UNIVERSITY OF PENNSYLVANIA - AFRICAN STUDIES CENTER
[Copyright 1998, Solimar Otero, All Rights Reserved. This work may be cited, for non-profit educational use only,
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This paper examines those underlying conventions used in the construction and acceptance of discourses that blame the infected African other, their "sources of articulation" and "sociological consequences" (Treichler 1989: 48). The pursuit of whether statements in the international discourse of AIDS and Africa are true or false obscures the more important questions of how these statements are produced, sustained, and function socially and politically within given contexts. Specifically, this analysis examines the inappropriate use of western culture to define epidemiological risk in relation to ethnicity and nationality; transforming the once neutral term of "high risk-group" into a politically charged device for labeling the dangerous infected African other. Biomedical and popular discourses have influenced global representations and perceptions of AIDS and Africans worldwide resulting in what one can argue as a dangerous epidemic of discrimination and blame.
Since the advent of the AIDS pandemic, Africans (and people of African decent) as well as homosexuals and intravenous (IV) drug addicts have been blamed internationally for the etiology and global diffusion of the HIV virus. The staggering geographic disparity of today's pandemic has further fueled both xenophobic fears of contamination and the blame of AIDS onto the continent of Africa. Western anxieties over African diasporic flows, whether migrational or cultural, emerge within popular and medico-scientific discourse as "metaphors of contagion" (Browning 1998) to often justify extreme and racist measures of control and surveillance of HIV infection for the public good. Within this xenophobic and racist discursive frame, the "infectious rhythm" (ibid.) of Africa not only represents the perceived threat of the dangerous infecting flow of African culture and society, but also the racist fears of western adulteration by the virulent African body. Tropes, however, are also rhetorical tools for the act of persuasion in the 'practice of everyday life' which transform these 'figurative imaginations' of the dangerous infected African other into politically charged discursive symbols used to further victimize and blame the infected other (Fernandez 1986). Moreover, these tropes of African virulence and danger engrained in the American imagination of the 'Dark Continent' are compounded by Hollywood's morbid fascination with the unlikely possibility of a highly contagious African Outbreak in small-town USA (Browning 1998: 65).
Popular media representations of African vectors of contagion are also substantiated by the current biomedical debates over the African origin of the HIV. Implicit in the search for the origin of the virus is the assignment of blame. Richard and Rosalind Chirmunuta argue in "AIDS from Africa: A Case of Racism Vs. Science? " that the pursuit of an African origin of AIDS has opened a "Pandora's box of racism and prejudice"(1997: 179). Racist representations and perceptions of black people as "repositories for disease, dirt and sexual promiscuity" have skewed scientific approaches and understandings of the complex socioeconomic and political dynamics of HIV infection in Africa (Chirmunuta and Chirmunuta 1989:9; and 1997: 179). Although Chirmunuta and Chirmunuta's theories have been dismissed by many as counter-accusations against the hegemony of western biomedicine, an examination of the early medico-scientific discourses on AIDS in Africa reveals that their claims have merit. For example, researchers at the Center for Disease Control (CDC) first attributed the transmission of HIV in the U.S. through the highly implausible "circuitous route " reminiscent of the bogus "magic bullet theory" behind the solo gunman explanation in JFK's assassination. According to the CDC the global pandemic first started with the infection of Haitian nationals working in central Africa, who upon returning to Haiti spread the disease to homosexual American tourists. The virus then proliferated throughout the U.S. to the rest of the world through travel, trade, tourism, the movements of military personnel and prostitution (Gallo 1987; cf. Chirimunuta and Chirimunuta 1997: 166).
As a result of these early discourses of blame and accusation, Africans worldwide experience a parallel epidemic of AIDS discrimination based solely on their ethnicity or nationality. Today, African nationals, especially those from regions with high HIV prevalence rates, are commonly detained in airports and refused visas. Many African countries who were cognizant of this disparaging treatment to their nationals traveling abroad down-played the severity of their growing rates of HIV infection for fear of losing tourism, trade, and foreign investments. Unfortunately, over time many of these fears proved to have a real basis. For example, Uganda, which was the first African country to openly admit to having a severe AIDS epidemic, was subsequently labeled "the AIDS capital of the World," which resulted in a backlash of humiliation and discrimination for its nationals living abroad. In Britain, immigration officials instituted compulsory HIV testing for all African visitors after hearing similar reports about the growing AIDS epidemics in Uganda, Tanzania, and Kenya. In addition, in the late 1980s, African students studying in the Soviet Union and China were forced to leave due to growing hostilities and violence instigated by local fears of HIV infection. Since the beginning of the pandemic in Africa, foreign investments within the region have declined 20%, further weakening already fragile developing economies strapped with the oppressive burdens of structural adjustment (World Bank 1999).
International AIDS discrimination against peoples within the African Diaspora was equally severe, especially for Haiti. After CDC announced in 1983 their hypothesis that Haiti was the epicenter of the global pandemic, Haitian tourism -- the country's largest source of foreign currency, dropped significantly -- crippling all aspects of the nation's economy (Farmer 1992: 212). In the U.S., the fear of the HIV-infected Haitian "other" resulted in stringent visa restrictions, freezes on immigration, and bans against blood donations . In New York and Miami, the Haitian communities also experienced physical assaults, vandalism, bankruptcy, and eviction. They were also denied housing, refused medical treatment, faced job discrimination, and even the expulsion of their children from public school (Sabatier 1988:47; cf. Farmer 1994: 214-6). Faced with the economic burden of prejudice and discrimination association with AIDS, one can understand why countries in Africa (and within the African Diaspora) would deny their high levels of HIV.
Paula Treichler (1988: 31) defines AIDS as "an epidemic of signification" a complex web of "meanings, stories, and discourses that intersect and overlap, reinforce, and subvert one another" which result in blame and accusation towards those infected with the HIV virus. Treichler argues that AIDS, as a "nexus of multiple meanings " is not only a crisis of public health; it is also a crisis of identity (1988: 31). Central to this discussion on the sociological consequences of racist constructions of those infected and afflicted with AIDS Treichler (1989: 48) suggests:
If we relinquish the compulsion to separate true representation of AIDS from false ones and concentrate instead on the process and consequence of representation and discursive production, we can begin to sort out how particular versions of truth are produced and sustained, and what cultural work they do in given contexts. Such and approach illuminates the construction of AIDS as a complex narrative and raises question not so much about truth as about power and representation. To understand the ways AIDS comes to be articulated within particular cultural contexts, the major problem is not determining whether a given account is true or false but identifying the underlying rules and conventions that determine whether that account is received as true or false, by whom, and with what material consequence.
Just as this "epidemic of signification," first transformed the cultural
politics of homosexuality in America, I argue that this growing epidemic
of discrimination against Africa, sustained by discourses of social distance,
blame, and accusation threatens to do the same internationally with respect
to ethnicity and nationality.
Medical Discourse, Knowledge & Power
Biomedicine within Western society is considered the authoritative source of truth and knowledge about the human body and disease. Biomedicine is a particular regime of truth (Gordon 1980) whose sociopolitical power and hegemonic authority is based on the firm belief in the rationality and veracity of empiricism and positivism. The study of disease as an objective reality under the empiricist theory of medical knowledge must have an empirical referent grounded in a tangible disordered physiology. Medicine was the first scientific discourse concerning the individual in the formation of the human sciences, which subsequently discursively transformed the human body into an object of empirical knowledge through the medical gaze.
The exclusive and highly specialized nature of human biology and physiology has afforded biomedicine, as an institution the power, to assert (without restraint) truth claims about the body, and the nature of disease and illness. This has consequently made it one (if not "the") most powerful regimes of truth of all times. Foucault argued that every society has its own regime of truth in which there is an explicit political struggle over knowledge and truth (Gordon 1980: 131). Barry Smart (1985: 68) purports that the central issue in understanding the relationship between knowledge and power is not to the critique of its "ideological contents" in order to restore " the purity of scientific practice" but to detach "the power of truth from the forms of hegemony, social, economic and cultural, within which it operates." Western biomedicine, and other social institutions are the product of their episteme, their underlying epistemological superstructure, which in the case of biomedicine has evolved into a hegemonic ideology. Therefore, medical institutions and their mechanism for the production and accumulation of knowledge are key sites for the analysis of power and domination in relation to knowledge.
The epistemological foundation of medical knowledge was first based on an understanding of the body's structure (gross anatomy) and function (physiology). However, the "chronological threshold" (Foucault 1972) which issued in the modern form of medical knowledge and clinical practice was the change in "forms of visibility" - between seeing and understanding the molecular dimensions of the body. Consequently, the corporeal dichotomy of medical knowledge evolved into the segmentation of the body into discrete bodily systems and areas of medical specialization (i.e. psychiatry, neurology, ophthalmology, cardiology, obstetrics, gynecology, pediatrics, infectious disease, histology, pharmacology etc.). With advancements in biotechnology, scientific-medical researchers have further expanded the study of disease to the molecular level to include microbiology, pathology, and pathogenesis, but also highly specialized studies of pathophysiology, virology, paricitology, bacteriology, mycology, biochemistry, genetics, and embryology. The "medical model" or epistemological foundation of clinical practice and research used to discursively frame illness
[a]ssumes that diseases are universal biological or psycho physiological entities, resulting from somatic lesions or dysfunctions. These produce 'signs" or physiological abnormalities that can be measured by clinical and laboratory procedures, as well as "symptoms" or expressions of the experience of distress, communicated as an ordered set of complaints (Good 1994: 8).
In conjunction with the empiricist theory of medical knowledge and the use of the medical gaze to objectify disease and focus on the identification of its defining symptoms, Smart (1985: 31) argued that "the advent of the anatomo-clinical method also inaugurated a shift in medical conceptualizations of disease from case and classification to individualities." Epidemiology, the formal study of distribution and determinants of health and disease in population, the basic science underlying public health, and preventative medicine, is a sub-field of medicine that explicitly attempts to realign the individual within the study of disease risk.
The Birth of the Clinic: An Archaeology of Medical Perception (Foucault 1975) is arguably the first seminal study on biomedical discourse examining the historical shifts in the conceptions, structures, and forms of organization of medical knowledge and the semantic mutations in medical perceptions of the body, disease, and illness. Foucault demonstrates that medicine's supposed steady progression towards a greater objectivity, understanding, and precision of the truth is instead false, imagined, or invented. A critical chronology or archaeology of events reveals that western biomedicine's history is full of ideological ruptures, disjunctures and discontinuities. Instead of focusing on these inaccuracies, Birth of a Clinic emphasizes the important epistemological and ideological transformations from the end of the 18th century from a classificatory medicine, where disease was organized into hierarchies, families, genera and species, to a medicine of indexical symptoms, and finally to today's medicine of anatomo-clinical understanding.
What is central in Foucault's (1972, 1973, 1975) archaeology of medical discourses is not only how the "medical gaze" transforms or reconfigures the perceptions of medical objects through specific discursive practices, but how it constructs disease and illness as an objective reality. The process of naming a disease or a particular disorder in medical discourses is not a neutral process of assigning a label to its empirical pathological referent, but is instead a politically charged discursive practices that "systematically forms the objects of which they speak" (Foucault 1972: 49). While the medical diagnosis is an individually authored and situated utterance, a formulation, the epidemiological discourse that defines who is at "high" risk of HIV infection is an assembly of statements that transcends actual micro level situations of discourse, achieving within biomedicine a unity and consensus as authoritative facts (Foucault 1972: 107).
Byron Good (1994:5) in Medicine, rationality, and experience: An anthropological perspective argues that the language of medicine "is hardly a simple mirror of the empirical world. It is a rich cultural language, linked to a highly specialized version of reality and system of social relations." For Good, the process of entering the body and pathology or "learning medicine" is a "process of coming to inhabit a new world" that discursively separates everyday world experiences (1994: 70). Good purports that,
Entry into the world of medicine is accomplished not only be learning the language and knowledge base of medicine, but by learning quite fundamental practices through which medical practitioners engage and formulate reality in a specifically "medical" way. These include specialized ways of "seeing," "writing," and "speaking"(1994:71).
Ways of perceiving and discursively constructing disease in biomedicine is guided by specific "methods of observation, techniques of registration, procedures for investigation and research, and apparatus of control"(Gordon 1980: 102; cf. Smart 1985: 80). Within the three basic levels of the diagnosis-- elicitation of the patient's illness narrative, physical exam, and lab test, disease, and illness is described according to a particular framework that provides a uniform structure for the organization of data. However, these guidelines not only help to organize medical knowledge, they discursively frame diagnosis. Although each domain of medical specialization has its own diagnostic modalities there are basic test administered to all patients. First, the physician elicits from the patient a narrative known as the History of Present Illness (HPI), which is a subjective account of the illness experience. Once the chief complaint has been identified, the doctor will follow a proscribed checklist guided by the acronym PQRST (place, quality, radiation, severity, and timing) to construct a narrative that is both uniform and unencumbered with superfluous details.
Following the elicitation of HPI, the doctor conducts the ubiquitous medical exam, beginning with another series of more specific questions about the patient's general medical history (infections, surgery etc), associated symptoms (shortness of breath), allergies (medical and environmental), medications currently used, family medical history, and social history. However, the core data collected during the physical exam is the documentation of patient's vital signs such as blood pressure, body temperature, and weight. Most physicians will also routinely examine (regardless of the complaint) your head, eyes, ears, nose, and throat. Depending on the nature of the ailment the physician may also customarily listen to your heart and lungs with their stethoscope. At the end of the exam, the physician will then conduct a review of systems from head-to-toe to make sure that all the possible contributing factors or are addressed. This part of the exam is visually guided from the head down the body using generic questions: do you have any headaches, problems with your vision, chest pains, constipation, diarrhea or bloody stools, and aches and pains, which theoretically cover most of the major organ systems (neurological, cardiovascular, gastro-intestinal, skeletal etc).
Depending on what information is revealed in both the HPI and physical exam, certain laboratory or imaging test will be prescribed. Laboratory test may include routine blood, urine, spinal fluid, or sputum test to determine bacterial, viral or parasitic infections. Radiological or imaging studies includes simple X-rays, CAT scan, MRI's, or ultrasound. If imagining test remain inconclusive, there are surgical tests such as biopsy to determine the presence of pathogens.
Once all the data is collected the doctor is then able to makes a diagnosis. The formation of a diagnostic statement varies according to the field of medical specialization. For example, in psychiatry, the diagnosis is analyzed according to four axis of illness (major disorders, personality disorders, medical problems, and social stresses), which are then numerically tabulated into a score on a scale from 1-100. In contrast, diagnosis in internal medicine (or general medicine) is based on what data is reveled through the HPI, physical exam and laboratory test. In Epidemiology, the criteria supporting casual nature of a disease association include: 1) coherence with existing information (biological plausibility); 2) time sequence (cause proceeds effects); 3) specificity (does the cause ever occur with out the effect); 4) consistency (reproducibility); 5) strength of evidence (prevalence; does response relationship (the more exposure more effect); and study design).
However, the formation of these diagnostic statements is not entirely objective. Some doctors may be advocates for particular diagnosis.  They intentionally or unconsciously craft their medical reports and presentations to lead others to arrive at a similar conclusion -- the same diagnosis. Diagnosis advocacy contradicts the supposed objectivity of the biomedical gaze. Often diagnosis advocates are proponents for a particular field of study.
However, in the process of framing information about the global AIDS pandemic, the doctor/researcher (author) and the HIV-infected patient (audience) are seldom co-present. Joel Kupiers (1989:109) in "Medical discourse in Anthropological Context: Views of Language and Power" argues that certain types of [medical] discourses are relatively decontextualized... [and] detached from the actual situation of performance"; however, an integrated approach entextualizes these discourses and connects both the situated conversation and decontextualized discourse indicative of medical discourse. Furthermore, Kupiers argues that:
the gradual objectification and decontextualization of discourse from its immediate situation of utterance exercises power by extracting, appropriating, and reporting the speech of other, detaching it from whatever meaning prevailed at the time of its original utterance, and redefining it in a new context (Bauman 1987; Bakhtin 1981, 1986; Voloshinov 1971; cf. Kupiers 1989: 110).
Biomedical discourses on HIV/AIDS transcend particular settings and participants, rendering them as de-centered texts, which are easily extracted, appropriated, and reported again in the statements of others. Once detached from their original contexts, they become susceptible to redefinition and new meaning by the popular press to fit new uses and different contexts; however, some statements or groups of statements become institutionalized and accepted as fact. Following Kupiers (1989), the study of epidemiological discourse on HIV risk must be entextualized in order to situate it in communicative interaction and grounded within its particular historical context.
The epidemiological discourses on HIV risk-groups and AIDS in biomedical journals, surveillance reports, prevalence rates of infection, and statistics of mortality and morbidity transcend not only decontextualized texts but they are author-less texts which are masked by perceived or real authority of institutions or de-centered by polyvocality of multi-authored texts. Statements presented under the aegis of international agencies such as the World Bank, the World Health Organization (WHO), the Center for Disease Control (CDC), or the United Nations Global Programme on AIDS (UNGPA) can remain author-less texts because of the hegemonic authority and prestige these institutions posses. Similar to Foucault's 'death of the author', the anonymity of international AIDS discourse becomes a necessary strategy for authenticating and legitimizing particular statements. In contrast, the identification of prominent researchers as the primary investigator for collaborative papers also turns authorship into a signpost of authenticity. Although this notion of discourse as a de-centered text is criticized for being as detached from its frame of reference (where the micro-physics of power is believed to be exercised), both the biomedical and activist discourses on AIDS is often intentionally de-centered to emphasize the content off the message and not the messenger.
The hegemonic authority of epidemiology to define the demographic nature
of the AIDS pandemic, and to subsequently shape sociological perceptions
and popular media representations is a politics of knowledge in which power
emerges within discourse. What is central in this discussion of 'blaming
the African other' is not the veracity of the statements but how they are
produced, reproduced, contested, and sustained through the inappropriate
use of western cultural constructs to define and interpret epidemiology
cross culturally. A closer examination of the micro-politics behind the
maintenance of such stereotypes, illuminates how discourses of stigmatization
and otherness govern the construction, negotiation, contestation, and maintenance
of boundaries between the self and the HIV infected other through fear
of contamination by the dangerous African outsider.
The Cultural Construction Of Epidemiological Risk
Epidemiology is believed to be an objective science that assesses the correlations of disease with defined ecological, biological, social or cultural variables through measurement, counting, and statistical analysis. Epidemiologists correlate factors such as lifestyle (e.g. cigarette smoking for lung cancer) or physiological/biological proclivities (e.g. obesity for heart disease or diabetes) in order to characterize and generalize which populations at risk of disease. The discursive practice of labeling certain social or cultural groups with the field of epidemiology as high risk-groups "systematically forms," as Foucault argued, "the objects of which they speak" (1972: 49). This approach of isolating risk factors is based on the belief that individuals with similar diseases possess shared traits, which bind them together as a distinct group. Framing these particular populations as "risk-groups" is believed to be the most effective strategy for disseminating information to the population where behavior modification is needed most.
In "What's Wrong with this Picture? The Hegemonic Construction of Culture in AIDS Research in the United States," Glick Schiller (1992) challenges the culturally biased representations of AIDS and the hegemonic processes through which risk-groups have been constructed in the past. Glick Schiller (1992: 240) argues that the boundaries used by epidemiologist to create these high-risk populations "do not grow immediately and automatically out of epidemiological research"; instead, they are produced under specific social and cultural contexts, which are then extended to other contexts based on the assumption that epidemiological categories are universal. The tendency to stereotype cultural behavior within risk-groups has, according to Glick Schiller, "reified the concept of culture, overgeneralizing the behavior of internally diverse categories of persons within a defined sub-category"(1992:250). Epidemiological discourse on HIV risk-groups is inherently reductionistic, offering only one explanation for what is a complex socioepidemiological phenomenon. Such an approach is questionable because it presents risk-groups as an undifferentiated whole. Furthermore, Glick Schiller et al (1994) argue that it is a "Risky Business" to use the concept of culture to characterize "high risk-groups" because it socially "distances and subordinates" those designated as `at risk' of infection and fuels a "denial of personal risk" for those defined outside of the designated risk-groups (1994: 1337). This use of western culture to define HIV risk not only transforms the objective, and supposedly unbiased category of 'risk-group' into stigmatizing and alienating stereotypes, it also impairs efforts to prevent the spread of the virus by diverting attention away from the real risk behaviors, such as unprotected sex and the sharing of IV drug needles. The CDC's decision to include Haitian nationality as a high-risk group demonstrates not only the hegemonic power of biomedical discourse or the power of authoritative statements in general (regardless of its veracity), it also illustrates the profound impact these statements can have on social action and perceptions.
The Racialization of HIV Risk
On March 4, 1983, the Center for Disease Control (CDC) placed Haitians (along with homosexuals, heroin drug-users, and hemophiliacs) into the Four-H Club of those social groups with the highest risk of HIV infection. This was the first time that the CDC explicitly racialized the epidemiological discourse of risk. An entire population was defined as at risk of HIV infection based solely on their ethnicity and nationality, not because of their particular high-risk behaviors. The CDC's decision to include Haitians as an HIV risk-group was based on the fact that the epidemiological data on the route of HIV transmission among Haitian immigrants seemed incongruous at the time with the CDC's theories about how the virus was disseminated within the region. The CDC assumed that because of their close geographical proximity that the two epidemics should be similar. In the U.S., the pattern of HIV transmission was believed to be exclusively transmitted through homosexual behavior, IV drug use, and tainted blood supplies; however, in Haiti the route of HIV infection was characterized by unprotected heterosexual sex. In the absence of a clear link between the two epidemics, the CDC prematurely labeled the Haitian epidemic as an anomaly, speculating that the island was therefore the epicenter of the global pandemic. CDC researchers believed that the missing link between HIV infection among gay white men and heterosexual Haitians women was the answer to the mysterious etiology of AIDS.
Instead of following the more traditional epidemiological approach of correlating behavior with disease (i.e. unprotected sex) the CDC focused on culture and national identity. This unfortunate event was an important, but painful lesson for epidemiology and AIDS research because it not only exposed the inappropriateness of using cultural generalizations to define epidemiological risk, it also demonstrated, as Seidel and Vidal warned, how the "inappropriate categorizations or ways of classifying that derive from specialized and still hegemonic discourses, like epidemiology, may lead to further victimization and blaming of vulnerable populations" (1997:59).
Defining AIDS risk-groups as populations who are culturally different uses a "vocabulary of distance" (Glick Schiller et al 1994: 1341) and renders their actions exotic or deviant. The language used in the early HIV risk literature characterized homosexuals and IV drug users as socially deviant. In order to locate IV drug users outside the boundary of the "normal," they were never described as having loving nurturing families. Glick Schiller et al (1994: 1339) argue that such epidemiological discourse placed them outside the human family, dehumanizing and objectifying them as the withdrawn asocial diseased other. Similarly, gay men were described as having sexual partners or lovers instead of spouses, implying that non-committal promiscuity was a homosexual norm, or that homosexuals were incapable of maintaining long tern monogamous relationships (1994: 1339-40). The "vocabulary of distance" in these epidemiological characterizations mirrored society's preexisting derogatory stereotypes of gay men as sexually compulsive, and IV drug users as deviant loaners, separate from society.
Similarly, in Africa the use of western culture to define African sexual behavior has created a discourse of "evil sirens" or "reservoirs of HIV infection" which resulted in physical assault, harassment, and even incarceration in countries like Rwanda and Zimbabwe (de Zalduondo 1991: 224-5). In particular, the inappropriate use of the terms "promiscuity" and "prostitution" to define African sexual behavior is problematic because they impose western ideologies and morals, which are not necessarily shared cross culturally. For example, western researchers in Africa narrowly defined prostitution as the exchange of money for anonymous sex; however, this definition is inadequate because it does not account for the diversity of sexualities and sexual strategies for economic security, which fall outside of boundaries of commercial sex work. The difficulties defining prostitution in Africa have been innumerable (e.g., Caldwell, Caldwell, & Quiggin 1989; Day 1988). Under the rubric of sexual networking, researchers have gained insight into how Africa women exchange sex for social and cultural support as a wife or mother, as well as for more direct forms of financial assistance. For many women in Africa with limited socioeconomic and political choices, the commodification of their sexuality and fertility are the only vehicles through which they can achieve social status and economic support. Barbara de Zalduondo (1991: 224) argues that
efforts to understand prostitution and AIDS have been hampered by reliance on an epidemiological paradigm, which is poorly suited to the task of finding avenues for prevention. This frame of reference has prevented researchers from engaging with social meanings and functions of prostitution in relation to broader economic, political, and gender issues which vary from culture to culture.
AIDS has been blamed on promiscuity and the promiscuous. Despite the salience of this concept in the AIDS discourse of scientists, policymakers, the media, and religious leaders, critical analysis of the role of promiscuity in this epidemic has been lacking. Although what is defined as African male promiscuity is seldom stigmatized, monitored or punished as compared to the women who sell it; the term imposes a pejorative white, middle-class Victorian sexual ideology. The argument that African men are all promiscuous overlooks the sociocultural significance of particular sexual behaviors. African men's sexual behavior examined within its cultural contexts reveals that these behaviors are instead a form of neo-polygyny and a sexual strategy that is socially sanctioned in many communities. In Ralph Bolton's (1992) discourse analysis of promiscuity in American society and in HIV-prevention campaigns, he purports that the emphasis on partner-reduction strategy instead of addressing the socioeconomic and political factors that contribute to HIV transmission has been an impediment to AIDS prevention efforts. Bolton places the responsibility for this misguided strategy on the moralistic approach to AIDS and to the misapplication of epidemiological concepts and inappropriate social science models to the task of promoting healthy forms of sexuality.
The Archaeology of the Dangerous African Other
A Foucauldian archaeology suspends the concept of a linear or continuous history of ideas and is an inquiry of how certain assemblages of statements achieve unity and consensus as an authoritative fact. Foucault's archaeology of knowledge is therefore not a factual description of discourse but an examination of the relationship between statements. A Foucauldian archaeology focuses not on the history of ideas or the moment of scientific progress frozen in time but on the conditions in which a subject (the HIV infected African other) is constituted as an object of (epidemiological) knowledge and transforms of meaning over time. An archaeology of HIV risk groups aims to broaden the analysis of both spoken and written statements (discursive events) to include the historical or contemporary influences of parallel or competing discourses and sociocultural and political-economic variables. An archeology of HIV risk groups analyzes the conditions surrounding the formation of epidemiology and the associated practices and subsequent effects.
Discourses of blame and accusation are not new strategies in response to epidemics (Ranger and Stack 1992). The process of attributing the locus of a lethal transmissible disease to a marginalized sub-group perceived as culturally and socially different from the mainstream population has been a popular explanatory model for understanding plagues throughout history (Rosenberg, 1992). For example, in 14th century Europe, Christians blamed the Jews for the plague, and in the United States, the 1832 cholera epidemic was blamed on the immoral behavior of new immigrants (Glick Schiller et al, 1994:1338). The history of syphilis in the U.S. in particular illustrates the complex sociological interactions between medical discourses, stigma, and sexually transmitted diseases (STDs). Allan M. Brandt (1985), in No Magic Bullet, A Social History of Venereal Disease in the United States, argues that pervasive xenophobic fears of sociocultural and political contamination following both World War I & II informed the assignment of blame of syphilis and subsequent discrimination of poor immigrant populations from Southern and Eastern Europe. Both medical and moral-religious discourses framed syphilis as the 20th century 'carnal scourge' of society -- a sign of moral pollution and contamination. It was eroding away at the fabric of good Christian Victorian moral values (Brandt 1985: 376). In today's AIDS pandemic, one finds countless examples of "shifting the blame"(Mann 1988) to the marginalized outsider. While the US blames Haitian immigrants, authorities in Britain, China and the Soviet Union openly blame African students. In response, Africans blame Europeans. In addition, the Japanese blame all foreigners, and the French right initially blamed Arab immigrants (Panos, 1988).
Current constructions and representations of the African as the `dangerous infected other' is also not new. A Foucauldian archaeology of the medical discourses about Africa reveals that today's metaphors of contagion are in dialogue with the racist representations and stereotypes of colonial Africa. Jean Comaroff (1993: 316) in "The Diseased Heart of Africa: Medicine, Colonialism, and the Black Body, " surveyed colonial medical discourses about Africa and purports that images of the disease "infested native [as] indistinguishable from the pestilential surroundings" of Africa first emerged in popular traveling narratives in the late eighteenth century. Africans, as an object of the European imagination and speculation, were a "personified suffering and degeneracy... [in the] hothouse of fever and affliction" (Comaroff 1993: 305). The colonial conceptions of the African body was specifically linked with biomedical discourses of "degradation, disease, and contagion" to justify the hygienic missionary mission. Medicine and hygiene were used to "domesticate... the dark interior" of Africa (1993: 306). Megan Vaughan (1991: 1) argued in Curing their Ills: Colonial Power and African Illness that "the European imagination is easily captured by the image of the white doctor in a dark Africa." Today's xenophobic and racists discourses pertaining to AIDS and Africa continue to invoke these colonial images of the black body as the "very embodiment of dirt and disorder" which threaten "to invade the inviolable world of white order "(Comaroff 1993: 316). The imagined social body of the "dangerous African other" continues to metaphorically represent the social disharmony, chaos, and disintegration of African society and culture (Douglas 1970). What is problematic in the continued use of these racist perceptions and misconceptions is that they have been appropriated by the body politic to bolster the need to regulate, monitor, and control populations (social bodies) or individual bodies in the interest of the public's general welfare.
Stereotypes of stigmatized others are used to reformulate the boundaries between the self and the "unhealthy other," creating an illusion of insulation from the negative characteristics ascribed to that infected other. Terms such as "dirty," "disease-ridden," and "sexually promiscuous" are components of the negative symbolism used to describe AIDS and Africans today (1994: 1348-9). Robert Crawford (1994: 1348) in "The Boundaries of the Self and the Unhealthy Other: Reflections on Health, Culture and AIDS" examines both the biomedical and popular metaphors of contagion through which stigmatizing self images delineate boundaries between the self and the unhealthy other. Crawford concludes that these associations of contamination and impurity are projected onto individuals living with HIV/AIDS, relocating the symbolic weight of the negated self onto the "infected other" while maintaining the boundaries for the "healthy " social identity (ibid.).
Donna Haraway (1991), in "The Biopolitics of Postmodern Bodies: Constitution of the Self in Immune System Discourse," also notes how the notions of "selfhood" and "otherness" were often historically conflated with race in epidemiological discourses:
Expansionist western medical discourse in colonizing context has been obsessed with the notion of contagion and hostile penetration of the healthy body, as well as of terrorism and mutiny from within. This approach to disease involved a stunning reversal: the colonized was perceived as the invader. In the face of the disease genocides accompanying European "penetration " of the globe, the "coloured " body of the colonized was constructed as the dark sources of infection, pollution, disorder, and so on, that threatened to overwhelm white manhood (cities, civilization, the family, the white personal body) with its decadent emanations
Haitians, according to Farmer (1992) in AIDS and Accusation: Haiti and the Geography of Blame, Haiti, the first independent Black republic in the world, was an easy target for AIDS stigmatization because they were already a highly stigmatized group in the West. The link of HIV etiology was discursively connected with Western romanticized views of voodoo and animal sacrifice. The concurrent outbreak of African swine fever in Haiti or the readily available images of squalor, and boatloads of disease-ridden refugees in the media further fueled these associations of Haitians as the dangerous diseased other (Farmer 1992: 438).
The AIDS epidemic came at a time when the U.S. government policy, as evidenced by Coast Guard interdiction of Haitian vessels and by the prolonged incarceration of new Haitian arrivals in Krome and other camps, seemed to most Haitians to single them out as special targets of a racist and exclusionary attitude pervasive in this country (Nachman & Dreyfuss 1986: 33; c.f. Farmer 1992: 214).
An understanding of the long associations of these stigmatizing metaphors illuminates how readily available images and metaphors of contagion were successfully deployed in AIDS discrimination against Africans.
Experiential Knowledge & Counter Accusations
The production of meaning and understanding of AIDS is also not exclusively limited to biomedical experts. The myriad and diverse levels of expertise and knowledge engaged in the production of AIDS discourse include:
biomedical researchers, health care professionals, activist, advocacy
groups, people with HIV/AIDS, health educators, social scientist, politicians,
public health officials, government agencies, advisory committees, pharmaceutical
and biotechnology companies, writers, journalist, and institutions of mainstream
and alternative media.
Steven Epstein's (1996: 2), in his survey Impure Science: AIDS, Activism, and the Politics of Knowledge challenges the assumption that "knowledge-making is the province of a narrow circle of credentialed experts" by emphasizing the role of lay people in the "proclamation and evaluation of scientific claims" and the production of biological knowledge (1996: 4). For Epstein, the process of claim making emerges from a struggle for credibility in which the trustworthiness of a statement relies not only on the authority of credentials and degrees but also on who advances the statement, its plausibility, and the evidence used to support its claims (1996: 3). How experts acquire their 'authoritative voice' to articulate statements illustrates how knowledge and power are intimately linked in discourse.
Institutions of mass media, have been central in shaping how both the scientific controversies over AIDS are interpreted and adjudicated and how people living with AIDS (PWA's) are represented within the American imagination. Africans were repeatedly characterized as backward, uncivilized savages that are dirty and disease ridden, that practice exotic rituals involving animal sacrifice within the early international discourses on AIDS in Africa. The media, according to Epstein (1996: 22) function like a "filter" to:
translate scientific information, construct public images of scientific certainty and uncertainty, shape the way in which people understand the 'sides' and 'boundaries' of a debate, certify scientific and medical celebrities, affect perception of risk, and reinforce popular stereotypes of scientist and doctors as both heroes and villains.
Although medical researchers blamed the media for sensationalizing and misrepresenting AIDS, both were guilty of using "readily available images of filth and squalor, voodoo, and boatloads of 'disease-ridden' or 'economic' refugees" to support their theories of a Haitian/African origin and its routes of transmission to the United States (Farmer 1992: 221). Paul Farmer (1992: 221) argues that the medical-scientific community upstaged mainstream media by using the popular press as a venue for the presentation and dissemination of the latest research.
Lay specialist and PWAs (People with AIDS) challenge the assumption that "knowledge-making" is the province of only "credentialed experts" (Epstein 1996: 4). Early in the U.S. epidemic, AIDS activist reconstituted themselves as "a new class of 'lay experts,' [putting] forward their own claims " (1996: 17). AIDS activist are "more than just a 'disease constituency'" they are an "alternative basis of expertise" (Epstein 1996: 6-7). People living with HIV/AIDS have an experiential knowledge of the viral infection of diseased syndrome. These lay forms of embodied knowledge expressed were initially blocked, prohibited, or even disqualified by the hegemonic authority of biomedicine to define the pathophysiological phenomenon for those afflicted. However, over time biomedical researchers recognized the import of their phenomenological knowledge and lived-experience of HIV infection and AIDS to understanding the nature of the virus.
Gill Seidel (1993) also identifies the multiplicity of actors involved in constructing the discourse on AIDS in Africa. According to Seidel (1993: 175), the competing discourses of HIV/AIDS in sub-Saharan Africa fall into the categories of "control and exclusion" or "rights and empowerment." Discourse of "control and exclusion," are defined by Seidel as those biomedical or medico-moral discourses which proclaimed that AIDS is God's punishment and that disease reflects moral disorder (1993: 176-180). In contrast, discourses of "rights and empowerment" are characterized by legal and ethical discussions surrounding the preservation of civil liberties and human rights of people with AIDS (1993: 180). Dissenting voices in both Africa and the U.S. both use discourse of human rights and empowerment to challenge the dominant medico-moral discourse. In Africa, community activism has not only transformed discourse they have influenced public policy. Organizations such as the Society on AIDS in Africa (SAA), the Society for Women and AIDS in Africa (SWAA), and The AIDS Support Organization (TASO) have implemented agendas based on human rights and social, economic and political empowerment to influence government prevention and assistance programs (Seidel 1993: 184-6).
In conjunction with these competing discourses of experiential knowledge are the numerous conspiracy theories and counter-accusations for the etiology and suffusion of the HIV virus. In Haiti, Farmer (1992) identified three different levels of competing discourses of blame and accusation: (1) the local or micro level of explanatory models, sorcery and witchcraft; (2) national counter-accusations and conspiracy theories in response to western blame against Haiti; and (3) the international biomedical-scientific and popular media accusations about a Haitian/African origin of AIDS and the proliferation of HIV infection to the west (1992: 244-5). AIDS-related discrimination against Haitians and Africans, counteraccusation, and conspiracy theories are "'macro sociological' models constructed to assign blame on top of etiology," which blame the victim, while sorcery and conspiracy theories blame institutions or anonymous agent in society (Farmer 1992: 247).
Counter-accusations against those theories supporting an African etiology often manifest as conspiracy theories against western or American imperialism. The majority of these conspiracy theories assert that AIDS (American Idea to Destroy Sex) is an "imperialist plot to destroy the Third World" (Farmer 1992: 230). Renee Sabatier (1988: 63), in Blaming Others: Prejudice, Race and Worldwide AIDS examines the most notorious Third World counter-blame theory that the HIV virus was artificially manufactured in the U.S. Defense Department laboratory at Fort Detrick, Maryland, as part of biological warfare experiments. Although these conspiracy theories may seem ludicrous or paranoid, Third World suspicions about western abuses of scientific knowledge (especially pertaining to disease) against people of color are historically grounded in the recent painful lessons of the Tuskegee Syphilis experiment. Barbara Browning (1998: 52) astutely concludes that:
Conspiracy theories of a western propagated genocidal campaign to wipe out African and diasporic populations are not really more far-flung than epidemiological finger-pointing at Haiti or Africa. Neither accusation, finally, is of help in keeping more people from getting sick or dying, and in fact, in this respect, both can be extremely counter-productive.
Finally, there are also numerous conspiracy theories generated by peripheral parties to fulfill ulterior agendas of racism or xenophobia. The following excerpt from a British fascist leaflet entitled "Conspiracy to destroy our nation through AIDS" exemplifies the racism found within the international discourse on AIDS and Africa.
Whilst 'AIDS' infested Africans are brought into Britain from 'AIDS' infested Africa (supposedly to work) to live on the dole and social security (at our expense)... our young highly fit British soldiers are transported to 'AIDS' infested Africa (at our expense) to work as laborers, making roads and building (at our expense) for a six week period. Whilst there are given a six day holiday and 200 [pounds] extra spending money to blow in the local town where the only past time is brothels and brothel bars to which hundreds of 'AIDS' infested prostitutes have been brought by train and bus. This expenditure of our money (and men) is to assist the local economy on which Africa depends...part of the African drain which on our country/people (Guardian report 3rd February; cf. Chirmunuta and Chirmunuta 1989: 100).
Blaming the infected African other is a dangerous epidemic of discrimination and racial prejudice. What is central in this discussion of 'blaming the African other' is not the veracity of the statements but how they are sustained through the inappropriate use of western cultural constructs to define and interpret epidemiology cross culturally. The authority of epidemiology to define risk is a politics of knowledge that is produced, reproduced, contested, and sustained through the discursive hegemonic authority of biomedicine and science as the truth. According to Glick Schiller an "understanding of the hegemonic processes have given us new insights into the historical, structural, and authoritative location of symbolic construction" (1992: 248). However, an examination of the micro-politics behind the maintenance of such stereotypes, illuminates how also discourses of stigmatization and otherness govern the construction, negotiation, contestation, and maintenance of boundaries between the self and the HIV infected other through fear of contamination by the dangerous African outsider.
These stigmatizing discourses and counter-discourses are ideological
terrains used to insulate the perceived uninfected other from the afflicted.
Stereotypes and generalizations about particular populations perceived
to be at risk have provided a misleading backdrop for policy formation
because they underestimate the diversity of sexual culture within seemingly
homogenous sub-groups. Although the social and political consequences of
culturally constructing risk of HIV/AIDS are innumerable, there are three
primary consequences: (1) wide spread misunderstanding of who is at risk
and who is not; (2) the continued spread of the diseases by those infected
who are define themselves outside of those populations at risks; (3) and
the perpetuation of the stigmatization of people living with HIV or AIDS.
The question therefore remains "does it really matter where AIDS came from?"
Shouldn't we concentrate our efforts on improving the quality of life for
those suffering with the diseases instead of blaming them for their illness?
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 At the end of 1998, the joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) estimated that over 34 million people were infected with HIV, and since the advent of the pandemic more than 14 million deaths have been attributed to AIDS (UNAIDS & WHO; 1998 Global Report). Over two-thirds of all the people living with HIV in the world and 83% of the total AIDS, deaths are from sub-Saharan Africa (ibid.).
 Barbara Browning (1998:65) in Infectious Rhythms: metaphors of Contagion and the Spread on Africa culture argues that "media attention to AIDS in Africa is not so much a response to the gravity of the situation as it is a fascination with what appears as the specter of a western threat."
 Biomedical researchers speculated that virus either originated in a remote central African "lost tribe," where the HIV virus had been present for centuries (De Cock 1984), or was somehow acquired through contact with monkeys in the last thirty years (Hirsch, Olmstead and Murphy-Corb et al. 1989).
 In 1990, the U.S. Food and Drug Administration banned Haitians form donating blood (Singer 1994: 1323).
 The study of fungi.
 The acronym PQRST refers to: P-place (the physical location on the body, i.e. the forearm); Q-quality of pain (i.e. sharp); R-radiation (does the pain go anywhere, i.e. or down the arm); S-severity (on a scale of 1 to 10, how much does it hurt); T-timing (does it happen all the time, some of the time, in the morning or at night).
 Social history involves marital status, dependents, living arrangements, substance abuse (cigarettes, alcohol, or illicit drugs).
 HEENT, is another acronym, which stands for head, eyes, ears, nose, and throat.
 Major psychiatric disorders are typically mood or affective disorders such as depression or schizophrenia.
 An example of a medical problem would be hypothroidism as a cause of depression.
 The numerical score is based on a global assessment of function.
 For example, if you specialize in HIV-related TB you may be more likely to conclude such a diagnosis even if all of the data (i.e. lab test) is inconclusive or pending.
 Kupiers argues that "surgical reports, drawing on [specific] scientific terminology, are constructed according to implicit generic conventions "(1989:109).
Kupiers suggest an integrated approach of poststructualism and interactionism to medical discourse, which links social differentiation, institutional structures, power, and language, without rendering discourse a vague and transcendent construction (1989: 101).
 Instead of a language of risk-groups, researchers today are using terms such as risk-behaviors and risk-environments to represent the complexities behind the risk to HIV.
 There are two distinct patterns of HIV transmission now recognized in the world today: Pattern I, which is defined by homosexual behavior, IV drug use and tainted blood supplies; and Pattern II, which is characterized by heterosexual transmissions.
 Sexual networking according to Heise & Elias is the phrase used by anthropologist and public health analysis to describe "patterns of multi-partnered sexual relations" (1995: 935)
 In Zimbabwe, for example, a woman may pursue sexual relationships with several itinerant men, who when they occasionally pass through town may buy groceries and pay the school fees for her children in return for continued conjugal rights and domestic services (i.e. laundry, cooking etc). Sexual networking, within this context is not a form of prostitution; it is an economic survival strategy for young women who are politically, socially and economically disenfranchised.
 Susan Sontag (1988) seminal survey on popular metaphors of social stigma also examines the phenomenology of the AIDS disease and the cultural construction of the unhealthy other.
Haiti has always been criticized within American discourse because it was the world's first independent Black republic. Furthermore, these fears were further exacerbated by the negative stereotypes of Haitian folk culture. Vodoun, the indigenously formed syncretic African religion became synonymous in the west as black magic and epitomized by Hollywood presentations of zombieism, strange trances, animal sacrifices etc.
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