Differentials considerations for the caribbean



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GLOSSARY
AIDS

Acquired immunodeficiency syndrome


ART

Antiretroviral drugs, therapy or treatment


Drivers

Events which make people, households, communities and organizations more or less susceptible to infection and vulnerable to impacts
Endemic

A disease is considered endemic if there is continuous presence in a population, but at low or moderate levels
Epidemic

An epidemic embodies three main aspects: it is a rate of disease that reaches high levels, affecting a large number of people and it does so in a short amount of time. “Epidemic” is a relative concept: a small absolute number of cases of a disease is considered epidemic if the disease incidence is usually very low.


GDP

Gross Domestic Product


Gini coefficient

Aggregate inequality measures


HIV

Human immunodeficiency virus


Incidence

The number of new infections which occur over a period of time


Incidence rate

The number of infections per specified unit of population in a given time period


LEA

Adult life expectancy


LEB

Life expectancy at birth


Markers

The status of the disease within a household or community


Morbidity

Sickness


Mortality

Death
Opportunities



Activities and actions that people, communities and organizations can undertake to strengthen resistance and resilience to the disease and its impacts
Pandemic

An epidemic of worldwide proportions.


Prevalence

  1. The absolute number of infected people in a population at a given time

  2. The proportion of people living with HIV


I. INTRODUCTION
Quo Vadis?
The purpose of this Research Paper is to bring to light the economic concerns that are brought about by the devastating consequences of the HIV/AIDS pandemic. The Paper aims to explore the microeconomic and macroeconomic areas that are influenced and changed by the emergence, spread and maturity of the disease in the Caribbean. Both micro and macro economic impacts of AIDS have to do with costs --- short terms and long terms costs, measurable and immeasurable costs --- that are attached to the welfare and well-being of individuals, their households, their communities and ultimately their entire societies. These costs take their toll from the minute the disease is diagnosed, lived with, to well after the victim is deceased. The upshot of the “cost of AIDS” implies additional constraints on already strained resources in the Caribbean region and elsewhere.
With respect to projecting the economic impact or speaking to the societal costs of HIV/AIDS, this Paper emphasizes the human capital approach which places emphasis on the income foregone due to increased mortality as well as recurrent expenditure on the costs of treatment and dealing with AIDS-related externalities. Simply put, because the first visible impact of HIV/AIDS is a demographic one, there follows a ripple in human costs that are both pecuniary and emotional as well as a larger societal cost that is also pecuniary and emotional. The costs of HIV/AIDS are serious but the impact is uneven across individuals or households; communities and nations; and finally, regionally.
It must be pointed out that we do not intend to provide economic models that measure the financial cost to human beings and their household members nor dare to tabulate the immeasurable emotional cost to individuals or monetary costs borne by businesses or whole societies. We do want to underscore that AIDS impacts on economies by negatively interfering with the channels of growth and development on a ‘micro’ level such as in households and business and on a ‘macro’ level such as in national development and growth. The upshot of such seriousness is that HIV/AIDS has a sheer impact on population: on susceptible and vulnerable individuals, communities and whole societies.
It is particularly apt to underscore that in the Caribbean region the putative economic effects in CARICOM and CAREC member countries hit women especially hard. Because of the “feminization of poverty”, the Paper will highlight specific gender differentials of HIV/AIDS in order to take into account how this disease specifically impacts women in the region. How AIDS specifically has any economic bearing on and relationship to women is informed by a plethora of social and economic realities in the region which together diabolically speak to well-defined “differences” that address females’ susceptibility and vulnerability: precocious sexual activity of girls; frequent partner exchange, and age mixing—younger women having sexual relationships with older men; single-female headed households and visiting relationships; tourism and its corollary, sex-tourism; outmigration and the resultant Caribbean diaspora, to mention but a few phenomena which buffet women with a singularly hard thrust in the context of HIV/AIDS.
While this Paper wants to go beyond the immediacy of the present dramatic situation of increasing AIDS within certain target populations in some countries in the Caribbean subregion, it also recognizes that there are technical problems in measuring the economic impact and social fallout of excess death and intransigent illness as it unfolds every second of each day. It is difficult to measure phenomena that are happening as the clock ticks.2/ There are fewer problems however, to describe some of the socio-economic drivers that fuel HIV/AIDS in the region and as well as the economic concerns and impact associated with the consequences of AIDS.
This Paper draws on secondary sources of information and research as its font to provide an overview of the ineluctable impact HIV and AIDS have on economic relationships To facilitate an understanding of the economic concerns and impact, the Paper will move from the general to the specific by presenting some overarching concepts and generalities before it speaks to the specifics in the Caribbean subregion and women. Some of the questions that we intend to answer are:


  • What socio-economic conditions drive the epidemic?

  • What is meant by impact?

  • What makes women particularly vulnerable?

  • Where are economic impacts felt?

  • How will the epidemic impact on the economies of the Caribbean region over time?


It is hoped that the Paper will be interesting enough to elicit and merit attention for a CIM strategic plan of action to contribute to the fight against AIDS. It is further hoped that the information and recommendations in this Paper will assist the Organization of American States’ Anti-American Commission of Women (CIM) to design projects and programs in keeping with the Millennium Development’s Goal to contain the spread of HIV/AIDS during this century, especially as it relates to women and their lives.

OVERVIEW: THE PICTURE WE SEE
“I don't know where the next generation will come from. There are only 60,000 of us now, and a lot of people have got the disease.”—Resident of Tobago
The health sector, globally, is currently under severe pressure. The history of this pressure has a time line and is no longer new. Before the initial “wake-up call” in the 1980s, scientists had asserted that HIV arrived in the United States in the late 1960s and that it continued to spread undetected in the US and other countries during the 1970s. By the end of 1982, AIDS was detected in five countries. By 1985 every region of the world reported cases of AIDS. Two years later, by 1987, a total of 71,750 cases of AIDS were reported to the World Health Organization (WHO). By the mid-1990s, one million cases were reported to the same international organization. According to detailed statistics in a country-by-country analysis of HIV prevalence released in 1998 by UNAIDS, approximately 5.8 million people worldwide were newly infected with HIV in 1997 alone. Alarmingly, in 27 developing countries, HIV prevalence more than doubled between 1995-1997.3/ In less than a decade, in 2001, UNAIDS said there were an estimated 21 million people worldwide who had died of AIDS and in its inexorable devastating way, in 2003 the biggest number in a year, to that date, were newly infected with the disease: five million people.4/ In 2005, an estimated 38.6 million (33.4 million – 46.0 million) people worldwide were living with HIV. An estimated 4.1 million (3.4 million – 6.2 million) became newly infected with HIV and an estimated 2.8 million (2.4 million – 3.3 million) lost their lives to the full-blown disease of AIDS.
In its 2006 report, UNAIDS estimates that to date, around 65 million people worldwide have been infected with HIV and AIDS has killed more than 25 million people since 1981.5/ The number of people living with HIV/AIDS over the past two years has increased and the worldwide total now stands at nearly 40 million, according to a report released on Tuesday, 5 December 2006, by UNAIDS and the World Health Organization. The report, entitled "AIDS Epidemic Update: December 2006," estimates that 4.3 million new HIV infections occurred worldwide this year and that about 2.9 million people died of AIDS-related illnesses.6 The runaway figures related to HIV/AIDS underscore the explosive and unrelenting nature of HIV and AIDS and are of such magnitude that pressure on the health sector is no wonder. HIV and AIDS are ubiquitous.
In the Americas, the Caribbean countries have the highest infection levels in the world after southern Africa. Indeed, the Caribbean has a well-established HIV epidemic, making the region second most affected in the world. At the end of 2005, there were between 240,000 and 420,000 HIV-infected adults and children in the region. The region's HIV prevalence was estimated to be between 1.1% and 2.2%; among young people 15-24 years of age, HIV prevalence is approximately 1.6% for women and 0.7% for men. In 2005 alone, there were between 26,000 and 54,000 new HIV infections and between 19,000 to 36,000 AIDS-related deaths.7/
In the erstwhile idyllic picture perceived about Caribbean islands, HIV/AIDS has touched even the smallest islands. Almost three quarters of the 250,000 people (190,000-320,000) living with HIV in the Caribbean are located on the island of Hispaniola, in Haiti, which occupies the eastern one-third of the island and the Dominican Republic, which lies to the west and occupies two-thirds of the island. Of all the islands, Haiti is home to more people living with HIV than any other country in the region: 190,000.
Outside of Africa, Haiti is the country most affected by the AIDS pandemic in the Caribbean region. The national adult prevalence in Haiti alone was estimated at 3.8% in 2005. The latest HIV data for Haiti estimates national adult prevalence at 2.2% and 5.6% of the adult population is living with HIV/AIDS.8/ There is 1-2% adult prevalence next door in the Dominican Republic, where life expectancy is estimated to be three years lower than it would have been in the absence of AIDS. While the national prevalence was estimated at 1.1% there are pockets of infected groups such as men who have sex with men (MSM) where the infection levels were reported at approximately 11 percent, in 2005.9/
Alongside these twin-island countries, other islands have relatively high adult prevalence in the region as well: estimates are 1-2% in Barbados and Jamaica and 2-4% in the Bahamas10/ (3.3%) and, Trinidad and Tobago, an English-speaking country that is already losing its population to out-migration, has an estimated national adult HIV prevalence that exceeds 2% at 2.6% and is a small-island nation where AIDS mortality is expected to reduce the overall population by 2010.11/
It is apt to point out that the figures quoted tend to paint a general picture of the epidemic but do not highlight the fact that there are HIV and AIDS sub-epidemics. In Guyana and Suriname for example, where there are serious epidemics in urban areas, the national HIV prevalence hovered around 2.4% in Guyana while in Suriname 1.9% of adults were living with HIV in 2005.12/
Regarding rural areas, at the close of the twentieth century, it was reported that since the mid-1980s, residents of the bateyes, plantation-based communities for sugar cane workers, had the highest rates of HIV infection in the Dominican Republic. These high rates in bateyes had been widely attributed to the large number of Haitian immigrants who have historically resided in the bate yes. The higher prevalence of HIV infection in Haiti had led many in the Dominican Republic to view the HIV epidemic in the bateyes as a 'Haitian problem'. However, the highest HIV seroprevalences had been found in urban Haiti, whereas rates among rural adults (the origin of virtually all cane workers and year-round batey residents) were only about 2-3% up until the late 1980s, when rates of 10% and higher were being reported in the bateyes.13/ According to the Secretaria de Estado de la Salud e Asistencia Social de República Dominicana, recent information between 2005 and 2006 cites prevalence as high as 12% still found among some 40-44 year-old men in bate yes.14/
While the UNAIDS 2006 report underscores countries’ inroads and relative progress against the epidemic in the region because of greater access to antiretroviral treatments in such places as the Organization of American States member countries of the Bahamas, Barbados and Jamaica, it must be noted that there is much more work to be done to further stabilize any success and prevent the feared upswing in incidence, especially among more vulnerable countries such as Haiti and groups such as women and children.15/ According to a leading Jamaican newspaper, the Jamaican Gleaner reports that the HIV/AIDS pandemic is currently by far the leading cause of death in the Caribbean.16/
HIV/AIDS is well on its way into a third decade of existence. The world has changed a lot in the last 25 years since physicians first saw the earliest cases of AIDS in the United States of America, in the Democratic Republic of the Congo and around the shores of Lake Victoria, East Africa. As is often the case when a shocking new event takes place, in past decades the world was slow to recognize the gravity of the silent killer that heralded the new health crisis. Little thought may have been given to sectors outside of health because the initial onslaught of the disease “woke up” the medical and health industries as the disease first became a loud epidemic and then a boisterous pandemic. Now, we understand that the ramifications and consequences of this pandemic go far beyond the medical and health sectors and that HIV/AIDS is not a problem whose impact is solely felt by any one sector.
HIV/AIDS has affected every inhabited continent and has spread its plague across all professional sectors and personal fronts. The effects of the disease, hitherto rarely considered beyond its clinical impact on individuals or public health, are now widely understood to be a multidimensional ball and chain that hits hard at the very fabric of human society. The nature of the insidious disease makes it such that it cuts across politics, sociology, medicine and economics, to name but a few disciplines that together have analyzed the disease and tried to provide answers for its gradual process of attrition. It is this “gradual process of attrition” that affects the victims of HIV/AIDS and translates into the overarching impact of the disease.
AIDS obviously affects the health of individuals but it more insidiously also affects the welfare and well-being of households, communities and entire societies. At the end of the twentieth century, a time when emerging markets and modernizing nations held out the hope of increased socio­economic growth and development, the constant emergence of the scourge of the HIV/AIDS pandemic has possibly subdued expectations and dampened the predicted economic performance in the twenty-first century. Economists have predicted that in some nations that have been especially hard hit by AIDS, the epidemic may slow or even reverse hard-won gains in human and economic development.
When economic slumps or losses move from individual changes to communal and then become social upheavals the trajectory of history becomes irreversibly altered. It is hard to perceive or measure slow historical events. It is perhaps even harder to measure them in terms of cost because not all losses and costs can be afforded a monetary value. How do you measure the cost of parenting or the loss of a cuddle foregone? What is the cost to an organization of the loss of institutional memory? How does one tabulate or even estimate the loss of community morale or a broken heart? The impacts of HIV and AIDS are felt by those who experience them. An understanding of the overall magnitude of the consequences and the effects of HIV/AIDS are left to those who will read about them herein.
Scholars in the field of health economics say that, “Research on the impact of HIV and AIDS has increased significantly over the past five years. Studies concerned with socio-economic impacts have been carried out at many different levels (individual, household, firm, institutional, government and macroeconomic), employing various methodologies. While, in the past, model-based studies projecting future impact have dominated, there is now a greater focus on empirical analysis, as measurable evidence of the epidemic's impact increases.
Much of the research conducted, especially regarding effects on the household economy, has been country or sector specific. Thus, limited availability and "fragmentation" of relevant data - in terms of type of information collected and geographical area covered - has led researchers to integrate findings. Recent studies support models with empirical data,17/ consider information from a number of source surveys and combine quantitative and qualitative data. Literature reviews, which seek to present a theoretical framework, draw on similar findings of primary research within different contexts to explain causal patterns between variables. While some findings appear to be applicable to the broader discourse, others are too heterogeneous to allow generalization. In sum, researchers and analysts are slowly putting together pieces of a fragmented changing puzzle.”18/
As we chart the economic impact of HIV/AIDS, it is this puzzle that we speak to by emphasizing some of its pieces that underscore concerns for the Caribbean region, which in many instances is terribly blighted by socio­economic drivers that provide the bedrock of a scenario which itself must be called into question.

II. SOCIAL AND ECONOMIC DRIVERS OF HIV/AIDS: SUSCEPTIBILITY AND VULNERABILITY IN THE CARIBBEAN
“Most people in the region know about AIDS and how to prevent it, but we need to convert this into action.”—Fernando Zacarias, Pan American Health Organization (PAHO)
Although not across the board geographically nor sectorally in terms of target populations, there have been declining trends in some countries that are most likely related to some positive behavior changes that have become evident in specific groups such as female sex workers surveyed in Port-au-Prince who now more widely use condoms; young pregnant women whose prevalence rate has declined since 2000 in Barbados from 1.1% to 0.6% in 2003 and among the same group in the Bahamas, from 3.6% in 1996 to 3% in 2002. National adult prevalence in Jamaica appears to have stabilized, and was estimated at 1.5% [0.8%-2.4%] in 2005, but about 2% of pregnant women in the Sat. James and Westmoreland parishes of Jamaica tested HIV-positive in 2005.19/
Table 1 below illustrates, with estimates for 2003 and 2005, adults (15+) and children living with HIV were on the rise as were those newly infected.
Table 1
Caribbean regional HIV and AIDS statistics and features, 2003 and 2005


Caribbean
Year

Adults (15+) and children living
with HIV

Adults (15+) and children newly
infected with HIV

2003

310 000

34 000










2005

330 000

37 000

Source: UNAIDS, Report on the Global AIDS Epidemic, 2006
The following quote, from a 2004 publication, is noteworthy:
“It is reasonable to expect that a generalized epidemic fuelled by a virus for which there is no cure, is one with the potential to severely reduce, and probably annihilate small communities and the population of small communities. The fact that the rate in the Caribbean is more than twice the “generalized” [i.e. prevalence rate >1%, with certain subgroups having rates as high as 5%] threshold together with the fact that among some subgroups rates that exceed 5% have been found, means there is really no room for complacency.”20/ This silent reminder may underscore people’s alarm and or fear about the disease but the Caribbean has been anything but complacent over the last two decades since there are government efforts, initiatives by non-governmental organizations and regional networks that have worked to grapple with and responds to the region’s place in the HIV/AIDS world: second only to sub-Saharan Africa in HIV/AIDS adult prevalence rates, weighing in at 1.6% with 250,000 people estimated to be living with the disease at the end of 2006.

While the statistics are impressive in terms of the magnitude of the problem in this small region, it must be born in mind that numbers do not tell the entire story. There is the need to go beyond the mere numbers and percentages of the infected, the ill, the dead and the living to the drivers that inform the disease. The gravity of the situation in the Caribbean region is reinforced by the feeding of one crisis by another. Thus, underachieving or blighted economies characterized by economic recession, pockets of poverty, natural resource constraints such as droughts or single-crop concentration, the devastating effects of hurricanes and the evident lack of generalized economic opportunities and outlets intensify and complicate the effects of each other and bring susceptibility and vulnerability center stage in the Caribbean.
Susceptibility. The percentage or number of people infected in a population depends on the degree of susceptibility of individuals in that population. “Susceptibility” is a term that is usually used in the narrow biomedical sense of transmission efficiency. ‘Transmission efficiency’ is expressed as the probability that a contact will occur between infected and susceptible individuals multiplied by the likelihood that a contact will result in transmission (Anderson, 1996, p.73). Susceptibility however, has much more to it than the results of biomedical events in the body.
“Susceptibility” here refers to any set of factors determining the rate at which the epidemic is propagated. It is the general chance of being exposed to the virus. In a “risk environment” for example, individual, group and general social predisposition to virus transmission is increased. Because environments can and do change, “risk environments” in the Caribbean or elsewhere are not attributes of individual people or groups but rather reflect the environments in which people live their lives and make the decisions they take that are associated with their environment and shaped by their particular socio-economic, cultural, ecological and physical histories and circumstances.
Culture, as an aspect of susceptibility, is a case in point where the construction and reconstruction of what and whom people desire and how they realize this part of their life is captured in sex. In the Caribbean, expressions of sexual identity are diverse and fluid: they may be associated with social or physical survival or may affect who you are or who you become economically, or may impact the manner in which you earn your living or manage what you do with your body. The factors that increase or decrease susceptibility may at first flush seem inconsequential, but people who inhabit a “risk environment” may have to take decisions that are rational for them in their circumstances. It may be the case that people in a “risk environment” who consider social and economic factors or the dynamics of socio-sexual behavior may be compelled to take risks that are against their long-terms interests because they see little hope in the short run and end up with no hope in the long run. Conversely, it may also be the case that individuals see great hope for ephemeral pleasure in the short run and in the long run, such short run vision may result in no hope at all in the long run.
The idea of susceptibility is linked to short term social and economic realities and long term social and economic consequences and impacts of HIV/AIDS as it reveals aspects of situations, circumstances, organizations and processes that contribute to the increased or decreased “riskiness” of an environment within which disease can be transmitted. The relative “riskiness” of an environment may enhance or diminish the ease with which a disease is transmitted.21/ Transmission of infection and subsequent disease depends on people; individuals who take decisions about their circumstances and their choices.
In Barbados, for example, unemployed young men, called “beach bums”, often roam the beaches and are known to seek female sexual partners among tourists who make scheduled visits to the island. While sex has many variations of meaning and significance and is usually, a deeply private activity in most societies, a contrived social encounter on a beach, in which neither partner has had any previous contact or social/sexual history with the new potential sex partner, might easily constitute a present “risk environment” where a future sex event may be susceptible to transmitting and propagating infection.
It is interesting to note the interrelationship between the fact of male unemployment at home in Barbados, the availability of an ephemeral “employed moment” for economic gain (supplied by a female tourist) and the resultant increased risk and enhanced possibility of heterosexual transmission of the HIV virus. Not only are working age young men in this business for there is an increasing stream of young school-aged teenage boys who enter the business and never return to school. These boys are “treated” by older women to drinks, shopping sprees, luxury goods and sometimes even trips a broad.22/ The economic condition of “some young men in Barbados and /or the attraction to what might be perceived as an enhanced economic status seem to be linked to decisions that lead to a “risk-creating” environment that may ultimately involve health risks.
From a functionalist perspective, individuals perform roles within social structures, such as the unemployed studs who engage in sexual liaisons for income-earning opportunities. Unemployed young men, who may not necessarily be unemployable, face perceived social pressures which may exacerbate the pressures experienced by households, communities and ultimately the nation. Individuals who deliberately take risks with their health or that of others, are seen as ‘socially deviant’ since they do not “negotiate health” nor do they take into consideration how social obligations to preserve health interacts and may even be offset by other perceived social obligations. The norms that are established in such risky behavior --- an initial word of praise, a pat on the back, an approving smile, an encouraging glance and ultimate unprotected sexual favors ---all for monetary gain in the sex tourism trade, direct conduct in what is now an informal economy where the individual sanctions may end up being long-term sickness, or total demise because of the possible transmission HIV/AIDS. These socio-economic challenges, interrelated with HIV/AIDS, drive increasing demand for health services, should they be procured, and put a strain on the public health infrastructure.
Sex tourists are not a homogenous group: they may be women or men, Black, Asian or white, homosexual or heterosexual, middle class or working class. Numerically, the main group of sex tourists are Western, white, heterosexual men. However it is important to recognise that even amongst this group, there is diversity in terms of sexual interests and attitudes towards prostitute use. While it is necessary to recognise differences between sex tourists in terms of their sexual practices, it is also necessary to suggest that sex tourism offers the prostitute, male or female, different opportunities to earn money to mitigate the immediate stresses of relative poverty or economic neediness, if only momentarily. The tourist-based commercial sex industry, fueled by the eagerness and the decisions of certain travelers to seek out commercial sex opportunities while on a Caribbean vacation, also provides prostitutes with ample opportunities, in a heightened “risk environment”, to transmit or to receive sexually-transmitted infections (STIs) and/or HIV or from travelers in the absence of enforceable state control and regulation in the tourist sector.23/
Sex tourism is complex but it is not new and is increasingly part of a globalized culture where the sex tourism industry “sells” sex as an item for mass consumption. “Package deals” are offered to those who can afford to travel and messages are contrived about the nationals of a given destination. For example, sex guides written by white western men, such as Travel and the Single Male by Bruce Cassier, tap into the idea of ‘difference’ to justify the sexual exploitation of Black women in these countries. They tell tourists that prostitution does not have the same meaning in the Caribbean as prostitution in the West. The sex guides say that Caribbean women are not really prostitutes but ‘nice’ girls who like to have a good time.24/ These contrived cultural stereotypes have a bearing on gender and race, but equally importantly they create and promote a “risk environment” in which decisions are taken that may increase susceptibility for the HIV virus to be transmitted to fulfill its mission.
Similarly, poor women or financially dependent young girls in the Caribbean who have sexual affairs with “sugar daddies” or are “kept” by them in exchange for sexual favors may be more susceptible to infection than some other group in certain circumstances. Young women of the new generation who don’t have access to the latest clothes, French perfumes, nor their own house or a car have attitudes which point to evidence of a shift away from behaviors that prize “getting to know a marriageable bachelor” since the best men to catch are those who, because they enjoy the prerogatives of power, can provide them with what they need, and even indulge their whims.
In Jamaica for example, ‘transactional sex’ provides women access to resources of money or goods. It is reported that this acquisitive behavior is also practiced by schoolgirls who engage in ‘red-eye’ sex, an open trade of sex for “extra money” for certain status items such as fine shoes, clothes and earrings. While they had their basic subsistence taken care of, they offered sex because they wanted to “look good”, thus underscoring a connection between the acquisitive nature of popular fashion and risky sexual behavior that informs HIV/AIDS transmission.25/

The influence of money or other materialistic gifts on sexual activity26/ and relationship building with older men who can provide money or “buy things” are risk-factor indicators that may enable a “risk environment”, where sex is a unit of exchange thereby making women in some parts of the Caribbean more susceptible to infection and the spread of AIDS. The com modification of sex has a market value the behavioral cost of which is relatively high in the long run should HIV be transmitted. This is particularly poignant because the relatively high level of knowledge about AIDS in the English-speaking Caribbean region, as revealed in various surveys, has not translated into significant modification of high-risk sexual behaviors among its people.27/


The economic dynamics of either of the “risk environments” described above will ultimately identify the health outcomes in individuals, communities and societies which are wholly related to and dependent on the process of entering into sexual activity, the choice of partners and specific sexual practices. However, it is not the “environment” by itself that is the determining factor of the health outcome, but rather the individuals who act in the environment and who, in their perceived personal socio-economic circumstance take a decision that “plays to “ or “underplays” the specific environment and its “risk-related variables”. The environment can change because individual people might have the possibility to demand or supply change. That prospect is one that has to do with public policy options that are informed by decision-makers who address challenging economic conditions.
Just as the environment can and does change so too, does “risk” itself. We hear about “high risk behavior” which implies that there is also “low risk” or perhaps even, “no risk” behavior. “Risk” is not static nor is it unidimensional. The variability of “risk” or “risk factor indicators” may occur at different levels from the physiological (epithelial cells of young girls are less well developed and thus, during sexual events, young girls might likely be impacted by increased exposure to infection and disease in a particular way), to psyco­sociologial (women’s submission to men because of the force of patriarchy or so-called “macho” attitudes as opposed to economic dependence) to the macro-economic financial stress which makes life tough, makes livelihoods more difficult and makes some people necessarily less risk averse in their sexual behavior or in the general decisions they make about their life choices.28/
The female focus is understandable given that there is an increase in the percentages of women with HIV/AIDS world wide and women’s “risk” is fundamentally dependent on their ability and the ability of people to control their exposure to the virus. It is important not to confuse “risk” with what might appear to be so-called “risky behavior” lest our attention be misdirected. Behavior may be safe in one circumstance and “risky” in another but emphasis must be placed squarely and more specifically to combined behavior and decision-making ability in “risk situations”. It is within the confines of this “risk situation” that females may or may not have any control because of certain drivers of susceptibility that reflect social attitudes and pressures, economic power and the pressures of unexpected life events.
The following Box 1 provides some general disaggregated indicators that reflect drivers of susceptibility.
Box 1
Drivers of Susceptibility to Infection29/




  • Cultural practices and beliefs linked to sexual activity

  • Poverty as well as windfall cash

  • Payments/Income levels

  • Shocks to the livelihood system and lifestyle ‘choices’ (including climatic variability, conflict and weak governance)

  • High degree of mobility

  • Displacement from family

  • Shortage of appropriate housing

  • Lack of social cohesion

  • Unbalanced power relations

  • Incompatibility between knowledge systems


In general, the globalization process has dramatically transformed global tourist patterns. As there are clear indications that human mobility will further intensify over the coming years regardless of the setbacks experienced by the tourism industry resulting from the September 11 terrorist attack in the U.S., there are immense public health ramifications. Tourist health is practically treated as a hidden dimension of tourism and consequently neglected. Yet, both tourists in the Caribbean and host populations are increasingly exposed to new health problems as the circulation of pathogens and vectors increases due to intersecting epidemiological and socio-cultural boundaries. Discrepancies in the level of knowledge and types of beliefs, attitudes toward diseases and health, and expectations for and access to health services or information are likely to exist between travelers, home communities and the destinations they visit.
The health risks of travelers are related not solely to the destination and direction of travel but also to the movements of tourists across epidemiological, behavioral, and geographic boundaries. The multi-directionality of tourist flows in the Caribbean and their demographic composition can essentially determine the health characteristics of populations. Since tourism is of such importance to the Caribbean, the promotion of travel health represents a crucial strategy because subsequent public policies, if properly initiated, could make significant contributions to the maintenance and growth of international economies.30/
Vulnerability. Susceptibility of individuals, communities and whole societies has made it such that the global HIV/AIDS pandemic consists of many separate epidemics, each with its own distinct origin in terms of geography and population groups affected, and each involving different types and frequencies of risky behaviors and practices.31/ Whatever form susceptibility takes, it is differential and by itself is not the only determinant pointing to the potential for a continued AIDS pandemic. Susceptibility is accompanied by vulnerability.
When young people in the Caribbean for example, continue to be exposed to risk-embracing adult sexual behaviors which they will also adopt as they make their transition from adolescence into adult life, they continue a cycle of vulnerability.32/ Vulnerability is the likelihood of significant HIV/AIDS related impacts.33/ It describes those features of a society, social or economic institution or processes that make it more or less likely that excess morbidity (sickness) and mortality (deaths) associated with disease will have negative impacts. Like susceptibility the concept of vulnerability applies at a number of levels. For example, a household with only one breadwinner who is aged 25 is more vulnerable than a household with two breadwinners, one of whom is more than 50 years old;34/ or a migrant worker who temporarily leaves his home unaccompanied to seek employment, temporarily resides far away from his home to work and engages in sex for pleasure with an unknown partner is vulnerable.
It is apt to highlight that the prevalence and popularity of three different conjugal forms (visiting unions, concubinage, and legal marriage), and the pervasiveness of female-headed households (FHH) in the English-speaking Caribbean35/ may make females more vulnerable in the face of other accompanying circumstances. Early sexual initiation, unstable partnerships and pregnancies in young years often tend to be the main determinants of this living arrangement in the Caribbean.36/ Seventy-five percent of Caribbean women under the age of 25 are having their first child prior to the formation of a residential union.37/ With visiting unions for example, one cannot assume there is any obligation for a male to necessarily fully disclose or share information about other sexual activities or relationships. Such a lack of transparency suggests a possible increase in the risk of HIV transmission and a circumstance that may lend itself to increased vulnerability.
However and not withstanding the reason for single female headship, it is the decision to either engage in a “risk environment”, or a “risk-creating” environment or one in which there is inherent risk because of lack of transparency or inequitable power relations that may provide the backdrop for HIV transmission and increased vulnerability. For many women the most common risk factor they may face is living with an HIV-positive husband or partner (whether he is aware of his status of not).
“He never told me he was infected and he had so many chances to tell me. I am a good person and he took advantage of me. He took away my choice to decide the rest of my life. I am not able to work, and I just want to ask him why he did this to me....”38/
Female-headed households with one female breadwinner might likely be more vulnerable to HIV/AIDS, under conditions of poverty, where economic conditions are already precarious and where economic security is dubious. Economic security over the life course and the capacity to save are closely connected with gender. A woman’s economic security is highly determined by her attained level of formal education and her involvement in the formal labor market. The Caribbean region is characterized by a high percentage of FHH where women have to combine wage earning with their household responsibilities and thus experience greater time and mobility constraints than male household heads. Women carry a double burden and may sustain a harder blow from the onset and course of the panoply of ill-health associated with HIV/AIDS.
Women are the main care provider for both children and the elderly, and in many cases are fully responsible for the economic security of their dependents. A woman’s role as head of household, domestic unpaid worker or worker in the informal economy does not create monetary revenues and even when this happens, this income is most likely not within the parameters of the formal labor market and thus, does not feed into the formal social security machinery. High rates of unemployment, lack of access to stable and secure jobs, limited education (under conditions of poverty or even extreme poverty) and unequal opportunities presented in a woman’s earlier years can undermine her present and future financial security and as such, create a barrier to decreasing her level of vulnerability to HIV/AIDS. This suggests the conclusion that gender-specific structural constraints and opportunities under conditions of poverty, directly impact on present and future opportunities and present and future abilities to necessarily effectively stem vulnerability to this disease.
A last set of circumstances increase women’s susceptibility and vulnerability to HIV/AIDS: trafficking. The Caribbean region is a point of transit for trafficking in persons to Canada, the United States, the Netherlands, Spain and other European countries. Dominican women, for example, constitute the fourth largest group of women trafficked in the world after Thailand, Brazil and the Philippines. Women from the Dominican Republic are trafficked to Spain, Italy, Austria and the Netherlands to be prostituted. Often times young women, whose educational level does not exceed primary school and whose economic condition acts as a “push factor”, are hoodwinked. They end up in far-flung places and are powerless to return home because they have no savings and no power to somehow end the cycle of forced prostitution.39/ Under such conditions of utter social, economic and legal disenfranchisement trafficking leaves its victims open to unwitting vulnerability.


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