The AIDS Epidemic

Social Dimensions Of An Infectious Disease

William A Rushing

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429976490
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

This book, a comprehensive introduction to the problem of acquired immunodeficiency syndrome (AIDS), lays out the medical facts and social epidemiology of the infectious disease and illuminates the complex social problems this disease poses for the United States and other nations.

PART ONE

SOCIAL ETIOLOGY

For all but a tiny span of time in human history, infectious diseases have been the major diseases and causes of death, and they are still widespread in developing countries (World Health Organization, 1992:15). Sociologists have not studied these diseases very much.¹ One reason is that the etiology of these diseases is dominated by a single factor (a germ), whereas the etiology of the leading diseases in developed countries (e.g., heart disease, cancer) is more complex and involves a range of behavioral and social factors.² These factors, however, may also be important in infectious diseases, especially HIV-AIDS. Therefore, to comprehend the social etiology of this disease, we must understand some sociological principles regarding the etiology of infectious diseases in general.

The sociological approach to the etiology of disease is an extension of epidemiology, which studies the differences between populations in the prevalence of disease and the distribution of diseases between sectors (subpopulations) of one population. In this way hypotheses about the etiology of disease may be developed. The basic concepts of this approach are agent, host, and environment.

Agent, Host, and Environment

The immediate cause of an infectious disease is an invisible parasite or microbe called the agent (virus, bacteria). The agent attacks the host (e.g., people) and feeds on or in the tissues, organs, skin, and secretions of the host. In the absence of a medical cure, the host usually gets sick and sometimes dies. However, since the immune system of the host normally fights back, the host may survive and develop immunity to future attacks.

Germ theory led to the discovery that microorganisms cause infectious diseases. It also gave rise in medicine to the doctrine of specific etiology, which holds that for each disease there is one cause (Dubos, 1959:101-110). However, infectious diseases are more complicated than the doctrine suggests. The character of the population and the environment of the population are also important factors.

Some populations (and subpopulations) have stronger immune systems than other populations. For example, although the effect of inadequate nutrition on the immune system and hence on susceptibility to infectious diseases is complex, in general malnourished populations are more susceptible to many infectious diseases than are other populations (Ulijaszek, 1990; Chandra, 1983). Also, populations with a low prevalence of diseases have more resistance to new agents than do populations in which diseases are widespread because immune systems in the latter may already be compromised by so many diseases. Features of the environment may also be important. For example, person-to-person transmission of an agent is more likely to occur in environments in which individuals live in crowded conditions. The presence of an agent is thus not sufficient to cause a disease to be widespread in a population or subpopulation. How prevalent it is will depend on characteristics of the population and the environment. In comparison to the biomedical approach to infectious disease, the epidemiological approach places greater emphasis on these characteristics than on the characteristics of the agent.

The sociological approach to the etiology of disease builds on this idea. For this reason the approach is sometimes referred to as social epidemiology. Its focus is on the social characteristics of the population and the environment.³

Major Social Factors in Infectious Disease

Two demographic variables, population size/density and migration, are the most general social factors in the etiology of most infectious diseases. In addition, social norms and customs, social cohesion, social institutions, and social change may be significant.

Population Size/Density and Migration

Some infectious diseases exist only when populations reach a certain size and density. The larger the population is, the greater are the chances of host-to-host transmission of infectious agents. Consequently, many infectious diseases were probably very rare or nonexistent when hunting and gathering societies were universal (Black, 1975; Cockburn, 1977:89-90; Cassidy, 1980:120). As populations grew, especially with the development of cities, infectious diseases increased. Beginning with urbanization, societies were repeatedly wracked with devastating epidemics (McNeill, 1976).

As people move from place to place, they may carry infectious agents and introduce them to new populations. In this way the centuries-long rural-to urban migration led to the spread of infectious diseases, as did the development of intercontinental travel, which continues to be a factor in the spread of many infectious diseases.⁴

Social Norms and Customs

Social norms and customs may be important in the spread of disease. Habits of poor personal hygiene and the custom of living near domesticated animals are obvious examples. The social dynamics behind poor health habits may be less obvious. For instance, a study in rural India showed that a major source of disease stemmed from the fecal contamination of food and water due to the custom of defecating in the open field. To rectify the problem, public health officials installed public latrines, which people—especially women—promptly ignored. Using the open field to defecate was an important social activity. “Every morning and afternoon women go to the field, not only to relieve themselves but also to take time off from busy domestic routines, to gossip and exchange advice about husbands and mothers-in-law. ... The linked habits of going to the field for social gathering and for toilet ... meet a strongly felt need for community living” (Paul, 1977:235).

Social Cohesion

Since the 1970s a wide range of studies have found that individuals with extensive and cohesive networks of social relations have lower mortality rates from a variety of diseases than do individuals who have smaller and less cohesive networks (for a general review, see House et al., 1988).⁵ Significantly, noninfectious diseases have been the focus of these studies. A much different relationship probably exists for infectious diseases. Other things being equal, since wider and more cohesive networks of social relations bring people together, social cohesion probably increases opportunities for host-to-host transmission of infectious agents.

Social Institutions

Social institutions are the frameworks within which people conduct their day-to-day routines of living and working. Some institutions facilitate person-to-person contact and hence opportunities for infectious agents to move from host to host. For example, the extended family of early (and present-day) simple agricultural societies involved more extensive contact between people than does the nuclear family unit, which some anthropologists believe was typical in the hunting and gathering societies that preceded early agricultural societies (Dumond, 1977). This contact may have been a major factor in the emergence of so many infectious diseases in early agricultural societies as well as in many developing countries today.

Social institutions, such as religion, that lead to the gathering of people are also implicated in disease transmission. For example, ceremonial baths as part of religious pilgrimages have contributed to cholera epidemics in India (Briggs, 1961:81; McNeill, 1976:46). Likewise, most social institutions are associated with physical structures in which people gather (e.g., schools, business firms, hospitals, churches).

Social Change

Since the agent is produced in the environment, it follows that changes in the environment may lead to changes in infectious diseases. According to T. Aidan Cockburn (1977:95), a medical and anthropological expert on infectious diseases, “Every change in the environment or culture is reflected in the patterns of the infectious diseases of the population.” Changes in population size/density or migration patterns may change the prevalence of infectious diseases, as may an increase in social cohesion and population responses to changes in customs and norms. All were involved in the historical transition from hunting and gathering to agriculture about ten thousand years ago. Population size and densities increased, people began to live near animals, extended and cohesive kinship systems emerged, and infectious diseases increased (Cockburn, 1977; McKeown, 1979:45; Murdock, 1980:7). The transition led to new infections as well as facilitated the transmission of old ones (Cockburn, 1977:95). Some scholars believe that early agriculture led to the emergence of many common infectious diseases (e.g., rubella, smallpox, mumps, poliomyelitis, and chickenpox). Since agents for these diseases can exist only by rapid transmission from one host to another, they probably did not exist prior to agriculture and the existence of populations large enough to permit rapid transmission (Cockburn, 1977:89). It was not until the emergence of cities that the population threshold was reached for some infectious agents to thrive (Black, 1975; McNeill, 1976:50-51; Cockburn, 1977). For example, since it may take a population of about 1 million people in contact with one another (a single city or several populations close together) before the threshold is reached, many present-day common infectious diseases (e.g., measles) may have come into existence only when populations of this size emerged (Cockburn, 1977:91).

In addition, rural immigrants brought their rural customs to the city. They brought domesticated animals (Rosenberg, 1962:103, 191; Furnas, 1969: 455-456; Braudel, 1981:487; Evans, 1987:111, 114) and made no effort to collect and dispose of garbage and excreta (human and animal), frequently allowing both to pile up on the street (Burnet and White, 1972:13; Cornell, 1982: 204; Lyons and Petrucelli, 1987:55). (Much of the garbage was eaten by domesticated animals, just as in the countryside [Rosenberg, 1962:103].) Sewers were nonexistent or inadequate, and water was often contaminated (Lyons and Petrucelli, 1987:90, 203, 315). These conditions facilitated the spread of old microbes and could have led to the emergence of new ones.

Social Change and the Prevention of Infectious Diseases

Social and cultural change may contribute to a decline in infectious diseases. In societies that value science and have faith in knowledge based on science, people may change their behavior to avoid getting an infectious disease when medical science identifies how the agent is transmitted. For example, the development of germ theory led to segregating infectious patients, cleaning food, boiling water, practicing better personal hygiene, and improving infant feeding (Preston, 1976:86). Norms of behavior changed, preventive behavior increased, and infectious diseases declined.

Individual Infection and Epidemics

The focus of physicians and biomedical scientists is the physiological processes by which the agent causes an individual to get a disease. These processes are universal regardless of the environment in which the individual exists or the character of the population of which the individual is a member.

However, sociological phenomena, not just the agent, determine how widespread the infection becomes. Given the presence of the agent, the prevalence of a disease will vary depending on social norms and other characteristics of the population. For example, the greater the cohesion is, the more widespread a contagious disease is apt to be. Therefore, even though a microbe may be a necessary and sufficient condition for an individual to get infected, and a necessary condition for an epidemic to occur, it is not sufficient to cause an epidemic. Social cofactors must also be present.

The issue here is fundamentally different from the argument that HIV is not a sufficient (or necessary) condition for AIDS, in which different conceptions of the physiological causes of AIDS are the central issue (Root-Bernstein, 1993). That argument concerns the physiology of the disease itself, not the social factors that contribute to its epidemic form. The physiological action of HIV is the same for all individuals who are infected (though the speed of the action may vary between individuals). But before HIV could have led to the AIDS epidemic, social cofactors had to have been in place.

Guenther Risse (1988:55) stated that “epidemics are the result of a complex interplay of biological and social factors which at certain points in our history create favorable ecological niches for given diseases to thrive and therefore decimate humankind.” This proposition guides the analysis in the next four chapters, which explore the social epidemiology of HIV-AIDS, the possible origin of HIV, and the trends and containment of the disease.

Notes

1. For example, the index of the highly acclaimed Handbook of Medical Sociology(Freeman and Levine, 1989) contains no reference to infectious disease or to specific infectious diseases (other than AIDS), though numerous references appear for chronic illness, specific chronic illnesses (e.g., heart disease, cancer, stroke), stress, and mental illness.

2. Another reason is that when medical sociology became a recognized specialty in sociology after World War II, infectious diseases constituted only a small proportion of all diseases. In 1950 only one of the ten major causes of death was an infectious disease. This remains the case today (the disease is pneumonia-influenza, of which 98 percent of the deaths are from pneumonia [U.S. Bureau of the Census, 1988:77]).

3. The framework of agent, host, and environment is not limited to infectious disease. It is also used to conceptualize noninfectious diseases, though agent is frequently replaced by the more general term pathogen.

4. The colonization of the Americas highlights the social and cultural significance of intercontinental travel for the spread of infectious diseases. Europeans brought many infectious diseases against which Native Americans had little immunological resistance. This led to depletions of populations and, indeed, to the disappearance of entire civilizations in the New World. William McNeill (1976:204) gave an example of just how devastating infectious disease can be. In 1903 a previously isolated tribe of Caypao Indians of Brazil accepted a European Christian missionary into the tribe, which numbered at least 6,000 members. The spread of infectious diseases reduced the tribe to 500 by 1918 and to 27 by 1927. In 1950 there were only 2 descendants left.

5. The reasons for the relationship are not exactly clear, though two general hypotheses—the main effects hypothesis and the buffering hypothesis—have been posited. The former stipulates that a weak or weakened network of social relations has a direct effect on the individual state of health (e.g., death of a spouse may create stress, which leads to premature death). The latter stipulates that a wider and more cohesive network serves to support the individual in time of crisis and provide a buffer against its consequences (Berkman, 1985).

THE SOCIAL EPIDEMIOLOGICAL PERSPECTIVE

1. High-risk Groups in the United States

The first question social epidemiologists ask about a disease or cause of death is whether it is unevenly distributed in a population, as between age-sex categories, ethnic groups, social classes, or other populations with distinctive social or cultural characteristics. If this is the case, social factors are probably part of the disease’s causation. Early in the history of AIDS in the United States, the disease was found to be unusually prevalent in certain groups, which were subsequently designated “high-risk groups.”

High-risk Groups

In June 1981 the CDC (1981a) reported that five homosexual young men had Pneumocystis carinii pneumonia, which usually occurs only in individuals whose immune systems have been seriously damaged. A month later the CDC (1981b) reported that during the previous two-and-a-half years twenty-six gays had been diagnosed with Kaposi’s sarcoma, which is also associated with a weakened immune system. A few months later the afflictions were also found among persons who had injected drugs, Haitians and Africans living in the United States, and persons who had received blood transfusions and blood products. Further statistics soon revealed a very high concentration of PCP, KS, and other afflictions among gays, so the syndrome of diseases that later came to be called AIDS was believed to be associated with male homosexuality and was originally called gay-related immunodeficiency disease (GRID).

Although it is generally believed that the earliest known adult cases of AIDS were homosexuals who did not inject drugs, repeated serological analysis of stored blood samples taken from drug injectors from forty-two states and the District of Columbia in 1971-1972 revealed the presence of HIV in a number of them (the number varied depending on the test), whereas all tests for a control group of nondrug abusers were negative (Moore et al., 1985). Another study of the stored blood of persons in drug treatment programs in Manhattan found that HIV had been pres...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• List of Tables and Figures
• Preface
• Acknowledgements
• Introduction Sociology and AIDS
• Part One Social Etiology
• Part Two Societal Reactions
• Appendix
• References
• About the Book and Author
• Index