The AIDS Pandemic in Latin America by Shawn Smallman, University of North Carolina Press, 2007, 290 pages, $22.50 paperback
Next August, the 17th international AIDS Conference will take place for the first time in Latin America, in Mexico City. More than 20,000 delegates—research scientists, health care workers, journalists, businesspeople, philanthropists, religious leaders, artists, public health bureaucrats, and HIV-positive activists and advocates—from almost every country on earth are expected. The 2008 conference is already generating international attention to the lessons that might be learned from the region’s experiences.
Shawn Smallman’s The AIDS Pandemic in Latin America, an ambitious new study of the history of AIDS in the region, will provide conference-goers and anyone interested in the topic with an excellent introduction. The book is organized by subregion, with chapters on the Caribbean, Brazil, Mexico and Central America, and Spanish South America; in each, Smallman emphasizes the contrasts between countries with very different experience of the epidemic.
Despite Latin America’s widespread poverty, gender inequality, IV drug use, hidden male homosexuality, extensive sex trade, and often imperfect public health systems, it has largely been spared a generalized pandemic (with the exception of Haiti, Guyana, and perhaps Honduras). When viewed in an international context, Smallman argues, “perhaps the most compelling question about Latin America’s experience is why there [has] been so little spread of HIV.”
Acknowledging that much epidemiological work remains to be done, he argues that understanding the history of HIV/AIDS in the region and the international factors that shaped it can suggest some initial answers. In this, Smallman’s work follows in the tradition of Paul Farmer’s seminal work on the early years of Haiti’s epidemic, AIDS and Accusation. As Farmer made clear, while HIV is transmitted through the most intimate of personal behaviors (sex, intravenous drug use, breastfeeding), the pandemic reflects complex historical and international issues, from the economic forces shaping poverty and intellectual property regimes to the cultural beliefs that define difference, morality, and prejudice.
This is evident in one of the most mysterious aspects of AIDS: its ability to devastate one country, while a statistically and culturally similar neighbor escapes its wrath. The most dramatic example of this in the Americas is the contrast between Honduras and Nicaragua. Honduras, the epicenter of the disease in Central America, had a sharply higher rate of HIV infections early in the epidemic, which was predominantly heterosexual. Smallman examines the argument that the virus was introduced by U.S. troops or the CIA and Nicaraguan Contra forces stationed there during the war.
Yet the geography of the Honduran epidemic does not seem to support this hypothesis. Infections have been concentrated in urban areas in the central and northern part of the country, while the Contra bases were located along the southern border. Smallman concludes that there is no clear explanation of why the HIV/AIDS epidemic in Honduras emerged so early and impacted young heterosexuals so severely. As for Nicaragua, the isolation imposed by the war may explain its low rate of infections.
Furthermore, while poverty is an important factor in explaining the relative spread of HIV, poor countries are not all equally affected by the virus. Comparative studies from around the world have made clear that a nation’s level of economic development, in and of itself, is not a good predictor of how its population will be impacted by HIV. Perhaps the most dramatic illustration of this comes from the African continent, where the richest country, South Africa, has been most devastated by the epidemic.
In the Western Hemisphere, one of the poorest countries in the region, Bolivia, has a very low prevalence of HIV infection compared to the United States and Argentina. For this reason, Smallman worries that a focus on poverty can “let both national elites and the international community off the hook,” allowing them to point the finger at macroeconomic policies like structural adjustment and unfair terms of trade—obscuring the crucial role that political leadership can play in challenging stigma and defending the human rights of those infected, increasing popular awareness of effective prevention methods, and ensuring that those infected receive adequate treatment.
Such measures have the potential to dramatically slow the spread of the virus and to reduce mortality, as the Brazilian example dramatically illustrates. What’s more, Smallman argues, focusing on poverty alone can minimize other social factors that exacerbate the epidemic but whose interrogation may pose more of a challenge to national elites—patriarchy, gender inequality, ethnic and racial discrimination.
Overall, Smallman is struck by the effectiveness of many Latin American states in responding to the epidemic, even in the absence of economic resources. Many have created public health infrastructures, fostered communication systems that make international collaboration possible, and participated in the Pan-American Health Organization. But this is a hard area to delineate because of the integral role played by AIDS NGOs and community-based charities in almost every arena of national responses in countries like Brazil and Argentina.
The particular importance of NGOs can be seen in Mexico and Brazil, which both experienced a proliferation of AIDS NGOs in the late 1980s and early 1990s. Given the frequent distrust of government initiatives, the moral authority of NGO workers, who often share identities and problems relating to sexuality, drugs, and other issues with the communities they serve, can often be of great importance; Brazilian NGO workers, for example, are more likely to enter places like favelas than state employees. In Oaxaca, given the tension between the government (both state and federal) and rural indigenous communities, NGO workers are able to carry out sex education and HIV-prevention campaigns in the countryside.
Beyond these domestic factors, however, “perception and response to the epidemic in [Brazil and Mexico] was shaped by its relation to the United States as well as its particular political culture.” The Brazilian National AIDS Program (NAP)—widely recognized as the leading example of an integrated HIV/AIDS prevention, care, and treatment program in a middle-income country with significant levels of social inequality—illuminates the contradictions and complexities of globalization in the AIDS era.
On the one hand, the Brazilian government was forced to contend with intense opposition from the multinational pharmaceutical industry and the U.S. government for its efforts to produce generic antiretroviral medications. On the other hand, the Brazilian government’s policy of universal treatment was bolstered by a massive investment in health infrastructure and training financed by three successive loans from the World Bank.
By regional standards, Mexico has a relatively low rate of HIV infection. This may be because the government has provided health testing to sex workers and because IV drug use is uncommon. But the reasons may also lie in cultural and social responses that are partly outside the federal government’s control and come from the local or state level.
Smallman admirably synthesizes information from a range of available sources from the social and biomedical sciences. His inclusion of key Spanish- and Portuguese-language texts generated by Latin American scholars and activists in the early years of the epidemic are especially noteworthy, attesting to his linguistic competence as well as his dedication to providing a carefully documented historical overview of the epidemic. Smallman demonstrates a remarkable resourcefulness and creativity in using whatever sources are available to illuminate facets of the epidemic he is unable to tackle in a more straightforward journalistic mode, like the experiences of Cuba’s roqueros and the perspective that the beliefs of Candomblé offer HIV-positive Brazilians.
But while he contextualizes the social and cultural research, he settles for only the occasional cautionary note when presenting quantitative data. This is particularly true when he relies on World Health Organization and UNAIDS figures to illuminate important differences in countries’ experiences of HIV/AIDS. The statistics, and the social categories upon which they are based, go unquestioned. This is unfortunate, since a comparative history of the ways in which biomedical knowledge about the epidemic has been produced would illuminate the interplay between exactly the international and local forces that Smallman is after. Such an effort would also contribute to the growing literature on the history of science, technology, and medicine in Latin America.
Although he is characteristically cautious positing conclusions, Smallman ultimately declares that “HIV would have had a far more serious impact on Latin America if it had not been for the flowering of civil society that accompanied the region’s democratization.” While there are notable exceptions like Peru, the historical context in which HIV/AIDS emerged in Latin America was one in which authoritarian regimes were crumbling while civil society, in the form of grassroots groups and internationally connected NGOs, was flourishing.
In country after country, Smallman demonstrates, the popular protests of grassroots activists, often acting with funds from international donors, have led to key policy changes, from the enforcement of human rights provisions to the provision of free treatment for the ill. Smallman calls the relationship between democracy and HIV “probably the most understudied question in the field.”
Shanti Avirgan is a documentary filmmaker and graduate student in New York University’s anthropology department.
