When reviewing pivotal works in anthropology it is important to address frameworks, concepts, and the general ideas of the literature. When reviewing publications that have overarching sociopolitical messages, authors need to be able to state explicitly how their publication is representative of what needs to be changed and considered with regards to the topic under study. Sometimes this is easier said than done, and no work of literature is perfect. However, Paul Farmer’s 2006 book entitled AIDS and Accusation: Haiti and the Geography of Blame and Robert Thornton’s 2008 publication entitled Unimagined Community: Sex, networks, and AIDS in Uganda and South Africa are important ethnographies that present the HIV/AIDS epidemic in a whole new light. They debunk certain assumptions about the epidemic and how it spread in specific geographical areas while addressing the local understandings of knowledge, power and sickness that serve to perpetuate and/or mitigate the spread of the deadly virus. However, both books have certain shortcomings and do not explicitly address how education can influence local understandings of HIV/AIDS and sexuality as well as how cultural heuristics and rational decision theory explain what is happening on the ground in all three region-specific scenarios.
Paul Farmer’s AIDS and Accusation: Haiti and the Geography of Blame is an original case study on the HIV/AIDS epidemic in a rural village in Haiti. By reviewing the stigmas associated with blaming Haiti for the rise of HIV/AIDS in North America as well as theoretical frameworks for understanding the epidemic in Haiti in ways that were groundbreaking and critical, Farmer’s book is a critical case study in understanding HIV/AIDS. Farmer presents new ways of understanding the epidemic from the firsthand accounts of the villagers themselves, which makes the account personal to the reader while inspiring empathy and understanding. The differential experiences of HIV/AIDS worldwide are vast and complex, and Farmer’s book offers critical insights into understanding the devastating effects of HIV/AIDS in Haiti. Throughout the book Farmer presents the lived experiences of different people, the ways in which the epidemic affected their lives, the ways in which they understood what was happening to themselves and their loved ones, and the ways in which they dealt with HIV/AIDS in the wake of political change, disaster and disorder.
In order to understand the setting of the ethnography Farmer contextualizes the way life is experienced in impoverished, rural Haiti. The book educates the reader on the already dire condition of Haiti before the epidemic, recognizing that it was the poorest country in the western hemisphere and one of the poorest countries in the world (Farmer 2006, p.6). By taking readers through the history of the village of Do Kay, the ways in which AIDS was first understood when it came and swept through the village, and through understandings of sida, or ‘the sickness’ Farmer paints a very descriptive picture of the case. By understanding sickness theory in the village of Do Kay and in rural Haiti, Farmer enables readers to understand that HIV/AIDS experience must be understood through local cultural understandings of infectious disease and causation. The experience of HIV/AIDS as described by Farmer alludes to the various ways in which local understandings can mitigate HIV/AIDS prevention not only in Haiti but also in rural villages worldwide and in areas in which sickness and disease are understood through different lenses outside of scientific fact.
Unfortunately, the book does leave many unanswered questions that are emblematic of any case study under review, such as: were the described persons representative cases for persons that have contracted HIV/AIDS infections in rural Haiti? Was the village of Do Kay a typical Haitian village in which HIV/AIDS appeared at the time of writing? Farmer does not blatantly state whether or not the cases under review were representative of the epidemic in Haiti or other parts of the world, which is a critique that must be acknowledged. He also makes it a point to present very different and yet similar cases, highlighting the similarities and differences in the ways in which sida, of HIV/AIDS, the sickness, was experienced by these particular individuals. While highlighting individual experience evokes the emotional responses of the reader, the generalizability of the publication must be questioned critically.
The book does a great service in the academic world by acknowledging that HIV/AIDS transmission and the cultures of blame are directly related in often predictable ways that go underacknowledged. Since sorcery and witchcraft were well known practices for both healing and sickness and belief in sorcery and witchcraft was meaningful to the villagers, how rural Haitian villagers experienced sida, or HIV/AIDS, could have been predicted. If beliefs in witchcraft and sorcery had been acknowledged and understood by organizations seeking to prevent the spread of HIV/AIDS in Haiti, many lives could have been saved. Lack of communication and understanding often prevents effective HIV/AIDS prevention efforts and Farmer highlights this eloquently in his case study. This contributes to what Farmer meant by ‘the geography of blame’ in his title; villagers experiencing HIV/AIDS did not understand the causation and based their knowledge of the disease through local cultural understandings suggesting that the disease was actually a curse and not a virus that couldn’t be cured through ritual healing. Local knowledge, or ‘geographies’ posit local understandings of sickness and therefore, blame.
Similarly, there is an ideology in North America that the spread of HIV/AIDS was caused by a microbe specifically related to homosexuality (Farmer 2006, p.78). This represents a different example of how geographical understandings of disease causation and prevention can negatively affect HIV/AIDS prevention efforts. Distinct Haitian beliefs mitigated the spread of HIV/AIDS because inhabitants of rural Haiti did not understand the disease and causation. Accusation and blame related to the spread of HIV/AIDS varies greatly worldwide and Farmer’s book calls into question the ways in which cultural ideologies can predict how the disease is spread while also suggesting ways in which education needs to take place on the ground in order to save potentially thousands, hundreds of thousands, and even millions of lives.
Farmer also makes a very critical analysis based on a framework that he termed “The Anthropology of Suffering” in relation to sickness and the meaning behind the experience of sickness (Farmer 2006, p. 255). The collapse of the Duvalier regime contributed to the poverty of Haiti and the suffering of the Haitian people. Those that were already impoverished suffered more and those that were already sick became sicker without understanding why (Farmer 2006, p.255). Farmer acknowledges that international politics demand significantly more attention when it comes to sickness and sickness theories and the lived experiences of persons contracting HIV as well as those already living with AIDS. He also acknowledges that a village-level analysis is inadequate in understanding international and national measures that affect the spread of HIV/AIDS. However, no ethnography is perfect, and it is almost impossible to present an exhaustive ethnography that addresses all issues necessary when it comes to this complex and devastating virus.
With regards to international and national understandings of HIV/AIDS causation and prevention, a discussion of Robert Thornton’s 2008 publication entitled Unimagined Community: Sex, networks, and AIDS in Uganda and South Africa, is in need of examination. Both books under review here make great contributions not only to the field of anthropology and epidemiological studies, but they highlight what anthropology can do for the fields of medicine and international health policy. Anthropologists recognize that global and local inequalities based on ethnicity, class, and gender as well as powerlessness and stigma drive the spread of HIV/AIDS (Schoepf 2001, p.335). Anthropology incorporates sociocultural theory in epidemiological studies and recognizes this as best practice (Schoepf 2001, p.35). While 90% or more of those infected by HIV and AIDS live in the Third World, anthropologists recognize that a biosocial perspective is needed in not only curbing the epidemic but also understanding it. Both books actively encourage this approach in their in-depth ethnographies highlighting different influences concerning the spread of the deadly virus in different locales.
Incidences of HIV prevalence also varies across the African continent with some countries and tribes such as the Zulu tribe having infection rates as high as 30% while other countries have rates less than 5% (Schoepf 2001, p.336). Thornton’s Unimagined Community offers a comparative approach as to why the epidemic spread rapidly in South Africa while the epidemic was decreasing at the same time in Uganda; the prevalence fell from approximately 24% in Uganda in 1992 to around 5% in 2002, while in South Africa the infection rate increased to almost 30% in some parts of the country (Thornton 2008). On the surface these numbers seem extreme and cause assumptions that suggest political changes in Uganda were successful in preventing HIV/AIDS while political change (or lack thereof) in South Africa failed in HIV/AIDS prevention. However, Thornton debunks the surface-level misunderstandings and argues that these numbers should not be taken at face value. The president of Uganda implemented the ABC campaign: abstinence, be faithful, use condoms, which, on the surface, proved to be effective in drastically decreasing the spread of HIV/AIDS in Uganda. However, respondents in Thornton’s study did not see abstinence as a viable option. Regardless, there was much propaganda surrounding the ABC campaign in the western world (Thornton 2008). Thornton suggests that the ways in which culture and sex were understood helped the ABC campaign in its success.
Regardless of the propaganda surrounding the effectiveness of the anti-AIDS Ugandan campaign or the lack of effectiveness/secrecy in the South African case, Thornton explains that a key difference between the two countries was cultural and that differential practices in sexual networks contributed to the spread and/or containment of the virus. This is how Thornton justifies the title of the book; ‘unimagined community’ suggests the secret, or seldom discussed, sexual networks within communities that contribute to the spread and/or containment of STI’s. In Thornton’s observations, South African culture was characterized by more random acts of promiscuity as opposed to Uganda’s cultural sexual networks. Sexuality, or ‘promiscuity’ in Uganda was characterized by a higher degree of localized sexual activity and the ABC strategy influenced a substantial decrease of sexual intercourse across localized sexual networks which lowered the spread of HIV/AIDS. The ‘be faithful’ piece did not necessary increase monogamous sexual practice; rather, people in Uganda kept sex closer to home.
Thornton, like a good anthropologist, stresses the implication that different histories and cultures suggest that vastly different strategies should be utilized in the campaign against HIV/AIDS. While both authors stress the need for increased cultural understanding in disease prevention there are certain themes that both authors leave out. Education about sexuality and safe sex practices should be directly stressed within geographical areas where the HIV/AIDS epidemic is the most prevalent.
One thing that isn’t stressed in either book explicitly is the power of education. It is well known that educated persons’ behaviors changed vastly with the influx of new information (Vandemoortele, Delamonica 2002) Education, after all, is generally a good proxy for socio-economic status, and both ethnographies under review are reviewing undereducated communities in poorer nations. With greater amounts of education in general on the subject of sex as well as general education people are more likely to protect themselves (Vandemoortele, Delamonica 2002, p.7). Silence, shame, stigma and superstition are all aspects that thrive in climates of illiteracy and superstition (Vandemoortele, Delamonica 2002, p.7).
Under education and illiteracy contribute to the HIV/AIDS pandemic directly and indirectly, including but not limited to sex education. In both publications a discussion dedicated to educational attainment, sexual and non-sexual, would have been desirable in order to make stronger arguments for what contributes to HIV/AIDS spread in both communities as well as what can be potentially integrated to mitigate the spread. From the outside looking in, cultural understanding and the differing histories as well as ‘anthropologies of suffering’ contribute to our understandings of the epidemics in those particular places. What UNICEF authors Jan Vandemoortele and Enrique Delamonica suggest is that greater amounts of sexual education and education in general would help in the prevention of the virus (2002).
Both books do highlight the political reactions of what can be construed as a social disease. HIV/AIDS affects communities in different manners; the ‘value’ of sexual transactions and the ways in which the lives of the people in said communities are affected by HIV/AIDS are different but also comparable. Both books highlight characteristics of what Thornton would deem ‘unimagined communities’ although Farmer does not state this directly. Communities of taboo, of sexual networks, of superstition, and of masked political and public relations, are highlighted in both publications. Thornton presents a cross-cultural comparative study while Farmer presents a singular ethnography. The utility of both can be realized in the field of anthropology and epidemiological studies.
A different example that suggests the utility of understanding ‘unimagined communities’ can be examined in the United States. There exists an ‘unimagined community’ in the United States where African American men are having sex with other men that otherwise lead heterosexual lives. This community is known as the Down Low (Bond et. al 2008). Although condoms are often available at bath houses and clubs where men on the ‘down low’ often meet, ideologies of raw penetration and masculinity thwart safe sex practices for many, which contributes to higher levels of HIV/AIDS risk (Bond et. al 2008). From this it can be gathered that sexuality is not understood in such forthright terms. Humans are sexual beings that will engage in sexual behaviors that vary from culture to culture but are nonetheless implicit of ‘unimagined communities’ and are veiled by secrecy.
Thornton contributes to this anthropological idea that suggests how sexuality can problematize and further perpetuate the silences amongst communities, such as those communities where men are having sex secretly with other men. Examples include prison communities, Down Low communities, and religiously and sexually conscious communities (Bond et. al 2008). Other works that explicitly or implicitly suggest that the ways in which secret sexual communities and sexual networks contribute to the spread of STI’s and HIV/AIDS risk are also pivotal in confronting this issue and can be modeled after Thornton’s Unimagined Community.
However, neither books take too much of an in-depth look at what these epidemics meant to the international communities when it comes to the politics of worldwide powers mitigating or influencing the spread of HIV/AIDS in both countries.
We recognize that unequal balances of power in both texts suggest that unequal power in the realm of sexuality is influenced by gender roles. For instance, male pleasure usually super cedes female please and men have greater agency and control over sexuality and sexual practices (Gupta 2000, p.2). Geeta Rao Gupta discusses the components of sexuality as defined by the center that she worked: practices, partners, pleasure/pressure/pain, and procreation (2000, p.2). These four Ps are good frameworks for analysis in understanding sexuality across both books and all three case studies. Greater attention could have been paid to the unequal balance of power on the individual level and the unequal power distribution across both genders in all three countries. If there was an agreed-upon framework for assessing the balance of sexual power and the balance of power across sexes and genders across works there may be a better framework for analysis in assessing prevention across groups, countries, localities, and ethnicities. Gupta argues that in areas where there is a greater or closer to equal balance of power and when both men and women are empowered sexually, implying greater understandings of sexuality and vulnerability, there would be better discourse about sexual silences, stigma, and superstition, which could mitigate the risk of HIV/AIDS risk in all three cases under review.
Both authors suggest this, however covertly, through their frameworks of analyses. However, stating it explicitly and dedicating more in-depth analysis of the balance of power within and across communities nationally and internationally without necessarily using mathematics could serve both books well.
It has become increasingly evident that each individual HIV/AIDS epidemic is different from the next case because of local-level understandings as well as national ideas and cultural norms concerning sexuality. For the purposes of this review it is important to address cultural heuristics in risk assessment of HIV/AIDS. This framework is suggested in both books. Cultural heuristics suggests that bounded cognitive and cultural devises are used to rationalize uncertainty in specific situations (Bailey, Hutter 2006). Individuals assess risk by using cultural heuristics. Other geographical regions around the world have differing and varying cultural heuristics. It is useful to understand a different example of how cultural heuristics can influence risk assessment of contracting HIV/AIDS in order to clearly understand that different manifestations of the same mental models can either mitigate or influence HIV/AIDS risk. In the following paragraphs I will refer to specific cultural heuristics among Indian men, which demonstrates a separate geographical assessment of the HIV/AIDS epidemic and also demonstrates a cultural heuristics (mental operations/logical shortcuts) that often lead to poor decision making and increase the risk of contracting HIV.
Ajay Bailey and Inge Hutter, the authors of “Cultural Heuristics in Risk Assessment of HIV/AIDS” (2006) use examples of ‘visual heuristics’, heuristics of gender roles, vigilance and trust. Heuristics are bounded by and influenced by culture, meaning that knowledge of what is considered risky is not only individually determined but is based upon teachings of the social environment (Baily, Hutter 2006, p. 468). For example, men in India (as well as men in the United States and worldwide) often ‘sanitize’ their sexual encounters by claiming that their partners were known to them (vigilance and trust heuristic) and that their partners looked ‘clean’ and otherwise healthy (visual heuristic), or that their partners embraced proper feminine behavior and were therefore uninfected (gender role heuristics) (Bailey, Hutter 2006). What we can glean from these specific heuristics that affect risk assessment and ultimately often lead to poor decision-making is that it becomes obvious that if people truly believe that the locus of control lies beyond themselves, their self-efficacy to take action will be reduced. These cultural heuristics could have been defined more clearly in Thornton’s ‘sexual networks’ and in Farmer’s sida sickness theories.
Farmer’s AIDS and Accusation clearly suggests this theme of HIV/AIDS risk lying outside of individual control. The poor effects of cultural heuristics can be seen in the ways Haitians initially understood HIV infections (Farmer 2006). Haitian sickness theory included witchcraft, and many Haitians believed that HIV was acquired because of the jealousy and anger of someone else that had sent the virus through witchcraft. Sickness theories that are justified through cultural heuristics have continuously stood in the way of effective HIV prevention efforts of international and local agencies. However, Farmer does not state this explicitly and relies mainly on theories based on the anthropology of suffering and the effects of natural disasters. Thornton’s Unimagined Community does not explicitly explain the visual, vigilance and trust, and gender role heuristics, although the ways in which men and women mentally ‘sanitize’ their sexual networks is defined quite clearly and necessarily for the purposes of his double ethnography.
The authors could have also dedicated more time to the discussion of what is ‘rational’ and what is ‘cultural’ and how the two are not necessarily mutually exclusive. Cultural heuristics theory goes against rational decision theory (Bailey, Hutter 2006). Rational decision theory, which has been used in economics, psychology, and philosophy, implies that humans are mainly rational and will weigh the pros and cons which optimally leads to the best decision possible (maximization) (Bailey, Hutter 2006). Cultural heuristics theory exemplifies how rationality is subjective. It can be rational to act according to one’s own local cultural heuristics, ultimately allowing one to be accepted by members of one’s own culture. Also, having grown up understanding one mode of thinking (with regards to sexuality and sickness, in this case) implies that decisions made hastily that influence sexual practices can in fact be considered rational in specific cultural contexts. It becomes clear that the ways in which people make decisions regarding their sexual practices seem rational in the context of their own culture, but in reality these culturally-rational decisions can lead to HIV infection. Farmer’s AIDS & Accusation and Thornton’s Unimagined Community suggest this teaching by explaining their examples of cultural/rational decision-making, whether that is through sickness theories or sexual networks.
It becomes clearer as the story progresses that what is culturally rational can be extremely problematic when prevention is the main concern. The biggest challenge in HIV/AIDS prevention is changing behaviors and attitudes not only towards the virus but sexuality in general. Directly addressing how men and women rationalize sexual practices and sickness is key in prevention efforts. Through the teachings of anthropology and ethnographies such as Unimagined Community and AIDS and Accusation, readers can understand how the manifestations of local, regional and national beliefs and practices can hinder and/or change the ways in which the deadly virus is spread. The two books under review are very important works in the field of anthropology, medicine, and sociopolitical intervention when considering action and understanding concerning the epidemic of our time.
Bailey, A., & Hutter, I. (2006). Cultural heuristics in risk assessment of HIV/AIDS. Culture, Health & Sexuality, 8(5), 465-477.
Bond, L., Wheeler, D. P., Millett, G. A., LaPollo, A. B., Carson, L. F., & Liau, A. (2008). Black Men Who Have Sex with Men and the Association of Down-Low Identity with HIV Risk Behavior. American Journal of Public Health, 99(S1), S92-S95.
Farmer, P. (2006). Aids and accusation: Haiti and the geography of blame. Berkeley: University of California Press.
Gupta, G. R., Ph.D. (2000). Gender, Sexuality, and HIV/AIDS: The What, the Why, and the How. In XIIIth International AIDS Conference (pp. 1-15). Washington, D.C.: International Center for Research on Women.
Schoepf, B. G. (2001). International AIDS Research in Anthropology: Taking a Critical Perspective on the Crisis. Annual Review of Anthropology, 30(1), 335-361.
Thornton, R. J. (2008). Unimagined community: Sex, networks, and AIDS in Uganda and South Africa. Berkeley: University of California Press.
Vandemoortele, J., & Delamonica, E. (2002). The "Education Vaccine" Against HIV. Current Issues in Comparative Education, 3(1), 6-13.