CHAPEL HILL — Twenty years ago, Adaora Adimora was puzzled and frustrated by what she saw.
It was the mid-1980s, and she was starting her medical career in New York City. Conventional wisdom about why black people seemed more suspectible to HIV and AIDS didn't make sense to her.
"The number of black people that I saw with HIV was just overwhelming," she said. "The question was -- even back then -- why are so many black people HIV-positive?"
The question followed her as Adimora moved to North Carolina, joined the faculty at UNC-Chapel Hill's medical school and became a distinguished researcher in the field.
Last week, Adimora went to Capitol Hill to tell a congressional committee her best answer to that question. It surprised committee members.
People are still responsible for their behavior, she told Congress, but if the U.S. wants to slow the rates of HIV infection among African Americans -- which are as much as 10 times as high as in whites -- then long-standing issues of inequality will have to be addressed.
Social forces such as poverty, discrimination, residential segregation by race, and incarceration disparities, she said, all conspire to increase the risk of disease among African-Americans, even among those who don't engage in high-risk behavior.
"The HIV epidemic among African-Americans should be formally declared a national emergency and moreover, the U.S. should act as if the epidemic is a true national emergency," she told the House Committee on Oversight and Government Reform. "The absence of social justice is a major root cause of many of the racial disparities in health that we're seeing."
The research of Adimora and her colleagues is different from most of the other research into why and how the disease spreads. It focuses not on how the disease works but on how social conditions affect the way people live.
"She's marrying a whole bunch of disciplines in one package," said Dr. Myron Cohen, the director of the Institute for Global Health and Infectious Diseases at UNC-Chapel Hill. "Her work has helped shine a light on the magnitude of the problem."
Adimora, 52, grew up in Manhattan. From an early age, she was interested in medicine and she planned to become a psychiatrist. At Yale University School of Medicine in the late 1970s and early 1980s she became interested in the field of infectious diseases. Part of the attraction was that colleagues she met in the field just seemed nicer than in other specialties.
"They were my kind of people," she said.
By the late 1980s, she had become chief of the Infectious Disease Clinic at Harlem Hospital. In 1987, she was a guest at a wedding in Los Angeles. There, she met the groom's brother, a doctor who was an oncology fellow in North Carolina.
On their first date, Dr. Paul Godley encouraged her to shift away from the purely clinical work of treating patients and start doing research on infections.
Seven months after their first date, the couple married. Adimora moved to the Triangle, where she eventually joined the faculty at UNC-Chapel Hill's medical school. She earned a master's degree in public health and set about trying to answer the question that had first puzzled her in New York clinics: Why were black people infected at so much higher rate than whites?
To curb the spread of HIV, researchers and activists traditionally think in terms of individual risk factors. Does a person use injection drugs? Does a person have sexual contact with men who have sex with men?
Beyond risk factors
But looking simply at those risk factors does not explain why African-Americans are infected at such a high rate. According to 2006 data released this month by the state Division of Public Health, whites in North Carolina were infected with HIV at a rate of 11 cases per 100,000 people. The rate for blacks was 102 cases per 100,000 people. The rate is only slightly lower for African-Americans nationally.
Risk factors -- not using a condom, sex with multiple partners, drug use -- aren't enough to explain those numbers.
Adimora and colleagues began studying the problem in the mid- 1990s. After several studies, particularly ones in Eastern North Carolina, the researchers have concluded that social forces contribute mightily to a black person's risk of infection.
"If you were to follow a logical conclusion to where she's going with her research, it's that intervention directed toward individual risk factors is not going to be that effective," Godley said. "The issue is really these societal forces. Telling people to use more condoms or not to use drugs or other things may not have the intended effect."
Adimora acknowledges the wide-ranging implications of her findings. But she says it's not impossible to change long-standing social trends. It's a theme she seems to sound often. Whether talking to a reporter, to members of Congress or to a conference audience full of HIV researchers, she acknowledges the vastness of the problem. And then says it can be fixed.
After all, she said, how would the nation react if white men in their 40s were 10 times as likely to be infected with HIV as blacks?
"There has been a tendency for people to throw up their hands and say, 'We can't do anything about poverty and racism,' " she said. "I don't believe that people cannot find a solution to some of these problems."
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