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Discrimination against people with HIV and AIDS in Poland
Renee Danziger,
research fellow a
http://www.bmj.com/cgi/content/full/308/6937/1145
a
Health Policy Unit, London School of Hygiene and Tropical
Medicine, London WC1E 7HT
Correspondence to: 19 Primrose Hill Road, London NW3 3DG.
The recent
increase in HIV seroprevalence in Poland, particularly
among injecting drug users, has been accompanied by
widespread discrimination against people affected by
HIV and AIDS. As in other countries, this
discrimination may be attributed to a large extent to
fear and ignorance about HIV and AIDS together with
pre-existing prejudices against the people who are most
commonly associated with the epidemic. In Poland extreme
hostility towards drug users combined with the
powerful influence of a traditional Catholic church
have so far impeded effective education about HIV and
AIDS and anti-discrimination strategies.
Infection
with the human immunodeficiency virus (HIV) has spread
rapidly in Poland in recent years, the cumulative total of
reported cases having risen from 435 in 1990 to 2476
in 1992 (Piotr Jaworski, personal communication).
Reported cases represent only a fraction of the
actual total, which has been estimated at between 10
000 and 20 000.1
The AIDS epidemic in Poland has been characterised by
widespread discrimination against people affected by HIV
and, though piecemeal efforts have been made to reduce
discrimination, the development of an effective
anti-discrimination strategy has been impeded by a
complex web of cultural, social, and political
pressures.
Injecting
drug use and homosexuality
The HIV
epidemic in Poland is closely associated with drug use,
over 70% of reported cases of infection being among
injecting drug users. HIV prevalence among this group
rose from 0.8% in 1988 to 8.7% in 1989 and to 20% in
1991.2
3
Three factors
help to explain the rapid transmission of HIV among
drug users in Poland: the easy availability and wide use
of cheap, home produced heroin known as kompot; a strong
tradition of syringe sharing; and a general shortage
of disposable needles and syringes.
Most addicts
in Poland are homeless, unemployed, and unskilled.4
They are widely perceived as irresponsible and dangerous,
an image compounded by reports of drug users stealing
in order to pay for drugs. The surge in HIV infection
among drug users has intensified pre-existing fears
and prejudices while at the same time contributing to
a more general intolerance towards all people
affected by HIV.
At present
homosexual activity accounts for a comparatively
small proportion of Poland's cases of HIV infection. This may
explain why the AIDS epidemic, and discrimination against
people with HIV and AIDS in particular, has not led
to an increase in hostility against homosexuals to
the same extent as among drug users. A further factor
is the "invisibility" of many homosexuals in Poland.
According to one public health official, though drug
users are almost always identifiable by their appearance and
demeanour, homosexuals in Poland are "not overt about
their sexuality and don't draw attention to
themselves." As a result, homosexuals are less often
targeted for violence or discrimination.
Monar (the
youth antidrugs movement) is Poland's main voluntary
organisation helping drug users and people with AIDS. Monar
provides a range of services to current and ex-drug users,
either directly or by referral, including
psychosocial support, rehabilitation, housing, and
health care. Its efforts have frequently been blocked
by public disapprobation and protest. For example, in seven
separate towns attempts to provide homeless HIV positive
drug users with accommodation were vehemently opposed
by local residents. In several instances violence was
threatened and sometimes used to prevent drug users
from moving into a community. The Social AIDS
Committee, a Polish non-governmental organisation working
on the social aspects of AIDS, reported that many of the
drug users' homes were firebombed and the inhabitants
harassed by having their water cut off or being
refused admission to local shops.5
In one
particularly notorious case the residents of Laski, near
Warsaw, protested against a proposal to provide eight
children of HIV infected drug users with
accommodation in their village. Despite efforts by
government officials to allay fears about
transmission via mosquitoes and sewers, the villagers persisted
in their opposition. When eventually a suspicious fire
occurred in one of the houses the project organisers
were compelled to relocate the children.6
Ignorance and
fear of HIV and AIDS
In addition
to the deep rooted hostility towards drug users and
the people associated with them, a further cause for
discrimination against people with AIDS is confusion
about the modes of transmission of HIV. A survey of
1123 adults by the Warsaw based Centrum Badania
Opinii Spolecznej (Centre for Public Opinion Surveys)
in 1992 found that 89% of respondents (999) knew that HIV could
be spread through sexual contact; 93% (1044) knew that it
could be transmitted by shared needles, syringes, or
medical equipment; and 94% (1056) knew that HIV could
be spread by blood transfusion.7
The survey also found that almost a quarter of the
respondents (258; 23%) believed that HIV could be
caught in public toilets and baths; one fifth thought
that it could be spread by sharing pots, pans, and
eating utensils with infected people; and as many as
31% of respondents (348) believed that HIV could be
transmitted by mosquitoes.
Misunderstanding of how HIV is transmitted helps to explain
many cases of discrimination, including that of a woman
forced to leave her job after she had provided
temporary shelter for HIV infected people, the mother
of an infected drug addict who was banned from local
shops, and infected fathers who have been denied
access to their children by divorce courts on the ground
that this is necessary to protect the children.5
Nor have
health professionals been immune to confusion about
HIV transmission. A survey among health workers in the southern
town of Sosnowiec found that 40% of respondents were
unaware that HIV could not be spread by insects, and
30% believed that daily contact with HIV infected
people carried a risk of transmission.8
Fears among
medical personnel about the risk of HIV infection
have been expressed in many ways. Drug users are frequently
refused admission to hospital because of fears that they
may be infected with HIV and thus pose a risk to
staff. In Warsaw's psychiatric hospital for many
months only one doctor worked in the drug
rehabilitation unit because the rest were worried
about the presumed risk of HIV transmission.5
Elsewhere a gynaecological hospital reportedly turned
away a female drug addict who was haemorrhaging
because of concerns that she was infected with HIV.5
LEGISLATION
VERSUS EDUCATION
Hospital
patients in Poland are often tested for HIV without
their consent and sometimes without their knowledge. Though
testing for HIV without the patient's informed consent
breaches Polish civil law as well as the physicians'
code of ethics, such tests are being carried out with
increasing frequency before the provision of surgical
or other treatment (parliamentary reply by Andrzej
Wojtyla, minister of health and social welfare, May
1993). In some cases doctors have refused to operate on
patients who test positive. In others health workers
receive bonus payments for treating patients
identified as HIV positive, though this system has
proved unworkable in some areas. For example, in
Lublin 30 male nurses reported for work to transfer a
single infected patient in the hope of receiving extra pay.8
Even a proper
understanding of the mechanisms of HIV transmission
does not ensure tolerance or solidarity with infected people.
Of the 354 people in the Centre for Public Opinion Surveys
sample who correctly identified the modes of HIV
transmission, nearly half favoured isolating infected
children in uninhabited areas, hospital wards, or
special ghettos. Data such as these underline the
need for comprehensive education about HIV and AIDS which
addresses the social as well as the medical aspects of the
epidemic. As one study has stated: "[HIV and AIDS]
education must be more than the provision of
information. Information alone can increase, rather
than reduce, fear and prejudice. Education must address
not only the facts of HIV infection, particularly the
means of transmission, but also the bases of
pre-existing prejudice, stereotypes and
discrimination against those popularly identified
with and discriminated [against] because of HIV and AIDS."9
The same
study noted that antidiscrimination strategies are
most likely to be effective when education is accompanied by
legislation which prohibits discrimination against people
on the ground of actual or suspected HIV infection.
In Poland, however, there are several reasons why
such legislation is unlikely to be introduced.
Firstly, there is no evidence of popular support for
the introduction of protective legislation. On the contrary,
it might well be opposed by large sectors of society which
consider AIDS to be a fitting punishment for immoral
behaviour. Secondly, the Polish legal system does not
include any general or specific antidiscrimination
regulations, so there is no precedent on which to
base anti-HIV and AIDS discrimination laws.10
Thirdly, as Poland struggles to address the far
reaching social and economic consequences of its
recent political and economic transformation it is
unlikely that enough parliamentary time or resources could
be devoted to an issue which still affects a small and
comparatively powerless minority of the population.
For these reasons education remains the main tool
available for achieving a reduction in HIV and AIDS
related discrimination.
Obstacles to
effective HIV and AIDS education
Efforts in
Poland to educate the public, and particularly young
people, about HIV and AIDS have been confounded by a range of
social, cultural, and political forces which prevent open
discussion and effective education about HIV and
AIDS, safer sex, and the need for tolerance.
Dialogue
about HIV, AIDS, and related issues is severely inhibited
by strong taboos surrounding sex and sexuality in Poland.
A survey in 1991 among 2963 16-18 year olds found
that the top five sources of information about AIDS
were non-interactive--television (1956 respondents;
66%), periodicals (1482; 50%), radio (1304; 44%), sex
periodicals (859; 29%), and books (711; 24%). Only
178 (6%) respondents reported receiving information on HIV and
AIDS from their mothers, 148 (5%) from their girlfriend or
boyfriend, and just 89 (3%) from their fathers.11
The
reluctance to discuss HIV and related matters within the
family is further underlined by a survey in 1993 among 987
married women with children in the 16-18 year age
group. Most respondents reported that they avoided
talking about sex with their children and would
prefer schools to take on more responsibility for sex
education.12
Only 19% of 16-18 year olds in Poland receive
information on HIV and AIDS from school-teachers.11
To the extent
that information on HIV and AIDS is provided in
classrooms it is chiefly limited to basic technical information
on transmission, with little opportunity for discussion on
the personal and social dimensions of the epidemic.
This reflects the policy of the Ministry of National
Education, which until recently opposed the
introduction of sex education classes in Polish
schools, claiming together with many church spokesmen
that the existing provision of biology lessons is enough for
children to understand the principles of procreation and
healthy living.
The Ministry
of National Education and the Ministry of Health and
Social Welfare have disagreed sharply in the past over the
issue of sex education in schools, the Ministry of Health
and Social Welfare proving more supportive of efforts
to introduce a new curriculum on sex education,
including HIV prevention, in secondary schools. The
conflict between the ministries was highlighted when
the Ministry of Health and Social Welfare translated
the United Kingdom Health Education Authority's brochure AIDS
and You into Polish and arranged for its dissemination
free of charge among schools in Poland. This move was
severely criticised by the Ministry of National
Education on the ground that much of the
brochure--which was intended by its British authors for
health workers, teachers, and parents--contained material
deemed unsuitable for young people.13
The disagreement was eventually resolved when the
Ministry of Health and Social Welfare agreed to
reproduce the pamphlet omitting those sections considered
too explicit.
ROLE OF THE
CATHOLIC CHURCH
Opposition to
forthright discussion on sexual health and social
issues related to HIV and AIDS, both within and outside schools,
has been spearheaded by the Catholic church, which has
enjoyed considerable political influence since
political reform was introduced in Poland in 1989. In
1990 Catholic instruction was incorporated in the
school curriculum and a series of laws introduced to
ensure that television and radio broadcasters respected
Christian values in their transmissions. A further
sign of the church's rising political influence can
be found in its pivotal role in the introduction of
the new abortion law in March 1993, which greatly
limited legal abortion in Poland.
The church's
influence over the provision of sex education in
Polish schools was in evidence recently following the
development of a comprehensive sex education syllabus
by Professor Zbigniew Lew-Starowicz, of the Academy
of Physical Education, Warsaw, one of Poland's
leading experts on sexology and family planning. The
Ministry of Health and Social Welfare had supported Professor
Lew-Starowicz's work while it was in progress, but when
the syllabus was finalised and ready to be launched
the ministry abruptly withdrew its support. This
reversal was traced to pressure on the ministry from
senior members of the church, backed by the
episcopate's commission for family affairs (interview with
Lew-Starowicz, October 1993). Aware of the forthcoming
parliamentary elections and of the church's
considerable public support, senior officials at the
ministry had bowed to the pressure and abandoned the
project.
Some
individual Catholic clergymen actively support efforts
to educate the public about HIV and AIDS. Father Arkadiusz
Nowak, for example, is known for his tireless work on
behalf of HIV infected drug users. He runs a centre
for these people just outside Warsaw and has
attracted considerable attention for his public stand
against both the bigotry and violence directed
towards his centre and the church's continued opposition to
the use of condoms even for prophylaxis.14
People such
as Father Nowak remain very much the exception, but
there have been signs that the electoral success in September
1993 of Poland's Democratic Left Alliance (a group of
parties and unions associated with the former Polish
United Worker's Party) might herald a shift towards
more progressive social policies. In December 1993 a
group of MPs proposed a liberalisation of the
existing law on abortion. The recent relaxation of the
medical code of ethics as it relates to abortion, agreed
by the third congress of Polish doctors, similarly
reflects a move away from the control of the church
over health and social affairs.15
Sceptics maintain, however, that the scope for social
reform is severely limited in practice, pointing to
the fact that the Polish United Workers' Party ruled
Poland for 45 years in the post war period, during
which time the country's allegiance to tradition and
Catholicism remained virtually unshaken.
The task
ahead
Most people
in Poland continue to cherish traditional values and
remain wary of any perceived challenges to these values.
Villagers are often suspicious even of the inhabitants of
neighbouring towns and villages. In this context it
is not suprising that there is widespread fear and
condemnation of "alternative lifestyles." People
engaging in drug use, homosexual activities, or extramarital
sex are seen as outsiders guilty of mortal sin and there
is consequently little sympathy for those who become
HIV infected through risk behaviours. The task facing
Poland's public health authorities is to find a means
of accommodating the widely held traditional values
of the Polish people while providing effective
education on HIV prevention and on the importance of integrating
people affected by HIV and AIDS at all levels of society.
Research for
this paper was made possible by a grant from the
Economic and Social Research Council (grant number R000234585).
I thank Piotr Jaworski and Gill Walt for helpful comments
on an earlier draft and Leo Danziger for
translations. The views expressed in this paper are
mine alone.
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(Accepted 25
January 1994)
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