The term promiscuous was used more in Thailand than in any other country. Usually it was part of a conditional expression, comparing the persons who got HIV from promiscuity to those who got it from their family or occupation. For example:
T25 Female 34 Thai Buddhist Not too important Sympathy for doctors and nurses who were infected but dislike for one who was promiscuous or use needles. T27 Male - Thai Buddhist Somewhat important Sympathy for transfusion or those infected by spouse but dislike for one who had bad behaviour. T106 Male 18 Thai Buddhist Very important Sympathy for one who got it by genes and blood, but dislike for one who got from prostitution. T574 Male 20 Thai Buddhist Somewhat important No feeling for one who was promiscuous, bisexual and using needles and I feel sympathy for one got it by accident. Among the other countries, in the Philippines it was used more by those who were very religious, but not only religious persons: JS434 Female 19 Japanese None Not important at all Among the many people who spend the promiscuous lives, I think others are very pitiful because they are regarded as like them. I332 Male 29 Indian Hindu Very important Sad about people who contracted it through promiscuous sex. Pity people who contracted it through other sources. S105 Female 19 Other Moslem Very important If they are promiscuous, serves them right! Prostitution was mentioned by 3% of people in Singapore, but by none in India which probably reflects ignorance of the infection route which was reported to be high at that time. Comments: A147 Female 60 Other Christian Very important Feel sorry for them, but if they get through prostitution or "running around", they should not do that and it is a lesson for them. J190 Male 33 Japanese Other Somewhat important Except blood products, the infection by abnormal sex and prostitution is unforgivable and helpless. J348 Female 53 Japanese Buddhist Somewhat important It depends on the channel of the infection but I feel pity for the patients infected through blood transfusion. Think the patients infected through prostitution are dirty. I wish they won't infect it to their families. S140 Female 18 Asian Moslem Very important If they got it through sex in prostitutes....they deserve it! The terms “Homosexual or Gay” were more common in Australia and Hong Kong, and New Zealand (Table 1), countries which at that time had almost no reported cases of heterosexual transmission beyond an initial infected partner (4). However, still less commonly quoted than one would expect from transmission incidence, or social phobia. Age may be important as seen in Australasian comments, as they may be less tolerant towards alternative sexual choices. In New Zealand eleven people used these words and eight of them considered their religion to be important, and seven were over 60 years old. In Australia thirteen people used these words and eight of them were over 61 years old. For example: N71 Female 65 Caucasian Christian Somewhat important I am plain scared of them. Through blood transfusions I am really sorry . All blood must be meticulously tested. As for Homosexuals its their own fault -their misbehavior has brought to AIDS which will be the plague of the earth. N73 Male 70 Caucasian Christian Somewhat important No pity for homosexuals (active). Sorry for those contaminated, with blood transfusion. N304 Male 70 Caucasian None No too important Depends on how they contracted it. If sexual indulgence, either homo or hetero, serves them right. If blood transfusions complete sympathy. A51 Male 67 Other Christian Somewhat important Very sad if caught other than homosexuality. A125 Female 76 • Christian Somewhat important Sorry for the ones who get it from blood. Not so sorry from the gay people. Another key word one would expect to be associated with AIDS because of earlier infection routes is drugs or needles. In Australia for example, seven people mentioned about the people infected through drugs and all of them made a distinction between people based on the channel of infection. Four people expressed pity only for the people who got it by accident like through blood transfusion. Five people showed that they don’t have good feelings towards the people infected through drugs. Comments: N82 Female 52 Caucasian Christian Not too important Depends how it was acquired. Sadness for blood recipients. Disgust for sexual deviants and drugtakers. N321 Male 42 Asian None Somewhat important Depend on how they contact the disease. No sympathy for those who use drug. A36 Male 21 Caucasian Christian Very important Sorry for those who got it through blood transfusions etc. through no fault of their own. The others and druggies, gays, those who sleep around, BAD LUCK. S119 Female 19 Asian Moslem Very important I don't feel sorry for those who had it through unhealthy sex, drug abuse. The distinction with so-called “Innocent” persons was most common in Singapore. This type of comment was seen everywhere except notably in Japan and Philippines. For example: I12 Male 29 Indian Christian Very important My feeling depends on the way how they got infected. If they are innocent I will show sympathetic approach. I131 Female 23 Indian Hindu Not too important Some innocent people also infected by this through blood transmission. I729 Female • Indian Hindu Somewhat important Sympathy for innocently affected. S1 Female 21 Asian Christian Very important For innocent people or children who got it from their mothers or through blood transfusion etc., I think it is really unfair to them. For those who get it through casual sex etc., I think it serves them right! S71 Female • Asian Christian Very important Some are innocent. Some got it because of themselves. e.g. flirt around. S90 Female 19 Asian Other Somewhat important Scared and sometimes sympathize with them if they are innocent people who got it from blood transfusion or from their mother. S163 • 18 Asian Moslem Very important Feel sorry for innocent victims. HK38 Female 19 Asian Christian Somewhat important Some are innocent e.g. babies, patients infected by blood transfusion. Some should bear the responsibility. At the bottom of the table, the keywords “blood transfusion or hemophilia” are given, as they were quite frequent, usually in a comment making a comparison or distinction between two groups of patients: J62 The people who got infected because of hemophilia or blood transfusion are pitiful. Sorry for the people who got it through dishonest sexual matters... Privacy One of the bioethical issues closely related to AIDS, is privacy. Confidentiality is a consequence of respecting autonomy. People were asked the question "If someone has HIV (the AIDS virus), who else besides that person deserves to know that information?" (2). People in all countries are similarly positive about sharing information with a spouse, with 85-98% saying that a spouse deserved to know if someone was the carrier of a defective gene or had a genetic disease, with 88-98% saying the same for HIV (Table 2). Less people were willing to share with family, and about half the people thought that the information should be shared with the insurer or employer, except in Japan were only one quarter did. If so many people would be willing to share the information with others, then the attitudes that people have towards the disease are even more important than in the case when people do not want to share that information. In 1994 Macer et al. (5) conducted a survey of members of the Japan Association of Bioethics, which included the same question on attitudes to persons with AIDS. Strikingly, 24% of the 175 respondents said that they knew someone with HIV. This is high in a country with a low prevalence of HIV, but not so different to the general public in the USA, where even in 1991 17% of people reported that they knew someone with HIV (6). The types of comments expressed were similar to the public in general, suggesting the educated people in bioethics were equally likely to distinguish between someone being a so-called “innocent” and “guilty” victim. Personal knowledge of someone with the disease may not make people more sympathetic to any of the diseases examined in the survey (2). However, this group of persons were less willing to share information with others about HIV status, with the equivalent values for Table 2, being 14% responding that the employer deserved to know (and 74% stating they did not), 10% for insurer (75% no), 89% for spouse (5% no) and 76% for other immediate family (11% no). We could suggest that the people in the Bioethics Association were more concerned about privacy than the general public or medical students. Discussion Another method that could be used to examine the attitudes towards people with AIDS is to interview people who carry HIV directly about their experiences. One of the problems with this method is that in some countries included in this comparison, for example Japan, people with HIV do not openly disclose their infection because of fears of rejection or ridicule. Even in countries like Australia or New Zealand which have a more open social image of AIDS, there may be some people who are afraid to announce that they have HIV, and certainly there are some circles in any society where one would not say “I have AIDS”. In addition if such a method is used responsibly, it needs considerably more investment in terms of counseling and followup. There have been some studies published on the results of interviews with people with HIV infection. One group of studies has focused on the discrimination that people report in practice. Danziger (7), and Andre et al. (8) examined cases of discrimination by health care workers in Poland and Italy, respectively. This practice was also been reported widely in Japan in the early 1990s. Dentists are one of the groups most frequently reported for discrimination, and often the persons were denied health care services or forced to seek other care. One of the reasons for this fear is that the hospital or clinic does not want to be labeled as a place where one may catch HIV. In the comments in this survey the most common medical term mentioned was blood transfusion (see Table 1). Only one person in this survey however, referred to dentists: Sorry. Especially sorry if contracted from infected blood or dentist but a serve-you-right attitude if from free sex. NZ315 This suggests that most people did not especially associate dentists with AIDS. The student surveys conducted in Australia, Hong Kong, Japan, New Zealand and the Philippines were among potential health care workers of the future. There were a few comments about professional responsibility among more than 700 comments from these groups. The professional role did not seem to affect the attitudes, with 10% in Hong Kong rejecting persons with HIV, although in the future they would be health care workers and this attitude would be unprofessional. Examples include: I guess a feel a little worried by them but as a doctor I will take all precautions to protect myself and do my best to help them. AS49 In the sense of having had sex with unspecified persons, it serves them right. But I won't discriminate them because they are AIDS patients. JS18 If it is caused from the person's everyday behavior, it is proper punishment. As for other cases, I think there are less cases if doctors are careful on the time of blood transfusion. JS291 I don't tell (not to the patients him/herself). JS397 Fine -other than to take special care when dealing with them as patients. AS24 I want to know how they get the disease and then I can show my feeling. If I don't know that, I will see them as a patient only. HK80 There were only a few comments that mentioned a specific gender, despite the common distinction in the literature between men and women. At the time of the survey there was a trend for half the new infections to be women. These comments were most common in Thailand, and in other countries only one clearly blamed men. Men-no sympathy. Women-sympathy if they are decent, got from husband. S34 Have had no direct contact with any person -my feeling are complicated. Those who have contracted from blood transfusions and women from bi-sexual /drug users -then it is tragic. A32 Sympathetic. Particularly medically acquired HIV. Promiscuous homosexuals and women with recent infection sexually acquired were warned. Sympathetic with their suffering but not their carelessness. A173 In all countries people made distinctions between so-called “innocent” and “guilty” persons. Only one comment actually mentioned the term guilty, “If the patients got it because they did something to have a guilty conscience, it serves them right. The other patients are pitiful all the more for because there're this kinds of patients.” (J115) How do we assign people to a guilty category in our mind? Some people used religious criteria, others used sexuality, others use of illegal drugs. These groups may all be associated with behaviour that is against someone’s morality, and many of the people who gave negative comments were judgmental of other’s lifestyle. This type of reasoning may also attach much stigma to the people with AIDS. When people realize that they have HIV, they have to confront an altered identity, and have a long latent period before they start to show signs of AIDS, and have further intensive therapy as demanded by modern treatment strategies. There is a long time in which the psychology has to develop to being prepared for the disease, and beyond the normal regret of the actions which contributed to the disease, people who are called “guilty” may have considerable stigma about their behaviour (9). The degree of stigma may vary over the course of the infection, and depend upon changing social attitudes and reactions to the people with HIV. One of the goals of bioethics is to help people make decisions, so they can make better choices. It should also make us more tolerant of other’s decisions. There is some education of AIDS in schools, and in the 1993 International Bioethics Education Survey it was found that 94% of Australian and New Zealand biology teachers had taught about AIDS and 84% of Japanese biology teachers (10). Less social studies teachers had discussed AIDS in Japan, 60%, compared to 78% in Australia and 90% in New Zealand. However, this did not examine the ethical content of those classes. It is reassuring that most people expressed sympathy or compassion towards those with HIV. However, the hate expressed in some of the negative comments is not one we would like to have in a bioethically mature society. It can be found in comments of major public figures, e.g. “We've got to have some common sense about a disease transmitted by people deliberately engaging in unnatural acts.” (Sen. Jesse Helms, New York Times, 5 July 1995). We can also see this hate expressed in three countries included in this survey, though the events were after the survey was conducted so did not themselves alter the results. In 1996 Israel had a scandal over semi-official ban on the use of Ethiopian blood in donations, which was estimated to be actually protecting a risk of one infection every ten years (11). In 1997 the Indian state of Maharashtan forced compulsory HIV testing, segregation and branding for girls of 12 years and over who lived in homes for the destitute, and to brand HIV positive prostitutes with indelible ink (12), which was not allowed by the Supreme Court of India. Russia introduced a law in 1995 that demanded certificates of freedom from HIV for non-Russian citizens living there (13). In the surveys there were a significant number of comments expressing fear which are the reasons for such strong measures, but they were not limited to those countries. Pressure upon people with HIV may be just as great in the absence of clearly discriminatory laws merely by the combined attitudes of some groups in society which blame the person for having a disease. This paper summarizes some of the metaphors that were used about persons with HIV. It provides a complement to other works in the literature which deal with the popular metaphors expressed (14). Over time social attitudes change, and we can see that people in the United States displayed more tolerance towards people with AIDS after time, however, they still did not express compassion to those who contracted the disease through sexual or drug use practices (5). However, still people supported the presence of anti-discrimination laws passed in 1990 in the USA. Despite the opinions expressed to protect persons privacy in Table 2, there are cases still reported where employers test persons with HIV and illegally dismiss them (12). Such testing is actually even not economic, but based on public fear (15). One should also note that despite the anti-discrimination laws in the USA to protect persons with AIDS internally they had a policy to exclude HIV-infected foreigners from entering the country. One of the factors that might have been thought to influence attitudes was the frequency of AIDS cases, and the main routes of infection. In Table 1 the prevalence of HIV and number of reported AIDS cases for 1993, the time of the survey, are shown. There had been cases reported in all countries. For India there is doubt over the real number of AIDS cases at that time, but each country was at a different stage in infection route, and there was a trend over time in HIV infections from accidental transfusion and homosexually acquired HIV towards heterosexual routes. We can say that the metaphors that people have, can continue to maintain discriminatory attitudes towards persons with HIV. The results of this study suggest that the public education campaigns to reduce HIV spread, may have actually against increased discrimination persons with HIV and AIDS, if the metaphors expressed in this survey represent the behaviour of persons. We should be more careful in combating AIDS, so that only the disease and not the people with it, are targets of the negative campaign to eradicate the tragic disease. The social attitudes towards persons with HIV will also affect the risk behaviour and prevention measures that are taken, though it is difficult to predict in which way (16). The discriminatory attitudes may represent broader racial or sexual discrimination in society, and there have even been cases of persons led to seek deliberate HIV exposure as a sign of hopelessness (17). In Hong Kong, Japan and Singapore there had been media discussion of foreign persons as sources of HIV, for example foreign prostitutes, but there were no comments specifically mentioning foreigners in any country. There were also surprisingly few comments about homosexuals, given the prejudice that is shown against them (18). It appears that either people just inferred these groups in their comments, or they did not label persons and instead used terms like it serves them right - in general to anyone. It would have been interesting to conduct the survey at the end of the 1980s when such prejudice may have been more common. For example, in homosexual bathhouses in Japan, foreigners were excluded for fear that they would carry HIV (18). In Japan there are actually no open public associations of persons with AIDS, or homosexuals, while in countries like Australia there is still homophobia and AIDS-phobia but there are public associations for both homosexuals and for people with AIDS (19). A survey of 620 companies in Japan in 1993 found only 7% had an AIDS policy, but 85% were working on AIDS education (20). However, it is unlikely that those companies that actually discriminated would reveal they did so. Overall there tended to be less critical comments seen from females when compared to males, but there were more differences in the attitudes between some samples than between gender or age within the samples. Several studies have found that females tend to have more favourable attitudes towards persons with AIDS than males, including one conducted on studnts at Shimane University (21), and a survey in Scottish public (22). In conclusion, we can say that exploring the comments people make in response to the questionnaire can provide useful insights on their attitudes and background. We think we should reject the terms like “innocent victims” and “sinful or deserving of the disease”, because we have no right to be a judge of others. All sufferers are victims, and the social pressure can aggravate the stigma associated with the disease. The fear of discrimination is an important type of stigma, and a Scottish study found that people with AIDS probably felt disproportionately more negative attitudes towards themselves than the people had (22). Some social images differ between countries, and cultural specific pressures may alter the actual type of stigma that is put on persons, as seen in a study of USA and Africa (23). "Bioethics" means the study of ethical issues arising from human involvement with life, and we can call it simply the "love of life" (1). Love is a broad term, but includes the concepts of balancing benefits and risks. Love is the desire to do good and the need to avoid doing harm. It includes love of others as oneself, the respecting of autonomy. It also includes the idea of justice, loving others and sharing what we have - distributive justice. There should not be any distinction between “us” and “them” (24). Bioethics includes love for oneself and one’s family, love for other people, love for the environment around us, and love for God. Under the concept of love of others and loving good, there can be no discrimination of the sick, and we would argue that rejection of those with HIV is against bioethics.|
% |
Aus |
HK |
India |
Thai |
Israel |
Japan |
NZ |
Phil |
S |
||||
|
N |
296 |
94 |
700 |
867 |
30 |
610 |
308 |
131 |
209 |
||||
|
deserve, serve, ask for |
1 |
1 |
1 |
3 |
0 |
3 |
1 |
2 |
13 |
||||
|
fruit |
0 |
0 |
0 |
0 |
0 |
1 |
0 |
0 |
0 |
||||
|
fault |
2 |
1 |
1 |
1 |
0 |
1 |
1 |
2 |
2 |
||||
|
punish, sin |
0 |
1 |
1 |
1 |
0 |
1 |
0 |
0 |
1 |
||||
|
God |
0 |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
1 |
||||
|
ethic, moral |
1 |
1 |
1 |
1 |
0 |
1 |
0 |
0 |
1 |
||||
|
responsibility |
4 |
1 |
1 |
1 |
3 |
0 |
1 |
2 |
1 |
||||
|
promiscuous, loose |
1 |
0 |
0 |
9 |
0 |
1 |
1 |
3 |
1 |
||||
|
prostitution |
1 |
0 |
0 |
2 |
0 |
1 |
0 |
0 |
3 |
||||
|
homosexual, gay |
4 |
5 |
0 |
0 |
0 |
1 |
4 |
1 |
1 |
||||
|
drug, needle |
3 |
0 |
0 |
3 |
3 |
1 |
2 |
0 |
3 |
||||
|
innocent |
2 |
2 |
2 |
2 |
3 |
0 |
1 |
0 |
8 |
||||
|
blood, transfusion, hemophilia |
8 |
7 |
3 |
3 |
3 |
10 |
8 |
1 |
7 |
||||
|
Prevalence of AIDS and HIV in 1993 (per million persons)* |
|
|
|
||||||||||
|
*No. AIDS cases / million |
299 |
21 |
1.0 |
+ |
71 |
6.7 |
137 |
2.6 |
31 |
||||
|
*HIV seroprevalence / million |
647 |
546 |
1923 |
25000 |
476 |
50 |
364 |
277 |
418 |
||||
|
Total Cumulative Cases reported by 1 July 1993** |
3697 |
63 |
312 |
1569
|
234 |
543 |
63 |
92 |
58 |
||||
|
% |
Public |
Students |
|||||||||||||
|
|
NZ |
A |
J |
India |
Thai |
R |
Isr |
NZ |
A |
J |
India |
Thai |
P |
S |
HK |
|
Employer |
|||||||||||||||
|
Yes |
46 |
48 |
28 |
45 |
60 |
24 |
60 |
29 |
38 |
25 |
42 |
55 |
61 |
48 |
53 |
|
No |
29 |
33 |
52 |
31 |
19 |
55 |
32 |
45 |
40 |
55 |
34 |
25 |
30 |
35 |
26 |
|
DK |
25 |
19 |
20 |
24 |
21 |
21 |
8 |
26 |
22 |
20 |
24 |
20 |
9 |
17 |
21 |
|
Insurer |
|||||||||||||||
|
Yes |
58 |
57 |
24 |
54 |
61 |
37 |
74 |
44 |
36 |
27 |
51 |
63 |
64 |
63 |
61 |
|
No |
20 |
22 |
49 |
24 |
15 |
35 |
12 |
35 |
38 |
49 |
22 |
19 |
25 |
20 |
17 |
|
DK |
22 |
21 |
27 |
22 |
24 |
28 |
14 |
21 |
26 |
24 |
27 |
18 |
11 |
17 |
22 |
|
Spouse or fiancee |
|||||||||||||||
|
Yes |
98 |
98 |
93 |
82 |
98 |
96 |
92 |
96 |
96 |
94 |
76 |
96 |
99 |
98 |
92 |
|
No |
1 |
2 |
3 |
7 |
1 |
2 |
2 |
3 |
2 |
2 |
9 |
2 |
1 |
1 |
1 |
|
DK |
1 |
0 |
4 |
11 |
1 |
2 |
6 |
1 |
2 |
4 |
15 |
2 |
0 |
1 |
7 |
|
Other Family Member |
|||||||||||||||
|
Yes |
81 |
77 |
89 |
66 |
85 |
70 |
80 |
56 |
66 |
90 |
58 |
89 |
93 |
87 |
81 |
|
No |
9 |
14 |
5 |
6 |
7 |
17 |
14 |
25 |
21 |
4 |
20 |
5 |
4 |
8 |
8 |
|
DK |
10 |
9 |
6 |
8 |
8 |
13 |
6 |
19 |
13 |
6 |
22 |
6 |
3 |
5 |
11 |
Please send comments to Email < asianbioethics@yahoo.co.nz >.