Episode 5: Soma Sen

In this conversation with Soma Sen, Professor of Social Work, we learn about her work as one of the leading experts on the global HIV Aids epidemic, immigration, human trafficking and the ongoing stigma attached to living with a disease.

Episode Transcript

[ Music ]

Vincent Del Casino: In the time of COVID, have you found yourself wondering what is happening in the world of other epidemics, like HIV? Well, joining me today on the Accidental Geographer is Soma Sen, Professor of social work at San Jose State University. Soma is a leading expert on the global HIV/AIDS epidemic, where she's studied its spread in contexts as diverse as Sub Saharan Africa, India and the United States. In this conversation, we also learn about her work on immigration, human trafficking, and the ongoing stigma attached to living with diseases such as HIV. I'll be your host, Vincent Del Casino, and you're listening to the Accidental Geographer.

[ Music ]

Vincent Del Casino: It's so exciting to be able to have this conversation with you. I really appreciate it. You know, as I look through your record and your history, you know, clearly you have this wide ranging kind of global set of interests, and you've done a lot of work in different parts of the world. As I looked at your background, I noticed you started in economics, and evolved yourself towards social work. And I'm kind of curious, I mean, there's definitely overlaps there. But maybe what got you started in economics? And then what gets you motivated to make a switch and think about a different field and so forth? I'm always kind of curious how people get to where they are.

Soma Sen: Thank you for having me here. I know, it's really interesting. That question is really interesting. And I think I've been hearing that in the other podcasts that I heard, and everybody has this narrative about how they got to where they got to. And there's always a personal connection to the questions we ask, things that we're interested in. And it kind of blows in the face of this, you know, traditional epistemology of research being unbiased and all of that. But it's very interesting that every one of the people that you spoke to came into it with a personal narrative and a personal connection.

So I find that question really interesting, because I think about that question quite a bit. Particularly because as a social worker, you really have to kind of be aware of social location and positionality, and things like that. So that we kind of understand that it is the social location that I hold, and the perspective I hold as a result of that. It gives me a certain view of the world, and I look at questions within that worldview.

So I will talk a little bit about that interesting question, because you are right -- I was kind of wandering around about, I don't know what I wanted to do in life pretty much. And so my mom is an infectious disease specialist. She actually has retired now, but she's a doctor, she. You know, she worked with -- it's very comparable to Centers for Disease Control, but it is the School of Tropical Medicine in Calcutta, which is where I grew up.

Vincent Del Casino: In India. So, Calcutta, India, yeah.

Soma Sen: Yes, yes, yes. So she always sort of, you know, inculcated that curiosity about diseases. I find diseases very interesting. And so that that's kind of one sort of thought process, if you can keep that in mind, that I find diseases interesting because of my mom. And then my dad's an engineer, and as like just any other Indian parent, they obviously wanted me to be either an engineer or a doctor. And there's like, plenty of engineers and doctors in my aunts and uncles, and also sort of, you know, they were not only practitioners, they were teachers in the universities, you know, the medical schools. And I was like, "There's no way I will want everybody hovering over me all the time." So there's that rebellious streak in me, which led me to go for a subject that no one knows anything about, which is economics. So that's kind of how I landed in economics. And I convinced my parents that, you know, this is -- what this is important. This is what I want to do. I want to look at economic policies. And you know, I was really good at statistics. And so they were like, "Okay, you know, maybe this will work fine."

Anyway, so then long story short, I came to the US as an exchange student actually at Iowa State. And they had this really good agricultural economics program. And if you know anything about international students, they tend to go where there are other Indians. Or it's true for any immigrant communities -- they will go to places where there other groups of the same. And there were quite a few Indians there. And not only that, but there there was a particular woman -- I mean she's a woman, she was like my sister. We lived in the same building. So my parents were like, "Okay." I was really very young when I came here. So they were like, "Okay, that's fine. There's someone there. So you're not lost in this country we don't know anything about." So I was allowed to come as an exchange student at Iowa State. At that time also, I got an internship with the World Bank. And as an intern, as a summer intern, working with an economist. And what we were looking at was this HIV and the impact of HIV in northern Tanzania, and looking at policies and prescribing policies for these villages. And I was kind of a little bit put off by that process, because it just felt like, "Who are we to make policies where there's not a single person from those villages, those rural areas, or any representation of what they need at the table?"

So that kind of made me think that I don't think I could do economics for the sake of economics. I loved economics. I'm a quant at heart, it was it was good, it had econometrics, it had all those things that I really liked doing, but I didn't feel like I could do that as my life's process or life's job. So then that kind of led me to look for something that had an applied aspect to it, where I could bring in my economics skillsets to actually understand society and social justice. And those are the things that really interested me, hence, social work. That's kind of how I came into social work. And when I told my parents that, "Okay, I'm going to switch fields," they had a fit. They were like, "We don't even know what this social work is." You know, I've always been termed as this child that didn't know what they wanted, what I wanted to do so. But I was fine enough that they couldn't make a whole lot of decisions for me.

Now, of course, they are very happy that I'm a professor, of course. That has some status, I guess, in their mind. I didn't completely, you know, destroy my life, according to them. So that's kind of how I got into social work. And then even when I'm studying social work, as you saw, that my interests were -- it sort of circulated around the health and health disparities and other sorts of disparities and culture and gender. And, you know, when I try to explain to my mom with my research is, I always say that, you know, you understood, or you are interested in the medical side of things, whereas I'm interested in the social side of things. And very recently, we were talking and I said, "You know, there's the pathogen that you understand completely, but then you don't understand why human beings behave in a strange way that a pathogen could not have probably become so virulent without the human behavior that intercepted that."So yeah, we have really good conversations about that now. Yeah.

Vincent Del Casino: That's so interesting. You know, I could resonate with so much there because I started as a chemistry major. And I was like a recovering Catholic, who was looking for something else and started studying Buddhism and ended up in Southeast Asia. And trying to explain that to my father was a very interesting -- for years, he's like, "I do not get this. I love you, but I don't get it." And when I finally told him one summer after I got my first job, "Oh, I'm going off to Thailand to do work for the summer." He goes, "Oh, now I understand why you want to be a college professor. This sounds pretty good." But that question of the sociality of disease is very interesting, right? Because I wrote a little thing once on polio. And I was like, polio doesn't care if we think there are borders to countries. It doesn't matter to it. And so how we, you know -- it's the networks that make a difference. So this is really great. So you get this World Bank entry point, which is really interesting because health economics is a big field, right? It's a really important field. But World Bank, not surprisingly, a pretty prescriptive organization. You know, trying to create policies that they can just implement everywhere in the world, agnostic to the place. And that turns you to asking these more social questions.

And I noticed in your work, you're you are interested in bringing critical theory to social work, because I don't know if social work is always thought of as a field that intersects deeply with critical theory. So how does that kind of resonate for you and come to bear? Because there's definitely -- I mean, not only the explicit work, you've got some papers there. But more generally, that thinking of the critical theory and social work -- and how does social work grapple with some of that, I guess, is the question I have.

Soma Sen: So to be honest, I'm not sure how the trajectory of social work evolved. I know that social work itself has had tremendous impact on subjugating people, right? They played a major role in this country, at least I'm talking about in this country, which is interesting. Because when I was going to school in India, there was no social work, because it was all the family would take care of each other. So there was no need for safety net that was outside. So that kind of is changing now.

But back to here, social work, I would say that, I think initially started with, you know, this idea of white women going out to -- rich white women going out to immigrant communities and, you know, helping them out. Or, you know, they used to call them friendly visitors, and where they would go and train them how to behave civilly, I suppose. So it started with that sort of mindset of there was something deficient in these communities, and we are the people that can, you know, save them. Very colonialism in the way of thinking -- colonialist way of thinking. So however, I think more recently, you know, social work is grappling with this idea of what are we an extension -- are we a change agent? Or are we an extension of the forces, structural forces that, you know, control certain groups? So are we an arm of subjugation? Or are we really change agents? And so I think the, you know, critical theory and intersectionality, those things are coming in to social work.

One of the things I would say, and that's kind of where you'll see my work, I tend to be a little bit more theoretical in my work. Because I like to understand things more conceptually. And that's my interest. So I tried to look at, you know, whenever -- I mean, I've done different kinds of work. One of them was on human trafficking. And my thought was, well, social work, which is a social justice-oriented field, but they're not really having conversations around issues that are important. You know, like, for example, for human trafficking things, you know, theories or solutions, or even understanding the problem was coming from economics. It was coming from law enforcement, it was coming from migration work. And so, but nothing from social work. So those are the things that I find interesting. And that's where I say, you know, social work is very uniquely positioned, actually, because it looks at the person and it looks at the environment in which a person is. So I don't know why we don't use sort of more of those. And critical theory is, to me, is an extremely useful framework to do that, to have a critique, depending on in which -- you know, what pathway you're choosing to provide that critique in. But that I find it's a very useful tool and a useful framework. Yeah.

Vincent Del Casino: And I noticed that in your early work in Africa and some other places where you talk a lot about social capital. And social capital is an interesting framework. Can you kind of flesh out, you know, what that means in the context and why it's valuable for understanding both HIV as a disease, but the the risk nature of HIV and the risks associated with HIV?

Soma Sen: Yeah, that's interesting. So again, it's my own sort of positionality that helps me pick these theories. I think that I resonate with certain theories. So you know, same way -- critical theory, I have an economics background where we had to study Marx in length. And so it just kind of makes my mind go to those macro kind of theories. And social capital is -- I always felt that I gave up a big part of my social capital to come to this country and had to build a new set of social capitals that serves me in a certain way. But at any moment, that could have gone not the right direction, perhaps. And so that and the idea of social capital -- the basic idea of social capital is if you belong to a group, you accrue certain advantages from belonging to the group. And so that particular sort of social network, those kind of ideas have been used and held in all kinds of other literature.

What I'm interested also in sort of -- I call it the shadow side of social capital, because as much as you accrue advantages, there's also an expectation when you belong to a group that either you follow those norms or you're out. Or you have to contribute in a certain way, or you're out. So there are these tensions that also come with the social capital, with the idea of social capital. And actually, Badu talks about it as symbolic violence. It's that idea that it's not all good. So when you want to use social capital, you have to, again, think about it in its totality. And, you know, it's not a panacea for everything, or a silver bullet for everything. So, that kind of got me into looking at social capital, because of my personal sort of connection to, you know, losing and building new social capitals.

So I started looking at these migrant men in Sub Saharan Africa. And I felt like I had a connection with those men, because they left behind all their family and friends and traditions and norms that keep them grounded in their villages. And they come to these, you know, mines, where they work under deplorable conditions. They are, you know, living under horrendous conditions, and they're anxious, because mining is not a safe profession. And so what is the way that they can release those tensions, right? And so that's where the risk of behavior comes in. Because then that opens up a space for those kinds of, you know, risky behaviors to happen. And in fact, the mine workers would bring in sex workers on the day that they got paid. And it was a petri dish of HIV, you know, going everywhere. So my policy questions there were that if social capital is a barrier -- I mean, is a barrier. If social capital, you know, serves as a sort of preventer of spreading or high risk, then knowing that, what can we do? So can we have policies where families travel together? Because these men were coming in -- and young men between like 18 to 39. And you know, and then they would just -- and there are other cultural factors that come in, but then they would go back to -- they became the sort connecting population, bridge population as they call it. And they would spread HIV in their communities.

So policy questions were, would it be possible for policies to have whole families come, or brothers, mothers or whatever their close network? Or is it possible to connect them to communities around the mining and mining spaces? Those are kind of things that come out of that kind of questioning that, you know, yes, HIV is a -- you know, obviously, it's a problem, but do you want to solve it from an individual level? Or do you want to -- because then the burden becomes on the individual. And you know, then it becomes like, if you are not able to solve it, then it's your problem, not society's problem and creating the circumstances in which these individuals are navigating. So yeah.

Vincent Del Casino: Yeah, it's that location of responsibility.

Soma Sen: Yes.

Vincent Del Casino: Where you know, and how it gets articulated. What's interesting here as well, right, is a concept like migration intersects with social capital to suggest that there are networks of these relations that are creating environments of risk that's tied to masculinity, the assumptions that one has about what is appropriate. And so to your point of belonging and community building and social capital, it's also difficult to not participate in the social relations that are being put in front of you.

Soma Sen: Right, exactly.

Vincent Del Casino: Hence the brothel being built at the corner where everyone's going to go.

Soma Sen: Right. Exactly, exactly. The other thing I was going to say is when you move away -- and this is, again, from my own personal experience. I moved away, I lived in a very sort of cloistered household with, you know, brother, father, everybody, you know. There's a lot of sanctions, you need to come home by this time -- to a complete freedom of not having to report to anyone for anything. And that in and of itself, having no sanctions, having no one to report to, can be good and bad, especially depending on where you are in the development process as a human being. Then, you know, those are the things that can become problematic. So that's where the social capital comes in, that, you know, the sanctions went away, your rules and regulations and norms and traditions that kept you grounded in a certain behavior -- now, those are gone. And you have the anonymity of this huge place where no one knows you.

Vincent Del Casino: Yeah, it's very interesting, right? And when you think about, you know, how that constitutes the sets of effects that lead to this -- plus just the ways in which the politics of outreach were going and, you know, knowledge distribution and all the other kinds of things that obviously didn't -- weren't in the front of mind right at the time. So just out of curiosity. You had mentioned Calcutta -- were you raised in Calcutta?

Soma Sen: I was raised in Calcutta. I was born in Assam, which is further east.

Vincent Del Casino: Yeah, I ask because having been to Calcutta obviously, it's an intensely political city.

Soma Sen: Yes.

Vincent Del Casino: And a very economic forward city, let's say. You know, a good healthy group of Marxists running around here and there.

Soma Sen: Yes.

Vincent Del Casino: Does that influence any of your thinking of economics. I was curious if that's like, kind of driven -- I could just imagine what your mother going, "Oh, great. a social scientist. That's what I get?" And a social scientist that's interested in economics, living in Calcutta. I didn't want to lose that thread. I'm just curious if there was something there because I always believe, like, you know, to your point, that local experience of place does really matter for how you think about where you're going to go and what you're going to be.

Soma Sen: Yeah, so I think what that experience growing up in Calcutta, and then, you know, 20-some years ago, that we had to actually study Marx in economics. It was a theory that you had to study. And also, we're also extremely -- if you know anything about the student bodies, we were extremely politically active. I mean, I just think about our poor chancellor, he was there out and the poor man never went home. So it's kind of that kind of mental, you know, way of thinking. It was also that, you know, it kind of inculcates those ideas of social justice and macro sort of social justice, not just one person to person. And to be honest, for a long time, this CPM which is the Marxist party, actually did a lot of good for a lot of people, particularly the farmers. Because the farmers were getting like literally subjugated by the landowners. And so these groups, actually, that's what kept them afloat for like almost 25 years. And so there is that sort of intellectual mindset in Calcutta. Calcutta is interesting, because it is a -- you know, it's a cultural hub. It was like Rabindranath Tagore. I mean, it's all of that, and, you know, scientists and social scientists. And so, that kind of also, you know, kind of gets you in the way of thinking about the world, that if you have some privileges, then you need to use it for something worthwhile for others. That's one. And then my parents and my aunt, they are all into NGOs. So they had you know -- my mom had set up clinics in villages. So you know, that already was kind of there. So the social work jump was not a huge jump for me. I don't think that the social work does enough micro work in my opinion.

Vincent Del Casino: Yeah. No, so I mean the nongovernmental organization movement in India is gigantic.

Soma Sen: Yeah.

Vincent Del Casino: I mean, it's a machine in and of itself. And it's a very important part of it. I found Calcutta just one of the most interesting, but one of the most intense places I have ever been. Like those politics are on the walls, literally, as you're walking down the street.

Soma Sen: Yes.

Vincent Del Casino: And people don't let you forget it, and it -- you know, but I just remember, I've only been there once. But it was just like, I was tired at the end of the day, you know, from just the energy of what it was like as a city. Very cosmopolitan, but also very much embedded in these kind of big political questions. So I guess I'll circle back and somehow we'll make a nice segue out of this, somehow. But going back to your work then, one of the other sets of work that you did was on faith based organizations, which play a tremendous role, right? Because Jennifer Walsh -- I don't know if you know her work.

Soma Sen: Yes.

Vincent Del Casino: She wrote about the Shadow state, right, the emergence of a state beyond a state, which was largely these nongovernmental organizations, these faith based organizations. And HIV, as you know, challenged the health networks of every country in a way that many had not seen before. Because where I was in Thailand, actually a pretty decent health care system, couldn't manage the pandemic or the epidemic at the time, right? So faith based organizations and others come in to fill the gap. So tell me a little bit about that work on faith based organizations. Because they play an interesting role. But there's also a tension within that community as it tries to struggle with what role it's going to play in HIV work, right?

Soma Sen: Yeah. And I think it has to also do with where it's happening. So if you know -- like Mozambique or, you know, South Africa, and certain places where Christianity is not questioned the way it might be questioned otherwise. And there is a strong sense of faith. But you want to do that in the intellectuals in Calcutta, that is not going to work, that kind of faith based approach.

Vincent Del Casino: Right.

Soma Sen: And so I think there's a history of faith based organizations stepping up to do the work, right? That's across the world, that when this society fails, the faith based organizations step up. It is very true about that sort of the contention between. It always comes with an expectation of some sort, right? And faith based organizations really like sort of popularized the abstention intervention, rather than the harm reduction. It was like ABC. I think, abstain, be faithful and use condoms. It was like that's it. There was no other way of thinking. And what was interesting to me, I did this work with sex workers in India. We all know that poverty and all that, gender issues and all of that, that brings people into the sex work. However, my question was, why do you stay? Because there were lots of interventions coming out of faith based organizations and NGOs that were providing these alternative means of gainful employment. Which is like basket weaving -- very, very gendered kind of work. And the women that we interviewed, they said, I I would never make as much money I'm making right now with basket weaving. I'm making a whole lot of money as a sex worker. And then this idea of be abstinent and use condoms, that does not work with that population at all, particularly use condom. If the client does not want to use condom and this woman is thinking about whether I should put food on the table or electricity, that I need this money, they're not going to question that, you know, you have to use condoms. So it's very interesting that, while I completely get the sort of -- we need them. We need them because they do provide an immense amount of service. But there is that kind of, you know, sort of this idea of these are, you know, wrong women and we need to do something about bringing them back to the fold of society. I's a problematic, you know, kind of way to see it.

Vincent Del Casino: Well, the focus on the women.

Soma Sen: Yeah.

Vincent Del Casino: You get the condom on the man who's the client on the other side, that changes the game a lot. And that was the interesting thing about Thailand. Thailand, you know, the epidemic in Thailand was severe and bad where I was in the north in the '90s. It was tough. And a very -- you know, I lost a lot of friends, you know, during that period of time. But it could have been a lot worse. But Thailand had a rich history of family planning.

Soma Sen: Yeah

Vincent Del Casino: So contraceptive pills, for example, were ubiquitous throughout the country, and the condom campaign was not as big a deal. You know, it's like, well, this is just the other side of the coin of, you know, the family planning campaign. And they just made condoms ubiquitous, like you couldn't go anywhere. It was like, you walked anywhere, it was like, bowls of it everywhere, you know. And they made it a serious thing. And it shifted. There's no question, it shifted the nature of it. It didn't necessarily address the inequity in the gender relations that produces an economy of sex work, which is the other underlying problem that the government wasn't actually interested in. But they did tackle the HIV epidemic, right, its spread.

Soma Sen: Right.

Vincent Del Casino: And it of course, for us, we want both those things. You know, we want an economy beyond basket weaving. And we want condoms, but you know, that nature there. But the interesting thing too about the piece that you did, you know, is the churches themselves are in tension over kind of how they do this, and who does what.

Soma Sen: Yeah.

Vincent Del Casino: And that's the other thing. You get organizations, they're human constructions. And they play this role. And that's where, you know, your work -- interesting mixed methods, right? You seem to like to do the survey work. But those longer informal interviews and so forth are important for your work as well, I think, right?

Soma Sen: Yeah. I mean, I'm actually like -- the more and more the questions that I'm getting interested, it's not very conducive. Like large data sets are not yet conducive to get those sort of in depth data. So I'm now actually kind of moving towards more of the narrative and more phenomenology and that kind of research design. I just wanted to tell you one thing, if you ever look up [inaudible] project that's in Calcutta, it's in the red light district of Calcutta. But it is one of the best community based interventions that these women came together. They got started as a public health -- so the public health workers would go out to them, give them information. The whole thing sort of evolved in the community getting involved. And then they got the police force, the law enforcement on their side. And now when the john or whatever the client comes in, it's like, if you don't use condom, you're out. So it became one of the best practices of WHO that was looking at how in certain places -- in certain, and I would say this, you can also say, I think, in most of the Southeast Asian countries are more maybe collective for lack of a better word. That the community based interventions work better than individual interventions.

Vincent Del Casino: I was actually very interested in people who are positive. So I worked with support groups, and they were all community based, because it was all home based health care. There was there was no choice. The hospitals were never going to be able to manage these patient loads, that was not possible. And they didn't have the medications even yet at that point. We were barely looking -- I mean, the antiretrovirals are so expensive, even in the early to mid-90s. They were not in anyone's hands, and we didn't get the reasonable stuff until the later '90s and, you know, early 2000's. So yeah, the home based care and the community based programming was critical for you know, survival and community building, and so forth. Well, I could go on -- this topic I could definitely dig into for years, because one, it's just very important to me. But also I see the synergies with your work. But you also now have done a lot of work with Asian American Pacific Islanders, and looking particularly at intersections of treatment and substance abuse, but also HIV risk. So what brought you to this kind of -- it seems like a new project area for you.

Soma Sen: Yeah.

Vincent Del Casino: And what do you see as the key issues in this space that you're trying to address with your work?

Soma Sen: That's a really good question. So you know, I mean, obviously, I still have the global perspective, because that is my area of interest. But I've always looked at immigrant communities, whether it's here or if it's somewhere else. But it's how are immigrant communities impacted by this particular disease, right? I'm interested in HIV or other health disparities, but particularly HIV. And so given I am an Asian woman, so I had a more easy like sort of in into that community. And honestly, that community, it's so interesting because nobody wants to talk about HIV, literally. In my community, nobody's going to -- nobody's going to talk about sex with me. Forget that. And so I tried doing -- it was funny, I'll tell you a funny story.

So when I first started here, I have a very good senior colleague, and there's the Indian community center. And I was telling her -- so she's interested in aging, and I'm like, "You know, aging population, nobody's really paying attention to HIV in the aging population. Let's do a project." And she's looking at me, she's like, "Are you thinking they are going to talk to you about their sexual practices? What is wrong with you?" I was like, "Yeah, that's true." So, you know, I just kind of abandoned that project. So we all know that it's problematic, because API is not a monolithic group at all. However, there are some common things that impact this community. So that kind of got me into like, there's the banyan tree project in San Francisco that started here. When I first started in 2007, there was a core group of people from that project that were in this bay area. So that's kind of how I got involved in it. And then AACI is Asian Americans for Community Involvement. It's an NGO, they've been my partner for -- they've been providing services for more than 40 years now to this community. And they are a community clinic. They provide HIV testing. So they kind of became my partner.

And then now I'm on the Planning Commission, HIV Planning Commission for the Santa Clara County Public Health, and I'm the only Asian on it. So I'm always harping about these things like, look at your population. Look, what representation do you have? I'm the only Asian here. And so also maybe in some ways, the wrong kind of Asian too. So kind of that got me interested. And another part of it was really about the ease of doing research, when you're not trying to do something like, you know, from a different -- in a different country. Even if you have like the project that I did with the NGO in Bangalore with sex workers, it was fantastic. But that's because the person who was there, my contact person, the co-PI, she was very interested in research. So otherwise, it wouldn't have worked.

So I think that was another reason why I kind of, you know, moved away into here. So your question about what are some of the issues -- if you look at sort of the CDC and other kinds of data, you'll see that, you know, it's a very small sliver of people who are HIV. Our surveillance data is very slim, but it sort of obfuscates the actual issue because people say, "Oh, you know, this community, it is model minority. You know, they don't have any problems." And obviously, none of the immigrant communities are going to say we have problems. So there's not much research. And that's one. And the second thing is that all the data that is reported, they're all surveillance data, which means that you have to be, you know -- you must come into the system somehow, either through testing, treatment, or whatever it is. So if you don't test, you're not part of that data at all. So the problem is that people are not testing. What happens is in the Asian community -- and this is more or less ubiquitous in that way -- that if an individual test positive for HIV, they convert into AIDS within a year, which means that you really came in pretty late and you didn't have anything -- you know, we couldn't do anything for you because now you have full-blown AIDS. And I think quite a high percentage, I don't remember what exactly, they did not know they're CD-4 counts.

So it's that part that is the huge problem. But once these individuals are in -- they have tested and they're in care, they actually retain in care. And so that's the interesting part. Once we get them in, they will retain in care. They will do what is needed to be done to stay there and stay healthy. But it's you know, you can have all these u equals u which is on untransmissible, you're undetectable, all those good things. But we're not getting people early enough. And then when I was doing that research, which is you'll see my more focus -- I've been focusing on stigma now. We all know that there is stigma, that there's no doubt about that. However, the way -- stigma is not really understood well, because HIV stigma is always conflated with homosexuality and the stigma and homophobia. You just don't even -- it's hard to separate them out. So the worst thing that I've been hearing through my, you know, through the work that I've done is people say, "I don't even want to go get tested, because the service providers are the ones that are behaving in a stigmatizing way."

So now, my interest now has switched to specifically looking at service provider stigma at various levels. Not only at the individual clinicians, but also at the policy level, at the language of the, you know, material that you, you know -- education material, policies within a clinic. So yeah, so that's kind of where I am now.

Vincent Del Casino: Well, in the intersections -- I mean, HIV is such a -- it's still even to this day, it's like single modes of transmission and even the way we report data. When I was in Thailand in the mid-90s, and I sat down with a health worker one day, I said, "What percentage do you think has some relationship to intravenous drug use?" Because intravenous drug use in northern Thailand was -- they drop all the bad heroin in that area, right, on the way out of the country? And she said, "Probably 40%." And I said, "What does the state report?" She's like, "One." Like, right, you know, like, it's all heterosexual transmission? Well, yeah, there's a lot of that going on. But similar sorts of things, the intersections -- like things we're not going to talk about in certain communities. Methamphetamines, right, which we've studied. Which are in my mind, one of the most like damaging set of drugs I've ever seen in my entire life. And then sex, right, two things you can -- here's two things you can't talk about. They're perfect intersections for exactly the kind of spread. And so you take what you say is an ecological framework. So what do you mean by an ecological framework? And how do you apply that to thinking about these intersections between all these issues? And then what's happening on the side of the support, the so-called support people who are helping to produce some of that stigma in the first place?

Soma Sen: Yeah. So ecological framework, it's a purely social work framework, which I find really useful. And I would think that people would use more of it, because it allows you to look at the person in environments. You're not just looking at the person, you're not looking at the environment. It is the person in environment. And so the framework developed by the theorist, he was he was actually a biologist, and he was looking at -- you know, he took those information and made it into more of, how do you understand society and human behavior this way? So basically, the theory says that human beings are embedded in, you know, in various concentric circles. And as you move away from the human being, the circles become more and more distal factors than when you're right there. So it's about proximal and distal factors in some ways. And so in that, how he defines is that the micro is the individual itself, and all those people with whom they have contacted. Again, in some ways social network comes in here, right?

So all the people they have immediate contact with. And then the second level is -- second and third level is a combination where it includes the systems where, you know, -- what is the relationship between the people that I as a micro will have contact with? So let's say for example, if I, you know, I have a friend and my parents, right? They're both in my microsystem, but the relationship between them is going to impact how I see something or how I behave. And then the higher factors are, you know, what about the systems in which I am not directly connecting? But whatever happens in that system after that impacts for example policy, right? Clinic policies, I have no sort of, you know, say on the clinic policy. But whatever that policy is, is going to impact how receiving care, am I going to receive care. You know, do I fall -- can I access care? So that's kind of like that higher circle. And the highest one and, the most furthest away from the human is macro structural, like poverties as economic, you know, culture, you know, other isms and all those demographics and social location stuff. And what this theory allows me to do is identify who these -- who are in these systems. And allows me to look at those relationships in that way.

Vincent Del Casino: It's just absolutely fascinating. It's such important work, and I appreciate you doing it. And I appreciate you being at San Jose and doing it and contributing to our community as you do through the work in Santa Clara. And I'm sure with our students who are probably just really engaged with this, we have a really robust social work program. And I would say today, you know, what we learned in the last eight months is, this is even more important.

Soma Sen: Right.

Vincent Del Casino: And we need to put more value in this sort of work. Because otherwise, you know, the other pieces of the social network are not necessarily there for everybody.

Soma Sen: Right.

Vincent Del Casino: And that's a real fundamental challenge on the ground every day with people, I could probably do this all day, because, you know, I just think about -- it made me think about all the work I've done in the past and the kinds of things. But I just really appreciate you taking some time to sit with me and go through this and talk about your work. It's really energizing, it's really important. And I just want to thank you for doing it. It's really great.

Soma Sen: Yeah. Thank you for having me. And, you know, just one thing that, you know, you brought up students. Students are always a big part of our projects. I mean, any community based work that we do, the papers that I write, they're all students on that. So you know, it's a mentorship, it's reciprocity. It's kind of like, you know, teaching and making people interested, or the pipeline. I love that about San Jose actually, that students are a big part of what we do. Yeah.

Vincent Del Casino: Yeah, you know, learning is not a one-way street. And the more you do this, and the more you open yourself up to letting students teach you and bring you ideas and challenge you, you learn really interesting things as you're doing that. That's why I love co-authorship.

Soma Sen: Yes.

Vincent Del Casino: And I haven't -- it's been a while since I kind of sat down all by myself and wrote something, because there's so much energy that goes, but also that people are just going to be multiplier effects on that. And students are really fabulous for that. So it's great to see them connected and deeply engaged in your work. Well, again, really, thanks so much. I really do appreciate it. I know how busy you are. And it's that time of year and you're doing all the things you got to do to get to the end of the semester. But for me, it was just a joy to be able to learn more about your work and have a conversation.

Soma Sen: Thank you, and it was wonderful.

[ Music ]