Elsevier

Social Science & Medicine

Volume 54, Issue 7, April 2002, Pages 1093-1110
Social Science & Medicine

Treading the path of least resistance: HIV/AIDS and social inequalities—a South African case study

https://doi.org/10.1016/S0277-9536(01)00083-1Get rights and content

Abstract

This paper outlines aspects of the HIV/AIDS epidemic scenario and the complexities associated with it. It reveals the socio-epidemiological patterns of the epidemic and in doing so identifies the populations with the greatest and fastest growing rates of infection. From the data presented it is evident that the pattern of HIV/AIDS in developing countries in sub-Saharan Africa in particular is unique. The pattern emerging in South Africa follows closely. The features of this pattern are as follows: the epidemic is mainly a heterosexual epidemic, the rates of infection in the general population are very high and the percentage of HIV-positive women is greater than men. An additional unique feature is the young age of onset of infection for women. These data demonstrate the need to focus our attention on young African women and the factors underpinning their predicament. In order to understand their position we examine the long standing relationship between social inequalities and health in general and further invoke the concepts of vulnerability and social capital to shed light on the position of women in the epidemic.

Within the constraints of limited and problematic statistical data, the paper argues that a mixture and complex interaction of material, social, cultural and behavioural factors shape the nature, process and outcome of the epidemic in South Africa. It concludes with recommendations for the way forward.

Introduction

For 1/4th of the world's population, absolute poverty remains the principal determinant of their health status, exposure to HIV/AIDS and high fertility levels. Health indicators from Least Developed Countries reveal vast global disparities. Women represent 70% of the world's poor and they have less education, longer working hours and lower life expectancy. Maternal mortality in LDCs is 15 times the rate of that in industrialised countries. There has been a sharp re-emergence of infectious diseases such as TB, diphtheria, HIV/AIDS and hepatitis B. About 17 million people a year in developing countries die from curable, infectious and parasitic diseases that affect the poorest disproportionately (EU Development, 2000)

Since the beginning of the AIDS epidemic 50 million individuals have been infected with HIV and over 16 million have died (UNAIDS, 1999). In 1999 AIDS deaths, internationally, reached a record 2.6 million with a further 5.6 million adults and children becoming infected (UNAIDS, 1999). In 1990, 1% of pregnant women attending ante-natal services in the public sector in South Africa were HIV positive. By the end of 1999 this figure had risen to 22.4% (Department of Health, 2000). Furthermore, it is estimated that over 1500 South African's are infected with HIV daily. Recent figures indicate that “one in eight adults (15–49 years of age) is infected with HIV” (between 12% and 14%), in South Africa (South African Health Review, 2000). The HIV/AIDS epidemic is clearly the most serious health and development crisis facing South Africa in the new millennium. Its social and economic costs will be devastating. Some of the economic costs were highlighted in a report released by the department of finance: It is predicted that in 2003, the HIV prevalence rate will be “12% among highly skilled workers, 20% among skilled workers and 27.2% among low skilled workers” (Mail and Guardian, 2000, p. 40). Yet the burden of this epidemic does not fall evenly or equally. Rather, as also mentioned in other studies (Susser & Stein, 2000), this paper demonstrates that the overwhelming majority of those currently living with HIV/AIDS are young African women in developing countries. We argue, it is these women who are most susceptible to infection, have the highest rate of infection, get the most inadequate and inferior access to treatment, take most responsibility for caring for the sick and dying and have the shortest survival rate.

An examination of recent South African patterns of infection and death from AIDS related illness, strikingly reflects broader social cleavages and inequalities. Sociological literature and health education programmes which primarily argue that individual behaviour needs to be challenged and altered before transmission rates will decline are naive, misplaced and misleading. Campaigns in South Africa to this effect have failed to curtail the epidemic. While behaviour patterns cannot be ignored this paper argues that social inequality is the greatest transmitter of HIV/AIDS. Strategies for change need to address social inequality and the empowerment of women in particular if rates of transmission are to decline.

This paper presents the multiple dimensions of social inequalities and their complex relation to health. Furthermore, it engages the concepts of vulnerability and social capital and their value in understanding the nature of the epidemic.

Section snippets

Health and social inequalities

The existence of health inequalities (measured in a variety of ways by comparing various indices) between populations in more and less developed countries as well as within different groups in industrial countries is a well established phenomenon (Kaplan 1996; Wilkinson, 1996). There is no doubt that the size and nature of these inequalities present a major public health issue and as such they have been the focus of numerous health studies as well as health policy undertakings (Black, 1991;

Place/geographical location and health

There is considerable evidence to suggest that place or geographic location is another social dimension linked to inequalities in health (Whitehead, 1992; Gillespie & Prior, 1995). Curtis and Taket (1996, p. 95) discuss ‘spatial expression of health inequalities’ and argue that the debates over social inequalities are important to the understanding of regional differences within and between countries. There is no doubt that the geographical distribution of social factors known to be associated

Racial and gender inequality

This paper rests on a series of assumptions, one of which is that all societies continue to be divided along the ‘fault line’ of gender, which considerably affects the health and wellness of both men and women. The differences (and the factors which influence them) between men's and women's health have been extensively researched and well documented (see for example, Doyal, 1994; Graham, 1993; Oakley, 1984; Papnek, 1990; Roberts, 1985; Miles, 1991; Annandale, 1998). Lane and Cibula (2000) argue

The position of women in South Africa

A recent base-line study ‘Key Indicators of Poverty in South Africa’ revealed that South Africa still had one of the worst records in terms of social indicators and income inequality. About half (44%) of South Africans were poor. Nearly 95% of poor people were African (South African Health Review, 2000, p. 3). While population estimates (based on the 1996 census) reveal similar numbers of men and women living in urban areas (although there are differences across provinces), in non-urban areas,

The concept of ‘vulnerability’

So far the paper has demonstrated that women in South Africa are disadvantaged on various levels and as will be shown later have higher rates of HIV/AIDS. In an attempt to further understand this complex scenario, we are posing the question of how do the concepts of vulnerability and social capital assist us in both explaining and changing the current situation?

There has been much interest in social determinants of health since the public health movement in the 19th century, and the literature

Social capital

The concept of social capital is strongly contested and consequently, variously defined in the sociological and development literature. Putman (1996), one of leading writers in the field, defines social capital as “features of social life, networks, norms and trust, that enable participants to act together more effectively to pursue shared objectives” (Putnam, 1996, p. 114). Briggs (in Budlender & Dube, 1997) understands social capital as “resources stored in human relationship” and suggests

HIV/AIDS—the global picture

According to the AIDS epidemic update (UNAIDS, 1999) the overwhelming majority of people with HIV—some 95% of the global total—live in the developing world. It is argued that the “proportion is set to grow even further as infection rates continue to rise in countries where poverty, poor health systems and limited resources for prevention and care fuel the spread of the virus” (UNAIDS, 1999, p. 4).

Sub-Saharan Africa continues to have the highest rate of HIV/AIDS, with 23.3 million people

Some methodological issues

One of the major problems in South Africa is the inadequate quality of statistical information. All data should thus be interpreted carefully recognising potential inaccuracies. The main problems are related to inaccuracies in population estimates and registration of information. The general data presented in this paper are derived from three different sources: Statistics South Africa (2000), UNISA's Market Research Bureau and Community Agency for Social Inquiry.

The HIV/AIDS data are obtained

Discussion and conclusion

This paper outlines aspects of the HIV/AIDS epidemic scenario and the complexities associated with it. It reveals the socio-epidemiological patterns of the epidemic and in doing so identifies the populations with the greatest and fastest growing rates of infection. From the data presented it is evident that the pattern of HIV/AIDS in developing countries in sub-Saharan Africa in particular is unique. The pattern emerging in South Africa follows closely. The features of this pattern are as

The way forward

Attempts to intervene in the spread of HIV/AIDS in South African have not been very successful. There are a range of reasons for this, one of which has been the simplistic focus on changing individual behaviour patterns due to the early framing of HIV/AIDS as an individual health issue (Marais, 2000). Others include, the inability to merge the “paradigms of the medical and the political, the scientific and the social” (Marais, 2000, p. 10). In addition, a lack of political will has

References (107)

  • Abt Associates Inc. South Africa. (2000). The impending catastrophe: A resource book on the emerging HIV/AIDS epidemic...
  • Akinsanya, F. (1984) Ethnic minority nurses, midwives and health visitors: What roles for them in the national health...
  • Albertyn, C. (2000). Law, women and HIV/AIDS: Challenging the role that human rights and the law can play in addressing...
  • Andrews, A., Jewson, N. (1993) Ethnicity and infant deaths: The implications of recent statistical evidence for...
  • E Annandale

    The sociology of health and medicine

    (1998)
  • A Antonovsky

    Health, stress and coping

    (1980)
  • Baden, S., Hassim, S., & Meintjies, S. (1999). Country gender profile: South Africa....
  • T Barnett et al.

    HIV/AIDS and developmentCase studies and conceptual framework

    The European Journal of Development Research

    (1999)
  • Barnett, T., Whiteside, A., & Decosas, J. (2000). The Jaipur paradigm: A conceptual framework for understanding social...
  • Y Ben Shlomo et al.

    Does variation in the socioeconomic characteristics of an area affect mortality?

    British Medical Journal

    (1996)
  • Benzeval, K., Judge, K., & Whitehead, M. (Eds.). (1995). Tackling inequalities in health: An agenda for action. London:...
  • M Blaxter

    Health and lifestyles

    (1990)
  • P Bourdieu

    The forms of capital

  • B Bozzoli

    Women of phokeng. Consciousness, life strategy and migrancy in South Africa, 1900–1983

    (1991)
  • Briggs, X. de Souze. (1997). Social capital and the cities: Advice to change agents. National Civic...
  • Britton, M. (Ed.). (1990). Mortality and geography: A review in the mid 1980s. London: OPCS,...
  • D Budlender et al.

    Starting with what we have—basing development activities on local realitiesA critical review of recent experience

    (1997)
  • M Bury

    Postmodernity and health

  • Caelers, D. (1999). Women bear the brunt of the AIDS epidemic. The Star, Johannesburg, 25...
  • J.C Caldwell

    Routes to low mortality in poor countries

    Population and Development Review

    (1986)
  • Case—The Community Agency for Social Inquiry. (1995). The national household survey of health inequalities in South...
  • J.S Coleman

    Foundations of social theory

    (1990)
  • S Curtis et al.

    Health & societiesChanging perspectives

    (1996)
  • Department of Health. (2000). Tenh national ante-natal survey, 1999. Pretoria: Government...
  • L Doyal

    Waged work and well-being

  • L Doyal

    What makes women sick, gender and the political economy of health

    (1995)
  • N Eames et al.

    Social deprivation and premature mortalityRegional comparison across England

    British Medical Journal

    (1993)
  • EU Development. (2000) The health status of the poorest: What we know....
  • EU HIV/AIDS Programme in Developing Countries. (2000). Special report: Gender and HIV/AIDS—women: The gender...
  • J.S Feinstein

    The relationship between socioeconomic status and healthA review of the literature

    Milbank Quarterly

    (1993)
  • M Foucault

    The birth of the clinic

    (1973)
  • N.J Fox

    Postmodernism, sociology and health

    (1993)
  • D Gilgen et al.

    The natural history of HIV/AIDS in South Africa—A biomedical and social survey in Carletonville

    (2000)
  • R Gillespie et al.

    Health inequalities

  • A Gordon

    Learned helplessness and community developmentA case study

    Journal of Community Development

    (1985)
  • H Graham

    Hardship and health in women's lives

    (1993)
  • Health Systems Trust. (2000a). The equity gauge. Durban: Health Systems...
  • Health Systems Trust. (2000b). The 1999 HIV survey....
  • N Hart

    The sociology of health and illness

    (1986)
  • N Hart

    Sex, gender and survivalInequalities of life chances between European men and women

  • Cited by (139)

    • COVID-19, control and confusion: experiences from Cape Town, South Africa

      2023, Inoculating Cities: Case Studies of the Urban Response to the COVID-19 Pandemic
    • A qualitative approach to examining health care access in rural South Africa

      2019, Social Science and Medicine
      Citation Excerpt :

      Add to this the debilitating effects of the HIV/AIDS crisis, which put a strain on the system, undermined efforts to improve equity, and sucked up any increases in resources, and one sees a post-apartheid healthcare system which is at least as bad as it was under apartheid (Benatar, 2004; Harrison, 2009). This inequality in healthcare and in the population more generally has had dire effects, leading to higher rates of mortality and morbidity among poor Africans (Bradshaw et al., 2003; Gilbert and Walker, 2002). South Africa's long history of inequality has shaped more than its healthcare system.

    • Exploring Women’s Decision-Making Power and HIV/AIDS Prevention Practices in South Africa

      2022, International Journal of Environmental Research and Public Health
    View all citing articles on Scopus

    This paper was prepared as a background paper for the XVth International Conference on the Social Sciences and Medicine, held in Veldhoven, the Netherlands in October 2000.

    View full text