Power in the Blood: A Handbook on AIDS, Politics, and Communication.

Power in the Blood: A Handbook on AIDS, Politics, and Communication. Edited by William N. Elwood. Mahwah, NJ: Lawrence Erlbaum Associates, 1999, 442 pages. Cloth $99.95.

For this volume, Elwood gathered together an impressive array of scholars to address the intersection of AIDS, politics, and communication. But where do these broad topics overlap? And how can the reader make sense of them together? For Elwood, the intersection of these themes is at the level of conversations between a wide variety of people and organizations. In the introduction, he states that "talk may be the most important component to HIV prevention and treatment" (p. xvii). Elwood proposes that all communication, or conversation, is in some way political, particularly discourse about HIV and AIDS. Thus, Elwood links his three themes by illuminating the variety of micro- and macro-level political conversations about AIDS.

Elwood focuses on the range of public and private conversations about HIV and AIDS that affect this continuing public health crisis, including one-on-one dialogues (e.g., individuals speaking with their drug-using and sex partners), scientific discourse (e.g., discussions among researchers from different disciplines), political rhetoric (e.g., politicians speaking to the public, constituents, or other politicians), and messages communicated through mass media (e.g., what television, newspapers, and other media say and do not say about HIV and AIDS). The book examines these communications and how they influence the way people think, act, and talk about HIV and AIDS. The book's thesis is clearly illustrated by providing many examples showing that how HIV and AIDS is talked about, both publicly and privately, can dramatically help or hinder HIV prevention efforts.

What makes this book challenging is that rather than grounding the book in one intellectual tradition, Elwood has brought together two very different research areas: public health and communications. Although this might be a difficult task for many researchers, Elwood's training, research, and professional interests emanate from both fields, lending credibility to his look at HIV and AIDS through a wide lens. Elwood provides a structure for examining the intersection of AIDS, politics, and communication by grouping the 30 chapters into seven sections. Each section addresses a different type of conversation, and then illuminates the implications for HIV prevention and public health. Four of the sections focus on very broad perspectives (the politics of illness and HIV, political campaigns and policy, mass media, and the relationship between individuals and institutions), two sections focus more at the individual level (an "intrapersonal" section on individual behavior, and an "interpersonal" section on relationships between individuals), and the final section tries to synthesize this diverse offering.

Depending on the reader's theoretical orientation or academic background, certain sections or chapters will likely be more interesting or relevant than others. In the section on individuals and behavior, the diversity of the topics highlights two important take-home messages; first, the need to understand the target population and their construction of risk, and second, the importance of tailoring HIV prevention interventions for specific communities--drug-using women, gay men who patronize public sex environments such as bathhouses, truckers along the Trans-Africa highway in Kenya. From these selections, the reader is left with the clear idea that an important first step to intervening with any population is to conduct formative research to illuminate the understanding of risk behavior. In fact, many of the chapters are based on formative research with various populations.

In the interpersonal section, the chapters highlight the importance of relationship dynamics in helping or hindering HIV prevention while reinforcing the message that targeted interventions are needed. For example, one chapter makes a strong case for tailoring intervention messages for adolescents. The research presented shows that youth may not protect themselves and their partners from HIV because they may fear romantic rejection more than death, thereby making some prevention messages for adults not as pertinent to youth. These chapters also start to make the important connection between more intimate relationships and the social structures in which they are embedded. Thus, this section provides a nice bridge to the other sections of the book, which focus on communications at a more macro level. For example, some of the interpersonal chapters focus on the experience of women by discussing the fact that although HIV is transmitted intimately, the social rules and conditions governing this intimacy may not rest solely with the couple or the woman. Many chapters in this book and in other publications make the point that the power of women to protect themselves from HIV risk can be hampered by a number of structural factors (e.g., the lack of availability of female-controlled prevention methods, the lack of power over sexual decision making, the lack of economic power).

Although the interpersonal section begins its focus on intimate relationships, the recommendations for prevention quickly move to a broader level, to include suggestions for addressing structural factors that affect prevention efforts. Although the book does not use the term structural-level interventions, some of the chapters highlight the fact that larger social, legal, and organizational forces can directly or indirectly affect an individual's prevention behaviors, and that structural interventions are needed to address this influence. In fact, developing structural-level interventions is of increasing interest in HIV prevention. In February 1999, the Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention held a meeting in Atlanta on structural factors and their effect on HIV prevention. For that meeting, structural factors were defined as organizational, community, economic, legal, or policy circumstances or actions that are barriers or facilitators of an individual's HIV prevention behaviors. For example, changing drug paraphemalia laws to decriminalize the possession of needles can facilitate HIV prevention behaviors among some injection drug users. One way to unify the public health and communications research presented in this book might be through collaboration on structural-level interventions. For example, researchers in these two fields working together might be able to work to change media standards so that more explicit (and effective) prevention messages could be presented on television and in newspapers.

Another chapter in the interpersonal section introduces one of Elwood's concluding themes--that disseminating HIV prevention information through multiple channels is an effective strategy that leads to behavior change. Data are presented showing that a mass media campaign is more effective when an interpersonal component is added in which important community members reinforce the messages presented in the mass media campaign. This type of complex and multitiered HIV prevention program, which integrates prevention efforts at individual, small group, community, and structural levels, has been developed in some countries other than the United States. It would have been helpful if the book had provided a detailed description of the prevention program in a country where communication strategies have been coordinated and made consistent across the various levels of intervention. One of the frustrations inherent in working in HIV prevention in the United States is that integration is often blocked by structural barriers such as prohibition of explicit messages in mass media campaigns.

In the four sections focusing on broader levels of communication, the tone becomes more historical and theoretical. The four introductory chapters provide a nice historical context for placing rhetoric about AIDS alongside messages about diseases throughout history. The sin and stigma that have accompanied unexplainable diseases through the ages were amplified with AIDS because it seemed to start in a stigmatized and largely hidden community. When the "gay plague" was found to be blood-borne, fear generalized from gay men and injection drug users to anyone working with or having contact with blood (e.g., physicians, blood banks). A final theme that recurs throughout the book concerns the deafening silence about AIDS at the beginning of the epidemic, and the selective silence or vagueness that still attends the topic in many public forums. One chapter explores the commercialization of AIDS through red ribbons and gift shops. In an attempt to keep AIDS in the public discourse and to combat the primary societal message that AIDS should be private, this commercialization strategy was developed and has been copied by constituencies for many other diseases.

The section on political campaigns and policy follows in the tradition of Randy Shilts' 1987 book And the Band Played On, which chronicled the lack of media and political interest in AIDS in the early to mid 1980s. These chapters continue that legacy by documenting the lack of rhetorical leadership regarding AIDS by U.S. presidents from Reagan, to Bush, to Clinton. Although President Clinton initially sounded different from his predecessors, research presented in one chapter suggests that he has not used his office to speak about AIDS broadly but rather has focused most of his AIDS speeches on gay and lesbian audiences. As interesting as I found this historical documentation of the power that leaders wield by speaking or not speaking 1 about AIDS, I think some of these chapters would have been stronger if they had suggested concrete solutions or structural adjustments that might combat this tendency.

This same criticism applies to some of the chapters in the section on mass media, which persuasively tell a story of the difficulty in getting balanced AIDS coverage in the news. By counting the number of stories and examining the guest lists of news shows, research in these chapters document how AIDS was kept out of the media in the early 1980s, and how in the late 1980s and 1990s AIDS news has been sanitized by excluding those most affected by the epidemic (e.g., gay men, injection drug users, members of minority populations). These studies clearly document important and ongoing phenomena, but they tend to lack public health relevance because of the historical nature of some of the reviews (e.g., news stories from 1983-89 or 1988-93) and the lack of suggestions by the authors to address these inequities. The most interesting mass-media chapter focuses on the lack of specificity in public service announcements about AIDS in the United States. This chapter highlights, and Elwood points out in his conclusion, that for prevention to work, specific sexual behavior and drug-use practices must be talked about in the context of peoples' lives, something that seldom happens in mass media in this country. This conclusion is supported by a recent study of sexual situations on television in the United States: More than 90% of the media images of sexuality were unencumbered by discussion of HIV, STDs, or safer sex.

This volume does an admirable job of making important points. For example, (a) people's beliefs and actions regarding HIV and AIDS are intricately tied to many levels of communication about AIDS, (b) effective interventions combine communication through many different channels and levels, and (c) inequities in many intimate relationships are based on characteristics such as gender or serostatus. I hope that this book marks the first step in increasing connections between public health and communications researchers. People in these two fields have a lot to learn from and to teach each other, and this book suggests that their combined knowledge can lead to sophisticated, multilevel HIV prevention interventions. Looking at these two fields together particularly suggests the need for structural-level interventions to help out HIV prevention efforts. This book starts us on a path suggested by Elwood, a path on which powerful communication strategies are developed to promote HIV prevention and treatment and to encourage social relations that are supportive of prevention goals.

REFERENCES

Shilts, R. (1987). And the band played on: Politics, people and the AIDS epidemic. New York: St. Martin's Press.

David W. Purcell, J.D., Ph.D., Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of HIV/AIDS Prevention--Intervention Research and Support, Behavioral Intervention Research Branch, 1600 Clifton Road, MS E-37, Atlanta, GA 30333.