Nationalism, Sexuality, and the HIV/AIDS Epidemic in Modern Greece

Abstract: This paper summarizes an investigation into the socialized medical system of Greece at a local, national, regional level, and as a working member of the European Union, focusing primarily on the policy of the Greek state concerning the HIV/AIDS epidemic. The intent is to draw attention to the impact ideology can, consciously and unconsciously, have on the development of public health policy. First, a brief outline of the history of the HIV/AIDS epidemic in Greece and how the government has reacted and organized to combat it is necessary. I then apply an anthropological lens, utilizing explanations of nationalistic and sexual ideologies as appropriate to Greek culture to elucidate their impact upon public education and outreach/intervention efforts.

I. Introduction
This examination of the HIV/AIDS situation in Greece focuses on the administrative policy of the state and its relationship to the public conception of the disease. This paper incorporates a holistic perspective that considers the country’s unique geographical, political, and cultural position and extends beyond health statistics to consider how conceptions of sexuality and nationality have influenced and been influenced by the relatively recent epidemic. In this analysis the United States is sometimes used as a comparative reference, not as a model of superiority, but because it is the industrialized country that I can most accurately draw comparisons to. As a visiting student of Anthropology, the recognition of differences in the overall public concern for HIV and STDs, contraceptive practices, and sex education efforts in Greece is what originally sparked my interest in the topic. The explanation for these differences is complex and concerns population size, perceived religious and ethnic homogeneity, medical infrastructure, and other factors. This paper addresses such issues and utilizes previous anthropological research on gender and nationalistic ideologies in modern Greece to expand upon how these relate to and explain the HIV/AIDS situation there today.

II. History of HIV/AIDS in Greece
The HIV/AIDS epidemic in Greece is monitored and managed by the Hellenic Centre for Infectious Diseases Control under the Ministry of Health and Welfare. The Ministry maintains testing and reference centers along with outpatient and hospital clinics, which provide services to HIV/AIDS patients. AIDS case reporting became mandatory by law in 1984, and the process of building this system was soon well under way. Four years later the reporting of HIV cases was mandated as well. The Ministry of Health and Welfare aims to work in accordance with the European Union and to use similar case definitions and treatment procedures.
    KEEL (another name for the HCIDC) released a full epidemiological report on all HIV and AIDS statistics in 2002 that provides all cases and fatalities from 1984-2001, and the following statistics are from this document. The total number of HIV cases including AIDS cases since 1984 through the year 2001 was 5,859. The overwhelming majority of which are male patients - 80.9 percent male and 18.4 percent female (gender unreported for some cases). Throughout the early 1990’s the rate of HIV infection was steadily and significantly increasing. This trend eventually commanded the attention of the state, and by the end of the decade, more focused intervention and public education were implemented. Since the beginning of the new millennium though (2000 and 2001 statistics), the rate of infection has returned to less dramatic levels, possibly signifying the effectiveness of these administrative efforts.
    The AIDS statistics follow a similar pattern. The cumulative number of cases reported through 2001 is 2,254, again predominantly male patients (86 percent). When viewing the AIDS statistics, there are certain large shifts in the data, and it should be noted that these are not representative of actual fluctuation in disease prevalence. For example, there was a large jump in new cases from the years 1993-1996, one that was alarming even in the context of an already significant increase similar to that of HIV infection. Yet this is more accurately attributed to the simultaneous adoption of expanded diagnostic definition, i.e. broadening the category of symptoms classified as AIDS related resulted in more diagnoses. And soon to follow was a significant drop in AIDS cases because of new access to highly effective antiretroviral drugs, which delay the onset of the disease. Finally, and most importantly, the primary mode of transmission of the HIV virus for all recorded cases has been and continues to be sexual contact, homosexual males accounting for the largest proportion each year. The primary mode of transmission in the female subcategory continues to be heterosexual contact (KEEL 2002).

III. Sexuality and Sex Education
In comparison to other European countries, Greece has fortunately maintained a low incidence of HIV/AIDS since the discovery of the disease. There have only been 1,299 total deaths reported since 1984, and very few pediatric cases as well. The exact explanation is difficult to pinpoint. According to the condom producer Durex’s worldwide report in 2001, Greeks are some of the most active lovers, second only to Americans (Greece Now 2001). Yet one must question the reliability of this information and whether or not Greeks are primarily monogamous. Interestingly, there have been few cases reported which identify blood transfusion as the mode of transmission, thus it appears that the medical infrastructure has been impressively successful in monitoring the blood supply. But the causal relationship between the monitoring system and the incidence of HIV infection remains ambiguous since the incidence of HIV cases was relatively low to begin with.
    It has been well documented that Greece is only recently becoming more progressive on issues of sex education and contraception, and the fear of HIV/AIDS precipitates much of this change. Until the late 1990’s contraceptive use was not widespread. A Metron Analysis study sponsored by Greece’s Institute of Social and Preventative Medicine reveals, “Accidental pregnancy results in over 200,000 abortions per year (vs. 100,000 live births)” (Greece Now 2001). A continually declining birthrate and the widespread prevalence of abortion is a high-ranking concern on the national agenda and has been coined the dhimografiko within public discourse (Halkias 1998:112). It is also of interest that most Greek women do not take the initiative in contraceptive decisions and leave this up to their male partner (Greece Now 2001). This is not surprising and a review of feminist anthropology pertaining to modern Greece will easily reveal that the sexual and social subordination of women is still prevalent. Dubisch poignantly phrases that “Because it threatens family reputation, female sexuality is viewed as a danger to society, and it must be kept under strict control by male guardianship, both before and after marriage as well as by the women’s own sense of modesty and shame (dropi)” (Dubisch 1986:196).
    This concept of dropi is central to gender discourse in Greek ethnography, which often depicts the perception of female sexuality as threatening to the family and social structure due to its vulnerability to pollution. Dubisch explains that “A woman’s body thus becomes the symbol of family integrity and purity and, more generally, of society as a whole” (Dubisch 1986:211). So it is ironic that as mothers, Greek women are the primary educators of their children regarding sexual education in the home (Attitudes 2000: 3), leaving it to question how openly sexual matters are discussed there.
    This has been a heated topic of debate in the last decade, especially since the increased incidence of HIV in Greece and worldwide. Only since 2001 has sexual education been included in the public education curriculum (Greece Now 2001). In response to a group of concerned Athenians, a private NGO, SEXTANT, conducted a pilot survey in the Athens area. The survey, funded by the Ministry of Health, aimed to assess parental attitudes towards sexual education. They found that although parents agree that sex education is important to protect their children against STDs and AIDS, there was significant resistance to this education beginning before high school and also hesitation surrounding the inclusion of anything other than contraception and STD information. Other sexual matters such as masturbation, and ironically enough, homosexuality and abortion, which were deemed less worthy of attention, are the same subjects that most parents admitted remained unaddressed in the home. The general concern was that such information and early education would foster an interest in sexual activity at a much younger age (Attitudes 2000).
    Such reservations demonstrate that the open discussion of sexuality still retains an element of taboo in the public and private spheres, and this directly relates to the public conception of HIV/AIDS and the conception of personal risk involved. Dr. Imvassilis Kioses MD/PhD heads the Center for HIV/AIDS in Thessaloniki, and reveals that 70 percent of the new patients each year who utilize the voluntary testing centers and are diagnosed as HIV-positive are already at full-blown AIDS status. Roughly 40 percent of these individuals die within 21 days. Thus, these individuals are waiting until they are highly symptomatic to confront their illness, which means they lived for several years infected with HIV and able to transmit the virus. Since HIV and AIDS treatment is “technically” free to everyone who seeks it, and since the system maintains a high level of anonymity and confidentiality through the use of personal identification codes, certain assumptions are validated: Most patients are unaware or uneducated of their HIV status, are possibly unaware if they are highly at risk for infection, or are unaware/uneducated of the diagnostic and treatment services available.

IV. Nationalism and Sexual Pollution
The emphasis on the phrase “technically” free in the previous section is meant to address the inconsistency between theory and practice, legislative policy versus what actually transpires. It is neither surprising nor dramatic that, even in a socialized system, disparity exists amongst levels of care, especially in the circumstance of non-nationals (refugees and immigrants). Complex and controversial matters pertaining to migrant populations and nationalistic ideologies become relevant when seeking to understand the government’s response to HIV-positive non-nationals and the perceived level of risk within these populations. Greece is a common destination of economic and political refugees and other migrants from the Balkan and former Soviet regions. There is also a reported influx of other nationalities such as African, South Asian, and Turkish from the western border with Turkey. The Greek state has been under fire from human rights organizations in recent years for the mistreatment of migrants in general. Even more central to this discussion is the issue of migrant sex workers predominantly from the Balkans and eastern Europe - the largest proportion being of Albanian and Ukrainian origins - which has received major attention from the media and the Greek government. To comprehend the complex relationship between these issues and the HIV/AIDS situation, one must be aware of certain ethnic and nationalistic ideologies in the sensitive area of the Balkans and Greece.
    Much scholarship has been devoted to what Pietro Vereni terms “border anthropology” and the socially constructed notion of “ethnic purity” in modern Greece (Vereni 1996:79). He explains that in the volatile struggle to define geographical and ideological borders, nations and national identity must be forged. He discusses the implications of developing a hypothetical national identity that in areas such as the Balkans usually consists of a prescribed ideal language, culture, and/or religion. He distinguishes between ethnic boundaries, frontiers, and administrative borders to accurately describe the typical process of nation-building in areas where nationality is so indelibly tied to notions of ethnicity. The ethnic boundary is an ill-defined boundary area, which a certain ethnicity occupies, yet the definitive characteristics of that ethnicity - language, religion, etcetera – remain ill-defined as well.   In contrast, a frontier, while still ideological in essence, is geographically defined by the two self-acribed national groups on each side of it. It is this frontier that must be legitimised by administrative borders. Vietri describes the evolution of this process,
    The shift from ethnic boundary to frontier, and the attempt (an essentially successful one in the case of Greece) to make the administrative border coincide with this frontier imposes severe and inescapable decisions on the impure. Flexibility is reduced to a minimum, the manipulation of identity in accordance with context becomes virtually impossible. (Vereni 1996:86)
This perceived ethnic homogeneity of the nation thus must be protected from outside (foreign) threats and is fundamental to the discourse of pollution and sexuality and the abortion situation in Greece (the dhimografiko) discussed previously.
    In the Greek society there can be definite categories of within and without, and the category of stranger varies contextually. But traditionally the home and family is the integral unit, then the community, and then the nation. Thus, if we consider the female as assigned to the primary maintenance of family integrity and purity, we can easily recognize how her “vulnerability ” to contamination is dangerous. Dubisch, among others, refers to the distinction Greeks make between us and them, explaining, “Within the house is order…without is the “wild” (competition and “strangers”) (Dubisch 1986:210). We can extend the dichotomy of the home versus all that is outside to contrast the ethnically “pure” nation versus the foreign. Sexuality, especially female sexuality, becomes a symbol of the larger body politic and is something that must be protected from the contamination of outsiders. Halkias identifies such concerns as the root of the dhimografiko, “ The dhimografiko operates as a powerful reproductive technology that contributes to the ongoing state-building project of policing particular configurations of race, religion, gender, and sexuality as properly “Greek”, while excluding others” (Halkias 1996:112). The ultimate issue is the fear that the dwindling population of “pure Greeks” will be overrun, since in this construct ethnicity and nationality – culture, religion, and language – are interdependent.

V. Current Controversies
These anthropological accounts are not to be interpreted as evidence that all Greek citizens are sexists or xenophobes. These are generalizations that reflect the traditional culture, remnants of which are highly prevalent in the modern society. Yet such ideologies exist at the foundation of a larger social reality and cannot, should not, be disregarded as irrelevant. One can now return to the HIV/AIDS discussion and examine it through this anthropological lens. There are multiple reasons, though not always fair or warranted, for negative attitudes toward migrant populations. Initially all migrants, or those seeking refuge and coming from impoverished nations, are a financial and administrative burden upon the state. For strictly epidemiological purposes, the monitoring of all infectious diseases must strive to include migrant populations in order to effectively track disease spread. Within the last few years, there has been a major epidemic of HIV infection in the eastern European countries of the former Soviet bloc due to infrastructure collapse and lack of education, and this has received major attention from the World Health Organization and the European Union. Illegal immigrants, such as migrant sex workers, pose a tremendous problem for the Greek government’s attempts to monitor the HIV/AIDS epidemic. Thus, it is not difficult to ascertain that this situation fosters concern about the risk to public health.
    The Greek administration can be commended in some aspects on their approach to assisting these migrant populations and controlling the spread of HIV/AIDS. The relevant legislation and Greek government reports state that all migrants, regardless of legal status, are afforded equal testing and health care measures. According to Dr. Kioses, the government provides a stipend of 714 euros every two months to any who request it. Such a policy is not a universal of every European nation (nor the US), for it is possible that migrants may be deported or sanctioned if their HIV status is revealed. A report on the National Focal meeting in Athens, which concerned mobile populations and HIV/AIDS concludes with,
    It should be stressed that in Greece all people, including migrants regardless of whether they have legal or illegal residence status, have free access to all state hospitals, health care centres and other health care services. Moreover, all people living with HIV/AIDS are entitled to receive treatment with all of the new therapeutic agents free of charge (Ballas 2000:82).
    This is a grand and virtuous policy in theory since these measures serve the interests of both the migrants and the Greek state. If someone infected with HIV (aware of their status or not) migrates to a country and is either denied access to treatment or fears deportation and legal sanctions, then their condition will worsen, and they will be more likely to spread the disease.
    But it appears that beneath this noble pledge lies the red tape of bureaucracy and that the actual implementation of these policies is not so cut and dry. In the last few years, KEEL has made tremendous outreach efforts towards mobile populations and is the National Focal Point of AIDS & Mobility in Greece (Zacharouli 2003:61). KEEL networks extensively with other European agencies and with NGOs within Greece and also has funded a program called the Umbrella Network, which aims to assist migrant sex workers in receiving full treatment and to educate them about HIV/AIDS and their rights.
    Yet, even reports made by KEEL administration depict a reality that contrasts the intent of the legislation. A report by KEEL’s Zacharouli and Mavraki states, “Even immigrants who reside in Greece illegally have access to services. They are not reported to the authorities” (Zacharouli 2003:63). And the grievances of multiple NGOs resound a cry of inconsistency, one NGO appropriately denoting a “legislative gap” in regards to organization and funding (Zacharouli 2003: 65). Migrants must be officially recognized as refugees or asylum recipients/applicants and have the according paperwork to receive full benefits. So, while praising Greece for making notable progress in improving health care for mobile populations, most NGOs still characterize the official process as lengthy and inefficient (Zacharouli 2003:64-68)
    But an imperative question that remains unaddressed is whether the administration devotes a disproportionate amount of attention to this small sector of individuals. In the mid-1990’s, the state, in concordance with the EU, began the first massive public health campaign devoted to the HIV/AIDS epidemic. There was focus on educating migrant populations, and pamphlets were produced in English, Albanian, and Bulgarian (Ballas 1998:83). This is a noteworthy fact because in relation to the HIV/AIDS epidemic in Greece and the rest of western and eastern Europe, Albania and Bulgaria have extremely low HIV incidence rates. (But one must also question the effectiveness of the epidemiological surveillance and reporting in these less developed countries).
    Furthermore, KEEL’s comprehensive report highlights the proportion of heterosexual patients originating from countries where HIV infection is prevalent, along with the proportion of patients infected within Greece by people from such countries. This is not unusual for the division and documentation of heterosexual subcategories is reported by the majority of European countries. But, interestingly, the reporting is highly variable. For example, Belgium distinctly divides citizens and migrants with heterosexual categories such as Belgian nationals and non-nationals. Britain presents heterosexual subcategory classification identically to the Greek report but provides homosexual subcategories as well. Yet, the British report distinctly defines a country where heterosexual transmission is prevalent as one where more than five percent of the adult population or more than one percent of pregnant females is diagnosed as HIV-positive. The report identifies the majority of these countries as sub-Saharan African countries, not the Balkan countries of Albania or Bulgaria. A newly updated report by Zacharouli and Mavraki of KEEL does recognize that the majority of HIV- positive immigrants in Greece originate from sub-Saharan Africa and eastern Europe (Zacharouli 2003:62). Yet, the lack of clarity and uniformity in the epidemiological reporting makes it difficult to discern which migrant populations face the largest risk and need more focused intervention efforts. And in light of this information, it seems surprising that due either to lack of monetary or linguistic resources or just plain misallocation there has been no outreach focused towards the Sub-Saharan migrant population. Another curious fact is that the KEEL report presents no division of homosexual subcategories when the overwhelming majority of the HIV cases reported in Greece identify homosexual contact as the mode of transmission.

VI. Conclusion
Thus the threat of HIV/AIDS may still be, unfortunately, regarded as “foreign” or outside of the mainstream population. This situation strikingly parallels that of the United States years ago at the onset of the HIV/AIDS epidemic. Many people conceptualize it as a disease that affects homosexuals and foreigners. And, through this conception, it is yet another factor that elevates the threat of contamination from the outside through the sexual mode of entrance. In reference to the tremendous aid afforded to non-citizens on behalf of the Greek state, Dr. Kioses replied that, while it is a measure of duty and goodwill, “We must protect our ethnicity and nationality”. This is a truth coming from a man who devotes his life to patients with HIV/AIDS, and it is assuredly not meant to harbour racial overtones. And it is true that in Greece 10 to 15 percent of new HIV patients each year are of migrant status. Yet, the remaining roughly 85 percent are Greek citizens. If we hypothetically can include all of this migrant population in that seventy percent of patients who are at full blown AIDS status when they test positive for HIV, then this means that the remaining 50 percent are Greek citizens who do not confront their illness until there is little that treatment can offer.
    While the administration recognizes the increased incidence of HIV contraction through heterosexual contact in the late 1990’s, outreach focuses intensely on migrant populations which account for a much smaller percentage of HIV-positive individuals than that of Greek patients, homosexual and heterosexual subcategories independently and combined. It cannot be denied that migrant populations are an important issue in epidemiology and deserve attention for the benefit of themselves and the rest of society. But prevention efforts must also strive to deliver the cliché but fundamental message “AIDS does not discriminate” to the mainstream population.   In the case of Greece, the administration may be inadvertently perpetuating a skewed conception of HIV/AIDS, thus leaving the public misinformed of the level of personal risk and the magnitude of the epidemic.

REFERENCES

Ballas, Costis
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Dubisch, Jill
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International Planned Parenthood Federation
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KEEL
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Vereni, Pietro.
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Zacharouli, Eva and Amalia Mavraki
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