Surprisingly scant attention has been given to the links between HIV/AIDS and the role of US neo-colonial rule in Puerto Rico. Puerto Rico, whose population of 3.8 million makes it the most densely populated of the Greater Antilles, has been under US rule since 1898. The Island serves as a profitable labor reserve for key industries, particularly pharmaceuticals, while vast stretches of land and beaches have been used as military staging grounds. As in other parts of the world, a large military presence has contributed to high levels of prostitution and drug abuse. At the same time, US and European “sex tourism” has flourished. The annual per capita income hovers around $8,000 with a cost of living comparable to many US states (due largely to a domestic market that is dominated by US imports).
Given this backdrop, it is certainly not surprising that over the past two decades, the AIDS epidemic has washed across Puerto Rico with horrific consequences. Its impact on the health of Puerto Ricans and on the public health infrastructure has been devastating. By almost any comparison, the Island’s rate of reported AIDS cases ranks high. In comparison to other US states and territories, Puerto Rico ranks third behind only the District of Columbia and New York State (see Table 1). While official AIDS statistics are notoriously unreliable throughout the Americas, were Puerto Rico a nation, it would easily rank among the top 5 in the hemisphere with respect to the number of AIDS cases. In light of such conditions, it is essential for persons conducting HIV/AIDS prevention campaigns in Puerto Rico to consider the implications for such campaigns of the on-going project of colonial rule.1
Table 1: Top 5 US States and Territories Based on the Cumulative Number of Reported AIDS Cases Per 100,000 Persons, 1981-(June) 1999
|U.S. State or Territory||Cumulative Number of Reported AIDS Cases||Reported AIDS Cases per 100,000 Persons|
|1. District of Columbia||11,634||2,196|
|2. New York||132,086||728|
|3. Puerto Rico||23,027||602|
|5. New Jersey||39,344||488|
|All U.S. states/territories||711,344||261|
Source: United States HIV/AIDS Surveillance Report. Centers for Disease Control, Washington, DC: June 1999.
Since the mid-1980s, the public health services in the US have been increasingly concerned with controlling the spread of HIV. Given the epidemiological nature of the virus, this has resulted in government health officials targeting specific segments of the population identified with particular behaviors, e.g., gay men, injection drug users (IDUs), sex partners of IDUs, etc. Health experts have been trained to enter the communities that these populations reside in or frequent, and put an end to these particular behaviors. Behavior modification models represent the basic tool for health experts in such efforts. These models are based on cognitive learning theories developed by US social psychologists since the 1930s (Becker/Maiman, 1974; Rosenstock, 1974; Leviton, 1989; Coates et al., 1984).
Data on specific populations are collected and manipulated to induce behavior change. The ostensible purpose is to reduce harmful behaviors; a residual effect is social control. There are certain core methodological and pedagogical characteristics of the behavior modification models relied upon by health professionals engaged in HIV/AIDS prevention campaigns. It is useful to consider the implications of these approaches for a colonial setting.
Behavior change models operate with an implicit notion of rationality. The colonized subject is presented knowledge based on the colonizer’s rationality. Any resulting behavior change is thus tied to cultural and normative usurpation. The collision of rationalities (colonizer vs. colonized) is a central feature of such behavior modification efforts. This aspect of behavior modification parallels the Taylorist separation of knowledge and work in workplace settings. The separation of managerial knowledge from the laborer (reduced to a mechanical appendage) serves two purposes: 1) greater control over the production process, and 2) greater dependence of the worker on the manager. Minimizing the autonomy of the social actor in this manner is key to the design of behavior modification models.
Furthermore, each model attempts to effect behavior change through motivational programs based on an implicit ideology of abstinence. Delaying immediate gratification, while clearly beneficial with respect to risky health behaviors, at the same time must be placed within the larger agenda of the colonizer. An ethic of restraint does not apply only to risky health behaviors; it is a personal ethic informing one’s expectations, and one’s propensity to adapt or make greater demands in general. In a colonial setting, the effect (directly or indirectly) is political pacification. This strategy has always had only a tenuous legitimacy within Taylorism. Thus, always paired with abstinence themes are threats of disciplinary action (such as firing a worker) which, as will be seen, have their parallels in behavior modification models.
Similarities between Taylorism and HIV/AIDS behavior modification models in Puerto Rico are numerous. The goal of Taylorism is the adaptation of workers to conditions of factory life; the goal of behavior modification is the adaptation of individuals to the impoverished, marginalized conditions of colonial rule. The method of Taylorism is to reduce workers to sets of finite physical motions; the method of behavior modification is to reduce persons at risk of contracting HIV to sets of quantifiable “deviant” behaviors. The strategic focus of Taylorism is on the acceptance of factory regimentation through individual-level coping rather than addressing factory conditions; the strategic focus of behavior modification is on the acceptance of conditions of colonial rule through individual-level behavior change rather than addressing the broader oppressive social conditions.
Finally, Taylorism gave birth to the modern manager and his attendant monopoly of expertise (or knowledge). The role of the manager in the factory as “expert” serves to institutionalize- formally and ideologically-the separation of knowledge (supervisors) from muscle (frontline workers). The manager’s power to tell someone what to do or not to do is based not simply on a relation of authority but on the possession of superior knowledge. This separation of knowledge and muscle (real or perceived) has its direct counterpart in public health and HIV/AIDS prevention. Just as workers look to managers, so members of target populations look to health care experts for instruction, explanation and permission. A major source of the power and control of managers and health care experts over others is this separation. The most insidious aspect of these models is their narrow individualizing effect.
Exporting Social Control
To understand the mechanism by which the US influences the use of behavior modification models in its colony, it is always helpful to follow the money. HIV prevention in Puerto Rico is carried out by three primary groups, the Puerto Rican Health Department, local health departments, and community-based organizations (CBOs). Most funding for local health departments and CBOs is channeled through the Puerto Rico Department of Health or other government agencies set up for this purpose. This arrangement is deceptive, however, given that most of the money that the Puerto Rican Health Department (or its agencies) gives out is provided by the Centers for Disease Control and Prevention (CDC) in Atlanta. Local health departments and CBOs who wish to conduct HIV prevention work in Puerto Rico must, therefore, follow the edicts emanating from the CDC when designing such programs.
Thus, the expectations for HIV prevention work in Puerto Rico with respect to the use of behavior modification models are set at the level of the US government through the CDC. However, they are enforced at the level of the Puerto Rico Department of Health, which directly disburses the money. By all appearances then, the drive to adopt behavior modification models is the brainchild of colonial health officials on the Island. A further source of funding-one tapped by Fundación SIDA de Puerto Rico for its innovative work discussed below-are US-based private foundations. Often, private foundations are more open to innovative projects because they are generally more concerned with providing assistance to communities than with focusing on the details of the intervention. Due to shifting foundation priorities, however, this is a very unreliable source of sustained support.
There are a number of behavior modification models currently in vogue with CDC officials. Here the focus will be on those that are most common to Puerto Rico-the Health Belief Model and, to a lesser extent, the Theory of Reasoned Action.
The Health Belief Model is by far the most commonly used behavior modification model for HIV prevention in Puerto Rico. It has been a staple of US public health campaigns for four decades (Becker/Maiman, 1974, Becker, 1974, Becker, 1988, Janz/Becker, 1984, Kirscht/Joseph, 1989, Rosenstock, et al., 1994). Though it has gone through several modifications, the model’s basic features are easily summarized. There are three levels of beliefs (or perception) insofar as they determine behavior changes related to health. First, there is a person’s perception of the severity of a given ailment. Second, there is a person’s perception of her/his own susceptibility to a given ailment. Third, there is a person’s perception of her/his efficacy with respect to behavior change (necessary for avoiding a given ailment). A central focus of the Health Belief Model is the so-called “cues to action.” These are social stimuli that alert individuals to dangers at the first two levels of perception. The model itself, as reflected in the nature of various critiques of it here, has focused more on knowledge as an inducement to change than on barriers to efficacy.
The most common examples of HIV/AIDS prevention programs in Puerto Rico based on the Health Belief Model are school-based and workplace-based programs. The target population for school- based programs is (potentially) sexually-active teens. Predictably, the content of HIV/AIDS prevention programs often conflicts with predominant community sexual mores. As a result, students are either specially selected (those with parental consent) or the content is significantly watered down to the point of irrelevance. Abstinence remains the central, driving prevention message (aimed at straight teens). Any consideration of gay lifestyles is taboo and off limits in such settings, while the dangers of injection drug use and of abusive relationships for women are not a concern. Both through the presentation of basic information regarding the dangers of HIV/ AIDS as well as through the ritualistic parading about of someone living with HIV/AIDS, it is hoped that teens will gain the knowledge and the motivation to avoid risky behaviors-despite the absence of explicit discussions of those behaviors.
The Theory of Reasoned Action accepts many of the Health Belief Model’s assumptions with respect to the first two levels (perceptions of severity and susceptibility) and focuses on barriers to change at the third level (perception of efficacy). Behavior is believed to be determined by underlying cognitive structures (Ajzen, 1988; Ajzen/ Fishbein, 1975; Ajzen/Middlestadt, 1989). Specifically, behavior change is held to depend upon the interrelationship of beliefs, attitudes and intents. In effect, behavior is a function of intent. The knowledge being passed on in the Health Belief Model, according to Ajzen and Fishbein, runs up against barriers to change at the level of deciphering the bases for a person’s intent to act.
There are two factors to consider. First, there is one’s own attitude toward a particular behavior-which presumably is the target of the Health Belief Model. Second, there is how one’s peers feel about a particular behavior-which presumably the Health Belief Model is neglecting. The Theory of Reasoned Action, therefore, targets the larger circle of persons influencing an individual’s intent to act. The basic campaign is the same-informing persons of a particular danger and their susceptibility to it. But proponents of the Theory of Reasoned Action hope that by incorporating both one’s own perspective and that of one’s peers (the two components determining one’s intent to act), they can make up for a significant lacuna of the Health Belief Model.
Examples of HIV/AIDS prevention programs based on the Theory of Reasoned Action in Puerto Rico are the many peer-based interventions. For instance, many prevention programs targeting IDUs make an effort to employ former drug addicts to provide HIV/AIDS education and to counsel current addicts. The information itself is less important than who is delivering it. The premise of such an intervention is simply that a current drug addict is more likely to listen to (or to trust) a former drug addict than a generic public health worker. In this manner, the current drug addict is influenced both by the prevention information and by the perspective of her/his peer (the former drug addict). Programs targeting at-risk women work in a similar manner, by enlisting formerly abused women to counsel women currently in abusive relationships.
These behavior modification models share a common set of assumptions and a basic structure which are based on the manipulation of knowledge and motivation. Knowledge, properly deployed, convinces a person of the need for behavioral change. Motivation, properly framed, convinces a person of the benefits of change. The distinctions between approaches to behavior modification center on factors contributing to the enhancement of both of these.
Knowledge and Manipulation
Rationality (the capacity to reason)-and not knowledge-is in fact the presumption of behavior modification. It is presumed 1) that a person needs knowledge and 2) that with such knowledge, a rational person will become motivated. Hence, a person with knowledge and without motivation is either irrational (i.e., not responding appropriately to a particular stimulus) or operating with a different rationality (i.e., reacting at variance to initial expectations but in a consistent manner to a particular stimulus). Such tautological reasoning comforts the social scientist greatly, as the model cannot be questioned. Either the person is irrational (i.e., unreachable) or the approach must be re-oriented to better address the rationality of the person. Failure (a non-change) is by definition impossible. Either the specific approach was wrong or the person was unreachable. The project itself never comes into question.
Importantly, none of these models maintains that the simple presentation of information regarding HIV transmission is sufficient to induce behavior change. However, all are agreed that there is an objective set of facts regarding HIV transmission which, properly understood, will contribute significantly to behavior change. The models differ over the most effective strategy for imparting this knowledge, not over whether or not this knowledge is necessary. Reason transforms knowledge into action.
Herein lies the basis for “respecting” cultural differences while imposing behavior modification in a colonial setting (or among marginalized populations in general). A central component of all efforts to adapt US-based HIV/AIDS prevention programs for Puerto Rican consumption is an emphasis on culturally sensitive program content. This invariably entails the use of language, customs and cultural images familiar to the audience. English is translated into Spanish. US-based learning tools (games, anecdotes, songs, etc.) are supplanted for those with indigenous roots. Issues of women’s social position, food and nutrition, and various social taboos (homosexuality, drug abuse, female “promiscuity”) are re-interpreted to reflect the indigenous reality. Importantly, adapting programs for cultural sensitivity is not the same as adapting programs to take into account patterns of colonial domination insofar as they contribute to the spread of HIV/AIDS. Indeed, as will be seen, it is a concession to local custom only insofar as it allows the program to surreptitiously alter the population’s behaviors without fundamentally impacting the colonial order.
The concern with “non-rational” responses represents an effort to avoid directly confronting the fact that there are certain communities which present distinct difficulties for behavior modification-most particularly, as a project of social control and conformity. Within the US itself, the historical experiences of some groups with public health agencies (or government agencies in general) present specific obstacles. For example, behavior modification models rely heavily on the target community’s acceptance of the health expert as a neutral, “scientific” agent. In this sense, the Tuskegee syphilis experiments on African American males resulted in a unique “trust” issue.
The historical role of the US with respect to public health in Puerto Rico remains a source of genuine distrust and suspicion. The US government’s support for sterilization campaigns across the Island for almost five decades, along with early experimentation with contraception, colors the response of Puerto Ricans to the supposed benevolent motives of US-sponsored health officials today. Additionally, though long forgotten episodes of colonial rule for most in the US, for many on the Island incidents such as the so-called Rhoads Affair further shape Puerto Rican attitudes toward US-sponsored health campaigns.
Cornelius Rhoads was a physician working in San Juan’s Presbyterian Hospital in the early 1930s. In a letter to a friend he detailed his hatred for Puerto Ricans and his desire for their “extermination,” which, he bragged, he had personally already begun “by killing off eight and transplanting cancer into several more” (Ramirez/Seipp, 1983, p. 27). The letter was intercepted and published in the Island’s main newspaper.
“The Porto Ricans . are beyond doubt the dirtiest, laziest, most degenerate and thievish race of men ever inhabiting this sphere… What the island needs is not public health work but a tidal wave or something to totally exterminate the population. It might then be livable. I have done my best to further the process of extermination by killing off eight and transplanting cancer into several more. The latter has not resulted in any fatalities so far… The matter of consideration for the patients’ welfare plays no role here-in fact, all physicians take delight in the abuse and torture of the unfortunate subjects.”3 (Ramirez/Seipp, 1983:27)
The AIDS Institute scandal in the 1990s, in which millions of dollars were stolen by public officials, feeds further skepticism among the Puerto Rican public. Thus, issues of colonialism (as well as racism) cannot simply be ignored with respect to explaining how people react when presented with information based upon rationalities at variance with their own. The structure of the colonial discourse (not simply local culture), in large measure, determines the success or failure of behavior modification. Success or failure, in this sense, is essentially a matter of judging rationality.
Returning to the logic of behavior modification and the presumption of a rational actor, the choice is simple: a person is either rational, needing only to be presented the consequences of pursuing immediate gratification, or else irrational and hence unreachable. As behavior modification models develop, however, rationality (on the part of the participant) appears to play less of a role than deliberate manipulation (on the part of the health expert). In fact, knowledge-resistance to which provides the basis for judging irrationality-is presented to the participant in a deliberately deceptive manner: 1) masking its hidden agenda, 2) purporting to be a neutral entity, rather than an instrument for gauging rationality, 3) appealing to (and promoting) a dominant societal ideology of abstinence (based upon the construction of indescribably horrid, long-term consequences), and 4) implicitly endorsing the goal of social/ personal control.
Knowledge is no longer an objective set of facts. It is a tool within a larger strategy-a means to an end. Its manner of presentation provides a textbook definition of manipulation, that is, presenting knowledge in a manner designed to cause change in a person without that person’s full understanding of the process of presentation. The accuracy of the information is less important than the manner of presentation. The design of AIDS 101 presentations targeting IDUs in Puerto Rico is a case in point. AIDS 101 presentations are designed to provide the target population with a basic understanding of the causes and impact of HIV/AIDS.
With respect to manipulation, there are three factors to take into account. First, there is the issue of who is selected to disseminate the information. Generally, the presentation is handled by a health expert-or a person living with AIDS and/or former addict under the guidance of a health expert (this contrasts sharply with the role of autonomous, self-organized former sex workers in the alternative approach to HIV prevention discussed below). The selection of who speaks is thus based on a judgment by program-designers, who focus on the audience’s receptivity not to the message, but to the person.
The second consideration is the setting. The IDUs may be gathered in a church or a school auditorium with fellow addicts or, more commonly, they may be addressed individually (or in small groups) through street outreach. The goal, as in the case of who delivers the message, is to determine which setting puts the addict most at ease. Thus, prior to even saying hello, the addict’s environment has been carefully studied and analyzed so as to choose a setting that will maximize one’s opportunity to effectively reach the target population. While the target population is expected to presume that the setting is a neutral location based on convenience or utility, it is actually a purposely staged and controlled environment.
Third, the manner of message delivery is specially designed to penetrate the addict’s world. This is done through the adaptation of street slang, the design of easy to understand pamphlets and the intermixing of graphic, street-level anecdotes. In this manner, the entire presentation is carefully orchestrated through a manner of message delivery that minimizes input from the target population. What emerges is a stilted, one-way conversation. The presenter is allowed to ask about (or assumed to know about) any aspect of the addict’s personal life history and habits. However, addicts are allowed to ask the presenter only about basic clinical information.
Again, the goal is to have the nature of the audience impact the content of the presentation as minimally as possible. The working assumption is that the presenter has an objective set of facts, the content of which does not change, though the manner of presentation must be specially tailored to penetrate the world (and ideally the psyche) of a given target population. The very fact that supposedly objective knowledge is manipulated in this way demonstrates that the model does not, in fact, rely upon an appeal to (or faith in) rationality. The entire presentation is based upon a presumption of irrationality (i.e., the implicit notion that were the information presented in an objective manner free of manipulative orchestration there would be less chance of change). Importantly, knowledge in this sense is not gained by participants. Rather, an interpretation or perspective of the world is transmitted.
Health experts operate at the precipice of colonialism; they stand at the meeting point of colonizer and colonized. They present themselves (their knowledge) as “neutral” and “scientific.” They are presenting a set of data whose receptivity is assumed to be independent of historical social context. Just as the scientific manager is simply trying to help the worker with some task, the health expert is merely passing on some useful tips. The extent to which the worker may be ceding power to the manager by accepting such “help” or the health expert’s subject may be legitimizing colonial domination is not a consideration.
Knowledge alerts a (rational) person to the fact that there is a danger. Motivation demonstrates that there is a way to avoid the danger. At this point, however, our health expert is strangely transformed from a detached social scientist into a Bible-thumping preacher. Put most simply, the goal becomes the promotion of abstinence from a particular activity, which is the source of immediate gratification, by means of a promise of a later reward.
There remains a paralyzing dilemma, however. If the choice were simply between “certain” immediate gratification (Sin) and a “possible” long-term reward (Heaven), then the choice would remain less than clear. Therefore, a negative influence is called for (Hell). Further, immediate gratification is certain and concrete while long-term rewards are uncertain and abstract. Thus long-term negatives must be represented as concretely as immediate gratification. The more concrete the immediate gratification (adultery, a drug high, stolen goods), the more concrete must be the negatives (the fires of hell, a long and tortured death, inhuman prison cells).
Within a colonial setting, this ideology of abstinence has several distinct consequences. Modern colonial rule is premised upon-and legitimized by-the presumption of mutual material gain. Short-term sacrifices (sovereignty, cultural autonomy, language, etc.) are seen as necessary inconveniences for long-term prosperity in a colony. Puerto RicoHail the Queen’s post-war, US-led industrialization was sold by Luis Muñoz Marín (its political architect) and his followers to the Puerto Rican public based upon this basic notion of abstinence. Hence, to the extent that behavior modification models act to foster and legitimize this ideology, they may be seen as contributing not only to a public health campaign but also to a politics of apathy. Dilapidated social infrastructures, chronic poverty and everyday forms of social injustice are all temporary (and necessary) inconveniences if one is to reap long-term rewards. The ideological content of a public health campaign aimed at behavioral conformity must be analyzed in the context of a society’s historical and social situation.
The manipulative nature of these models is embedded in the basic relationship between the “sick” person at risk of contracting HIV and the “caring” health expert. The health expert must possess knowledge in three areas: epidemiology, sociology and psychology. Epidemiological data informs the health expert as to the nature of the actual public health danger. Sociological data informs the health expert as to the social context of the target population. Psychological data informs the health expert as to the manner in which the target population will receive and react to information. Thus the health expert’s task is to identify, locate, assess, inform and manipulate the target population. The health expert is the subject and the target population is the object of this process (discourse). The “scientific” knowledge about the nature of the public health danger and the pedagogy used to present it are assumed by behavior modification models to be neutral and unaffected by the process.
With respect to HIV/AIDS Illness; immune problem, the connection between the health expert (the subject) and the at-risk individual (the object) is HIV/AIDS itself. Mediating this relation is the medical/scientific establishment and governmental social service agencies which establish the perimeters of the relation. This structuring of the relation between the health expert and the at-risk individual is a factor which the at-risk individual remains acutely aware of. Put differently, the object (of behavior modification) remains aware of her/his objectification. The health expert (the subject), meanwhile, proceeds as if unaware of this awareness on the part of the at-risk individual. A peculiar interplay of subject/object results.
An analogy can be made to a theater audience (the subject) watching a play (the object). It would be as if suddenly the audience forgot that the actors (the objects) were consciously performing for them and audience members came onto the stage to interact with the role-playing actors. The moment that an audience member disrupts the understood subject/object relation there is no longer a “play”. There is no longer a subject/object relation. The health expert stands in relation to the at-risk population precisely as the audience stands in relation to the play. The at-risk person is never allowed to forget the nature of this relation-as embodied in the health expert’s role as “expert”. The health expert, however, by entering the “natural” setting of the object (stepping on stage, so to speak), imagines that the subject/object opposition has been overcome.
A case in point is a typical HIV prevention campaign in Puerto Rico in which community health educators conduct HIV/AIDS outreach among gay sex workers. In order to gain the trust of the population, the health educator must first familiarize her/himself with the vocabulary, schedules, norms and basic operating codes at play. To do so the health educator strikes an amoral pose, though the sex workers understand clearly that this person would not be there were s/he not interested in changing their behavior. The sex workers play along with the health educator’s amoral charade either for a stipend or perhaps out of boredom. Separate residential neighborhoods, separate social circles and separate workplaces/colleagues mark the true nature of the (foreign) health educator’s role. By entering the sex workers’ environment and over time establishing contacts, the health educator imagines that s/he has gained acceptance, understanding and genuine empathy. The fiction is broken, however, each evening when the health educator retreats from the sex workers’ environment. Indeed, were the health educator and sex worker to meet in the former’s neighborhood, social hangout or workplace, the neutral façade would evaporate and the pair’s true relation (defined not by charitable individual intention but by concrete social convention) would emerge.
This is a reality that the sex worker remains keenly aware of, and it is extremely rare for her/him to cross the unspoken boundaries of neighborhoods, social circles or workplaces-though health educators make such transgressions on a daily basis, assuming acceptance due to their good nature and neutral, amoral presence. They are there merely to befriend and inform. Their information, they assure-sound, scientific learning-is as neutral as their friendship. Thus, the health expert stands in relation to the target population (a messenger of objective, medical science) as the preacher stands in relation to the sinner (a messenger of God). Never open to question in such a structure is the nature of the relation of the health expert to the medical science or of the preacher to God. This is the basic foundation for an authoritarian model.
Within the colonial setting, just as within the Taylorist factory, the struggle for control of the subjectivity of the colonial population (or of assembly line workers) lies at the heart of establishing the subject/object relation. Colonial subjects exist in relation to the colonizer (or its agents). Their history is an extension of the history of the colonizer. Their customs and languages are adapted to those of the colonizer. Their social organization is developed to serve the colonizer. They are the object in this relation, and any questioning of this fact is tantamount to open rebellion. The colonial object remains aware of this peculiar interplay-constantly suppressing one’s history, customs, languages and pre-colonial relations of social organization. Hence, the introduction of behavior modification in a colonial setting is simply one more denial of the colonized person’s subjectivity, in this case, vis-à-vis the health expert.
A Radical Alternative: Resistance Through Community Organizing
At the core of behavior modification is an emphasis on the individual rather than community. The implications of this are clear. To address obstacles at the level of the social setting would require addressing individuals as full social beings. In contrast, these models emphasize preparing individuals psychologically to overcome social barriers by addressing self-esteem, self-efficacy and self confidence. The self is antiseptically treated apart from the community and apart from one’s material existence. Self-autonomy is paraded as the antidote to the social being. Indeed, denial of the targeted (colonial) subject’s individual subjectivity is a central premise of such behavior modification campaigns within colonial settings.
While the vast majority of HIV prevention efforts are consistent with the above description, there are some efforts to introduce genuine alternatives. One community-based organization, in particular, has taken the lead to counter this approach in Puerto Rico. Founded in 1983, Fundación SIDA de Puerto Rico emerged in the early 1980s from the organizing efforts of a handful of gay, lesbian and transgender activists on the Island in the face of the devastating spread of AIDS. Located in the working-class neighborhood of Caparra Terrace in greater San Juan, the agency has always served as a haven for the gay, lesbian and transgender community of San Juan (and from across the Island), providing both basic HIV/AIDS treatment and prevention services as well as a safe space for the gay, lesbian and transgender community to organize.
Within the agency’s prevention education division, a variety of programs have been developed which target IDUs, gay men, women of reproductive age, youth, and sex workers. However, a central concern of the agency’s HIV prevention work has been efforts to organize the Island’s gay, lesbian and transgender community through these interventions. A primary focus has been work with gay men, young gay hustlers and transgender sex workers. Much of this work has centered in the San Juan area. The Condado neighborhood of San Juan has developed into a thriving destination for the international sex trade. It is also one of the few “reasonably safe” gathering areas for gay men on the Island. An adjacent neighborhood in Santurce has developed into a popular gathering point for transgender sex workers. Working with gay men and sex workers in this area, Fundación SIDA has developed an innovative HIV intervention that seeks to reduce at-risk behaviors by treating individuals as members of oppressed and alienated communities. This provides a radical alternative to programs based on the Health Belief Model and the Theory of Reasoned Action.
The intervention for gay men and gay hustlers is called “Ata-cando los Raices de SIDA” (Attacking the Roots of AIDS). It begins with street-level outreach to gay men and gay hustlers. For example, former gay hustlers develop relations with active hustlers and invite them to take part in different activities. This includes anything from sharing a cup of coffee to giving someone a ride. The major activity, for those who are interested, is a series of HIV risk education workshops. The purpose of the workshops is two-fold. On the one hand, they provide a basic introduction to HIV prevention information. On the other hand, they provide gay men and hustlers with an opportunity to consider and discuss the implications of being a part of the larger gay, lesbian and transgender community. In this way, gay men and gay hustlers are introduced to a dynamic, politically-charged group of self-organized gay men. In effect, the prevention information itself is less important than creating an organized and self-directed cadre of gay men and gay hustlers.
Workshop topics include self-esteem and intimacy, alcohol and drug abuse, sexuality and social behaviors. The workshop on self-esteem and intimacy is often a participant’s first opportunity to openly discuss issues of sexual identity and social homophobia with a group of peers and gay community leaders who have been organizing around these issues for years. This provides gay men and gay hustlers with an introduction to the larger, organized community of gay men and leads to the realization that they are part of a larger movement of gay, lesbian and transgender Puerto Ricans. Political empowerment and mobilization is thus the first step toward effectively reaching community members with an HIV prevention message. Workshop participants are not there as individuals but as members of a vibrant (though often invisible) community.
The other workshops build on this theme to make clear that drug abuse, sexuality and social behavior are all products of specific historical and social conditions. The message is clear. Gay men and gay hustlers are, first, members of a historically-oppressed community in Puerto Rico. They are, second, a community threatened by HIV/AIDS. However, you cannot fully understand why the gay community is uniquely threatened by HIV/AIDS unless you first understand the historical and social conditions contributing to social homophobia, anti-gay violence and discrimination. Thus, gay men and gay hustlers must first become aware of their own community’s struggle and they must next become part of the organized gay, lesbian and transgender community that is mobilizing to fight homophobia, violence and discrimination across society. This is the starting point for any effective HIV prevention campaign over the long term.
Perhaps the agency’s most radical alternative to behavior modification is its work with transgender sex workers. Based on its prior success with gay men and gay youth hustlers, Fundación SIDA expanded its HIV prevention outreach and community building efforts to include transgender sex workers. A distinct set of workshops, entitled “Ponte el Sombrero” (Put on the Hat) was designed with the assistance of transgender sex workers. The seven workshops are organized around practical themes that are relevant and meaningful to them. The first workshop on self-image uses make-up as a vehicle for participants to identify their feelings about themselves and their body image and how these affect their sense of self and their relationship to the images they present through their cosmetic changes. The second workshop is a self-defense workshop, where martial arts techniques are discussed and presented. The third and fourth workshops on Health, STDs and HIV address safer sex methods within the context of sex work. The emphasis is on strategies for avoiding high-risk sexual practices despite client insistence otherwise. In the fifth workshop, on the use and abuse of hormones, substances and alcohol, participants examine their own patterns of alcohol/drug abuse behavior and the possible interactive effects of these substances with the use of female hormones.
The sixth workshop addresses both practical, day-to-day legal problems facing sex workers in Puerto Rico as well as the law as it relates to transgender sex workers. The workshop also addresses police abuse and harassment specific to the transgender sex worker population and how-individually and collectively-sex workers might respond. The final workshop addresses gender roles in Latino culture and the role of men who take on female characteristics in a manner stigmatized by society. “Being” a woman versus “feeling” like a woman and the significance that this has for the participants is a key focus.
Throughout consideration of all of these topics, the transgender sex workers are introduced to a broader community of gay, lesbian and transgender life. They are encouraged both to participate in existing gay and lesbian organizations as well as to form new transgender groups to address issues specific to their community and to empower the transgender sex workers. Through this empowerment, it is hoped that transgender sex workers will recognize that their individual interests are intimately tied to the interests of a broader oppressed and marginalized community that requires collective action to pursue these interests.
Importantly, Fundación SIDA took on this work with no illusions regarding the difficulties associated with community organizing among transgender sex workers. In general, transgender sex workers are a transient, alienated and-for reasons of self-preservation-highly individualist community with a great deal of turnover. Fundación SIDA, however, is committed to working with transgender sex workers for the long-term. Indeed, the agency spent five years working within the transgender community, gaining people’s confidence and trust before even considering attempting to organize transgender sex workers.
The basic premise of Fundación SIDA’s work is that attempting to conduct HIV prevention campaigns with gay men, gay hustlers or transgender sex workers without addressing community organizing and mobilization is a wasted effort. The only effective strategy for protecting this community is for its members to recognize the dangers themselves and to self-organize to confront these challenges. This is the antithesis of the Health Belief Model and the Theory of Reasoned Action that inform mainstream HIV prevention campaigns in Puerto Rico. Rather than US-sponsored efforts to empower the rugged individual, effective HIV prevention campaigns in the colony of Puerto Rico require community organization and mobilization as exemplified by Fundación SIDA. HIV/AIDS may not be a product of colonialism. However, public health campaigns to address HIV/AIDS can easily serve the interests of colonial rule through campaigns of surveillance and manipulation.
1. The truly virulent nature of the link between HIV/AIDS and colonial rule is further borne out by the pattern of reported AIDS cases among Puerto Ricans living in the US. Puerto Ricans in the US suffer from the same high incidence rates as well as the same primary transmission patterns-IDUs and female sex partners of IDUs (Selik et al., 1989; Díaz et al., 1993).
2. Unless indicated otherwise, the term “target population” is to be interpreted in line with its use within the public health lexicon, referring to any population specifically selected for an intervention.
3. Rhoads was investigated and forced to leave Puerto Rico, whereupon his admitted racist malpractice earned him a promotion to Director of the Sloan-Kettering Institute in New York City.
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