PMTCT) through counseling on infant feeding is the subject of the article Breast or Bottle? HIV-Positive Women’s
Responses to Global Health Policy on Infant Feeding in India, written by
Cecilia Van Hollen, an anthropology professor at Syracuse University. The
article presents an ethnographic study of HIV positive woman living in Tamil
Nadu, India concentrating on their experiences with maternal counseling,
responses to the seemingly constantly-changing guidelines set by WHO and
UNICEF, and a study of the complex decision making process of selecting
breastfeeding or bottle-feeding. Interviews suggest that decisions were based
on availability and affordability, but more importantly cultural values,
perceptions, history. This study also suggests that sociocultural values are
dynamic and can shift depending on global health initiatives.
Hollen does
an excellent job of viewing the problem from a holistic perspective. She is
clearly knowledgeable in Indian culture since she is able to make connections
with women’s reasoning and Indian perspectives of female power and motherhood.
Through the thoroughness of her study, I was able to recognize the importance
of sociocultural beliefs for understanding the thought processes of these
Indian women. Coherent to our class teachings, this situation clearly
demonstrates how cultural perceptions and social representations overlap
between medical anthropology and global health. Hollen’s anthropological
approach to HIV/AIDS prevention provides insight on the shortcomings of the
present systems in practice.
Before
further discussion of the article, it is important to gain overview the history
of AIDS/HIV. In accordance with the disease’s identification followed an incredible
amount of social stigma. Initially, the lack of understanding surrounding
transmission, treatment, and prevention ignited reactions, from the public and
even within the healthcare community, of anxiety towards AIDS sufferers. The
community response was probably heightened by the grave health risk posed in
conjunction with the disease’s untreatable aspect. Adding to the fear was the
fact that early victims of the diseases experienced painful deaths from rare
complications. A great deal of negativity sprouted from the disease’s “GRID”
origin and the fallacious belief that the disease selectively affected
homosexuals.
Numerous
records from 1980’s onward indicate discrimination against people with AIDS, which
include many cases of social rejection and violence. Even after proven to
affect broader populations, including children and heterosexual people, HIV/AIDS-related
stigma has continued and resulted in social discrimination, ostracism, fear,
and hate. Having the disease is often associated with negative assumptions of
one’s behaviors regarding promiscuity, prostitution, drug use, etc. Although
later information has specified the virus’s route of transmission, public fear
has persisted, even causing self-stigmatization by people living with the
disease.
The
Global Health Watch 3 does not address the stigmas of AIDS specifically, but
notes that social factors play a role in maternal mortality, gender inequality,
and mental health. The existence of “cultural and stigmatized notions of
sexuality and morality” is attributed to numerous factors, some which are,
“discrimination on the grounds of gender, race, ethnicity, religion, caste, and
social factors such as lack of education and employment opportunities,
increased workload, and political and legal issues” (Global Health Watch 3,
page 125). Gender biases lead to “barriers in emergency care, poor referral
practices, gaps in continuity of care, and improper demands for payment as a
condition for delivery of health services,” for women in India. (Global Health
Watch 3, page 125) The combination of these multiple social factors play a
significant role in the uncomfortably high maternal mortality statistic of
500,000 women per year. Undoubtedly, a combination of these factors affects the
target population in the article, Breast
or Bottle?…, as well. First of all as women of Indian culture, they are already
subject to minimal socioeconomic status and individual autonomy; thus as
HIV-positive positive women, they are prime victims to the stigmas surrounding
sexuality and morality.
The reason
that I found it necessary to include extensive background information is
because in order to fully comprehend current AIDS-related health issues, an understanding
of its history is required. Since its origin, AIDS has been complexly intertwined
between a health condition and mark of social judgment. Society reasoned that
AIDS was a punishment for deviancy, a violation of social norms, thus
discrimination was justified. Thus, people suffering from the disease are often
shameful and secretive. Prevention or treatment of aids is stunted by people’s
reluctance to be tested or seek out medical help. Fortunately, the adverse effects
of society’s predispositions are widely recognized and targeted as problems in
need ot immediate resolution. The theme of World AIDS Day 2012 hosted by World
Health Organization was: Getting to Zero:
Zero new HIV infections. Zero deaths from AIDS-related illness. Zero
discrimination. It is important to note that alongside the goal for
eradication of the disease is the elimination of discrimination, suggesting it
is an equally important factor.
Thus
returning to the article, Breast or
Bottle?, HIV-positive mothers interviewed in the article were receiving
counseling because of WHO’s efforts to prevent mother to child transmission
(PMTCT). Several options of infant-feeding are available, each with different
success rates.
“…Using the
‘full package’ of PMTCT interventions (antiretroviral treatments, cesarean
section and replacement feeding) in industrialized countries have been able to
reduce the rates of transmission to less than 2 percent. The risk of HIV
infection through exclusive breastfeeding…is approximately 4 percent. However,
the possibility of morbidity because of malnutrition, dehydration, or infection
from improper use of replacement feeding may exceed 4 percent. And the risk of
HIV transmission with mixed breastfeeding and alternative feeding is higher than
exclusive breast feeding” (Hollen page 500).
Although the “full package” is the most
successful prevention method, it is not economically available for all women,
in addition to posing a risk of malnutrition. The distinction between versus
bottle-feeding in determining the superior prevention method is highly
dependent on each mother’s situation. Because the risks and benefits of each
option don’t point to a clear solution, WHO and UNICEF implemented a system
where counselors are faced with subjective decision of determining eligibility
for replacement feeding using the AFASS criteria, which stands for
Affordability, Feasibility, Acceptability, Sustainability, and Safety. If a
woman meets the AFASS criteria, a counselor may recommend replacement feeding
if guidance is sought.
Hollen
mentions two major problems that exist with this system. First, the guidance
counselor is supposed to provide the proper information in order to allow women
to make informed decisions themselves. However, in practice, the counselor
almost always steers their client in one direction or another. Mothers are much
less given a choice, but told what to do. In just one of many examples, the
counselor is found dictating the decision for the mother. Hollen writes, “a
counselor working in one government hospital with a PPTCT program told me that,
‘we tell them not to breastfeed; to only give bottled milk’” (Hollen 503). Here
issue lies in the fact that replacement feeding is expensive and when directed,
women are forced to make incredible sacrifices. Even for women meeting the
AFASS criteria, sustainability is a challenge and often women dilute the
formula in order to extend its use, thus unknowingly restricting a child’s
nutrition and potentially harming his/her growth and health. Lack of finances
could possibly lead to inconsistent feeding methods, which could be harmful for
HIV transmission.
The second
problem concerns the lack of feasibility of the AFASS assessment. Most often
the counselors consult HIV-positive mothers once in a hospital setting in order
to determine their socioeconomic standing. Hollen suggests that current
assessment practices are inadequate. “In principle the AFASS approach is
laudable, but can a counselor really assess all of the AFASS criteria in the
context of a very brief, decontextualized counseling session in a hospital? My
research suggests not.” (Hollen page 515) The criteria itself is creditable,
but because AFASS is not a simple checklist, yet an intricate measurement
involving multiple factors, counselors are probably unable to make a correct
evaluation in one brief sitting.
A
culmination of these problems has revealed an instance where two women in seemingly
identical situations were counseled in opposing directions. The counselors
stated that the difference was that one woman was receiving financial/emotional
support from a local NGO, “whereas the other woman was not affiliated with any
such organization and, therefore, her family would not be able to overcome the
social stigma that she would face from community members if she did not
breastfeed.” (Hollen page 503) Despite the AFASS criteria, the end-deciding
factor was sustainability via external support and the counselor explicitly
directed the women. Interestingly, the counselor recognizes the critical impact
of social stigmas, which is in agreement with Global Health Watch 3.
An
often-overlooked, but highly influential factor is the powerful cultural norm
of breastfeeding. Many women are inclined to breastfeed because it is a symbol
of maternal love, a fulfillment of a woman’s duty, and the transfer of
“ethirppu sakti”, meaning immune power. Paralleling this is the notion of shame
when a woman diverges from these norms, which is evident in Indian society. A
woman not breastfeeding could be subject to high communal scrutiny and
judgment. Because of the stigmas surrounding HIV/AIDS, a majority of the women
who bottle-fed gave secondary rationales to curious community members. “To
avoid public stigma, women therefore have developed creative, culturally informed
rationales to avoid the critiques and also to avoid disclosure of their HIV status
and the stigma and discrimination that may ensue” (Hollen page 509). Dealing
with the negativity may truly be unbearable for some women, thus becoming a key
determinant in their decision to breast or bottle-feed.
Important
as it is, the cultural perspective of breastfeeding is not explicitly included
in the AFASS criteria. Therein lies the key difference between the medical
anthropology perspective compared to the approach by the WHO and UNICEF. An
anthropological perspective would focus on the sociocultural values engrained
within Indian society and the effect of social stigmas. This perspective would
focus on societal factors and women’s response to them. It would also study the
fluidity of perceptions and how they are affected by global health initiatives.
The approach by the WHO and UNICEF is the one in place today, which accounts
for mainly affordability and sustainability. The assessment will be more
qualitative rather than quantitative.
I agree with
Hollen that the AFASS assessment in practice is underdetermining. Conceptually,
it would be ideal to have an anthropologist assessing each HIV-positive woman’s
mental health and socioeconomic status in order to assess which prevention
method will be most ideal. The benefit of having an anthropologist is that
he/she will account for current and shifting cultural perceptions in the
assessment. This will allow a more inclusive understanding between the
counselor and the counseled, increasing communication, therefore having better
results. Actually, the most ideal situation would be if funding were available
in order to provide the “full package” of PMTCT free of charge to the mother.
By being free, the concerns of affordability and sustainability are resolved.
Unfortunately, it is not practical
since that would require tremendous funding.
A practical perspective could
possibly suggest a more extensive AFASS assessment that encompasses multiple
visits and an emotional/social/cultural component of consideration. This
perspective is practical because it utilizes the current system in place, but
improves it in a realistic way. A possible challenge could be the subjectivity
of assessing an individual’s emotional/social/cultural being. Researchers could
possibly find certain indicators that may be easier to assess.
In
conclusion, in this essay I have discussed the history and current HIV/AIDS
related health problems from an anthropological perspective. HIV/AIDS is a
concrete example of a global health problem that entails much more than the
“disease” aspect of it. In order to understand AIDS, it is necessary to
recognize how it is socially constructed as a “sickness” and the personal
“illness” experience. By approaching the problem through a medical
anthropological perspective, I was able to recognize often-overlooked
characteristics and gain a better understanding of how to proceed in a global
health perspective.
Bibliography:
Global Health Watch 3:
An Alternative World Health Report. London: Zed,
2011. Print.
Ogden, Jessica, and
Laura Nyblade. Common at Its Core: Hiv-related Stigma across
Contexts. Washington:
International Center for Research on Women, 2005. Print.
Van Hollen, Cecilia.
"Breast or Bottle? HIV-Positive Women’s Responses to Global
Health Policy on Infant Feeding in India." Medical
Anthropology Quarterly 25.4 (2011): 499-518. Web. 10 Dec. 2012.
World Health
Organization. World Health Statistics 2012. N.p.: World Health
Organization, 2012. Print.
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