Geography 280 Final Hana Alicic Prof.

Jonathan Mayer March 13, 2012

I.b. In Mountains Beyond Mountains, Paul Farmer quotes a woman from Cange. "You want to stop HIV in women. Give them jobs." Do you agree with this woman's comments? How does political and economic inequality contribute to the spread of HIV/AIDs in places such as Haiti or Ghana? In what ways is the situation similar or different in the United States? Does this fit into the concepts of the political ecology of disease? Make sure that you justify and explain your answer.

II.a. As discussed in lecture, the factors or catalysts of emergence are due largely to changes in society and environment. Within this framework, what factors cause the emergence of new infectious diseases? Discuss three of these, using specific diseases for examples.

III.b. Define structural violence. Give 3 examples of health-related structural violence from lecture and the books we have read throughout the course. Your examples should include the role of social stigma.

Alicic 2 I. Poverty undoubtedly serves as a precursor to disease; Tracy Kidder states in Mountains

Beyond Mountains that while meager incomes don't guarantee abysmal health statisticsthe two usually go together (Kidder 125). HIV/AIDS, however, has become more than an issue of poverty, much less one of biology: the pandemic has become an issue of societal inequalities and misogyny. As one doctor states, The reason that AIDS has escalated into a pandemic is because inequality between women and men continues to be pervasive (Gwanmasia). Those without the power to protect themselves become victims of poor health. Worldwide, political and economic inequalities, especially those experienced by women, have greatly contributed to the continued spread of HIV/AIDS. Political ecology provides a framework for analyzing the HIV/AIDS epidemic by setting the disorder into a social, economic and political context and placing an emphasis on the role of human agency (Mayer 443). Though the framework does not overtly address gender, the focus on human agency can be used to identify inequality and misogyny as human standards that greatly influence the health of populations. The effect of people and governments is epitomized by the fact that countries with the steepest grades of inequalityhave the biggest AIDS problem (Kidder 199). HIV/AIDS in women results from the convergence of factors that ultimately leave them especially vulnerable to infection. Many women are handicapped early on in their lives when economic hardships force them to leave school in order to become family wage earners (Women and HIV/AIDS). As a result, women lose the ability to both learn about health education and to eventually become self-sustaining. Abject poverty and a dependence on men for survival result. In Haiti, HIV-positive women named desperation, deep poverty and illiteracy as the reasons for cohabiting with the men who infected them (Kidder 199). Women whose poverty forces them

Alicic 3 into prostitution face the additional risk factors of multiple partners and forced sex (which results in tears in the bodys natural barriers). And, as is the case in Bangladesh, where in 2005 between 52% and 60% of street-based sex workers reported being raped by men in uniform, women cite police officers as seriously impeding their ability to practice safe sex (Violence). Even within seemingly secure marriages, women cannot find safety from HIV. Sociallysanctioned male extramarital relationships and polygamy result in over four-fifths of new HIV infections in women occurring from sex with a husband or primary partner (Fact Sheet). Women retain little clout to change such a system as they often have no alternative but to depend on their boyfriend or husband. Those who do request the use of a condom potentially anger partners by defying traditional gender roles. Some governments legally bar women from asking for divorce, or protecting themselves from forced marriages and limit the resources, financial or otherwise, that women can access (Turmen). As a result, women believe the economic consequences of leaving a high-risk relationship [are] far worse than the health consequences of staying with their partners (Turmen). Even within the United States, low-income women are particularly vulnerable and are disproportionately affected by HIV/AIDS; again, economic discrepancies play a role, with 64 percent of women with HIV/AIDS and only 41 percent of men having annual incomes below $10,000 (Turmen). Though providing treatment and ensuring that more individuals are educated about HIV/AIDS will play important roles in eradicating the disease, perhaps helping women become economically self-sufficient, both by providing jobs and by supporting appropriate legislation, will play an even more crucial role. As Kenyan First Lady Lucy Kibaki stated, the empowerment of womenconstitutes an integral aspect of the fight against HIV/AIDS (Gwanmesia).

Alicic 4 II. Human health is not controlled by the whims of microbes. While a virus or bacterium

may be the apparent cause of an illness, an emerging infectious disease is the product of a multitude of factors and can be seen as a biological, environmental and social phenomenon (Mayer, January 24). The role of human agency has been increasingly recognized as a major force in emergence, a process complicated by social, political and economic factors (Smolinski et al). Humans have come to play a key role, intentionally or not, in the spread of diseases among their own populations: environmental factors such as modifications of the landscape and societal factors such as international travel and poor public health measures are all major contributors to the constant interplay between man and microbe. Humans have come to so fully interact with their surroundings that the environment has become a malleable entity: rivers are dammed, swathes of forest are removed, and resources are quarried. But changes do not occur without consequences as even the most advanced pathogens require an ecological cofactor to actually take root (Smolinski et al). Transformations in space bring about new interactions with animals and new opportunities for carriers to flourish. In the United States, the reforestation of former farmland and led to a surge in the population of tick-infected deer. The advancement of humans into these wooded areas led to their infection with Lyme disease, a disorder unseen before the reforestation took place (Smolinski et al). The standing water resultant from dam-building often precedes the emergence of diseases carried by water-dwelling vectors. Schistosomiasis greatly increased in frequency following the construction of dams on the Senegal River basin (Smolinski et al). In both instances, interactions with the environment had the unintended consequence of spreading disease. Human human interactions can have the same effect, especially since human populations have transformed from largely isolated pockets to much more complex networks as a

Alicic 5 result of international travel, commerce, and migration. A new threat emerges from the fact that average spatial mobility has increased more than 1,000-fold since 1800 (Smolinski et al). Especially dangerous are microbes that lie latent in a host and are as a result easily and unknowingly spread. The rapid rate at which people disseminate throughout the world ensures the easy spread of pathogens and the occurrence of disease on a much greater scale. A 2000 outbreak of W135 N. meningitides during the Hajj in Saudi Arabia resulted in pilgrims unwittingly transferring the pathogens to their home countries (Smolinski et al). On a domestic scale, AIDS initially circl[ed] the periphery of the United States and in a matter of years spread into the interior of the country (Verghese). Much as with environmental change, increasing travel and commerce contributed to unintentional grave consequences. The breakdown of public health measures is perhaps the factor of emergence most directly related to the health of populations. 20th century optimism about the eradication of infectious disease led to the erosion of the public health system so that later threats could not be properly handled and the importance of basic health measures was deemphasized (Mayer, January 24). In the United States, a nation with advance medicine technology, immunization rates are low and hospitals frequently fail in controlling infection (Smolinski et al). A 1995 Ebola outbreak in Zaire affected 296 people, many of whom were sickened due to the absence of appropriate precautions to prevent exposure to blood (Smolinski et al).The lack of seemingly simple measures such as immunization and proper sanitation can lead to drastic consequences. In almost every instance, disease emerges from societal and environmental factors in which humans are deeply involved as much as it does from biology. Thus, it seems fitting that we are especially cognizant and wary of our own impact in addition to the influence of the natural world.

Alicic 6 III: Structures are patterns that have come to be accepted by society as unarguable

realities: laws, governments, economic practices. Structures are passively understood as the way things are. Conversely, violence implies an purposefully malevolent act. Structural violence, by pairing the two terms, forces the acknowledgment of the suffering and injustice that are deeply embedded in the ordinarypatterns of the way the world is (Taylor). Societal differences in wealth, power, and health are not simply the way things are but are the products of human constructs; as Tracy Kidder states, there are inescapable connections between the gleaming corporate offices of Paris and New York and a legless man lying on the mud floor of a hut in Haiti (Kidder 218). Structural violence with regard to health is epitomized by structures that are biased against certain populations and as a result leave them predisposed to disease and rob them of the opportunity for treatment. Paul Farmer emphasizes the ease with which cultural relativism and the use of appropriate technology can become entrenched structural violence that results in lower quality treatment and technology for the poor. Rather than serving as a framework with which to understand different cultures, cultural relativism can end up justifying inequalities and unequal treatment (Sparke). Oversimplification often leads to insufficient action and upholds the stigma that giving the best care to the most impoverished is unrealistic. The resultant structural violence adversely affects those whose social status denies them access to the fruits of scientific and social progress (Structural Violence) In Haiti, Paul Farmers use of expensive antiretroviral drugs for the poor leads others to consider him insane. Requests for money to supply drugs to poor Haitians were rejected as the drugs were too expensive for the Haitians to buy for themselves in any conceivable future (Kidder 243). Ironically, poverty correlates not only to poor health but to poor care. One Haitian priest most aptly summarizes the situation when he

Alicic 7 states Do you know what appropriate technology means? It means good things for rich people and shit for the poor (Kidder 90). Subpar AIDS treatment results from detrimental social structures and constructs which have a profound influence on effective diagnosis, staging, and treatment of the disease (Farmer). While AIDS may be a social disease, many focus on behaviors and lifestyle choices while disregarding social factors like poverty, gender inequality, and racism. Social stigma plays a major role: Verghese discusses the widespread belief that HIV/AIDS is a disease of gay men and IV-drug users and that anyone else who may be afflicted is an innocent, a notion that ignores the reality that the virus lacks class prejudice (Verghese 250-251). As a result, premature death from AIDS becomes the embodiment of social inequalities (Farmer). Due to the demonization of the patient population and the social inequality they face, those with AIDS face the barriers of poverty, sexism, and racism and struggle to receive adequate care. Social inequality and stigma play similar roles in American healthcare, a system in which class differences are deeply imbedded. As Cohn explains, the fact that many Americans are left vulnerable to illness because they cannot find adequate insurance is the product of years of policy-making. The stigma attached to poverty ensures that spending money on national health insurance is seen as a waste. Public apathy toward government spending on health programs in the inner city leads to the isolation of individuals facing the health challenges seen in impoverished neighborhoods (Cohn 175). While many Americans believe that most people without insurance are unemployed, the truth seems to be that those without insurance are not overtly wealthy (Cohn 215). Though the US may consider itself a stalwart of equality, unequal access to care and the contrasting health status of the rich and poor identify the health care system as an archetype of structural violence that upholds classist, racist, and sexist standards.

Alicic 8 Works Cited Cohn, Jonathan. Sick: The Untold Story of America's Health Care Crisis-and the People Who Pay the Price. New York: HarperCollins, 2007. Fact Sheet: Women and HIV/AIDS. AmFAR, Mar. 2008. <www.amfar.org>. Farmer PE, Nizeye B, Stulac S, Keshavjee S (2006) Structural Violence and Clinical Medicine. PLoS Med 3(10): e449. doi:10.1371/journal.pmed.0030449 Gwanmesia, Ignatius. HIV/AIDS Prevention in Developing Countries : Examining the Justification for Putting Gender Inequality at the Heart of Prevention Policies. Kidder, Tracy. Mountains Beyond Mountains. New York: Random House, 2003. Mayer, J.D. (1996) The political ecology of disease as a new focus for medical geography. Progress in Human Geography, 20:441-456. Mayer, J. (24 January 2012). Emerging Infectious Diseases: Geog 280. Seattle, WA. Mayer, J. (February 2012). HIV/AIDS Epidemiology and Geography From Molecule To Globe. Seattle, WA. Smolinski, Mark S., Margaret A. Hamburg, and Joshua Lederberg, eds. Microbial Threats to Health: Emergence, Detection, and Response. Institute of Medicine of the National Academies, 2003. PDF. Sparke, Matthew. "Meanings Beyond Mountains: A Glossary of Terms from the Work of Paul Farmer." Center for Curriculum Transformation. "Structural Violence." Structural Violence: This Is about Inequality and the Harm It Causes. Taylor, Janelle S. Explaining Difference: Culture, Structural Violence, and Medical Anthropology. Center for Curriculum Transformation.

Alicic 9 Turmen, T. (2003) Gender and HIV/AIDS. International Journal of Gynecology & Obstetrics. 82.3:411-18. Violence against Sex Workers and HIV Prevention. WHO, 2005.