Women, Poverty and AIDS: Sex, Drugs and Structural Violence.

Women, Poverty and AIDS: Sex, Drugs and Structural Violence. Edited by Paul Farmer, Margaret Connors, and Jane Simmons. Monroe, ME: Common courage, Press, 1996, 473 pages+ xxi. Paper, $19.95

Reviewed by Lawrence Hammar, Ph.D., Department of sociology/Anthropology, Smullin Hall, Willamette University, 900 State Street, Salem, Oregon 97301.

Women, Poverty and AIDS is innovative in both organization and theme. Some of its nine provocative chapters are singly authored and others are collectively so, but their argumentative and writing styles are surprisingly even. Hammering persistently at the connections between AIDS, structural violence, and women, it departs radically from most AIDS-related literature. Most social, scientific, biomedical, and public health models involve gender to explain pathogens and transmission dynamics, but too many still consider gender to be an independent variable.

Such is not the case here. This book moves the debate forward greatly by engendering sexually transmitted disease. The editors began in a profound void: Their search of an AIDS database for "women + AIDS + poverty" found that "there are no references meeting these specifications" (p. xiv). The authors wrestle thereafter with the fact that sexually transmitted disease, while ubiquitous, is absent from typical research and reportage. They show just how complex are the links between gender, biology, social structure, culture, and political economy: Each interacts synergistically with HIV infection and AIDS-related symptoms, but neither evenly nor predictably so.

The authors seem uncomfortable dealing with the instability of moving targets. Though HIV and AIDS are manifest differently across time, space, and body--often wildly so--they emerge intact here. The authors explore the socioeconomic relations upon which HIV and AIDS are founded, but not really their own constructions; for example, when they conflate HIV with its antibodies, HIV disease with HIV infection, and AIDS with a virus. Their strong suit is to question why disease and suffering burden are so unequally shared. They ask that we link rich and poor as we model risk and risk-taking and that we connect individuals to groups without overstating personal agency. They argue with us when we choose cultural models of risk that reify and exoticize personal behavior over political-economic ones that consider transnational forces such as poverty, racism, and sexism.

Implicitly and sometimes explicitly they also ask why women comprise a group in which new HIV infections and AIDS diagnoses are the most rapidly increasing (p. 92), when women globally are often as different as night and day. Do women really belong to a "group" that is so empirically stable, given such differences across time and space of culture, history, sexual identity, race, and class? Are those increasing new infections being detected in them due to the risks of being gendered, due to women inhabiting differently sexed bodies? Are such increased risks due to a biological factor of genital permeability or immune system response, or is it due to something pernicious and hidden, the gender of risk itself? The answers each author provides are as complex and conflicting as HIV and AIDS themselves.

The book is divided into three parts. The first two tangle with the "exaggeration of personal agency" (p. 28). Most risk theorizing, they say, has tended toward 1) a focus on "local factors and local actors to the exclusion of broader analyses," 2) a "conflation of structural violence and cultural difference," and 3) the absence of "serious considerations of social class" (p. 29). These authors do not fall into such conceptual traps.

Part I, "Rethinking AIDS: Locating poor women," contains four chapters that each anchor individual women at the center of AIDS, not to its margins. Paul Farmer's first chapter narrates the lives of three women. Darlene, from Central Harlem, injects drugs intravenously and is subject and object of conflicting social forces. Guylene is from Central Haiti, caught betwixt and between a compulsory heterosexuality that is supportive and dangerous. Lata, a young Indian woman, is sold into sexual slavery in Bombay that is local, transnational, patriarchal and capitalist. Chapter 2, by Janie Simmons, Farmer, and Brooke Schoepf, turns from the local, individual, and narrative to the global, collective, and more statistical, but disturbs neither the voice nor the style of chapter 1. The next two chapters explicitly connect "Sex, Drugs, and Structural Violence." The first, by Margaret Connors, is categorically behavioral ("sex" is an act, drugs are recreationally taken); but the second, by Johanna Daily, Farmer, Joe Rhatigan, Joel Katz, and Jennifer Furin, is categorically clinical ("sex" is a treatment parameter, "drugs" are taken palliatively). Both are sterling.

Part II is differently painful to read. "Recreating AIDS: Examining claims of causality," is composed of three chapters authored by Kenneth Fox and William Rodriguez in addition to those mentioned above. Social scientists may relish scorching reviews of what's wrong with public health and clinical knowledge about women, HIV, and AIDS, but are themselves scorched for their own ill-theorization. Though quick to apportion blame, the authors just as quickly praise more resolutely gendered studies that factor socioeconomic class into the Structure/Agency/Risk equation. Those who are well read in one or two AIDS-related literatures will find these chapters particularly compelling.

Part III, "Reconceptualizing care: Pragmatic solidarity," includes two chapters, one written by and the other edited by Greg Rubin. Both contain up-to-date, useful, positive attempts to "make common cause." After providing contact numbers and addresses, he annotates models of treatment for and prevention of AIDS-related misery, in 10 U.S. based and 5 non-U.S, based organizations that "offer comprehensive social services to women, [that] have initiated progressive or innovative programs, or [that] are the sole providers in an area with a high rate of HIV among women" (p. 283). His data include organization mission statements and clinical specialities, and the personal testimonies he recounts regarding the obstacles that service providers and receivers face are all too telling and arc well linked to themes developed in previous chapters.

Rebecca Wolfe's bibliography (85 pages) and endnotes section (30 pages) tie together the entire book superbly. There is also a biomedically-oriented glossary and a sparse but accurate index.

This is as thorough and compassionate a book on AIDS as I've read. It marks and stretches disciplinary boundaries in a way equally suitable for university-level readership, activists, professionals, physicians, and ethnographers. Indeed, Women, Poverty and AIDS is so rich, comprehensive, and humane that I feel uncomfortable as a reviewer exploring even a few troubling editorial and conceptual aspects. It is both an important volume in and of itself and one that inaugurates a new series in Health and Social Justice, launched by the Institute for Health and Social Justice, founded by Partners in Health. The standards it sets and the stakes it gambles are remarkably high. Regarding editorial aspects, the tone is unremittingly grim, and there are no photographs or drawings and too few graphs, tables, and charts that might have made it a bit less so. The book employs a very small type-face, but it changes into one almost unreadably small in the notes and bibliography section. The book's central thesis is reiterated repeatedly, sometimes two or even three times on a single page, with apologies for doing so (e.g., p. 246).

More seriously, there is some nominalistic and conceptual laziness. AIDS (note the italicized S) is referred to repeatedly as a disease, not as a disease syndrome. AIDS is alleged to be transmissible (e.g., pp. 94, 208-09, 247), despite the physical impossibility of transmitting a disease syndrome. "Black" and "Hispanic" sometimes refer only to "men" (p. 267); women are "women," that is, as long as they are not "minorities." "Race" is not handled very well in some places, either, The authors frequently cite others' problematic constructions (e.g., "white and non-white," p. 231, following outdated dictionary practices), but sometimes they allow such constructions to stand or compound them further. For example, they frequently conflate race and ethnicity and skin color, whether researcher- or participant-identified or both. Chapter 7 hinges on a variably stated phrase, "the natural history of HIV infection in women" (pp. 245, 251-252), but the entire book deconstructs just such a notion: Any such pretense that some infections are not mediated is a jarring one. The authors are thus at cross purpose with Robert Root-Bernstein, whom they do not cite, who argued (1993) that "The data are correct; our interpretation of them is not" (p. xiii).

More troubling, however, is the fact that the authors accept that HIV is sufficient cause of AIDS: Everything else in the world is mediated, but HIV and AIDS and the unidirectional relationship between them emerge unscathed. So do such terms as "sex workers," "heterosexual transmission;" "prostitutes," "HIV [antibody] testing," and "seroprevalence studies." as if these were clear and stable. There is no gold-standards by which HIV or antibodies to "it" (remember, there are at least 12 recognized strains of just HIV-I) can be directly located without contamination: HIV antibody testing is far more problematic than these authors seem to allow (see Whitaker & Edwards, 1991). The hegemonic "claims of causality," the scrutiny of which the authors take to be their central task, are too often let go when it comes to technologies of power. The HIV-infected are allowed only one transmission route and infection per, which greatly drubs explanatory power.

Even more troubling to their politics, almost paradoxically so, is that research participants' knowledge of AIDS and of HIV transmission dynamics is rendered poor by comparison with that of the authors and the work they cite. This is clearly a "deficit" model no different than other versions they rightly excoriate. In both conventional health education materials they cite and their own formulations, "information" from the experts is seen to filter down, over, and out to different communities whose members will interpret it as they may. Rarely do these two domains overlap, though: Explanations of the disjuncture thus prefigure the relationship of the researchers to the researched. The authors cite Raffaelli et al. (1995; see their bibliography) who assessed street youth "knowledge" in terms of five "factual statements about HIV transmission" that the researchers provided. Each "factual" statement is demonstrably false, though; pregnant women cannot "pass AIDS" to their children. Study participants repeatedly come off as being partially knowledgeable at best, but the researchers become almost totally so. In public health-speak this is a "KAP-gap," where K means knowledge and A means attitudes; wherever these do not mesh with the P of Practice, there is a "gap." The authors here rightly decry claims of "gaps" consigned to the realm of culture, not political economy. Nevertheless, I find such evidence to abound in Women, Poverty and AIDS, too.

These are not semantic quibbles. The authors suggest briefly that HIV might itself be an opportunistic infection (as does Root-Bernstein more resolutely), the root cause of which is poverty (e.g., pp. 92-93), but only in fits and starts do they hit this fundamental point. If the root cause of HIV infection is poverty, fine; if AIDS is sexually transmitted disease, I'm with them; if epidemiology is the fault line of a global political economy, I'll buy it; but are they willing to roll with the sneaky, slippery, ontological statuses that such designations imply, much less the political implications that follow?

Finally, has all exclusionary bias been bad for women, for instance, in context of drug or clinic trails? Bias against women ranges from benign to malign ignorance, to misplaced paternalism, to greater concern for fetus than for mother--this is undoubted and palpably unjust. Nevertheless, it sometimes "protects" women in specific contexts. First, anthropologists know that colonial neglect of women's worlds and economic bases sometimes left them more intact than men's. Second, Dr. Peter Duesberg (1996), among others, has demonstrated how morbidity- and mortality-inducing the "magic bullet" of A.Z.T. really is, whether used singly or nowadays in "drug-cocktails." As I write, 12,211 pregnant women from the Dominican Republic, Thailand, and several African countries (each the site of experimentation in the past) are now enrolled in a study of the HIV transmission-blocking effects of A.Z.T. therapy (e.g., Saba & Ammann, 1997). The debate launched recently in The New York Times regarding the New England Journal of Medicine's editorial criticizing the ethics of the study is notable for not questioning the relationship between HIV and AIDS and, more to the point, erasing the woman in favor of the fetus. On these two most important points, respectively and respectfully, I find that Women, Poverty and AIDS does no better and doesn't go far enough. Whatever the HIV transmission-blocking effects may be, A.Z.T. increases morbidity and mortality, particularly in areas in which anemia is already endemic due to poor nutrition and high malaria load. Sometimes placebos are less hurtful, however obvious the malintent may in fact be. Sometimes exclusion is better when the medicine is worse than the pathogen or when the pathogen(s) are misplaced in terms of cause and effect. This was a lesson learned painfully by women almost a decade ago, less so by researchers, in context of trials of Nonoxynol-9 lubricated condoms (e.g. Berer, 1992). Such studies evince greater concern for fetuses than for women. Mere inclusion of women in clinical trials is not the answer, though gender equity is.

Despite these flaws, Women, Poverty and AIDS works exceedingly well on many, many levels, and it sets a standard of writing, critical scrutiny, and gendered praxis that will not easily be exceeded. Just its bibliography alone is worth the asking price, but the frameworks they critique and themselves put forth are carefully crafted and well substantiated. These sterling essays give as much credence to the lives and insights of Lata, Guylene, and Darlene as to Zena, Paula, Gena, Cindy, Brooke, Dooley, and countless other forthright women who have known that AIDS was gendered all along.

REFERENCES

Berer, Marge (1992). Adverse effects of Nonoxynol-9. The Lancet, 340, 615-616.

Duesberg, Peter (1996). Inventing the AIDS virus. Lanham, MD: Regnery Publishing.

Root-Bernstein, Robert (1993). Rethinking AIDS: The tragic cost of premature consensus. New York: The Free Press.

Saba, Joseph, & Amman, Arthur (1997, September 20). A cultural divide on AIDS research. The New York Times, p. A15.

Whitaker, Rupert, & Edwards, Richard (1991). A model-based approach to US policy on HIV-1 infection and immigration. AIDS and Public Policy Journal. 6(1), 3-14.