Treading the path of least resistance: HIV/AIDS and social inequalities—a South African case study☆
Introduction
For 1/4th of the world's population, absolute poverty remains the principal determinant of their health status, exposure to HIV/AIDS and high fertility levels. Health indicators from Least Developed Countries reveal vast global disparities. Women represent 70% of the world's poor and they have less education, longer working hours and lower life expectancy. Maternal mortality in LDCs is 15 times the rate of that in industrialised countries. There has been a sharp re-emergence of infectious diseases such as TB, diphtheria, HIV/AIDS and hepatitis B. About 17 million people a year in developing countries die from curable, infectious and parasitic diseases that affect the poorest disproportionately (EU Development, 2000)
Since the beginning of the AIDS epidemic 50 million individuals have been infected with HIV and over 16 million have died (UNAIDS, 1999). In 1999 AIDS deaths, internationally, reached a record 2.6 million with a further 5.6 million adults and children becoming infected (UNAIDS, 1999). In 1990, 1% of pregnant women attending ante-natal services in the public sector in South Africa were HIV positive. By the end of 1999 this figure had risen to 22.4% (Department of Health, 2000). Furthermore, it is estimated that over 1500 South African's are infected with HIV daily. Recent figures indicate that “one in eight adults (15–49 years of age) is infected with HIV” (between 12% and 14%), in South Africa (South African Health Review, 2000). The HIV/AIDS epidemic is clearly the most serious health and development crisis facing South Africa in the new millennium. Its social and economic costs will be devastating. Some of the economic costs were highlighted in a report released by the department of finance: It is predicted that in 2003, the HIV prevalence rate will be “12% among highly skilled workers, 20% among skilled workers and 27.2% among low skilled workers” (Mail and Guardian, 2000, p. 40). Yet the burden of this epidemic does not fall evenly or equally. Rather, as also mentioned in other studies (Susser & Stein, 2000), this paper demonstrates that the overwhelming majority of those currently living with HIV/AIDS are young African women in developing countries. We argue, it is these women who are most susceptible to infection, have the highest rate of infection, get the most inadequate and inferior access to treatment, take most responsibility for caring for the sick and dying and have the shortest survival rate.
An examination of recent South African patterns of infection and death from AIDS related illness, strikingly reflects broader social cleavages and inequalities. Sociological literature and health education programmes which primarily argue that individual behaviour needs to be challenged and altered before transmission rates will decline are naive, misplaced and misleading. Campaigns in South Africa to this effect have failed to curtail the epidemic. While behaviour patterns cannot be ignored this paper argues that social inequality is the greatest transmitter of HIV/AIDS. Strategies for change need to address social inequality and the empowerment of women in particular if rates of transmission are to decline.
This paper presents the multiple dimensions of social inequalities and their complex relation to health. Furthermore, it engages the concepts of vulnerability and social capital and their value in understanding the nature of the epidemic.
Section snippets
Health and social inequalities
The existence of health inequalities (measured in a variety of ways by comparing various indices) between populations in more and less developed countries as well as within different groups in industrial countries is a well established phenomenon (Kaplan 1996; Wilkinson, 1996). There is no doubt that the size and nature of these inequalities present a major public health issue and as such they have been the focus of numerous health studies as well as health policy undertakings (Black, 1991;
Place/geographical location and health
There is considerable evidence to suggest that place or geographic location is another social dimension linked to inequalities in health (Whitehead, 1992; Gillespie & Prior, 1995). Curtis and Taket (1996, p. 95) discuss ‘spatial expression of health inequalities’ and argue that the debates over social inequalities are important to the understanding of regional differences within and between countries. There is no doubt that the geographical distribution of social factors known to be associated
Racial and gender inequality
This paper rests on a series of assumptions, one of which is that all societies continue to be divided along the ‘fault line’ of gender, which considerably affects the health and wellness of both men and women. The differences (and the factors which influence them) between men's and women's health have been extensively researched and well documented (see for example, Doyal, 1994; Graham, 1993; Oakley, 1984; Papnek, 1990; Roberts, 1985; Miles, 1991; Annandale, 1998). Lane and Cibula (2000) argue
The position of women in South Africa
A recent base-line study ‘Key Indicators of Poverty in South Africa’ revealed that South Africa still had one of the worst records in terms of social indicators and income inequality. About half (44%) of South Africans were poor. Nearly 95% of poor people were African (South African Health Review, 2000, p. 3). While population estimates (based on the 1996 census) reveal similar numbers of men and women living in urban areas (although there are differences across provinces), in non-urban areas,
The concept of ‘vulnerability’
So far the paper has demonstrated that women in South Africa are disadvantaged on various levels and as will be shown later have higher rates of HIV/AIDS. In an attempt to further understand this complex scenario, we are posing the question of how do the concepts of vulnerability and social capital assist us in both explaining and changing the current situation?
There has been much interest in social determinants of health since the public health movement in the 19th century, and the literature
Social capital
The concept of social capital is strongly contested and consequently, variously defined in the sociological and development literature. Putman (1996), one of leading writers in the field, defines social capital as “features of social life, networks, norms and trust, that enable participants to act together more effectively to pursue shared objectives” (Putnam, 1996, p. 114). Briggs (in Budlender & Dube, 1997) understands social capital as “resources stored in human relationship” and suggests
HIV/AIDS—the global picture
According to the AIDS epidemic update (UNAIDS, 1999) the overwhelming majority of people with HIV—some 95% of the global total—live in the developing world. It is argued that the “proportion is set to grow even further as infection rates continue to rise in countries where poverty, poor health systems and limited resources for prevention and care fuel the spread of the virus” (UNAIDS, 1999, p. 4).
Sub-Saharan Africa continues to have the highest rate of HIV/AIDS, with 23.3 million people
Some methodological issues
One of the major problems in South Africa is the inadequate quality of statistical information. All data should thus be interpreted carefully recognising potential inaccuracies. The main problems are related to inaccuracies in population estimates and registration of information. The general data presented in this paper are derived from three different sources: Statistics South Africa (2000), UNISA's Market Research Bureau and Community Agency for Social Inquiry.
The HIV/AIDS data are obtained
Discussion and conclusion
This paper outlines aspects of the HIV/AIDS epidemic scenario and the complexities associated with it. It reveals the socio-epidemiological patterns of the epidemic and in doing so identifies the populations with the greatest and fastest growing rates of infection. From the data presented it is evident that the pattern of HIV/AIDS in developing countries in sub-Saharan Africa in particular is unique. The pattern emerging in South Africa follows closely. The features of this pattern are as
The way forward
Attempts to intervene in the spread of HIV/AIDS in South African have not been very successful. There are a range of reasons for this, one of which has been the simplistic focus on changing individual behaviour patterns due to the early framing of HIV/AIDS as an individual health issue (Marais, 2000). Others include, the inability to merge the “paradigms of the medical and the political, the scientific and the social” (Marais, 2000, p. 10). In addition, a lack of political will has
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This paper was prepared as a background paper for the XVth International Conference on the Social Sciences and Medicine, held in Veldhoven, the Netherlands in October 2000.