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Volume 20 - 2012 Lehigh Review

2012 Poverty, Inequality and Power Dynamics: Women and their Role in the Haitian AIDS Epidemic Emily Purcell

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Recommended Citation Purcell, Emily, "Poverty, Inequality and Power Dynamics: Women and their Role in the Haitian AIDS Epidemic" (2012). Volume 20 - 2012. Paper 38. http://preserve.lehigh.edu/cas-lehighreview-vol-20/38

This Article is brought to you for free and open access by the Lehigh Review at Lehigh Preserve. It has been accepted for inclusion in Volume 20 - 2012 by an authorized administrator of Lehigh Preserve. For more information, please contact [email protected]. Most countries in the Western Hemisphere have reduced their incidence rates of HIV/ AIDS, but continues to experience alarming increases in diagnosed cases. This paper examines how political turmoil, poverty, violence and contribute to the threat of HIV/AIDS throughout this region, and in particular, how POVERTY, gendered societal constraints make women especially INEQUALITY vulnerable by compelling them to prioritize economically- AND POWER beneficial sexual unions over personal health. Only when DYNAMICS: societal and economic factors Women and their Role in the Haitian are identified can a global AIDS Epidemic eradication of the disease become possible. by Emily Purcell

Winged Orange (detail) Heather K. Salwach

75 The Haitian AIDS Epidemic: The disease has shifted from prevalence in to the early years when cases of AIDS were An Introduction one gender to another. “By the end of 2007, observed almost exclusively in men, HIV he AIDS pandemic has 53 per cent of all reported cases of HIV in infection in today’s society has now shifted caused great alarm across the country were among women aged 15 to women and children.”7 When the first the globe in the past thirty to 49 years old.”5 The expansion of AIDS cases of the epidemic reached the village years. Initially, research ef- throughout Haiti is fuelled by poverty, of Do Kay, the people infected were inter- forts were launched in an at- various types of sexual union, violence viewed. Out of all the natives of Do Kay, Ttempt to control the spread of the disease: and power dynamics between genders—all “None of the first four villagers diagnosed However, the infection spread rapidly. No of which are factors involved in gender with AIDS had a history of transfusion longer just the disease of Caucasian ho- inequality. Societal expectations and limi- with blood or blood products; none used mosexual men, AIDS has expanded to en- tations for women draw the focus away illicit drugs, and none had a history of ho- compass people of all races, sexual orienta- from personal health and protection and mosexual contact or other ‘risk factors’ as tions, and genders. The shift from distinct towards economic support and stability. designated by the CDC.”8 All four natives risk groups to an entire global population Although dynamics within society did share one characteristic, though—they humbled all prevention efforts. Recent and between genders drive the majority all lived in severe poverty. Many women prevention efforts have resulted in reduced of the AIDS epidemic, women’s biologi- who contracted HIV, like those in Do Kay, or leveled rates of HIV/AIDS incidents in cal vulnerability plays a small role in their were blamed to be sexually promiscu- countries such as such as North and Latin increased infection. HIV is transmitted ous. However, in a cross-sectional study America. Unfortunately, not all regions more easily from men to women than from conducted on pregnant women attending are experiencing such favorable results. women to men. This is because the virus prenatal care in a hospital in Descha- According to the Central Asian Regional “is more highly concentrated in semen pelles, Haiti, “participants were primarily Economic Corporation (CAREC), “The than in vaginal secretions; male ejaculate monogamous, with 61% reporting only Caribbean remains the only region in the is orders of magnitude larger than that of one partner in their entire life…How- Western Hemisphere with steadily increas- females; anatomic considerations clearly ever, despite the monogamous behavior ing rates of HIV.”1 Areas within the Carib- favor viral penetration of the vagina (or by the women, 61% of women reported bean, including the Republic of Haiti, have rectum), in which infected ejaculate may that they perceived their primary partner been struggling to control the disease due easily pool.”6 Although this biological dis- had another partner.”9 Therefore, women to a long history of poverty and political advantage is not the underlying cause of were more at risk not because of their own turbulence. Just before the arrival of HIV/ the epidemic in Haiti, it does highlight the sexual promiscuity, but because of their AIDS, there was a sizeable interval of overall theme of female vulnerability. partners’ activity. Women with only a few political and social turmoil.2 This chaos partners still risked contraction of HIV. undermined preventative efforts, and was The Transition: The Risk Group Subsequent research conducted in the a catalyst for the rapid integration of AIDS Shift impoverished regions of Port-au-Prince into all aspects of Haitian society. Today, When AIDS first emerged in Haiti, the concluded that the “high seropositivity about six percent of Haiti’s adult popula- high risk groups, such as gay men, drug rate (8%) found in pregnant women 14 to tion is infected with HIV (the highest rate users and prostitutes, were blamed for the 19 years of age suggests that women [in of infection in the western hemisphere) spread of the disease. However, as the epi- Cite Soleil] appear to acquire HIV infec- and approximately 30,000 Haitians die demic progressed, it shifted to encompass tion soon after becoming sexually active. from the disease each year.3 Risk of HIV heterosexual couples and genders. It was Moreover, this age group is the only one infection spread from distinct groups, clear in the early phases of the AIDS epi- in which a higher seropositive rate is not such as sex workers and homosexual men, demic that the focus of the prevention pro- associated with a greater number of sexual to encompass the entire Republic of Haiti. grams was prostitutes and their customers. partners. Women with only one sexual Not only was the entire region affected, This was because the destitute conditions partner in the year prior to pregnancy but the demographics of the illness shifted. of Haiti drove women to sell their bodies actually have a slightly higher prevalence Eighty-eight percent of initial cases of to earn enough to survive. However, “the rate…This suggests that they were infected AIDS in Haiti were among men, but by epidemic moved out from these primary by their first and only partner.”10 This 1983, women accounted for about a quar- risk groups to Haitians not at first re- research discounts the former belief that ter to a third of all cases of the disease.4 garded as populations at risk. In contrast sex workers were the ones at highest risk

76 the lehigh review for contracting HIV. Because of this sig- in rural areas. Searching for conjugal al- around and saw how poor [they] all were nificant seropositivity rate, marriage and liances with men with salaries, such as …It was a way out, that’s how I saw it.’”15 sexual unions are now included in the risk soldiers or truck drivers, suggests women’s Acephie follows the trend of young, rural factors for women along with prostitution economic dependence on men for finan- Haitian women entering sexual unions and drug use. cial security.13 These unions with salaried in exchange for monetary support. Ac- men are an indicator of poverty, one of the cording to Farmer et al., Acephie is by no The Exodus Towards the Cities strongest causes for the increase in infec- means a unique story: “In fact, in each Haiti has experienced a significant amount tion rates in Haiti. case of AIDS diagnosed in Do Kay, young of political unrest, among other tumultu- adults were driven to Port-au-Prince by ous conditions. The spread of the AIDS Poverty, Inequality, and Sexual the lure of an escape from the harshest epidemic is fueled not only by poverty and Unions poverty…women were straightforward economic instability, but also by political Poverty has been an issue in Haiti ever about the non-voluntary aspect of their crisis. This is due to the fact that “anarchy since colonists started producing sugar sexual unions: in their opinions, they had and violence are likely to lead to higher cane as a cash crop. Foreigners exploited been driven into unfavorable unions by rates of rape, and women in isolated areas the countryside and its inhabitants, and poverty.”16 Unfortunately, because many who have no access to food for their fami- Haiti was left impoverished and desolate. of these sexual unions are nonbinding, the lies might be driven to form partnerships Numerous political upheavals and a his- men are free to leave the women without with soldiers or truckers.”11 Because of the tory of political unrest have encumbered consequence at any point in the relation- political unrest, the is Haiti with massive losses in unemploy- ship. According to marriage laws in Haiti, dwindling. People who live in the rural ment, education, and health care. These a husband is obligated to support his wife Haitian countryside travel to cities such issues affect all inhabitants of Haiti, but and children. However, “less than 25 as the capital Port-au-Prince in search “women pay the greatest price in terms of percent of Haitian men and women aged of better economic opportunity. Because low income, low literacy, high infertility, fifteen to forty-nine are married.”17 Many of societal expectations and restrictions and high infant and maternal mortality.”14 Haitian citizens simply cannot afford mar- that come into play with gender, women However, despite their disadvantages in riage, so many women are involved in re- are often forced into unions with men for almost every aspect of society, Haitian lationships lacking compulsory economic economic support. Women look to men, women are expected to find ways to sup- support. If a Haitian who par- often soldiers and truck drivers, for a port themselves and their families. Many ticipates in a nonbinding union contracts steady economic income. In a case-control Haitian women turn to men as a source HIV/AIDS, her sexual partner may leave her without consequence from the law. She will have to fend for the wellbeing of Because of societal expectations and herself and her children. For many women in this scenario, finding another partner is restrictions that come into play with their only option. This cycle contributes to gender, women are often forced into the expanding practice of serial polyandry, another contributor to the spread of HIV/ unions with men for economic support. AIDS in Haiti. Gender inequality in Haiti drives the study of AIDS in rural Haitian women it of fiscal stability. One young Haitian phenomenon of serial polyandry. This sur- was found that “the chief risk factors in woman profiled in Farmer et al., Acephie vival strategy occurs when a woman has this small cohort seemed to involve not Joseph, is from the rural village of Do Kay. “a succession of partners, each one provid- number of partners, but rather the profes- Acephie began to follow her to ing her with one or more children, along sions of these partners. Fully eight of the the market to carry produce to help raise with the hope that the father may offer women with AIDS/ARC had histories of money for her family. On one of her trips some support.”18 This phenomenon fuels sexual contact with soldiers or truck driv- to the market, “she met a soldier, formerly the AIDS epidemic because sex becomes ers.”12 The issue is that the men working stationed in Port-au-Prince, who began the only commodity that women can offer. in these professions have a higher risk for to make overtures to the striking young The chain of consecutive marriages begins contracting HIV than do peasants living woman from Do Kay. Acephie …‘looked early for women, where cultural tradition

77 promotes early sexual behavior. Accord- boyfriend, Acephie returned to Do Kay.”22 abuse. According to the Ministry of Wom- ing to a study conducted on Haitian street Instead of providing her with a stable part- en’s Affairs and Women’s Rights in Haiti, children, “adolescent are two to three ner, Acephie’s pregnancy made her even thirty percent of women living in Haiti times more likely to be HIV or syphilis- more economically unstable and reliable suffer physical, emotional or sexual vio- infected compared to boys of the same on finding a man for support. lence from their partners. Tanya, a young age due to sex with older men.”19 As with Both Acephie and Guylene spent their Haitian woman, recounts being abused Acephie, young Haitian women cannot lives in search of a stable relationship. “In by one of her partners. When she did not afford to refuse the sexual advances of a country in which few couples legally want to have sex, her partner “imposed older men. As related in Farmer, a young marry, bearing a man’s child (and hence himself upon [her] …He blamed [her] lack woman named Guylene from Savanette, putting oneself at further risk for HIV) of affection and even imagined that [she] Haiti, agreed to plasaj, a nonbinding union is one of the few ways in which a woman was having an affair with another man. with a man twenty years her senior.20 After can legitimize her relationship with a Finally, [she] had to let him do it.”27 This the man left Guylene with two children, man.”23 The practice ofplasaj , or nonbind- psychological abuse degraded Tanya until she met another man who offered a union ing union, outnumbers marriages in Haiti she agreed to have sex with her partner. once more. After three years, Guylene was three to one.24 Plasaj is understood to be Violence, such as in Tanya’s relationship, is diagnosed with HIV. After her positive polygamous, for men can have multiple one of the many reasons for a lack of con- diagnosis, Guylene reacted to the advances standing unions at once. This multi-part- dom use throughout Haiti. Although there have been significant increases in HIV knowledge, technology, Many are aware of the and treatment around the world, there has been little change in condom use and risks of unprotected sex but fear the protection from sexually transmitted in- consequences of asking their partners to fections in countries such as Haiti.28 Part of the reason for the unchanging practice use protection more than contracting HIV. of unprotected sex is due to lack of educa- tion. “Of a national study conducted in of another interested soldier, who had a ner system encourages the spread of infec- Haiti…24% of women and 14% of men wife and two children.21 Guylene’s story tion. However, the sexual relations are not believed that HIV could not be prevented. is full of poverty and death, and she ends always willing on the part of the woman. Furthermore, 35% of women…surveyed up with HIV infection at a young age. knew that HIV could be prevented, but However, despite her disease, Guylene con- Sexual Violence: The Fear of Re- could not name any method of preven- ceives another child. In doing so, she most taliation tion.”29 However, the majority of the ex- likely infects her partner, who goes home The patterns of sexual unions in Haiti are planation for the lack of adaptation in con- and infects his wife. This necessity to find driven by the necessity of women to find traception use is due to gender inequality a partner drives the AIDS epidemic in stability, in economic and social terms. and relationship dynamics in Haiti. Many Haiti. Although Guylene understood that These economic power differentials make women in Haiti are aware of the risks of she was infected with AIDS, she had little it difficult for women to exercise control unprotected sex but fear the consequences choice but to find someone to support her. in contraceptive decisions.25 According of asking their partners to use protection In the end, however, she was left relying on to Devieux et al., “A study among women more than contracting HIV. According her elders to care for her remaining chil- in rural Haiti found that 54% of women to a Yolette Gentil, a woman who assists a dren. This vicious cycle continues until reported forced sex. Factors related to eco- program for female victims of sexual vio- the woman finds a stable partner or death. nomic vulnerability … as well as a younger lence in Haiti, “One very common practice The act of acquiring a man and bearing age and having STD-related symptoms is that of women being beaten for having his children can drive a woman further were associated with forced sex.”26 Vio- demanded the use of condoms from their into poverty. For instance, Acephie worked lence against women, such as forced sexual male partner.”30 However, the fear reaches in the city until she discovered that she relations, promotes the spread of HIV beyond just physical violence. According was pregnant: “This displeased both her infection. Forms of such violence include to Millord Dexai, Coordinator of the Col- partner and employer. Sans job and sans psychological violence as well as physical lectif des Feminises Universitaires, many

78 the lehigh review women do not ask their partners to use condoms because they are afraid of being accused of disloyalty.31 By being accused of infidelity, they are afraid “of jeopardiz- ing a relationship in the building of which they have invested energy, emotion and many years of their life.”32 Many women are afraid of losing their economic stabil- ity if they ask to use protection. To some women, this fear of losing support is more imperative than the fear of contracting HIV. Women’s fear of retaliation is one factor relating to the lack of condom use. An- other is the cultural belief system, where gender inequality is supported by cultural convictions. For instance, some Haitian women believe that a woman is only right to ask her partner to use a condom when she is certain that he is being unfaithful; otherwise, she has no right to ask for pro- tection during sexual intercourse.33 Hai- tian society drives the insubordination of women economically and sexually so that they have little say when it comes to pro- tection from sexually transmitted diseases.

Gender Power Dynamics All of the factors driving the spread of HIV infection deal with the dynamics of power between genders. Employing pro- tective methods, such as condoms during sex depends entirely on the influence that each partner has within the relationship. Australian sociologist Raewyn Connell is the author of the theory of gender and power, which is comprised of three major categories: the sexual division of labor, structure of cathexis, and the sexual di- vision of power.34 The sexual division of labor deals with control of money and economic stability. The structure of ca- thexis deals with gender differences in the investment of emotional energy in the relationship. The sexual division of power deals with the dynamics of power between the genders within the relationship, which often reflect the forces of power between Turning the Corner, Tom McMurtrie

79 genders within society. These three sec- he will then carry back to the woman at Conclusion tions are vital in understanding the forces home. Women tend to agree that refusing Haiti has always experienced poverty behind the AIDS epidemic. For instance, sex amounts to less than a death warrant and inequality. With each successive the sexual division of labor dictates in- for themselves.”38 For this reason, toying political coup, poverty, violence and dis- come and economic consistency, which with sexual power is a dangerous game. ease have wracked the struggling nation. influences sexual risk behaviors taken by The forces of power within relationships Therefore, it was no surprise that AIDS Haitian women in search of economic sup- and society as a whole drive the insecurity emerged as a notable sexually transmit- port. The sexual division of power “seems of women, the lack of attention to contra- ted infection. However, the spread of the particularly relevant to the social and eco- ceptive measures, and therefore, the AIDS infection from risk groups in the cities, nomic environment of rural Haiti…Lack epidemic. such as prostitutes and homosexuals, to of economic resources, especially among heterosexual couples across the coun- women, can reduce decision-making pow- Pregnancy and AIDS tryside was a disconcerting dilemma. er and has been linked to increases in HIV A significant impact that serial polyandry Stigma and discrimination shrouded the and STI risk.”35 Women who are involved has on the AIDS epidemic is through cases disease as researchers and anthropolo- in relationships with power discrepancies of AIDS in children. In 1987, 3.6 percent gists searched for an explanation. Finally, often experience inferiority when it comes of all cases of AIDS in Haiti were pediatric gender inequality emerged as a culprit of to decisions relating to contraceptives. Ac- cases; just two years later, that statistic had the spread of infection. The disparity be- cording to the Bulletin of the Pan Ameri- risen to 6.6 percent.39 This statistic would tween genders determines “the extent to can Health Organization, in 1993 “61% of be even higher, but most of the children which will mark the course of HIV Haitian women felt it was exclusively the who are infected die before their HIV disease. In highly sexist settings, the dis- males’ right to choose whether or not to develops into full-blown AIDS. Also, closure of HIV infection is more likely to use a condom.”36 The power dynamics of because of infrequent medical care, many provoke stigma and threat of domestic vio- gender dictate women’s access to personal are not aware that they are in- lence than in environments where women health and protection. The authority of the fected with HIV until they visit the hospi- enjoy gender equity.”43 Domestic violence men in Haiti dominates that of the women tals for prenatal care. They most likely will is a consequence of the power discrepancy in many aspects of the relationship. When pass their infection on to their children, within relationships. Fears of retaliation sexual power is not shared equally be- who die from complications during the or abandonment promote habits of unpro- tween the two genders, decisions involving first years of development. Based on data tected sex and exposure to HIV. Societal sexual interaction lead to a lack of protec- collected by various research groups, “ap- expectations drive women into unwilling tion from sexually transmitted diseases proximately seventy thousand seropositive unions and, perhaps, even deeper poverty: like HIV/AIDS. women in Haiti will give birth to between Women bear children to legitimize their The unbalanced power within a rela- twenty-eight hundred and forty-five hun- relationships, and are often left without tionship is a catalyst for the spread of HIV dred HIV-infected infants a year, or an av- a partner for support. All of these fac- infection. While men often have author- erage of eight to twelve new cases a day.”40 tors driving the spread of HIV infection ity over women, women can also wield Also, based on data from the Centers for are connected in a complicated system of power over men. Many women refer to Disease Control and the World Health stigma, expectation and culture. By finally their sexuality as “‘my property’ or ‘my Organization, HIV infection, rather than understanding the underlying causes of capital,’ thus defining sex in terms of a malnutrition, was found to be the biggest the AIDS epidemic in Haiti, prevention marketable commodity.”37 This commod- contributor to child mortality in Haiti.41 efforts can be better directed and perhaps ity gives women the power to seek out an This figure is noteworthy, considering level the increasing number of AIDS cases. economically supportive relationship. This Haiti ranked above India and Sudan in Global eradication of the disease is a fan- influence, however, is fickle. Refusing to under-five child mortality in 2000.42 Soci- tastical goal. Nevertheless, understanding partake in sexual relations is not an option etal expectations compel women to have the causes of disease proliferation is a vital that many women feel they possess. Wom- children, and women spread HIV infec- step in the complex battle against HIV/ en fear that, by refusing sex to their part- tion through childbirth: this cycle is one of AIDS. ners, “they will send the man back out to many that perpetuates the AIDS epidemic the streets to find a more compliant wom- in Haiti. an who will infect him with HIV, which

80 the lehigh review