If a tree falls in the woods and

If a tree falls in the woods and no one is there to hear it, does it make a sound? The proverbial falling of the AIDS crisis upon the global community did not have much of a resonance in my insular hometown of Cohasset, MA. When small town protocol dictates the spreading of news faster than it happens, one assumes they are generally in the know. There are no recorded AIDS cases in Cohasset – but with no concrete point of reference, I settled on an overestimate of about 200 cumulative instances.

MY EXPOSURE

Over the years I’ve been made aware of AIDS via biology textbooks and international news articles – but never can I recall a mention of a local context. AIDS was an epidemic that affected the poor and underprivileged in Sub-Saharan Africa, where my cousin worked to eradicate the societal constraints fueling the fire of viral outbreak. These included issues such as gender inequality, poor health care, and political instability. Even in talking to her, however, the conversation was polemical and distant. Interactions with individual AIDS patients were not recounted, as were the larger scale political efforts. Because I cannot recall any local fundraisers or support groups devoted to the AIDS cause, I never saw AIDS as a disease that had devastated the US.

Having known no victims, I had no negative preconceived judgments. My impression of this disease was one of a scientific nature. After having taken many biology classes, I would like to believe that I'm relatively well informed on the mechanics of the HIV retrovirus; however, the social consequences of AIDS were something unbeknownst to me. Graduating from a public high school, I had only been taught that AIDS exists. I remember one student presentation in health class lasting about fifteen minutes, touching only upon the average prevalence statistics of the syndrome. Cohasset High School was strictly college preparatory. Because classes like health, art, music, were given little attention and funding, my health instructor was also the athletic director and boy’s basketball coach at my school. I’m not sure how knowledgeable he was about AIDS, but we certainly did not spend a lot of time learning about it. The Cohasset High school program of studies dictates that part of the health education mission is to aid students in simply "understanding HIV/AIDS."¹ The state of Massachusetts does have a compulsory health education requirement, but there is no specific mandate about AIDS/HIV education.2 The minimum requirements, and nothing more, were met in terms of AIDS education because there was no local problem.

I could not recall a single newspaper article in the local Cohasset Mariner concerning AIDS. A recent search of the online archives of the paper yielded no mention of the epidemic either. Although my hometown has never had a recorded case of AIDS, Norfolk County has had nearly a thousand cases (Table 1). Even with that level of prevalence, Norfolk is still one of the least devastated counties in the state³. Although Cohasset is a suburb, and is without the AIDS frequency that a more inner city region such as Brookline (Table 1) might display, it is still only twenty miles outside the city. It seems strange that such a great epidemic could go unreported.

Though I rarely read the Herald, the Boston Globe is a generally trusted paper. Searching recently in a news database, Lexis Nexis, I found that the only regional newspaper with AIDS information was the Boston Globe. As Massachusetts seems to be the bluest of the blue states, a strong liberal and polemical tone often enters the pieces. This is especially seen in the "Global AIDS" articles. From 2/20/06 - 2/20/07, 85 Globe articles revolved around the global issue, while about half (42) articles discussed the national crisis. This gives an impression that AIDS in the states is comparably insignificant. The US focused articles in the regional media, as well as national media, like the major news weeklies or television news, focused on certain high risk demographics that did not seem to fit my impression of the typical Cohasset resident. National Public Radio transcript archives exposed a broadcast claiming, "The CDC estimates that more than half of the young people diagnosed with HIV between the ages of 13 and 24 - that's roughly 14 percent overall - are black.”⁴ This means that 7% of the new cases are Black youths. A more local article in The Boston Globe reported Julian Bond, the chairman of the NAACP, saying, "Now is the time for us to face the fact that AIDS has become a black disease.”⁵ For the rest of the county, this statement seems to be true, with African Americans accounting for more than one-quarter of cases and an AIDS rate of 284.2 per 100,000. Compared to the national black rate of 594.2, Norfolk County seems to be in better shape (Table 4). Hispanics 7.6% of Norfolk County’s PLWA with a rate of 176.6, only marginally lower than the national rate of 191.1 (Table 4). Small suburbs in Norfolk County appear to be severely homogeneous, yet larger cities such as Brookline and Quincy have a much more diversified population. This may account for their high cumulative AIDS rates (Table 1).

Another demographic group with a large number of AIDS cases is injection drug users. Public outrage at the veto of a bill allowing the sale of over-the-counter hypodermic needles in Massachusetts spurred much media coverage and suggestion to reconsider. One editorial stated, “Drug abuse is a terrible problem, and is made worse when addicts reuse contaminated needles, running the risk of contracting AIDS, hepatitis C, and other blood-borne diseases.”⁶ This mode of transmission is the second highest in Norfolk County and Massachusetts (Table 2), though both lie below the 2005 US estimate accounting for 45.4% of PLWA. Cities closer to Boston like Milton, Weymouth, Quincy, and Brookline, usually have faster and greater access to the drugs coming into the city. This could account for the higher AIDS rates in the county (Table 1).

Exogenous sources of HIV/AIDS also struck me as strange. A recent influx of HIV positive immigrants has stuck the country, and particularly major coastal cities. “Statewide, from 2002 to 2004, 785 people born outside the United States were diagnosed with HIV, representing 28 percent of all HIV diagnoses in the Bay State [Massachusetts]…has risen from 18 percent.”⁷Although Norfolk County contains even more foreign-born residents than either the state or country (Table 5), I was unaware of a growing immigrant population. Most immigrants live in ethnic clusters near or in Boston, potentially explaining the higher AIDS rates in cities closer to Boston.

Although rising AIDS cases have been evident in new socio-economic groups, the number one high risk group in Massachusetts and Norfolk County is still men who have sex with men (Table 2). MSM transmission accounts for 37.7% of all PLWA in Norfolk County, whereas the national percentage estimate is 45.4%. One amendment that may have contributed to an immigration of gay men into the state is Massachusetts’ legalization of same sex marriage. If only one or two states in the country validated and welcome gay relationships, it would be no surprise if a great number of gay citizens moved there. Again, parts of the county closer to the metropolitan area of Boston would be likelier to have gay areas.

As widely reported in scientific literature, HIV/AIDS incidence is highly correlated with poverty in the US. A study performed in Massachusetts showed that, “In most of the AIDS cases in the state, the person lived in block-groups where at least 10% of the population was below the poverty line...Between 1988 and 1994, both relative and absolute risk of AIDS increased among persons in Massachusetts living in economically deprived and densely populated block-groups.” ⁸ The Norfolk County median family income averages marginally higher that of the state and country (Table 6). Patches of extreme affluence and extreme poverty are present in the county, and offset the “average” seeming economic situation.

My limited perception of HIV/AIDS is only fueled by the prevailing world news. Not only are the rising immigrant AIDS cases overshadowing the US citizen’s battle with AIDS, but innumerable articles concerning the African AIDS/HIV epidemic can be found in almost any publication. A recent CNN show explained that the US has a responsibility to the South African AIDS cause, because “South Africa doesn't just have a disastrous epidemic. It has a strange problem with official apathy.”⁹ It seems ironic that the US would have a responsibility to encourage another government’s action, when twenty years ago the encourager was denying its own AIDS epidemic. In 2003, the Bush administration's pledge of $15 billion to fight AIDS received generous local, national, and global news coverage¹⁰. However, all these stories pointed out that this effort was focused exclusively on Africa and the Caribbean. Since none of these funds were aimed at the US, Massachusetts, Norfolk County, or Cohasset, it is no surprise that we haven't heard the AIDS tree falling in our local forest.

I can’t remember the first time I had heard about AIDS, but it has always seemed a vague distant fact, and never an immediate concern in my life. Even when it may not be an issue that has devastated at the local level, AIDS awareness is clearly important for all citizens. Recently, more and more media coverage has been devoted to AIDS and the public’s education of the pandemic. Ironically, though, HIV infections are becoming less prevalent. While AIDS may not be as problematic in Norfolk County as New York City, it is more severe than one is led to believe by the media.