Discrimination against people with HIV and AIDS in PolandBMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6937.1145 (Published 30 April 1994) Cite this as: BMJ 1994;308:1145
- Renee Danziger, research fellowa
- Correspondence to: 19 Primrose Hill Road, London NW3 3DG.
- Accepted 25 January 1994
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.