Antiblack Racism and the AIDS Epidemic

State Intimacies

A. Geary

• Publisher: Palgrave Macmillan
• Year: 2014
• Print ISBN: 9781137389527
• eBook ISBN: 9781137438034
• Topic: Social Sciences
• Subtopic: Civil Rights in Law
• Index: Social Sciences

Anti-Black Racism and the AIDS Epidemic: State Intimacies argues that racial disparities in HIV rates reflect the organization of racialized poverty and structural violence. Challenging the popular perception of HIV, black vulnerability to HIV in the US is shown to be created by the violent intimacy of the state.

Chapter 1

Rethinking AIDS in Black America

The color of AIDS in America is black. Of the approximately 1.2 million people in the United States currently living with the Human Immunodeficiency Virus (HIV), nearly half (46%) are black as are nearly half of all people newly infected with HIV each year, even though African Americans account for only 12 percent of the total US population.¹ As with the global pandemic,² there are more black people living with HIV in the United States than whites or any other racial-ethnic group. The prevalence rate for African Americans is nearly eight times greater than for whites and three times higher than for Latinos.³ Broken down by gender, the numbers are even more extreme. Nearly 75 percent of those in the United States living with HIV are male. Prevalence rates for black men are dramatically higher than for any other group of people: six times the rate for white men and three times the rate for Latino men. Black women suffer an HIV prevalence rate only exceeded by black men. Black women’s prevalence rates are 18 times greater than those of white women and four times those experienced by Latino women.⁴ Black women’s prevalence rates are nearly 50 percent greater than Latino men’s, the next highest group.

Rates of new infection (incidence rates) closely parallel prevalence rates. Black people suffer about 45 percent of all new HIV infections, while whites account for 35 percent and Latinos 20 percent. New infection rates are greatest for black men, whose rate of infection is six and a half times higher than for white men and more than two and a half times that of Latino men. As with prevalence rates, the incidence rate for black women is dramatically disproportionate to all other women. Black women are infected with HIV at rates more than 15 times higher than white women, and nearly three and a half times higher than Latino women. At current rates, one in 16 black men and one in 32 black women are likely to be diagnosed with HIV in their lifetimes.

What theory of disease epidemic can help us understand the racial blackness of the US AIDS epidemic? Or, more pointedly, how does the racial blackness of the US epidemic challenge what we think we know about it? How do these numbers challenge what we mean when we say “AIDS”?

In what follows I argue that the racial blackness of the US AIDS epidemic has been produced not by the behaviors of African Americans but by conditions of structured, racist domination. Racism, not race, ethnicity, or culture.⁵ In dominant social and scientific discourses, HIV infection has been understood to index perverse intimacies of sex and drug use, what are politely named “risk behaviors.” AIDS has been considered a consequence of these intimacies. For black Americans, however, I argue that the primary structuring factor that has determined risk of HIV infection has been what I call state intimacy, or the violent intimacy of the racist state. From structured impoverishment to racial segregation, and from mass incarceration to the “political death” meted out to former prisoners, the state has structured the ways in which black Americans have been made vulnerable to HIV exposure and infection far beyond the capacity of any individual or community mitigation or control. This structured vulnerability entirely exceeds questions of so-called risk behaviors or their social construction.

The AIDS epidemic is structured not by the deviant behaviors or relations that people engage in, but by the unequal and violent conditions in which they are forced to live and that are embodied as ill-health and vulnerability to disease. Medical anthropologist and physician Paul Farmer has described HIV disparities as the biological expression of social inequalities, a position that resonates strongly with the nation’s racial demographics of suffering.⁶ While this is an essential starting point for any critical account of AIDS or other disease phenomena, to say that the racial distribution of the US AIDS epidemic indexes social inequality is simply to begin a discussion. That black people suffer disproportionately is not accidental or an intensification of otherwise “colorblind” forces of social inequality; it is a direct consequence of the centrality of antiblack racism in structuring the conditions of possibility and the conditions of continuance for this epidemic, conditions with social and health consequences for everyone, but especially for black people. This is not a conspiracy theory: I do not mean that AIDS is a plot to eliminate black people. What I mean is that antiblack racial formation—the organization of relations of violence, domination, and exploitation directed at people who are marked “black”⁷—has structured the conditions of living and dying that have enabled this epidemic, conditions that cultural theorist Lauren Berlant has recently named “slow death.”⁸ Although not exclusively a consequence of antiblack racism, antiblack racism has nonetheless been fundamental in structuring the conditions of possibility for the nation’s epidemic.

How to Have Black Materialism in an Epidemic⁹

A sustained account of AIDS for black Americans transforms what we know the AIDS epidemic to be, how it travels, and who it affects. Medical historian Elizabeth Fee and epidemiologist Nancy Krieger have described the dominant way of thinking about and responding to HIV risk as betraying a “biomedical individualism.”¹⁰ As Krieger describes it, the biomedical model has three key features:

It emphasizes biological determinants of disease amenable to intervention through the health care system, considers social determinants of disease to be at best secondary (if not irrelevant), and views populations simply as the sum of individuals and population patterns of disease as simply reflective of individual cases. In this view, disease in populations is reduced to a question of disease in individuals, which in turn is reduced to a question of biological malfunctioning. This biologic substrate, divorced from its social context, thus becomes the optimal locale for interventions, which chiefly are medical in nature.¹¹

HIV risk discourses have been thoroughly biomedical. They tend to individualize risk by treating it as the consequence of personal behaviors. They exhibit an isolated understanding of viruses, as though they were more or less self-contained biological machines that operated the same way under any and all conditions. And they tend toward an isolated understanding of human individuals in their interactions with viruses, as though the conditions of their meeting was irrelevant.¹² Both the actions of people and the actions of viruses are stripped of context, focusing attention on the nature of the virus and on the acts that potentially allow transmission of HIV from person to person. Group patterns, in turn, appear “simply as the sum of individual traits and choices.”¹³ The key disciplines for thinking about and attempting to intervene into the risk of HIV have been virology, psychology, and ethnography. Given the ongoing failure to create a vaccine for HIV, in turn, the primary method of intervening into the epidemic has been targeted, therapeutic modification of acts and the reformation (or punishment) of those members of society who engage in them: all those strategies that have gone under the name of “AIDS prevention.”

In the biomedical common sense of HIV risk, the disease disparities experienced by black Americans can only be understood as an index of their so-called risk behaviors. Medical anthropologist and physician Didier Fassin, describing this common sense as applied to Africans, might just as well be speaking of African Americans, when he writes,

Ordinary culturalism, on the one hand, explained the epidemic in terms of cultural specificities supposedly shared by all Africans or, sometimes, limited within ethnic boundaries. Commonsense behaviourism, on the other hand, restricted its focus to attitudes and practices disconnected from social realities. Both neglected the historical dimensions of the disease, its socio-economic determinants, its political implications.¹⁴

Black Americans too have suffered under the neglect of ordinary culturalism and commonsense behaviorism. Even if never stated explicitly, cultural and behavioral pathology have been presumed to be the cause of black HIV rates, as they are of other forms of black suffering. Always, the presumption is that black people experience higher rates of HIV because of what they do (or do not do), how often they do it (or not), and with whom. But black people’s experience of vulnerability to HIV is irreducible to numbers of HIV-transmitting acts, numbers of sexual partners, or numbers of concurrent sexual relations. It must be understood within the social determinants of health. Black people individually and collectively suffer kinds of increased malnutrition, concurrent infection, and overall immiseration that lend toward increased susceptibility to HIV infection.¹⁵ This health inequality is recognized as contributing to disease progression (black people progress from initial infection to advanced HIV disease faster than nonblacks), quality of care (black people are less likely to receive advanced care than nonblacks), and death rates (black people die earlier than nonblacks),¹⁶ but racially unequal health and healthcare must also be recognized as significantly structuring risk and vulnerability to infection as well. Poorer health, in fact, would account for the repeated inability in epidemiological studies to establish behavioral differences between black and nonblack populations in the United States that would account for racialized HIV disparities. Instead of behavioral difference, HIV disparities emerge from the structuring of ill health for blacks and the manner in which ill health increases vulnerability to HIV infection. Thus, critical analysis and political intervention must shift from attention to the structuring of risk behaviors and to the material structuring of health as the key condition for the HIV epidemic in the United States, as it is globally.

The understanding of black illness and disease as resulting from racist social relations has a long history. In his sweeping history of black urban health, medical historian David McBride traces a continuous black health tradition from the late nineteenth century to the present.¹⁷ While this tradition has evolved over time, from its earliest articulation it argued against racialist theories that reduced black ill health or disease to either black biological difference (so-called race) from nonblacks or black cultural pathology (so-called culture or ethnicity). Rather, black ill health and disease patterns were understood as emerging from racist inequality and domination. As W. E. B. Du Bois wrote at the turn of the twentieth century, “The Negro death rate and sickness are largely matters of condition and not due to racial traits and tendencies.”¹⁸

As McBride’s history demonstrates, the black health tradition has been one of the primary—if not the singular—vehicles for a materialist analysis of health and disease in the United States. The materialist tradition in health science “define[s] the social causes and origins of health and disease, relating them to the power relations in society.”¹⁹ For instance, Frederick Engels, in his masterful study of the conditions of life for the mid-nineteenth-century working classes of Manchester, England, presented a detailed analysis of the etiology and epidemiology of typhoid, tuberculosis, scrofula, and rickets as “part of an overall analysis of the working and living conditions of the working class under capitalism. He specifically related disease to the social relations of production and class structure they determined. Since the problem resided in capitalism, real solution required transcending capitalism.”²⁰ Drawing from but also extending the work of these founding authors, materialist health science has challenged and continues to challenge medicalized understandings of health and illness that treat disease as biological events that obey natural laws (positivism in the health sciences), insisting on their social structuring. Disease and epidemic are “social events” and entirely dependent on the social production of necessary conditions.²¹ They cannot be reduced to an agent (like a virus) and its “natural, biological, and harmonious laws,”²² let alone to kinds of people and their natural or unnatural dispositions.

Although the terms “materialist epidemiology” or “materialist health science” are rarely used anymore, even by those within the tradition that relates itself to the founding work of Du Bois or Engels, I want to reclaim those terms.²³ More commonly, health studies that insist on the social origins of disease and health are produced under different names: the social determinants of health and disease; the political economy of health; social medicine; and social epidemiology.²⁴ These other terms, while indexing real distinctions in theoretical and practical orientation, also index a more or less explicit distancing from the Marxist, materialist tradition. At times, the difference appears to be mostly strategic, carrying out materialist analysis but under another name, one that might, for instance, be funded by the bourgeois institutions that control health knowledge and health research in the United States and globally. More often, though, materialist analyses that take place under these other names pacify the social conflict determining the conditions that they study as foundational to health and disease. Those conditions of health and disease are reduced to a listing of proximal causes without an overall structure or engine; or, in the words of epidemiologist Nancy Krieger, a “web of causation” without a “spider.”²⁵ While this research may assist in understanding micro-level conditions that structure health and disease susceptibility, it fundamentally obfuscates the structured social relations through which those conditions are produced, often leading to medical interventions into the effects of social inequality while functionally protecting that inequality.

A materialist epidemiology of the AIDS epidemic, and especially of racialized disease disparities, departs completely from biomedical epidemiology, with its narrow, fetishistic focus on virus and behaviors. Whereas materialism situates health and illness within contexts formed from social inequality and argues for intervening in those contexts to improve health or fight disease, biomedicine tends to scale in toward isolated biological entities when examining disease and health, from the isolated human individual to the isolated virus, bacterium, or other disease agent. Biomedicine “de-socializes” health and illness, treating viral disease epidemics as simply the transmission of virus from individual to individual on a mass scale. Both virus and individual body are abstracted as points on a grid that are connected through transmission vectors. The contact chart is a favorite visual technology. What comes into focus in biomedicine, then, are...

Table of contents

• Cover
• Title
• Chapter 1  Rethinking AIDS in Black America
• Chapter 2  AIDS, Place, and the Embodiment of Racism
• Chapter 3  Mass Incarceration and the Black AIDS Epidemic
• Chapter 4  Representing Global AIDS: Africa, Heterosexuality, Violence
• Conclusion  The Politics of Crisis
• Notes
• Bibliography
• Index