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A New Paradigm for Hope
by Barb Wood
Last year the 20th Anniversary of the discovery of HIV was observed. There
was a story to be told about AIDS, about suffering and loss and stigmatized
groups. It was about a time when gay activists, public health programs and
researchers focused on one epidemic, and hoped for the magic bullet that would
make it all go away.
 ‘Color
Me Healthy’ Promote Healthy Lifestyles in Communities of Color – the upcoming
Michigan STD and HIV conference in November has a new paradigm with a positive
affirmation. Keynotes and workshops will look at the big picture for the
community now most affected by this epidemic. For African Americans HIV is just
one piece of a multi-epidemic under the umbrella of ‘health disparities.’
MDCH has focused on the larger issues for African Americans for years, but this
conference marks a whole new paradigm for hope. This is not just a Michigan
refocus. From the Centers for Disease Control and Prevention (CDC) to national
black organizations, leaders are rethinking the approach to HIV/AIDS. Kevin
Fenton, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis,
STD, and TB Prevention said in a Kaiser webcast this summer, “There are social
determinants of disease. The social context is driving multi-epidemics.” A panel
of national speakers – most notably Fenton and Phill Wilson, executive director
of the Black AIDS Institute – discussed the social context of AIDS in the August
webcast, What Would it Take to Eliminate the Disproportionate Burden of HIV/AIDS
Among African-Americans?1
A number of national reports have been released emphasizing the crisis of AIDS
in the African American community2 , 4 & 5. All identify the larger context of
this epidemic in social norms and health disparities.
The Michigan STD & HIV Conference speakers began discussing the growing epidemic
among African Americans years ago. They drew the big picture of contributing
health and social problems like homophobia (and other social and religious and
taboos that contribute to denial and stigma), racism (specifically
institutionalized racism), poverty, multiple epidemics of HIV, STDs and
hepatitis, lack of accessible addiction and mental health treatment, gender
inequality in sexual relationships, social sexual norms (i.e. multiple sex
partners), lack of universal health coverage in the U.S. and the resultant
health care disparities, social health norms and myths that have basis in
historical reality.
But we needed a paradigm shift. What we have had in the past is a failure to
communicate risk to this community, a failure to break the political glass
ceiling on science-based prevention, a failure of systems and bureaucracies to
work synergistically as well as collaboratively to address the multiple needs of
those most at-risk in a timely manner, a failure of leadership in the faith
profession to act compassionately, a failure by providers to integrate HIV
prevention and care into other health services, and a failure of individuals and
civil rights advocates to step up and fight for HIV awareness, prevention and
care as a civil rights issue.
For this shift in awareness, we need a new game plan. The CDC’s report, A
Heightened National Response to the HIV/AIDS Crisis Among African Americans,
revised June 20072, covers action strategies that include the CDC working
together with other federal agencies (NIH, SAMHSA and HRSA) to develop cross
agency plans for new and effective prevention interventions and mobilizing
broader community action by connecting HIV/AIDS prevention with efforts against
racism, homophobia, joblessness, sexual violence, homelessness, substance abuse,
mental illness and poverty. The report also suggests the CDC should work with
prisons, jails and detention centers to develop behavioral, social, and systems
level interventions to address the HIV prevention needs of incarcerated persons
as well as investigate the needs and strategies for African Americans
transitioning in and out of prisons. The report also recommends expanding
collaborations with community-based organizations (CBOs) serving African
Americans to develop and evaluate innovative and potentially effective
interventions.
Public Health views providing HIV testing as the cornerstone of HIV prevention.
As we already know, the CDC’s most recent push is for everyone (aged 13-24) to
be tested. During the Kaiser webcast, Phill Wilson voiced the concern of many
community advocates; ‘Will the care be there if you test positive?’ He said, “If
we don’t have something to offer them at that time, we are going to lose them.”
Care and prevention are not separate issues. This is another barrier that must
be addressed, and not just on a federal agency level, but right on down to
within CBOs. Prevention counselors need to communicate with case managers.
Prevention and Care managers have to work together to provide services for the
most targeted and effective HIV prevention we have available, prevention for
positives programs. These programs address multiple needs on both individual and
group levels and provide tools and support for individuals to change behaviors.
Traditionally, we have laid all of the responsibility for prevention on
individuals, to change their behavior, to protect themselves. According to
public health research3 reported this summer, “In the last 50 years, the
dominant view in the U.S. has been that lifestyle is the major remediable cause
of ill health…While most observers acknowledge that social forces influence
these choices, most interventions focus on changing individuals.” Last year when
the National Expert Panel on Community Health Promotion met they reported, “This
approach is inefficient, requiring health promoters, like [the mythological
figure] Sisyphus, to push every person who engages in unhealthy behavior up the
steep hill of disease-promoting environments toward health at the top, rather
than leveling the incline by changing policy.”
The July issue of the National Alliance of State and Territorial AIDS Directors
(NASTAD) HIV Prevention Bulletin4, acknowledged how HIV, viral hepatitis and STD
prevention programs typically focus efforts at the individual level. The
Bulletin took a look at models of health profiles and health determinants and
explored a new Model of Syndemics. A term first published in 1992, Syndemics is
defined as “two or more afflictions, interacting synergistically, contributing
to excess burden of disease in a population.”
“Rather than focusing on a specific disease, a syndemic orientation looks first
at a particular community to understand the causes of disease burden and to
identify what is needed to promote the community’s overall health,” stated the
Bulletin referring to the CDC’s overview. Using this approach and addressing the
collective needs of a population, the report stated, “programs can hope to begin
to alter the cycle of disease and disparity within marginalized population
groups.”
NASTAD interviewed Ronald Stahl, professor and assistant dean at the University
of Pittsburgh’s Graduate School of Public Health. “One of the striking findings
regarding MSM [men who have sex with men] in the context of AIDS has been the
high prevalence rates of other dangerous health conditions…rates of depression,
drug use, violence victimization, childhood sexual abuse, tobacco use and other
health problems are generally higher than among other populations of men,” said
Stahl. Stahl suggests that by partnering with violence prevention, substance
abuse treatment and mental health efforts we could increase the effectiveness of
HIV prevention work among MSM, still the most at-risk behavioral group. “We need
to identify ways via funding streams to increase cross-agency collaboration and
to encourage “cross-epidemic thinking when providing services,” he said.
So, what can you do as an individual? Call your colleagues outside of HIV/AIDS
(or STD) work, your favorite religious leader, your government representatives,
your doctor, your local school’s social worker and school board members. Invite
them to attend this year’s STD & HIV conference. Let’s stop preaching to the
choir, we have networking to do.
See the MDCH-DHWDC and Michigan News pages for collaborative efforts in
Michigan.
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