| Power and
Privilege: The Need for Social Justice in Public Health Societies are structured like ladders. The rungs of the ladder represent the resources that determine whether people can live a good life—prosperous, healthy, and secure—or a life plagued by difficulties—insufficient income, poor health, and vulnerability.1 People standing on the top rungs are the best educated, have the most respected jobs, ample savings, and comfortable housing. On the bottom rungs are people who are poorly educated, experience long bouts of unemployment or low wage jobs, have nothing to fall back on in the way of savings, and live in substandard homes.2 Your position on the ladder predicts how long you live and how healthy you are during your lifetime.3 A person’s position on the ladder is largely driven by societal norms and values which determine who is in a position of power and privilege and who is not. In the United States (U.S.), whites are the dominant socio-political group, and people of color are the subordinated group(s). This dominance means that whites define mainstream cultural values and set the cultural norms for what is accepted in our culture. In relation to this norm-setting power, all other views and values are seen as inherently less valuable to society. With dominant group power, white people therefore define the standard by which all others are measured. Consequently, subordinated groups are pressured to conform with these values in order to gain access to the power, privilege, and influence of the dominant group.4 In addition to race, gender and sexual identity play a significant role in the distribution of power and privilege, with white heterosexual males being most dominant and well-positioned to capitalize on the range of public goods and services. According to Peggy McIntosh author of White Privilege: Unpacking the Invisible Knapsack, whites are carefully taught not to recognize white privilege, as males are taught not to recognize male privilege. White privilege is like an invisible weightless knapsack of special provisions, maps, passports, codebooks, visas, clothes, tools, and blank checks. Moreover, whites are taught to think of their lives as morally neutral, normative, and average, and, at the same time, ideal. So, when they work to benefit others, this is often seen as work that will allow "them" to be more like "us."5 Historically, people of color in the U.S. have not been in positions of power and have experienced marginalized access to a range of public goods and services including education, housing, employment, and access to quality health care. The risk of dying before the age of 65 is more than three times greater for those at the bottom rungs of socioeconomic strata6 or those without preordained privileges, with communities of color disproportionately comprising lower socioeconomic status. Those lower on the socioeconomic ladder are also more likely to experience:
As the face of the U.S. rapidly changes and economic imbalance and inequality remains a reality, it will be critical that public health professionals continually acknowledge and address: 1) the social determinants of health (i.e., those conditions of life such as the quality and affordability of housing, level of employment and job insecurity, standard of living, quality of education, clean air and water, poverty, and workplace conditions); 2) the ability of people to participate democratically to effect change in their living and working conditions; and 3) the underlying injustices based on race, class, gender, religion, and sexual orientation that generate inequity in the distribution of disease.13 In addition to remaining vigilant about recognizing and working to address many of the structural challenges that systematically disenfranchise whole groups of people who lack power and are thus, “under-privileged,” it’s also important for those who have historically been in a position of power to recognize the inherent benefits and responsibilities of their position. Peggy McIntosh states:
References 1. The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health. Retrieved June 16, 2008 from: http://www.macses.ucsf.edu/News/Reaching%20for%20a%20Healthier%20Life.pdf 2. Ibid 3. Ibid 4. On Matters of Race, Power and Privilege. By Carol Brantley, Delyte Frost, Charles Pfeffer, Joan Buccigrossi, Marcus Robinson. 2003 wetWare, Inc. Rochester, NY 5. Ibid 6. The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health. Retrieved June 16, 2008 from: http://www.macses.ucsf.edu/News/Reaching%20for%20a%20Healthier%20Life.pdf 7. Ibid 8. Wikipedia, the free encyclopedia. http://en.wikipedia.org/wiki/Social_justice. Retrieved June 16, 2008. 9. Brainy Quotes. http://www.brainyquote.com/quotes/quotes/p/paulfarmer292678.html. Retrieved June 16, 2008. 10. The Center for Global Health. Global Health Pioneer Paul Farmer Calls for Improved Care for 11. Hofrichter, Richard. The Politics of Health inequalities: Contested Terrain. Retrieved June 16, 2008 from: http://media.wiley.com/product_data/excerpt/35/07879673/0787967335.pdf. 12. Ibid 13. NACCHO. Health Equity and Social Justice Strategic Direction Team 14. McIntosh, Peggy. White privilege: Unpacking the invisible knapsack. back to top > A Social Justice Orientation to Addressing Power and Privilege: Perspectives from Bob Fullilove Robert Fullilove, Associate Dean in the Mailman School of Public Health at NASTAD: Power and privilege is the advantage and dominance of one group over others, and commonly applies in race, gender, and sexuality issues. Many times the manifestation of power and privilege is institutionalized and serves to perpetuate the cycle of oppression of one or more groups of people by the dominant group. But what does this mean, exactly? Fullilove: Let me say that the one thing I think people see in their own lives about the way in which power and privilege act in our own democratic republic is around the issue of housing. Many people come from families for whom it was routine for folks to get married right out of high school and buy a home where they would remain for the rest of their lives. That’s no longer true. In fact, just the opposite is true. There’s a housing famine such that if you are a couple and each of you is making minimum wage, there is no city in the U.S. where you can afford housing, which is a way of describing how people with power and privilege can control things as essential as the housing market and create situations that put large numbers of people at risk. I think this is particularly important in poor communities of color, which every 20 years or so since the dawn of the twentieth century have found themselves in neighborhoods that have been bulldozed out of existence to make way for parking lots, malls, expanded university facilities…the list goes on and on. How does that happen? Because people in power can go to a city, ask the city to exercise the right of eminent domain and, despite the fact that you own a piece of property and have been regularly paying your mortgage, the city will say, “Sorry, we have first dibs on what is yours.” As a consequence, whatever your position might be economically with the bank and with your payments on a house, the city’s power trumps your own with respect to your ability to stay in your living facilities. Second example: prisons have always been ways in which people in power exercise their dominance over people who have no power. Our prisons are not filled with a representative sample of the NASTAD: Applied to public health, how does power and privilege further perpetuate disparities? Fullilove: I think that those of us in public health are acutely aware of the degree to which we don’t really have a system of public health; we have a system of disease management, and that system of disease management is particularly difficult for individuals who have no insurance that allows them to routinely practice what we in public health preach, which is ‘prevention is worth a pound of cure.’ Since you need insurance in order to have regular checkups, all the things that we urge people to do, from getting tested regularly for a wide range of issues, not just HIV, all the things that insurance will purchase for you in terms of improved quality of care, those things are completely off the table. As a consequence in too many instances, the HIV/AIDS epidemic has been driven by the fact that we see people very late in the cycle of illness and disease; and we’re seeing them late because access to routine healthcare simply has not been available. Had it been, then a lot of the conditions that we are treating by chasing after an illness that’s already pretty well progressed, a lot of that simply would not exist. I think it’s fair to say that folk who have access to the top forms of insurance, who have regular checkups, and who have clinicians being quite aggressive with them about making sure that they have everything from colonoscopies to having your teeth checked, not only have better health care, it’s born out in all of the statistics that describe life expectancy. Folk who can be rather crudely classified as ‘the haves’ live a great deal longer than folks who could be described as ‘the have-nots.’ NASTAD: There are very few Blacks or other minorities in public health leadership positions, which serves to reinforce the dominance of whites on systems and infrastructure. How can systems shift to encourage more leadership by minorities? Fullilove: I have been using the bully pulpit and talking about the relationship between HIV/AIDS in prisons to point out that it’s absurd that there was a time in the U.S. when prisons were really about rehabilitation and invariably that rehabilitation meant providing inmates with access to some kind of education so that you could not only get a GED, you could get maybe as much as a BA. The State of New York used to have an arrangement with something called Empire State College that worked with a couple of prisons in the State of New York to give inmates who were qualified access to a full range of educational services that could end in their getting a BA degree. Now what does that do for someone who is trying to rehabilitate his or her life? Well, the answer is obvious. They come out more likely to be in a position to compete for a job or for some other kind of position of responsibility; and, as a consequence, the likelihood that they’ll fall into the category of recidivist is dramatically diminished. If there was one thing that I would do in order to sort of change this balance of inequity, I would work to ensure that, since it’s not likely we’re going to disband our prison industrial complex anytime in the near future, that we do more to see prisons as places where we do a variety of rehabilitative services and where we step up our capacity to provide the kind of screening and aggressive healthcare that we would like to provide for all Americans. Of the number of folk who are part of the NASTAD system, I think about Tom Liberti in Florida, who’ve used jails, for example, as opportunities to test people for a broad range of sexually transmitted infections and HIV and, as a consequence, had a real opportunity to improve the likelihood that people were aware of their status and are going to get access to care. I think of those as the kinds of things that shift the paradigms with respect to the position of healthcare in a system that, at the moment, is one of the primary engines driving the lack of power and influence that exists in poor communities of color. If you added to that the capacity of prisons to make educational opportunity more available to folks while they’re there, I think you’d see a dramatic change in the profile of a lot of the folk who are in prison. The median, I believe, is an 18 to 24 months stay, but I think you’d see a dramatic shift in the prospects of folk who are poorly educated at the point when they get out of prison. I think you’d start to see that age old correlation that people in public health are fond of pointing to that one of the most solid predictors of health and health status in this country is quality of education. I think the simple fact of getting people more education would start to create a different orientation towards health than I think is currently at case, certainly for folk who have spent a lot of time locked up behind bars. NASTAD: How can we come together in public health in order to confront power and privilege and overcome the cycle which continues to disadvantage groups of people? Fullilove: Long before I got involved in public health research, and HIV/AIDS research in particular, I was an educator. Not only was I an educator, I was really concerned with what we in higher education like to describe as the education pipeline. Over the years that I have been doing this, and this dates back to 1964, one of the most dramatic shifts that we have observed is: 1) the creation of a black and brown middle class largely because of the provision of educational opportunity programs at the level of higher education, and 2) within black populations, in particular, we’ve seen a dramatic shift in two things: the ratio of women to men who are in undergraduate programs and a real shift in the career options that young people of color take as a result of being in college. Young men of color tend to be heavily concentrated in law, in accounting, in economics, and in other enterprises that tend to make money, and less and less present in fields like education, medicine, or public health. I keep thinking that one of the things that has to happen is people in public health, especially those who are concerned with schools of public health, have to think more about creating pipeline programs that boost the number of folk who come in to institutions of higher education and, as a result, boost the number of folk who are eligible to get into schools of public health, schools of medicine, schools of nursing, what have you. I also think that we have to be sort of aggressive in accepting that this is a long range plan. Most people who talk about this are looking for a quick fix. They think somewhere there’s a pool of eligible men and women who, when they’re simply told, ‘There’s this thing; it’s public health…you ought to come work with us,’ would jump at the chance and then we could change dramatically the demography of the public health workforce. Wrong. It simply doesn’t work that way. There aren’t enough people to go around. Part of the reason why there aren’t enough people to go around is the actual number of folks entering higher education and graduating with degrees who are members of poor communities of color has been going down steadily; and it’s been going down steadily as the quality of public education in the If there’s one thing that I would change, it would be to have people in public health become more involved in education below the level of the master’s degree and even below the level of bachelor’s degree to focus more and more attention on the leadership potential of folk who are in high school. Right now, what we do is think of young people in high school as potentially sexually active individuals who should be participants in our programs as opposed to young minds who really require as much training and education as we can possibly provide them so that they’ll not only succeed in making good choices around their health, they’ll also succeed educationally and, in so doing, ultimately find their way into the work that keeps you and I going. NASTAD: In various talks you've given, you discuss social justice as a strategy public health must take on. Can you talk about how we can translate this concept into action? Fullilove: We are really driven by the notion that if we don’t have the resources, the work won’t get done, which means that we’ve become dependent on grants and contracts from government as well as from private foundations, so dependent in fact that a lot of work will not ever get done because the resources aren’t there for it. Now what I thought was important about the Civil Rights Movement was the degree to which large portions of what got done was in fact proposed, created, and sustained by contributions that were made by ordinary citizens often in the communities where we worked that promoted the work. You could go regularly in the South to churches where people were rallying for this cause or that. In my case, it was often because you were getting ready to have a bunch of people go to try and register to vote, but we would pass the hat routinely; and it would be to do everything from bail people out of jail to actually fund some of the workers who were going to make the task of community organizing a part of what they did. Now I’m very aware of what’s called the analogical fallacy. This is a fallacy that occurs when you draw an analogy between two very different entities and say that they are very similar. The HIV/AIDS epidemic is infinitely more complicated than what people were trying to do in the early days of the Civil Rights Movement, but I do believe that what they have in common is the degree to which they share a passion for social justice. That this epidemic hit the poorest amongst us with disproportionate force isn’t simply a function of the genetic characteristics of the virus. It is much more a function of a social dynamic that perpetuates inequality, that maintains a system of apartheid in this country that creates segregated cities with segregated neighborhoods that segregates folks not just by race but also by social class. As a consequence, it creates ecological niches that HIV/AIDS exploits in maintaining its presence in our population. We recognize that what we’re talking about is not simply treating people with an illness. We’re also talking about an epidemic that’s driven by a social dynamic; and it is a social dynamic that is founded on fundamental inequalities. Going back to the Civil Rights Movement makes a lot of sense, but it also means that we’re going to have to stop thinking in terms of fighting the epidemic using the tools that are dictated by requests for applications (RFA) that say, ‘You’re going to do this; you’re not going to do that. You’re going to pay particular attention to this set of strategies, and you’re going to leave this other set of strategies behind.’ In any battle, what you want is the capacity to act freely, to maneuver with as few impediments as possible so that you can be as effective as possible. In HIV/AIDS, I think part of what that means is developing an agenda for generating resources that isn’t dependent on always going to a funder and saying ‘Give me the money so that I can do what I have to do,’ that isn’t so dependent on only doing what the funder is interested in and not doing some of the things that we all know because we are in the communities where the problem is hitting hardest, not doing the things that we know would probably make the most sense. The one model I think that everybody points to, and justly so, is Housing Works in If we were to expand the notion, learn lessons from the Civil Rights Movement and from other movements that have stressed social justice issues where the issue was: we’re going to do what’s right, not necessarily what pays. If we were to go to that kind of principle, I think we’d start to see some very different outcomes. I think a lot of people are willing to do it, and I think they’re willing to do it because they can see that, if they read the same newspapers that I do, that the well is rapidly drying up. If we don’t come up with something other than a reliance on the grant and contract mechanism, we’re simply not going to be effective in limiting the scope of damage that is associated with this epidemic. back to top > How Power and Privilege Impacts Gay Men/Men who have Sex with Men (MSM) The social and sexual lives of many gay men and other MSM have been impacted by at least three social oppressive forces—poverty, racism and homophobia—that together tend to produce heightened risk for HIV infection by increasing social isolation, alienation, and personal shame.1 Many men have responded to social oppression with resourcefulness, creativity, and personal agency. Others have been deeply troubled by financial hardship, family rejection, discriminatory practices, and stigma that create barriers to health promoting behaviors and prevent their fair and full participation in community life. As a whole, the dominant American culture gives preference to heterosexuals, manifested most outwardly through marriage rights and the ability publicly acknowledge one’s partner. Because of this overarching heterosexual privilege, everything that is not heterosexual receives less value and is often considered deviant. Furthermore, for young people, school-based HIV prevention curricula that address sexuality often reinforce heterosexual preference and privilege.Many widely used abstinence-only curricula address same-sex behavior within the context of promiscuity and disease. Not only do these models present incorrect information, but they also create a hostile learning environment for gay youth that negatively contribute to low self-esteem and enhance vulnerability to risky behaviors. There are also reverberations of power and privilege within gay communities that crystallize as internalized homophobia. To effectively combat the impact of power and privilege, gay communities must also look inwardly and address the fact that ‘masculine’ gay men are often granted power and privilege over ‘effeminate’ gay men. When gay men support an already pervasive societal norm, internal homophobia in the gay community serves to further marginalize gay men. Internalized homophobia is associated with increased risk behavior among gay men. Additionally, the various intersections of sexual orientation, gender, class, race, and immigration status often do not operate as distinct realities and often serve to amplify the impact of power and privilege on risks for gay men, particularly gay men of color. For instance, many Latino gay men feel the impact of power and privilege through overlapping experiences of homophobia, poverty, and racism. As a result, they are often isolated from the communities that would normally provide them support and safety. Many Latino gay men often have to deal with rejection from family, exclusion from places of worship, discrimination at work, and sexual objectification in the gay community. In some ways, this can be viewed as double or triply stigmatizing. Adding HIV/AIDS stigma to this may serve to “feed upon, strengthen, and reproduce existing inequalities of class, race, gender, and sexuality.”2 In attempting to address some of these issues, local and state health departments have prioritized HIV prevention strategies targeting gay men. Health departments across the country are now specifically considering the contexts and situations within which individual risk behaviors take place. Prevention programs funded by health departments are seeking to address situational and structural factors that make safer sex difficult, including mental health, immigration status, substance use, and other lived experiences. The following story profiles As an extension of the Florida Department of Health, the Office of HIV/AIDS of the Miami-Dade County Health Department (MDCHD) has served as a leader in the county, state, and nation in its work to address the multi-layered impacts of power and privilege on gay men of color. With the implementation of a Statewide Minority AIDS Initiative that includes a Statewide Latino HIV/AIDS Coordinator, Statewide Black MSM Coordinator and nine Regional Minority AIDS Coordinators, MDCHD has been able to develop initiatives that address racial and ethnic health disparities among communities of color, particularly gay men of color. MDCHD recently developed a participatory social marketing and community mobilization effort targeted at gay men (both HIV positive and negative) aimed at instigating resistance against HIV/AIDS-related stigma in relation to underlying social inequality, namely, homophobia. In developing their Anti-Homophobia and HIV Prevention campaign, By dedicating resources and staff, MDCHD has been successful in developing and implementing this Anti-Homophobia campaign. Components of the campaign include outdoor and print media to raise questions about social inequality, stimulate public discourse about HIV/AIDS-related stigma, and trigger action among gay men living with HIV/AIDS in MDCHD understands that stigma continues to complicate HIV prevention efforts in the gay community. With the department’s support, these and other initiatives are proving to be effective in increasing the perception of one’s own risk of contracting HIV, changing attitudes about HIV/AIDS, raising intentions to reduce risky behavior, deepening the knowledge about HIV transmission, and triggering community-wide discussion about prevention-related issues. NASTAD thanks Alberto Santana, Deputy Director of the Office of HIV/AIDS in the Miami-Dade County Health Department, for his assistance with this story. References 1. Diaz, R., Ayala, G. & Bein, E. The impact of homophobia, poverty and racism on the mental health of gay an bisexual Latino men: Findings from 3 2. Parker, R. & Aggleton, P. HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Social Sciences & Medicine, 57 (2003) 13-24. 3. Herek, G.M. AIDS and stigma. American Behavioral Scientist, Vol. 42, No.7, April 1999, 1106-1116. 4. Jones et al. Social stigma: the psychology of marked relationships. 5. Herek, G.M. & Capitanio, J.P. AIDS stigma and sexual prejudice. American Behavioral Scientist, 1999, 42(7), 1130-1147. 6. Klitzman, R. Being positive: the lives of men and women with HIV. back to top > Addressing the Impact of Power and Privilege on HIV/AIDS Among Women According to UNAIDS, women account for more than 50 percent of HIV infections worldwide. In the U.S., women account for one quarter of all new HIV/AIDS diagnoses, and HIV/AIDS cases among women have steadily increased over time. Furthermore, African American/Black and Hispanic women continue to bear the brunt of the epidemic among women.1 Researchers acknowledge that men often have greater social and interpersonal power than women.2 This manifests itself in external and structural advantages of men over women that impact women’s access to employment and education, their level of poverty, and their experiences with racism, all of which place burdens on a woman’s overall health.3 Added to that, power dynamics within heterosexual relationships also contribute to women’s vulnerability for HIV infection. Studies have shown that lower levels of interpersonal power interfere with women’s ability to initiate discussions of condom use and lead to conflict that threatens their relationships4. Moreover, other psychosocial factors, such as childhood sexual trauma, physical violence, and drug abuse, and behavioral risk factors, such as unprotected sex and multiple sex partners, add complexity to the impact of women’s power on their risk for poor health outcomes. These factors could be described as multiple “vectors” some women experience in any given period of time. Furthermore, ethnographic research describes how these “vectors” connect to each other, leading to what some have termed “structural violence” that further reinforces and exacerbates women’s experiences of poverty, drug abuse, violence, and unhealthy co-dependent relationships.5 To better understand how issues of power and privilege manifest in women’s lives, NASTAD interviewed a representative from a community-based organization that serves women at risk for HIV and other STDs, Paula French, Co-Executive Director of Step-Up, Inc. in Indianapolis, Indiana. NASTAD: Could you provide a brief description about your program? How long has your program been in place? How is it funded? Could you provide a brief description of the women your organization serves? French: Step-Up, Inc was founded in 2002. While Step-Up is still a fairly young agency, some of the programs have a long history in the community. We began the Youth at Risk program in 1995, the Community Action Groups began in 1996 and the Youth and Diversity program began in 1998. Step-Up believes in providing education, training, advocacy, and technical assistance to promote health and well-being, with a focus on HIV/STD prevention and diversity. The Women In Action Program started a year ago. The initial funder for our Women Taking Charge program (WTC) is the Nina Mason Pulliam Charitable Trust, with additional funding coming from the Indiana AIDS Fund and Women Taking Charge (WTC) is a program that addresses the needs of women at high risk for HIV/STD using a multiple session, skills building, group level intervention. The intervention offers women the opportunity to learn and practice the behaviors needed to protect themselves and live healthier lives. The focus is on women who are at particularly high risk for HIV/STD due to special circumstances such as having experienced domestic violence, substance abuse, and/or incarceration. The program reaches women who are currently incarcerated in the county jail system, pre-release programs, domestic violence shelters, or are substance users and sex workers. African American women account for 45 percent, white women 50 percent, and Hispanic women 2 percent of our current caseload. NASTAD: How does power and privilege impact and manifest in the lives of the women you serve? How do your empower women to recognize how gender dynamics and power imbalance impact their lives and help them learn how to overcome them? French: Generally speaking, most of these women see themselves as powerless. Until they access our program, most of them have never been told that they have the right to control their own bodies or even their own decisions (e.g., partner negotiation, substance use, etc.). In another part of the agency, we also work with young women in juvenile detention, and we find similar issues in both the girls and women that we serve. Some of this could be also be due to cultural values, but many of them don’t think they have the power over their own lives. The other issue is that many of them are economically disadvantaged and rely on a male partner for food or to provide for their children, and, for some of them, commercial sex is their livelihood. Most of them may not have the choice to stop trading sex for money or drugs. Our goal is to give them additional choices, but importantly, we use a harm reduction approach. We give them ideas how they can control their lives without putting themselves at further risk. Most of these women have been abused at some point in their lives, whether as children or adults, so they have multiple issues that they are dealing with. NASTAD: How do you empower women to recognize how gender dynamics/power impacts their lives and how to overcome it? French: In our program, we reach them through multiple sessions—they are either incarcerated or in domestic violence shelters and, as a result, we are able to see them multiple times. The key component of what we do is HIV and STD prevention. This is usually just the first step, to give them information. Then we talk about what key components of healthy relationships look like. Our approach is non-judgmental. We don’t tell our women what to do. We give them the information, and we do what we can to support them. Some of these women may think that they are in a healthy relationship, but they may learn through our program that they are controlled by their partners (e.g., someone calling you multiple times a day to verify where you are at all times). We also teach women how to negotiate condom use and talk about contraception, as well as provide information on general health issues. Some of these women don’t even know how their own bodies function. This curriculum has a holistic approach. The curriculum we use is based on Sisters Informing Sisters on Topics about AIDS (SISTA), but we have adapted it for our own use. We also held focus groups in the women’s prison and we asked them what they needed. It was empowering for them because most of these women had not ever been asked for their opinions or needs. Most women said they never thought about HIV because they trusted their partner. These women are grateful for the information that we give them because we (providers) tend to forget that not everyone is aware of the impact of HIV or STDs in a community. NASTAD: Did you work with anyone (e.g., from the community, thestate or local health department, technical and capacity building assistance providers) to develop your program? Do you have any information on the results/evaluation of the program so far? French: This program is about a year old. The program more or less started itself. Based on the work we did with the juvenile and substance use centers, the agency started getting requests to work with women in correctional facilities and domestic violence centers. We did not receive funding the first time we applied specifically to work on this initiative. However, we continued to press on and, as a result, got funded by Nina Mason Pulliam Charitable Trust to formally implement this program. Our amazing program director for WTC, Vicenta Muniz-Bledsoe, has brought the program to a level that most programs never reach or may take years to reach. The women she serves know that she genuinely cares about them and they respond accordingly. We partner with a local STD clinic (Bell Flower)—they test for everything and treat women who are infected. We provide the educational presentation and then the agency goes in and provides STD screening and HIV testing and offers treatment if needed. The agency provides us with quarterly reports. We are big on data—our philosophy is that if you can’t prove it, then it didn’t happen. We use several evaluation and self-assessment tools. An important objective of this grant is to collect data concerning the substance use/abuse of incarcerated women as well as women in other high risk circumstances. For the first quarter of the grant period, we found that 89 percent of women reported drug and/or alcohol use (crack use was 46 percent, alcohol was 63 percent). Of the women who reported drug use, we found that 56 percent have had multiple partners and 30 percent have traded sex for drugs or money. We use the data to see what the needs of the women are and make a concerted effort to address their needs and concerns, but also to share with our funding partners. These women are empowered in a way that they never thought possible, and their interactions with the Program Director have been particularly positive. NASTAD: What do you think are the most important lessons you've learned that would be important for others seeking to serve similar communities in other states or locations? French: The most basic lesson is to build a strong relationship with the facilities you serve. When we started our work in the women’s prison, we were confident that the reference from the juvenile facility we had previously worked with would be positive. We adhered to what they requested—from being on time to adhering to their rules. We were not a burden to them. We also treat the women with dignity and respect; we don’t look down on them and feel that women will know if you don’t genuinely care about them. Additionally, it is important to keep the program fluid and able to adapt to what women need at the current moment and to deal with crises as they arise. We developed sessions that specifically dealt with healthy relationships as this came up in conversations. We also bring in experts from other fields to address other issues that arise. Lastly, it is important to collect great data because it helps determine funding that is critically needed to address the needs of women at risk.
References 1. CDC. http://www.cdc.gov/hiv/topics/women/resources/factsheets/women.htm 2. Lober, J.1998. Guarding the gates: The micro politics of gender. In D.L. Anselmi & A.L. Law (Eds.). Questions of gender: Perspectives and paradoxes (pp.607-62*. 3. Carli, Linda.1999. Gender, interpersonal power, and social influence- Social Influence and Social Power: Using Theory for Understanding Social Issues. Journal of Social Science. Spring. 4. McNair, L, Prather C. African American Women and AIDS: Factors Influencing Risk and Reaction to HIV Disease. Journal of Black Psychology, Vol. 30., No.1. 106-13. February 2004. 5. Farmer, Paul, Connors, Margaret, and Simmons, Janie, eds., 1996. Women, Poverty and AIDS: Sex, Drugs and Structural Violence. Pp 91-13. back to top > The Center for Disease Control and Prevention’s (CDC) Heightened National Response: Reframing Leadership and Partnership to Impact the HIV/AIDS Crisis among African Americans In March 2007, CDC released the Heightened National Response to the HIV/AIDS Crisis among African Americans (HNR), which articulated a framework for action to address the impact of HIV/AIDS on African American communities. African Americans comprise less than 13 percent of the Taking into account the input of African American leaders from a range of sectors, which emphasized the importance of developing strategies to address social and cultural factors (e.g., homophobia, racism, stigma, denial, and history of sexual abuse) and interventions to reduce risk behaviors, CDC crafted a plan highlighting four focus areas including: 1) expanding the reach of prevention services, 2) increasing opportunities for diagnosing and treating HIV, 3) developing new, effective prevention interventions, and 4) mobilizing broader community action, all designed to strengthen HIV prevention activities targeting African Americans. When viewed through the lens of social justice, the HNR exemplifies the recognition by a federal agency of its dominance and influence over national prevention efforts to address the domestic HIV/AIDS epidemic. More importantly, the HNR demonstrates the attempt by this agency to reposition African American leaders—historically disenfranchised by racism, poverty, homophobia, and unequal access to a range of services including medical treatment—as meaningful partners in addressing the HIV/AIDS crisis in African American communities. Many of the proposed activities tied to each of the focus areas, specifically those related to increased access to testing and treatment and the need for increased interventions developed by and for African Americans, both directly and indirectly mitigate some of the injustices imposed by structural and institutional barriers. Since structural barriers often exacerbate symptoms of disempowerment among vulnerable populations, CDC’s attempt to address these issues not only introduces opportunities to make broad-ranging impacts on African American communities, but also begins to break down some of the institutionalized and unbalanced power structures within the public health system. In May 2008, CDC marked the one year anniversary of the HNR launch and convened a second meeting in Atlanta, Georgia, HIV/AIDS Crisis Among African Americans: Partnership in Action Meeting. This meeting provided participants the opportunity to learn about progress made since 2007 by both CDC and HNR partners and provided a forum to work with national partners to identify further opportunities for partnership and collaboration, identify sector-specific strategic for targeting programs in African American communities, and draft and publicly share commitments for the upcoming year. The one year anniversary also served as a catalyst for reenergizing and refocusing partners. Participants shared recommendations for enhancement of the HNR, some of which included the need for CDC to provide concrete and measurable outcomes for HNR commitments or activities, the desire for CDC to continue to engage and empower non-traditional partners, and the need for more a clearly articulated vision about interconnectedness of multi-sector activities and clearer direction about how to maximize these activities to most effectively prevent new HIV infections among African American communities. Despite the ongoing challenges of effectively implementing the HNR, a clear statement has been made by CDC about their recognition of the need to operate outside of the standard federal framework and power structure, and through parity and inclusion, leverage the collective wisdom of a diverse range of stakeholders. Additionally, the emphasis of the four HNR focus areas opens the door for structural level change and opportunities for African American leaders to more effectively and publicly assert their vision and leadership for addressing the impact of HIV/AIDS in their communities. The acknowledgment by CDC that they cannot confront this crisis independently, and the symbolic relinquishing of control and calls for partnership, marks a shift in the traditional paradigm of federal modus operandi and empowers historically disenfranchised leaders to harness their collective power to help end the HIV/AIDS crisis impacting African Americans. back to top > Conclusion Collectively, the issues and profiles provided in this Bulletin promote a social justice approach to HIV/AIDS prevention, indeed to public health overall. As we all know, and as NASTAD clearly articulated in the HIV Prevention Blueprint, a comprehensive approach to HIV prevention requires a multi-pronged effort that addresses not only individual risk-reduction efforts, but also the structural and community level interventions that will impact the conditions that create risk. Since unequal power and privilege lead to these structural conditions of risk, they should be factored into an overall response to the epidemic in any jurisdiction or community. Efforts to address the disproportionate impact of HIV/AIDS on various communities are a necessary part of the social justice movement. Sometimes, confronting these issues can be very difficult, and many community and health department representatives, planners, and advocates find it difficult to have these conversations. The oft-held up admonishment for people to be culturally sensitive/relevant/competent is not always the answer since people feel very differently about the value and possibilities for these concepts. However, another approach that holds great promise for these conversations is the concept of cultural humility. An approach championed by Melanie Tervalon and Jann Murray-Garcia, cultural humility supports a lifelong learning process based on mutually respectful and dynamic partnerships that emphasize self-reflection and humility— “Recognition and respect for others’ cultural priorities and practices is facilitated by…processes that engender self knowledge.”1 A key component of this approach is that it redresses the imbalance between the provider and client relationship. As we strive to address the structural issues emanating from power and privilege in our fight against HIV/AIDS, an approach predicated on humility and balance may provide the momentum we need to begin to turn the course on the domestic epidemic. As References 1. Melanie Tervalon; Jann Murray-Garcia. “Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education,“ Journal of Health Care for the Poor and Underserved; May 1998; 9, 2; Research Library, pg. 117 – 125. Meeting and Planning Calendar National Conference on Latinos and HIV/AIDS, XVIII International AIDS Conference, Ryan White HIV/AIDS Program Training and Technical Assistance Grantees Meeting and 11th Annual Clinical Update, September 29-October 1, 2008 National Hepatitis Technical Assistance Meeting, National Latino AIDS Awareness Day. World AIDS Day National Black HIV/AIDS Awareness Day National Women and Girls HIV/AIDS Awareness Day National Native HIV/AIDS Awareness Day HIV Vaccine Awareness Day National Asian and Pacific Islander HIV/AIDS Awareness Day Caribbean American HIV/AIDS Awareness Day National HIV Testing Day National HIV Prevention Conference, |
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Credits, Feedback
and Input The NASTAD Prevention Bulletin is edited by NASTAD staff and is written by staff and prevention experts from around the country. This publication was supported by Cooperative Agreement Number 5U62PS323958-05 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. If you have an idea or program that you would like to include in the Bulletin, please contact Dave Kern or Lynne Greabell (202/434-8090). NASTAD welcomes feedback to issues presented in Bulletin. To submit commentary, please e-mail us at NASTAD@NASTAD.org. Electronic versions of the Bulletin are available on our webpage. |
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