AIDS CandleLight Memorial

The health department says Harlem and Chelsea aren’t the only disparity: Across the city, people in whiter, wealthier neighborhoods live longer than those in poorer, darker ones—even when the two are side by side. Next to Chelsea, the (also relatively affluent) Greenwich Village–SoHo area had the city’s second-lowest PWA death rate, at 12.2, while an adjacent district with a high concentration of public-housing projects had the city’s highest—at 43.9, almost four times higher.

And it’s not just black and white. Consider other high-mortality neighborhoods, like the South Bronx and Crown Heights, both heavily Latino. “When we start comparing Harlem and Chelsea, one of the first differences that jumps out to us is race,” says Juan Battle, a professor of sociology at New York City’s Hunter College. “But if you look again, there’s another difference, which is class.”

And it’s there, at the American juncture of race and income, where HIV diverges into a kind of apartheid. The divide may not be as stark as that between HIVers in the West and those in Africa or Asia, but it’s impossible to ignore. Middle-class HIVers (still mostly gay white men) reap HAART’s promise of a “chronic manageable illness,” while the underclass (overwhelmingly African American) often lives as if HAART had never arrived. “What you see in Harlem mirrors a lot of urban areas in this country,” says Carole Bernard of the National Minority AIDS Council. And the disparity between Chelsea and Harlem could as well be the disparity between Dupont Circle and Anacostia in Washington, DC; West Hollywood and South Central in Los Angeles; South Beach and Liberty City in Miami; tony Atlanta and large swathes of the poor, rural south, where AIDS rates are climbing.

According to the Centers for Disease Control and Prevention, between 1993 and 2001 (a span during which life-saving HAART was introduced), the deaths of PWAs nationally dropped by an estimated 75 percent among whites, but only by 50 percent among blacks. By 2000, AIDS rates (as opposed to just HIV) were nine times higher in blacks than in whites. Most studies have attributed such staggering rates to both late diagnoses and poor HAART adherence. But they are inextricably linked to poverty itself.

When poor people get sick, it’s often from causes that are impossible to untangle: years of cheap food; asthma from pollutants (most of New York City’s bus depots are concentrated in Harlem); IV drug use—which has little to do with race but does correlate closely with geography and class—that weakens their bodies and their resolve.

Most damaging: the lack of preventive care that comes from having no health insurance or high-cost insurance, and relying on the ER. Says Battle, “Poor populations don’t see the health care system as serving a preventive function—it’s serving a treatment function. So if you’re not sick, you’re not gonna go.”

And then there are the intangibles: depression; hopelessness; a corrosive distrust of the medical establishment. “You say one word incorrectly, and you’ve suddenly got a very angry client who’s ready to run out the door and never come back,” says Daniel Weglein, MD, Deborah’s doctor and Harlem United’s medical director. “It doesn’t matter how much services, treatment and counseling is out there if people aren’t ready to engage in care.”

“If you’re HIV positive, and you’re also homeless, and you have a substance abuse problem, and your children are in foster care, getting treatment for HIV is probably last on your list of priorities,” says Harlem United’s Cynthia Ceilan. “You’re either looking for your next fix, or trying to get your kids back, or trying to find a place to live.” Even when low-cost AIDS treatment services are available, poor people often don’t—or can’t—use them. If they do, the effort it takes just to stay “compliant” can be overwhelming. “Can we deal with HIV in poor communities without dealing with poverty?” Battle asks. “I would argue no. It hasn’t worked with high blood pressure, it hasn’t worked with asthma, it hasn’t worked with diabetes, and it won’t work with HIV” (see “Closing the Gap” ).

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