Many women are also hiding the fact that members of their family have AIDS. Long-practiced and familiar cultural beliefs are breaking down in the face of AIDS in African American communities. There is little evidence that fear or stigma is decreasing. Anecdotal reports suggest that some families who have relatives die of AIDS are refusing to have public funerals or indicate the cause of death in obituary notices. I found Frances's story as the debate was being waged in Congress on the bill that would mandate that businesses protect the jobs of workers who had to take leave to care for family members who are ill. I heard no one speak to the need for this bill because of the spread of the AIDS epidemic.
THE GENDER OF AIDS
African American women have also been caught in the matrix of the construction of AIDS as a disease. As the discussion in “Searching for Women,” the excellent literature review on women and HIV in the United States, compiled by the College of Public and Community Service at the University of Massachusetts, Boston, and the Multicultural AIDS Coalition indicates, the Centers for Disease Control case definition of AIDS was first formulated in 1982. This case definition was based on clinical information from the groups of white gay men who had been studied. The natural history of AIDS in low-income men or in women was not included.
21
There is a great deal of debate as to whether there are female-specific manifestations of HIV infection. Cervical dysplasia, cervical cancer, pelvic inflammatory disease, and vaginal candidiasis are most commonly mentioned.
The problem for women though is that these diseases also occur among uninfected women. Therefore, any specifically female manifestations of HIV would be difficult to see clinically against the background noise of these other more common infections in women. This situation is even more complicated for African American women because they have higher rates of some of the infections mentioned. Reported gonorrhea is 10 times higher in blacks; black women report 1.8 times the rate of ambulatory or hospitalized treatment of pelvic inflammatory disease than do whites; herpes simplex virus is 3.4 times higher; syphilis rates are higher, and cervical cancer is 2.3 times more common in African American women.
22
These data suggest that the medical establishment has historically failed to deal with the prevalence of sexually transmitted diseases in African American women. As late as 1989, after almost a century of study of syphilis in this country, the authors of a 1989 paper wrote,
While the present study demonstrates the significantly greater prevalence of syphilis seroreactivity among blacks than among whites, we do not yet know enough about racial differences in sexual behavior through which infection is acquired, or about racial differences in ways in which infection is eliminated to explain persisting differences in prevalence.
23
Venereal disease control programs that have been touted as successfully diminishing the impact of these diseases on the larger United States population have broken down in urban communities of color. The failure of these programs is related to the AIDS epidemic in one very crucial way. The professional background of CDC (Centers for Disease Control) officials most responsible for formulating AIDS policy was in venereal disease control.
24
These are the same people who must now try and understand questions
with respect to AIDS that they have failed to answer in their attempts to control other sexually transmitted diseases in African American communities.
It is at this point that I realized that the silence around the issues of AIDS, sexually transmitted disease and African American women was not a new phenomenon, indeed its roots are very old. The impact of the failure to control sexually transmitted diseases on African American women has never been evaluated. Historical studies of the history of sexually transmitted disease have not placed black women at the center of the historical reconstruction of these diseases. For example, in rereading James Jones's book,
Bad Blood
, on the history of the infamous Tuskegee syphilis experiment, it occurred to me that many of the men in this study were married. Given that these men did not know they had syphilis, they must have continued to have sexual relationships with women. What happened to these women? In 1972 the study ended, and in 1973, compensation of the survivors began. Not until 1975 did the government agree to compensate treatment of the subject's wives and their children with congenital syphilis. In a footnote, Jones notes that health care for the surviving spouses could cost as much as $12 million, while medical care for the surviving children might cost as much as $127 million. As of May 1980, approximately fifty surviving wives and twenty surviving children were receiving full medical care after examinations revealed that they had syphilis that was directly attributable to the government's failure to treat the men. Why the government had to debate the issue of compensation to the wives and children of these men is unclear and unexplained. But this is perhaps not unusual; there are a number of long-unanswered historical questions about the role of African American women in the history of sexually transmitted diseases.
For example, historians note that “prostitutes” were specifically singled out as the source of venereal disease in the period between 1900 and 1930, when national attention was first focused on the issue of venereal disease. In the early decades of this century, immigrant and native-born working-class white women were targeted by physicians and public health experts attempting to control outbreaks of syphilis. Historians of medicine have failed to mention that African American women were targeted as well. And few explore the meaning of the term “prostitute,” particularly with regard to black women. Since slavery, as historians of African American history have shown, the label is often used against
all
African American women irrespective of class, education, and most importantly behavior.
Racial theories that ascribed to African American women an inherent immorality were buttressed by physicians and social reformers when the incidence of venereal disease among African American women began to rise in the twentieth century.
While the source and use of statistics on the incidence of venereal disease in the African American community was hotly debated, most observers agreed that the incidence was high in these communities throughout the country. One source notes that syphilis rates among African American women were as much as fifteen times those of white women, particularly for women in their childbearing years. Deaths from gonorrhea were also high.
25
Statistics collected by physicians at the Syphilis Division of the Medical Clinic of the Johns Hopkins Hospital in Baltimore show that African American women had the highest rates of syphilis from 1916 until 1928. And while rates among black males and white males and females began to decrease after 1925, the rate among African American women seemed to be rising.
26
No study that I know of goes beyond merely reporting that African American women were the most common sufferers of venereal disease to explore the meanings and uses that were made of this disparity by physicians, public health experts, and other social reformers in the past. I would argue that the historical record must be rewritten to illustrate how race influenced practices designed to control venereal disease, if we are to understand how the legacy of such practices affects current efforts to control AIDS.
Historians note that many repressive tactics were invoked by public health experts attempting to control venereal disease before World War II. Yet little is known as to how imposition of quarantines, detention, and internment were shaped by the racial and ethnic composition of the groups of women labelled prostitutes when the very possibility of infection could be used as a sufficient cause for incarceration. What was happening to African American women when physicians were simultaneously claiming that. “... ninety-five percent of the negro race are likely to contract syphilis or other venereal disease including those of the educated classes,” and “. . . the worn-out prostitute of today may be the woman you employ as your maid tomorrow?”
27
African American physicians, sociologists, educators, and club women vigorously protested the view that the presence of venereal disease gave credence to the racist assertion that all African American women were inherently immoral.
28
They pointed to socioeconomic factors and the exploitation of young black women in the cities by unscrupulous white and black men as important factors. In urban areas the increased visibility of African American women became a source of anxiety for whites. The interwar years were times of intense racial strife and severe economic crisis for African American women, who by the hundreds stood
in unemployment lines on the streets of many cities.
29
How and in what context were public health experts in their concern about venereal disease, supplying a new scientific justification to the existing process of policing so-called dangerous working women of color and white women?
Sexually transmitted diseases are highly stigmatized in this culture. How do we examine the impact of the stigma associated with these diseases on women's lives? In article after article in this period, white physicians echo the themes: that all African American people had syphilis; and that the immorality of African American women could be measured by the numbers of illegitimate infants and the numbers of those born with congenital syphilis. Black women as source, cause, and victims of venereal disease had to contend with both the stigma and the severe effect of venereal disease on their reproductive health. In 1924, a study by the Association for Improving the Condition of the Poor in New York City found:
Negro women suffering from syphilis but receiving neither adequate prenatal instruction nor medical treatment lost an average of fifty-four percent of their babies through miscarriage, still-birth, or death during the first two years . . . twenty-nine percent of surviving children of syphilitic mothers were diagnosed as syphilitic.
30
As it is with AIDS today, commentary on the impact of syphilis as experienced by African American women is absent from this literature. In addition, physicians' views of African American women were further diminished because they often failed to return to clinics for the expensive treatment of their disease during and after pregnancy, giving further “evidence” of their irresponsibility. Few of the white physicians and nurses who staffed these clinics showed any awareness that their attitudes and behavior toward African American women bore any relation to failure of these women to return for treatment.
The discovery that syphilis had a serious impact on maternal health and fetal death received a good deal of attention in the 1920s. Physicians at Johns Hopkins Hospital, who conducted a three-year study of the significance of syphilis in prenatal development and the causation of fetal death, argued increasingly for the need for complete medical control of pregnant women suffering from the disease. Their reports consistently articulate different methods of control for white women of the “intelligent classes,” described more as “innocent” victims, versus all black women, who are cited as “ignorant,” “unmoral,” and “unmanageable.”
31
Social workers enlisted to encourage follow-up care for women with syphilis also reported that native-born white women took an intelligent interest in learning the facts about syphilis and accepted that they should not have more children, while black women and immigrant women were censured for their refusal to submit to the control of medical and welfare authorities.
32
Given such
facts, we might ask how the stigma associated with venereal disease affected the kind of support given to efforts to provide infant and maternal care for African American women as the rates of sexually transmitted diseases and infant mortality rates fell among middle-class white women.
33
The incidence of venereal disease among African American women and the practices they were subjected to served as powerful ideological weapons to control the sexual and reproductive behavior of white women. African American women were punished because they suffered from disease associated with immoral behavior and for their so-called refusal to submit to medical authority. When physicians came to the defense of women who had a venereal disease, it was to a sentimental, objectified ideal, one that arguably bore little resemblance to most white women and hardly applied to African American women.
34
Programs for middle-class white women were designed to reduce the stigma associated with having syphilis and seeking treatment. African American women's options for treatment were limited by economic resources and the necessity of exposing themselves to censure by white professionals on an issue inextricably related to sex, in a context where their privacy and dignity could not be and never had been preserved. It is not surprising that programs that successfully treated African American women were largely staffed by African American physicians and nurses.
35
From 1945 to 1964, syphilis rates among all groups fell in the United States. In 1945, syphilis rates among nonwhites were thirteen times higher than among whites. By 1964, they were still ten times higher than for whites. Total expenditures for venereal disease control fell steadily throughout that same period of time.
CONCLUSION
I believe that the invisibility and objectification of African American women in the AIDS epidemic is tied to the historical treatment of African American women with respect to sexually transmitted disease. The Tuskegee syphilis experiment is just one example of the legacy of danger and death that sexually transmitted diseases represent for African American communities. For a black woman to expose that she had a sexually transmitted disease was, for much of this century, to render herself multiply stigmatized, bringing up older images of immorality and uncontrolled sexuality that neither class nor educational privilege could protect her from. It possibly meant that pregnancy carried more risks; it often precipitated long-term health problems and even early death. That physicians and public health experts have long accepted higher rates of sexually transmitted diseases among African American women is a sign that somehow this had quietly become a norm. That overt racial comments from white health care
providers on the cause of this higher incidence of sexually transmitted disease and the attendant problems for fetal and maternal health are less evident today than in the 1920s is not necessarily a sign that attitudes have changed or that the stigma associated with these diseases has diminished.