Agency and Structure in Public Health

Public health is widely contingent upon the correlation between two major effectors. For all individuals, there exists an intercession of personal agency and social structure. Between these two considerations rests the individual, whose agency endows her with the ability to make clear and self-guided decisions and to maintain control over her own life. This individual, however, bound to the conditions and pressures of a society and cultural context, must also recognize the impact of structures such as economy, family and ethnicity.

In order to address the consequences of an imbalance between these two forces, this discussion will consider three public health issues as they are impacted by such factors as ethnicity and social class. Here, we can detect a distinct relationship between such factors and the sense of agency or vulnerability to structure found in varying subject groups. HIV/AIDS is a public issue which has some distinct relationships to gender and ethnic groups, owing to the manners in which it can be contracts.

For an example, the perception of the public for needle drug use, which is decidedly critical and even criminalizing, represents a structure that may often obstruct AIDS prevention for the vulnerable group considered. The historical unwillingness of the public to view or treat drug addiction with compassion has helped to limit the agency of needle-drug users, instigating a greater vulnerability to HIV/AIDS. Indeed, the article by Anderson helps to reinforces this problem, noting that “from the beginning, New York’s experimental needle exchange chem. like so many other public health initiatives aimed at controlling HIV infection—was controversial, a focus for fear, frustration, and political maneuvering in the city. ” (Anderson, 1506) So many structural pressures above and beyond the individual control of needle drug users has helped to keep them disenfranchised, worsening what could be a treatable public health concern. This is demonstrative of public perception, within which the HIV/AIDS epidemic has been viewed by many, especially here in America, as a problem which has diminished in impact due to its lowered presence with mainstream groups.

This is at least the case relative to a decade ago when the deadly virus/syndrome began to make headway in public awareness. However, on both a domestic and international level, the AIDS crisis has taken on a number of new dimensions in the intervening time. One of the most troubling and underrepresented of these has been the decidedly greater impact which the crisis has had on women and non-whites. As a result, the World Health Organization has recently adopted a campaign initiative to expand on efforts at educating particularly vulnerable groups of women.

Though the AIDS crisis came into awareness during the late seventies as an epidemic to which homosexual men were particularly predisposed, there has been a dramatic shift in the onset of the disease in various populations. While there has been an overall declination in the occurrence of new cases of men with HIV/AIDS as a percentage of the total population in the decade and a half since public organizations had begun elucidating the virus’s demographic proclivities, women have experienced a contrary trend.

Worldwide, new cases of HIV/AIDS reported in women rose from 8% of the total percentage in 1986 to 23% in 1999. (Kates, 4) This statistically significant percentage rise illustrates that during this, the precise period where the greatest investment of public resources had yet been devoted to the AIDS crisis, there had been a dearth of attention devoted to the particular vulnerabilities of women. This, World Health Organization officials have begun to recognize, is illustrative of a sexist trend in many societies that has prevented them from winning sexual rights

On the African continent, for example, a grossly imbalanced relationship between the sexes in many of the poorest nations has contributed to this counter-educational perspective. “Minimal contraceptive use and acceptance, especially of condoms” is one of the problems which the WHO has targeted with its public campaign, especially “in southern Africa, where HIV rates are highest, condom use is lowest. Similarly, in Ghana, only 3% of women and 7% of men have ever used a condom to prevent sexually transmitted infections. (State of Ghana, 1) It is hoped that the efforts of the WHO will improve the quality of women’s rights worldwide and help to slow down the AIDS crisis. This is demonstrative of how the improvement of structural support for individual agency can help to improve public health even in the most dire of contexts. Another public health issue which does not seem to directly impact wealthier classes or hegemonic cultural groups, and which therefore remains often invisible in any meaningful institutional regard, is that of homelessness.

A public health issue which touches upon many of those matter already discussed here above with regard to HIV/AIDS, the direct correlation between mental illness, substance abuse and sexually transmitted disease can conspire to create a situation unthinkable to the comfortable middle class American. Namely, the ultimately loss of personal agency may be seen in the cross between homelessness and mental illness or addictive illness. For many Americans, the gamut of social crises such as domestic abuse and drug addiction, while troubling, may be easy to avoid.

These, like a significant number of infirmities that plague the population quietly and persistently, occur largely behind closed doors. Until such crises effect individuals personally, said individuals may never have to encounter them anywhere outside the realm of mere theoretical consideration. This unaffordable luxury is what sets homelessness apart from a broad range of social problems. Homelessness is right out in the open and, on occasions that are familiar and frequent to urban and metropolitan communities, it is wont to demand attention.

The greatest number of homeless people, according to data as recent as 2001, is concentrated in major cities. Here, over 70% of America’s homeless fall across a spectrum of categories, though there is a particularly disproportional number of African American men who are homeless when compared to the percentage population of this demographic (CMHS, 1). While the problem of homelessness is generally believed to be a chronic one, this is not actually the case for the majority of homeless people.

In fact, most homeless people are only temporarily out-of-doors, with an overwhelming 80% of them finding some form of temporal or makeshift shelter within two to three weeks of their eviction from a residence. Though these individuals are accounted for in assessing the annual total of homeless people to be somewhere in the approximated range of 3. 5 million, they do not represent the most vexing facet of the homelessness problem. While these individuals may find personal, communal or legal resources to draw on for assistance, those who are chronically homeless are most consistently sufferers of mental illness, substance abuse or both.

Those with severe mental disorders are of greatest concern due to the complexity and abstruseness of the topic itself. While only 4% of the American population is considered severely mentally ill, homeless individuals are some six times more likely to be mentally impaired. At twenty to twenty-five percent of the homeless population, this group is undeniably indicative of a larger social incapacity to handle severe mental disorders (USDHUD, 1). Indeed, this is a damning correlation between the failure of public structures such as treatment programs and halfway houses and the absence of agency for the homeless individual.

There is a clear crisis of incapacity for such individuals, with an absence of control over one’s decisions and behaviors, whether through inborn, acquired or chemically stimulated mental disability, leading to an incapacity to engage social structure properly. By and large, the popular association between homelessness and mental illness is well-founded and fueled by routinely explicit evidence. As the likeliest candidates for habitual homelessness, and in addition the most visible and distressing homeless individuals, the mentally ill strike observers immediately as those unable to help themselves.

Moreover, due to the severity of their illnesses, these individuals are unlikely to have any remaining familial or social networks that could potentially provide support. Those suffering from disabilities of such a nature as to be considered severely mentally ill are usually people with debilitating depression, bipolar disorder, schizophrenia or multiple personality disorders. And, in the absence of any meaningful support system, we may suggest that many of these individuals are directly produced impoverished or dysfunctional personal and familial circumstances.

Among the symptoms of these and other such mental disorders are paranoia, social dysfunction and cognizance deficiency, all of which can make it difficult or impossible to negotiate ordinary functions such as employment and residence maintenance. Lacking the proper initial resources of economic of familial support for treatment, such individuals often will find themselves on the street as a result of unraveled family structures, a background of poverty, chemical dependency or various manifestations of socialized discrimination that single out the mentally ill.

This is a situation that is only compounded by the individuals’ lack of personal agency and emotional wherewithal to seek assistance through the appropriate venue. Without the ability to comprehend any number of legal and social services that may be available, disturbed individuals are extremely vulnerable to sustained, isolated homelessness. In addition to the variety of social circumstances that will obstruct the disturbed individual from reconciling the situation, the pitfalls commonly associated with homelessness are likely to dramatically worsen his chances of making a transition into residency.

Exploration of the heightened susceptibility of mentally ill individuals to homelessness also reveals some alarming resultant trends. They are substantially more likely to contract HIV/AIDS while homeless due to a perilous combination of a cognizance deficit and financial desperation, both of which can invoke the individual to behave in a healthfully compromising manner. They are also uniquely vulnerable to substance abuse, with 50% of all severely mentally disabled homeless people simultaneously grappling with addictions as well.

There is also a well-documented relationship between mental disorders and severe hygiene and health deficiencies. Beyond the already prodigious difficulty of contending with the mental disorder, an individual is likely to be suffering from additional health problems that will range anywhere from treatable to fatal. Surprisingly, most of the individuals accounted for in this census of mentally disabled homeless people (derived from the National Resource Center on Homelessness and Mental Illness) have had encounters with various forms of treatment or shelter.

But on a whole, the most severely disturbed individual, though on record as having been an in-patient or out-patient for a state or municipal mental health facility, has maintained residence only for brief and fleeting periods. In many instances, individuals have been ejected for amassing the consecutive days of stay permitted by those shelters that levy such limits. In other cases, the mental disorders themselves may be too disruptive to tolerate.

Also arriving at halfway houses and jails by way of frequent arrest, it is often the case that mentally disturbed people have removed themselves from those undesirable situations intentionally, opting instead for homelessness. Moreover, “most programs have rules that restrict clients’ choices and that when violated are used as grounds for discharging the consumer from the program.

For example, despite having attained permanent housing, clients who relapse and begin to drink mild or moderate amounts of alcohol, may be evicted if the program has strict rules about sobriety maintenance. ” (Tsemberis, 652) This is, of course, illustrative of the challenge in contending with such an issue as homelessness as it correlates to the other relevant public health issues of mental illness, HIV and drug abuse. For many housing facilities, there simply do no exist the resources to attend to this cross-section.

And for the individual, the housing issue can be tantamount to a crushing sense of the loss of agency, which can ultimately produce a self-destructive evasion of structure. Accordingly, “the loss of control over one’s life resulting from housing instability, frequent psychiatric hospitalizations, and intermittent substance abuse treatment leaves some consumers mistrustful of the mental health system and unwilling to comply with demands set by providers. (Tsemberis, 653) Though these issues of homelessness, mental illness, HIV/AIDS and drug abuse/addiction do take an extreme case to demonstrate the matter, it is illustrative to the balanced individual of the absolute importance in maintaining a healthy balance between commitment to personal agency and reflection of the values of structure related to the retention of public health.

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