The Intertwining of AIDS and Poverty
In many parts of the world, high infection rates are caused by factors related to living in poverty. AIDS can also cause a vicious cycle in which it creates further poverty, leading to increased vulnerability. On the micro level, in nations around the world, people in rural areas struggle with poverty and dream of moving to urban areas where they believe they will be able to earn more money. Unfortunately, this economic migration has also led to an increase in HIV infection in countries as diverse as China, Thailand, Haiti, Kazakhstan, and Lesotho.
Often it is the men of the family who will migrate for labor. While they are away from their families, they may engage in activities that put them at high risk for contracting HIV, such as using intravenous drugs and visiting sex workers. When they return to their villages, they bring the disease back with them. The common belief is that AIDS first became widespread in this fashion. A main highway in southern Africa served as a primary trucking route; infected sex workers worked at the main rest areas and subsequently many truck drivers became infected with HIV. Upon returning home, these husbands gave the disease to their wives, posing a risk to subsequent children (Sunmola, 2005). Workers would also migrate to South African mines and bring the disease home in the same fashion; 90% of surveyed HIV-positive men in rural Lesotho had worked in the mines at one point (Furin, 2007, as cited in Furin et al., 2008).
Similarly, during the economic boom of the 1990s, many Thai workers left the rural countryside for the urban areas to find higher paying work. While in the cities, a number of them were infected with AIDS. When these workers returned to the countryside, they also transported the infection (Lim & Cameron, 2004). This economic migration pattern was also seen in India. Truck drivers traveled long distances on the highways and employed sex workers while away from home. They then returned home to their wives and spread the HIV infection (Waldman, 2005). The HIV epidemic has been growing in Central Asia, including Kazakhstan. Among migrant market vendors (both men and women), longer trips to sell one’s goods and more frequent travel were significantly associated with multiple sexual partners as well as unprotected sex. Additionally, the workers had low levels of HIV knowledge, especially the women (El-Bassel et al., 2011).
When women migrate for economic reasons, they are also vulnerable to HIV infection. Many of these women end up in the sex trade, since it is typically the highest paid work available to them. Once employed as a sex worker, they earn more money, often to two to three times as much, if they engage in intercourse without using a condom, raising the risk of infection. As a result, female sex workers are 13 times more likely to be infected with HIV than other women (UNAIDS, 2012b).
Poverty affects non-migrating people as well. In China, what is considered to be “the third wave” of AIDS in that country (from about 1994 to 2001) particularly affected the rural poor. Due to the poverty in China’s rural areas, these citizens earned extra money by donating blood and plasma to illegal traveling blood banks. These blood banks not only reused needles from donor to donor but would also mix all the blood together before giving it to the recipient. Therefore, if there was any infected blood, both donors and recipients were certain to receive it, causing high rates of infection in these areas (Kanabus, 2005).
On the mezzo level, increased familial poverty is due not only to the money that must be spent on health care and medicine but to lost income as well. AIDS is a particularly devastating disease in that it is centered not in children and the elderly, typically the most vulnerable, but in young and middle-aged adults. As discussed, it is often the men in the family who are infected first. With no access to treatment, the family’s income is sharply reduced as the man is typically the primary breadwinner. He may be too ill to work or may be fired due to stigma and discrimination. Even if he is not the first to become ill, he often loses income when taking time off from work to care for the person who is ill (Rajaraman, Russell, & Heymann, 2006). Mothers are often the next in the family to fall ill. With parents too ill to work, the family is in a desperate situation.
The loss of a father often results in lowered income and decreased access to resources such as land; the loss of a mother typically results in increased malnourishment and less care for the children (Commission on HIV/AIDS and Governance in Africa, n.d.). In agrarian societies in southern Africa, fields go untended due to the dire illness of the workforce. This pattern increases malnutrition and poverty, feeding back into the epidemic as medications must be purchased and then taken on a full stomach for optimal effectiveness (Panos, n.d.).
The death of middle-aged parents causes a rise in the number of orphans, straining the traditional kinship care systems. Children are doubly affected by AIDS: They are at risk of contracting it from their mothers, and when their parents die from the disease, they are left even closer to poverty. While access to medication to prevent transmission during childbirth has risen and almost 60% of women in low- and middle-income countries receive it, only 30% of them are able to access medication for their own treatment (UNAIDS, 2012a). Illustrating this impact, 3.3 million children worldwide are estimated to be infected with HIV or AIDS, but an additional 17.3 million (as of 2011) have lost one or both parents to the disease. More than 90% of these children are living in sub-Saharan Africa, putting a huge strain on traditional support systems within the family (UNICEF, 2012a).
Caregivers of these children have reported concerns about the ability to afford food, clothing, health care, and school fees; in addition, the health of the caregivers can deteriorate due to the added stress and burden of their caretaking duties. In response, “Granny clubs” have been started in Andhra Pradesh, India, to help grandparents who were caring for their grandchildren due to the death of their child from AIDS. Support is offered in a variety of ways: material support, including food and clothing; psychosocial support for grieving and the burdens of raising grandchildren; and childrearing training specific to children affected by HIV. Groups are formed so that members are geographically close to each other so they can attend monthly meetings (Vasavya Mahila Mandali, 2009).
School acts to provide a productive activity for children, keeping them away from high-risk activities, in addition to educating them about the risks of sexual activity. However, the increased poverty in the families of children who have been orphaned often forces the children to leave school for two reasons. First, they often must work to help replace family income; second, they can no longer afford the cost of school. Although some countries have eliminated school fees, these fees remain in other countries or they have been eliminated only for primary school. Even if there is no tuition, there may still be fees for uniforms, texts, and supplies. Some orphans receive financial support for education, but others do not. There are also often unmet needs for adequate food and medical care (Mhaka-Mutepfa, 2010). Some children own only one threadbare outfit and are too embarrassed to attend school due to their lack of adequate clothing.
Examining the impacts from the macro level, in Africa, the structural adjustment policies dictated by the World Bank in order to increase exports and imports for participation in the world economy were financed through large cuts in social services, including education and health care (Commission on HIV/AIDS and Governance in Africa, n.d.). In general, this lack of social services caused by the shift in funding results in less knowledge about HIV/AIDS, fewer protective factors (as will be discussed), and less ability to assist people who have been infected (Tlilane, 2004). The imbalance in global trade resulted in spreading, not reducing, poverty levels, increasing again the risk factors for AIDS (McCoy et al., 2005).
Continuing the cycle of AIDS and poverty, AIDS spreads poverty, which further increases vulnerability on all systems levels. On a macro level, a high HIV infection rate can threaten the development of a nation. As AIDS attacks the working-age population, the impact of the disease can result in loss of economic productivity due to illness and death. There are also fewer consumers to participate in the economy. Children orphaned by AIDS are forced to leave school, reducing the number of potential educated workers and thus the country’s economic output.
Some countries have what is known as a hyperepidemic, in which a high percentage, for example, over 15%, is infected with the disease (United Nations Development Programme, n.d.). With such high rates, it raises concerns that countries will be able to continue to function—economically, politically, and socially—if such a high percentage of their population is ill.
The following story, adapted from Paul Farmer (2005) (see Box 6.1), illustrates how personal poverty and structural factors in the culture led one young Haitian woman to die from AIDS:
Acephie was born in the small village of Kayin. The Riviere Arti-bonite, Haiti's largest river, ran through this village. Her family was initially relatively well off. However, her village was flooded to make a dam to provide electricity for the urban Haitians and the villagers were forced up into the stony hills on the sides of the new lake. This new land was not nearly as fertile as their old land and they struggled to survive. Acephie would carry the family's meager agricultural produce to the local market to earn money. The road to the market led past a military barracks and the soldiers often flirted with the girls as they passed. This flirtation was rarely openly rejected, as the soldiers were among the few men with an income in this now poor region. When a captain, Jacques, began to pursue Acephie, she eventually agreed, even though she knew that Jacques was married and had several other partners. The sexual relationship lasted less than a month, as Jacques fell ill and died a few months later of unexplained fevers.
Acephie eventually moved to Port-au-Prince and found a servant's job. She also began seeing a boy, Blanco, with whom she once attended school. He was doing comparatively well chauffeuring a small bus, and they planned to marry. However, when Acephie became pregnant, Blanco was not happy and eventually disappeared from her life. Due to her pregnancy, Acephie lost her job. She returned to her hometown to give birth to her daughter. Shortly thereafter, she soon fell ill and eventually died of AIDS.
BOX 6.1 Paul Farmer
Thanks to the work of Dr. Paul Farmer, a Harvard-trained physician, ideas about treating patients in poor countries have changed. Prior to his work, the common belief in the global health arena was that offering treatment to impoverished people in poor countries would not only be ineffective, as they would not be compliant in taking medications, but it would worsen the epidemic by increasing medication-resistant illnesses. In the early 1980s in rural Haiti, Farmer and his organization, Partners in Health (PIH), established a medical clinic where fees were nominal or nonexistent. Haiti has one of the highest adult HIV infection rate in the Western Hemisphere: 1.8% equaling about 100,000 people (UNAIDS, 2012a).
Farmer developed a model known as the directly observed treatment model (DOT). In this model, local community members are trained to assist and support HIV/AIDS patients. The DOT model has a third person (who is a local resident) responsible for observing the patient swallowing his or her medication. This local liaison helps the patient with particularly complicated prescriptions or medications with adverse side effects in order to help maintain medication compliance. In Farmer's model, since the third person is also a fellow village member, it decreases the power structure and helps increase trust and community support (D'Adesky, 2004). This person is known as an accompagnateur (one who accompanies) to emphasize the equal relationship. This model had great success and demonstrated that if a program was properly structured, individuals in impoverished countries could have higher treatment compliance rates than those in industrialized nations. Partners in Health is the nongovernmental organization providing health care in Haiti and in 2013 opened a 300-bed facility (Partners in Health, n.d.).
Partners in Health now works in 10 countries across five continents and in the Caribbean, fighting not only AIDS, but tuberculosis, cholera, and cancer. They also focus on mental health and how vulnerable populations such as women and children are affected (Partners in Health, 2013a). PIH has a “four pillars” approach to health. The first pillar is to integrate HIV care and treatment with primary health care. For example, PIH has helped to build houses, develop potable water projects, and help people gain access to education (PIH, 2005). The second is a focus on maternal and child health, and the third is to establish tuberculosis control. The fourth is the detection and treatment of sexually transmitted infections. They now provide antiretroviral treatment to more than 20,000 people in Haiti, Rwanda, Lesotho, and Malawi. Additionally, they have also provided survival needs such as housing, water, food, and psychosocial support. In this way, they are able to address the intertwining of poverty and AIDS (Partners in Health, 2013b).
The story of this one Haitian woman illustrates a number of the concepts discussed. Events on the macro level, in this case the building of the dam and the flooding of her family’s farm, sharply increased the poverty within the family. This increased poverty, in turn, increased her vulnerability to a relationship with the captain. This brief liaison eventually led to her death from his “mysterious illness.” Her story also illustrates how the female gender role increased her risk of becoming infected. It was the man who had greater social power, while she relied on either her family’s attempts at farming in the poor soil to which they have been relegated or to a servant’s job, which she lost when she became pregnant. Acephie’s story demonstrates how factors on the micro, mezzo, and macro levels all contributed to her eventual death.