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AIDS in Haiti: Situating the Incidence and 
Prevalence of AIDS in Structural Violence 

Samra Hasnain 
 

Samra Hasnain is in her final year at the University of Toronto, pursuing an 
undergraduate degree in Human Biology and Caribbean Studies. She is particularly 
interested in examining the structural forces that shape patterns of health and 
disease in the Caribbean and the ways in which these patterns illuminate the 
deeper rooted inequalities that exist globally.  

Introduction  

In light of the past decade of rising popular interest and 
alarm towards infectious epidemic diseases, there has been a surge 
of movement throughout developed nations in allocating funds 
towards research and action programs to respond to these concerns. 
However, while the popularization of the concept of “emerging 
infectious diseases” has fuelled a sense of urgency towards 
developing ways to curb the rise and the spread of disease, it also 
illuminates the inequalities that exist globally in the distribution and 
outcome of infectious diseases. Large-scale social forces, such as 
political violence, poverty, racism, sexism, gender and other social 
inequalities, rooted in historical and economic processes, shape the 
distribution and outcome of infectious diseases such as HIV/AIDS 
and TB. These social forces, coined as “structural violence” by Paul 
Farmer (2001), create spaces of vulnerability by firstly shaping the 
risk of infection and then the outcome by determining who has 
access to diagnostics and effective therapy following infection. Drugs 
that could stop or slow down these epidemics, such as first- and 
second-line antiretrovirals, are not available in the places where 
populations are most vulnerable and where these diseases take their 
highest toll. (Farmer 37-44). 

Amidst these infectious diseases, the AIDS epidemic serves 
as perhaps the best model for addressing the inequalities that exist in 
the distribution and outcome of disease. Emerging from its initial 
epicenters (America, Europe and Africa) in the early 1980’s, AIDS 
has followed the trail of human interactions to become a global issue 
(Kreniske 33). It differs from other infectious diseases in the sense  

 



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that it is transmitted without an intervening vector; human beings 
serve as the only carriers for the virus. HIV is most commonly 
transmitted in three ways; during sexual contact with an infected 
individual that results in coming into contact with bodily fluids 
(semen and vaginal fluids), exchanging blood with infected 
individuals (injection-drug use and blood transfusions) and via 
vertical transmission (perinatal exchange of fluids between mother 
and child – transplacental exchange vaginally at the time of birth 
and through breast milk). As a result, HIV strikes human 
populations at the very process of biological and social reproduction.  

 
Another important aspect to note is that the experience of 

contracting HIV infections in the developing and developed nations 
has been different from the onset of the pandemic. The appearance 
of HIV/AIDS in the global south did not receive the immediate 
attention and prominence it assumed in the United States and 
Europe. AIDS was just added to the list of the many deadly epidemic 
diseases that were already present (Kreniske, 33). This uneven 
impact of AIDS has matched the uneven distribution and spread of 
the virus. The differences behind these uneven distributions have 
arisen not from inherent biological differences between individual 
and groups, but rather from differences in patterns of behavior 
within populations in response to socio-economic and cultural 
determinants. This illustrates that the AIDS pandemic cannot be 
viewed as a single phenomenon for which there is a simple global 
solution. Instead, different neighbourhoods, cities, regions, and 
countries require different intervening strategies to curb the 
prevalence and spread of HIV (Lindenbaum, 192-193). 

 
Globally, among these developing nations, the Caribbean 

stands out as being the second-most affected region in the world 
(coming second to sub-Saharan Africa) with the Bahamas and Haiti 
having the highest prevalence rates of HIV infection in the region 
respectively. As a result, the study of the AIDS epidemic in a 
Caribbean context allows the opportunity to gain an understanding 
on the socio-cultural dimensions of disease. With a focus of situating 
the analysis in Haiti, this paper aims to investigate the social forces 
that have contributed to the generalized AIDS epidemic that exists 
within this nation at present. While there are numerous issues (such 
as the consequence of political instability, income inequality, land 
reform, the alienation of peasants from the land, labor migration, 
colonial and post-colonial patterns of industrial exploitation, the 
resulting proliferation of informal settlements (shanty towns), 



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gender hierarchies, and the traditional and emerging patterns of 
sexual union) that have caused Haiti to become a vulnerable space 
for the spread of HIV, this paper will focus specifically on the 
political, economic and gender dimensions of structural violence in 
Haiti.  In doing so, the aim of this paper is to analyze the link 
between structural violence and AIDS and address how these specific 
social forces have shaped the incidence and the prevalence of AIDS 
in Haiti.  
 
Conceptualizing the Vulnerability of the Haitian State: 
Situating Political and Economic Instability in Historical 
Processes  
 

To gain an understanding of the reasons behind the high 
prevalence rate of HIV infections in Haiti, it is essential to look at the 
factors that have caused the country to become vulnerable space to 
begin with. Like much of the Caribbean, Haiti’s vulnerability is 
rooted deeply within colonialism. The Spanish first arrived to the 
island they later named as Hispaniola in 1493 and subsequently for 
the next 125 years fought against other European powers for control. 
The French West India Company eventually established control over 
a third of the colony and named it Saint- Domingue. These French 
colonialists sought to make the colony profitable and established a 
large-scale farming system (plantation system) that required a large 
labor force (Farmer 1993:153-160). As a result, by the end of the17th 
century, African slavery was instituted to obtain labor to work on 
plantation crops of sugar and coffee for export. The plantation 
economy reached staggering proportions as the demand for these 
luxury products increased so much so that by the end of the 18th 
century, the colony's enslaved Africans were producing 40% of all the 
sugar and 60% of all the coffee consumed in Europe. Needless to say, 
Saint- Domingue undeniably became one of the wealthiest colonies 
in the Caribbean (Oliver- Smith 33).  

Hierarchies of class, race and gender were inherent to 
plantation societies as they served to regulate the slave populations 
and to justify the authority of the European plantocracy.  These 
boundaries were complicated when European planters fathered 
illegitimate offspring through the sexual exploitation of their 
enslaved population. The French colonial system often defined these 
individuals as free and able to inherit property and own slaves. These 
“mulattoes” added another dimension to the social hierarchies of the 



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plantation societies and would eventually resemble some of Haiti’s 
first national elites (Oliver- Smith 34).  

In 1789, the revolutionary fervor in France spread to these 
early elite classes consisting of free people of color in Saint-
Domingue, initiating a series of reform and resistance movements in 
1790 that progressed into full-scale slave revolts and ultimately 
culminated in the colony's independence in 1804. Haiti became the 
first independent nation in the Caribbean and Latin America. More 
importantly, Haiti became the world’s first black republic (Farmer 
1993:164-165). 

Since gaining independence in 1804, Haiti has been severely 
punished by the international community. It began immediately 
after independence with France refusing to recognize the new 
republic and demanding that reparations be paid for the loss of 
“property," (slaves and land) in the amount of 150 million gold 
francs (which translates to $21 billion). France threatened Haiti with 
invasion and simultaneously placed an embargo along with Britain 
and the United States to pressure Haiti into accepting its demands. 
In 1825, due to this intense international pressure, Haiti agreed to 
pay the reparation (Oliver–Smith 33-35).   
 

At this moment a question that is necessary to addresses is, 
“Why might a country of former slaves feel compelled to remunerate 
the plantocracy for losses incurred in a war of liberation?” (Farmer 
1993:168). Putting aside the threat of invasion and the pressures put 
forth by the embargo, it is necessary to mention that the Haitian elite 
saw their own survival at stake in this issue of diplomatic 
recognition. The growth of the Haitian republic was held, by these 
elites, as being tied to continued export of subtropical commodities 
(Farmer 1993:168 - 170). As a result, while European and U.S. 
leaders began a campaign to isolate Haiti both politically and 
economically in the early 19th century, the Haitian government and 
elites allowed these nations to extract Haitian resources (income 
largely from sugar, coffee, and indigo) to fulfill the debt obligations 
(Oliver-Smith 33). Thus while Haiti may have been diplomatically 
isolated, these political maneuvers did not include commercial 
isolation. The Haitian government and elites negotiated the 
extraction process with foreign powers, principally the United States, 
and began accumulating power and wealth while draining the 
nation's resources. This result was achieved through the use of 



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brutality, militarism, mismanagement, and corruption that 
subsequently impoverished the rest of the population. Under the 
weight of the crippling debt and the embargo, Haiti went from being 
the richest Caribbean colony, "the pearl of the Antilles," to the most 
impoverished nation in the Western Hemisphere.  Haitian elites did 
little to construct a viable infrastructure or a functional institutional 
framework in the country (Oliver-Smith 33-34). 

During this period, Haiti experienced almost continuous 
foreign intervention by both the United States and European powers. 
The United States alone sent warships into Haitian waters twenty six 
times during the period of 1849 – 1914 under guise of wanting to 
protect the lives and the property of American citizens. In 1915, 
penetration of foreign capital coupled with the continuous invasion 
by U.S warships led to an armed occupation of Haiti by the United 
States Marine Corps.  During this period of U.S. occupation in Haiti, 
between 1915-1934, the United States exerted enormous influence in 
Haiti. Unlike what is often suggested, the occupation was not the 
sudden manifestation of a new U.S. interest in protecting Haitians 
from their corrupt leaders. Rather, it was a continuation of the 
pattern of exploitation and domination (Farmer 1993:180-183).  

Recent developments, in the last quarter of the 20th century, 
have amplified Haiti’s impoverishment and vulnerability. Following 
the brutal dictatorship of "Papa Doc" Duvalier, his son "Baby Doc" 
(Jean- Claude Duvalier) inherited the regime in 1971 and left the 
nation in even greater debt to foreign lenders due to the continual 
misappropriation of resources and even outright theft. The second 
Duvalier regime, a virtual kleptocracy, was supported by the United 
States and as such approved the catastrophic USAID-ordered 
slaughter of all of Haiti's pigs to limit the spread of African swine flu 
virus (Dupuy 50-51). The loss of the pig population, which was 
essentially the source of peasant savings, emergency capital, and 
nutrition, left the rural people in an even more impoverished and 
vulnerable state. In addition to this, rural Haitians were forced to cut 
to trees to produce charcoal, which led an almost complete 
deforestation of Haitian terrain (Oliver-Smith 35).  

USAID programs along with the imposition of structural 
adjustment policies by the World Bank and IMF further weakened 
the rural economy. With a goal to develop Haiti’s cities into centers 
of export production for U.S. companies, USAID, working with large 
landowners, encouraged the construction of agro-processing 



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facilities, while IMF-imposed tariff reductions opened Haitian 
markets to subsidized U.S. rice surpluses, undercutting local 
production of the nation's staple crop and dismantling the rural 
economy (Dupuy 52-56). This resulted in a massive migration of the 
rural population to the cities where impoverished migrants took up 
residence in slums and shantytowns. The demand for jobs and 
services by the displaced rural populations quickly exceeded the 
supply, deepening the impoverishment of the extremely dense 
populations in cities. Political instability during the last 20 years has 
also led to high rates of unemployment as companies, having been 
forced to down size, have reduced the numbers of jobs available 
(Oliver-Smith 35).  

Within this context, when the AIDS epidemic emerged in 
Haiti in the early 1980’s, it surfaced during a period of massive and 
prolonged social upheaval. Political unrest undermined preventive 
efforts and may have helped, through other mechanisms, to spread 
HIV. Political disruptions have also served to paralyze coordinated 
efforts by the state to prevent HIV transmission. For example, while 
in 1991 the country’s first democratically elected government (led by 
Jean-Bertrand Aristide) installed a new Ministry of Health which 
promised to make AIDS prevention its top priority however; its 
initiatives were disrupted when, in September of the same year, a 
violent military coup brought a swift end to Haiti's democratic 
government. The 1991 coup d'état not only halted the coordinated 
responses to the AIDS epidemic, it had a direct impact on the pattern 
of HIV transmission. Prior to the coup, urban population in places 
such as Cité Soleil had higher rates of seropositivity than rural 
populations.  However following the coup, when the army targeted 
urban slums for brutal repression, large numbers of adult residents 
from these urban places fled to rural areas. This internal 
displacement substantially changed the equations describing the 
dynamics of HIV transmission within the country (Farmer 
2001:144).  

Since 1991, the office responsible with coordinating 
preventive programs has been further constrained by six coups 
d'état, which have led, inevitably, to personnel changes and to more 
significant disruptions. The result is there had been no 
comprehensive effort to prevent HIV transmission in Haiti. Even in 
Port-au-Prince, what has been accomplished thus far, in the way of 
spreading awareness of HIV transmission, has only reached a small 
segment of the population (for example, Haitians who are 



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francophone, literate, and have access to televisions). These 
messages have been especially unsuccessful in rural areas, where the 
populations are most vulnerable at present (Farmer, 2001:145).  

In addition to the failure of preventative programs, the lack 
of access to medical resources and services for the poor segment of 
the Haitian population has further entrenched AIDS within the 
society. Seeking medical help is challenging and costly for most of 
the population and for those who have been diagnosed with AIDS, 
antiretroviral are unaffordable and often unavailable (Farmer 
2001:146). As a result, political instability within Haiti has 
structured both the transmission of HIV and also the nature of its 
outcomes once an individual is sick with complications of AIDS.  

 
Economic Dimension of AIDS  

As mentioned earlier, the social and political unrest in Haiti 
(specifically in the last two decades) has had a massive impact in 
further impoverishing the Haitian state. Poverty has played a major 
role in generating vulnerability towards HIV infections by limiting 
the types of opportunities that are available for those living in the 
region. Low income, high rates of unemployment and the lack of 
social welfare have and continue to serve as strong motivators for sex 
work. Entering into this industry has exposed the improvised 
segment of the population to HIV infection and has increased their 
overall risk of contracting the disease. What is important to 
emphasize is that it is not sex work specifically that increases 
vulnerability but rather the economic conditions alongside   other 
social inequalities that have restricted individuals ability of choice, 
leaving them no alternatives but to engage in behaviour that 
increases their risk to HIV infection (Kreniske 37).   

Gender and Sexuality  
 
The fact that AIDS has been stigmatized globally as a 

homosexual disease (predominantly inflicting gay men) illustrates 
the need to examine the forces of gender and sexuality in relation to 
the epidemic. While the majority of infections in the developed world 
are among men, the complete opposite is seen in the developing 
world. Increasingly, HIV is predominantly infecting women as 
opposed to men via heterosexual sex in places such as the Caribbean 
(Kreniske 33-37). Due to the centrality of sexual behaviour to the 



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AIDS epidemic, since HIV is primarily sexually transmitted within 
populations, the examination of how gender and sexuality affect risk 
taking in sexual behaviour, sustain vulnerabilities and undermine 
resilience in dealing with the epidemic need to be addressed 
(Kempadoo 179-181). In doing so the hope is to understand why 
women and young girls face infection rates several times higher than 
the general population. 

 
 As stated earlier, HIV in the Haiti, as well as the 

rest of the Caribbean, is primarily transmitted through heterosexual 
intercourse. Despite the initiatives taken by the Ministry of Public 
Heath to disseminate information about HIV transmission and 
prevention, rates of infection have continued to increase. As Kamala 
Kempadoo states, there seems to be a “disconnect” between 
knowledge about sexually transmitted infections such as HIV and 
sexual behaviour. This is the reason as to why HIV prevention and 
AIDS treatment activities have failed in the region. What this 
indicates is that to create effective prevention strategies, the factors 
that are preventing the application of knowledge in sexual behavior 
have to be examined. Undoubtedly, power relations between sexes 
and hegemonic constructions of gender that are present within 
Haitian society are critical to this issue (Kempadoo 182).  

 
Within Haiti, a “risk” centered quantitative approach has 

been used to explain why certain groups within societies are more 
vulnerable to the AIDS epidemic than others. This concept of “risk” 
has come to be equated with individual behavioural risks, such as 
inconsistent condom use or multiple partners. Thus, HIV prevention 
has been focusing on an individualized view of sexuality and the 
physical act of unprotected sex has initially become the major focus 
for intervention aimed at behavioural modification. The assumption 
is that “high-risk” sexual behavior can be changed into safer sexual 
behavior by encouraging desired behaviors through the provision of 
knowledge. This approach, based on the biomedical model that 
focuses on individual behaviour change, makes the assumption of a 
rational individual who is motivated by self-protected and enjoys the 
freedom to choose exactly when, how and with whom to engage in 
sex. In such a scenario the risk that such an individual takes can be 
diminished through information and education. However, this model 
is deeply erroneous due to the fact that firstly it does not take into 
account that sexual behaviour is often driven by desire, which is 
deeply irrational. Secondly, this extremely narrow understanding of 
risk does not take into account the social inequities that exist 



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between men and women that play a substantial role in increasing 
women’s risk to HIV. Women’s very position in society is the primary 
cause of exposure to risk of HIV infection in Haiti. Thus when 
prevention is focused on promoting condom use, faithfulness, 
partner reduction and abstinence, it fails to consider the reality of 
what it actually means for women to abstain, be faithful or use a 
condom. The fact is that these options do not take place in isolation; 
each of them exists and is lived in specific socio-cultural, economic 
and political context, which predispose, enable and/or reinforce 
behaviour and constrict free choice. Thus in Haiti, the traditional 
gendered cultural norms of power and sexuality make it difficult, 
sometimes even impossible, for women to act on these behavioural 
suggestions as viable options for prevention. Cultural norms of 
power, unequal gender relations, social expectations, desire and 
unequal access to economic and cultural resources render knowledge 
alone inadequate, especially among poor women (Kempadoo 182-
188). 

Another aspect that has been disregarded in this approach 
has been the complexity of sexual relationships. These relationships 
are embodied in and are products of negotiated relationships to 
power, economic dependence and social inequality that 
contextualize, influence and in many ways determine sexual 
behaviour. In the majority of these relationships men hold the power 
and thus control the relationship and women are often left to 
negotiate their position. For example, the decision to use a condom 
is a decision to not reproduce at the same time as to prevent 
infection. It is also a decision that must be made for each act of 
intercourse. Thus women must repeatedly address the issue of sexual 
decision-making and sexual control and each time this is done they 
are emotionally, sexually, physically and economically vulnerable 
(McNamara 122-125).   

What this example highlights is that to implement 
successful and culturally relevant policies to prevent HIV 
transmission, the larger social and gender inequalities and structural 
determinants of choices and behaviors that exist within Haiti in 
which risky practices occur have to be addressed.  

 
 
 
 
 
 
 



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Conclusion 
 
This paper has attempted to illustrate and examine how the 

political, economic and gender dimensions of structural violence 
have shaped the incidence and the prevalence of AIDS in Haiti. This 
has illustrated in a broader way the fundamental idea that disease 
and illness are not random phenomenon. Each society by its 
organization and core economic features, rooted in historical 
processes, produces certain characteristic patterns of disease and 
death that are specific to it. As a result the load of disease born by 
each society is one indicator of the political economy and the social 
life of the society. As Kreniske has articulated, “disease, then, is, in a 
large part, a social event expressing the central realities of the society 
in which it occurs” (35). Thus, by examining the social determinants 
of AIDS this paper has illustrated how vulnerability to HIV infection 
are not simply due to certain risk factors that have manifested due to 
risky behavioural practices but rather that these risky behavioural 
practices have been the result of unequal gender relations, social 
expectations, desire and unequal access to economic and cultural 
resources.  

One dimension that this paper has not addressed is the 
impact of AIDS on the families of individuals that have been affected 
by the disease. Due to the fact that AIDS predominantly affects 
women within the Caribbean, how does the AIDS epidemic affect 
domestic arrangements and education of children?  How are social 
units in the event of loss of personnel impacted? And lastly, how 
does AIDS affect social reproduction? These questions serve to 
emphasize that while analyzing the impact of AIDS on societies we 
need to remember that like any medical condition, AIDS affects 
individuals and that their experience is just as important.  

 

 

 

 

 

 

 

 

 



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