Social Determinants of HIV/AIDS, Essay Example

Part I: Based on the evidence presented in the paper, materials covered in class (i.e. lecture and reading materials) and additional research of your own, propose a causal pathway that underlies the observed HIV epidemic among the risk group(s) in Odessa, as identified in the article. Provide an argument supporting your proposed pathway, and a figure that illustrates the key determinants and any relationships that may exist among them.

The findings of Strathdee et al. regarding the demographic characteristics of the most at-risk groups for HIV infection in Odessa, Ukraine, are relatively predictable. Injecting drug users (IDUs) account for the vast majority of all cases, reaching 85% by the year 1997 (272). Risky behaviors identified among this group include “unprotected sex and injecting practices, including drawing of drug solutions from common containers, shared syringe use,” and the like (272). This is especially the case amongst younger IDUs, with some 38% of all HIV cases in Odessa in the 21-30 age bracket (272).

Socially, forces that contribute to this very high rate of HIV infection include poverty, corruption, and the fact that the drug user subculture is deeply marginalized (Strathdee et al. 272). As Syme and Berkman explained, social class is a predictor of mortality and morbidity rates: persons of lower social class consistently have “higher morbidity and mortality rates of almost every disease or illness, and these differentials have not diminished over time” (2). However, it is not simply a case of differential access to care: in fact, these authors found evidence that in some cases, lower-class individuals had used more, not less, medical care (3). In fact, there is actually a very good case that what accounts for the disparity is not differential access to medical care, nor even differing environmental hazards, i.e. pollution, etc., but rather social and cultural factors operating in the environment in ways that produce more stress for those of lower class (5).

In particular, lack of social mobility has been identified as a risk factor for higher morbidity and mortality rates owing to various conditions, including diseases of all kinds (Syme and Berkman 5). One consequence of this is a pattern of well-known coping strategies utilized to a greater degree by the lower classes: smoking, chewing tobacco, consuming inexpensive liquor and spirits, and of course in some cases, drugs (5). Of course, the modern medical paradigm focuses on such behaviors as ‘voluntary’ risk factors and emphasizes a certain amount of individual responsibility for risks that one assumes with one’s health (60-64). However, this should not blind one to the very real social influences on the rates of HIV: the very high rates of HIV infection amongst IDUs in Odessa speaks to the tremendous problems with poverty and corruption that modern-day Ukraine has. And too, there is an important cultural irony in the fact that although values of individual responsibility are important for keeping down rates of drug addiction, alcohol abuse, and other ills, powerful social and political responsibilities define so much of how healthy different groups of people are.

From the above, it is not difficult to construct a causal pathway for the HIV epidemic in Odessa:

The figure is largely self-explanatory, but a word of exposition is probably in order. Poverty in Odessa includes the results of corruption and lack of job opportunities: an ugly confluence of social forces that keep Odessa locked into a self-reinforcing condition of extreme poverty. This leads to marginalization of the poor, and deep awareness of this marginalization contributes to stress. Stress produces a need for coping mechanisms, and not surprisingly, many people turn to drugs. Drug use, unfortunately, leads to addiction, which leads to addicts becoming further marginalized: now they are not simply poor, but also “addicts”, something ‘worse’ than being ‘just poor’. This is the meaning of marginalization+: they are, if anything, doubly marginalized, in that they are marginalized once because of their class and then again because of their addiction. All of this culminates in a very high HIV risk, which is responsible for the tremendously high rates of HIV infection amongst IDUs in Odessa.

Part II: Based on your proposed pathway, discuss merits and limitations of the intervention strategies proposed by Strathdee et al., and make further recommendations as needed.

What Strathdee et al. suggested was a change in policing practices: an elimination of police beatings, for example, which would allow IDUs access to needle and syringe programs and drug-treatment programs (273). Other practices that they recommended should be abandoned include “arresting of drug users for carrying of sterile or used syringes… soliciting of bribes to avoid arrest, or in extreme cases, sexual abuse…” (273). These are all very good recommendations, and I think that they identify an important component of the current social environment that can actually be changed structurally at the institutional level, that is, with regard to law enforcement policy (273).

What about unprotected intercourse? Might policies be implemented to help IDUs by providing them with condoms and information about HIV risk and prevention? Such an intervention seems appropriate, in light of the observed prevalence of such risky behaviors. By so doing, further reductions in HIV rates might well be achieved.

Of course, these recommendations still leave much to be desired: what is not addressed is the underlying structural root of the problem. In my model, poverty begets marginalization begets stress, and stress leads to higher levels of drug abuse and all the rest. Well, what is the root cause? Is it poverty, poverty begetting marginalization, or marginalization begetting stress? All three: it is the condition of poverty and the ramifications of that condition that are responsible, and it is all three that must be addressed if the problem is to be truly solved. Drug treatment centers already exist to help addicts leave their addiction, and further support for these centers in order to help them expand their services should be a priority for the city of Odessa—and for that matter, Ukraine nationally.

At a more fundamental level, grass-roots advocacy groups in Odessa need to change the engagement with drugs, need to change the culture of drugs and the drug-culture-producing culture of the city more generally. That is to say, local initiatives, not by government, need to address how people utilize drugs and why, and encourage them to go to treatment and find alternatives—and these same groups need to challenge the social and cultural forces that produce these users in the first place.

A key thing to realize here is that local activist groups, and non-governmental groups (NGOs) more generally—concerned citizens, activists, etc.—can probably achieve far more than governmental officials and ministries. Local, grassroots activist groups and NGOs generally have an interest in addressing their causes specifically, and they do so with passion and dedication. Governments have to balance many responsibilities and needs, and in democracies have to ensure voter approval. Moreover, NGOs are likely to be in touch with the reality on the ground, whatever it is, while governmental officials have all manner of political concerns to deal with and their connection with any one issue is often questionable or non-existent. While government has a role, NGOs can achieve far more with a committed force of dedicated, passionate, determined volunteers.

As long as the underlying structural forces are not dealt with, the problem of HIV infection and drug addiction will continue. Strathdee et al. have some very good recommendations, and those recommendations have much promise for helping addicts. However, the underlying structural forces must be addressed to cut off the supply of addicts, so to speak. This is extremely important if any real progress on the issue at a macro-level, i.e. at a sociocultural level, is actually to be made. While every infection prevented or addict helped is a good thing indeed, as long as the social determinants of the problem exist, the problem will continue. Fixing the problem at a structural level is the real challenge, and it is the real challenge because it is the only real solution.

References

Brandt, Allan M. “Behavior, Disease, and Health in the Twentieth-Century United States: The Moral Valence of Risk”. Morality and Health: Interdisciplinary Perspectives. Ed. Allan M. Brandt and Paul Rozin. New York: Routledge. 53-78. Print.

Strathdee, Steffanie, et al. “HIV and risk environment for injecting drug users: the past, present, and future.” Lancet, 376 (2010): 268-284. Web. 02 Mar. 2013.

Syme, S. Leonard, and Lisa F. Berkman. “Social class, susceptibility and sickness.” American Journal of Epidemiology, 104.1 (1976): 1-8. Web. 02 Mar. 2013.