AFRO-NETS> Culture Clash and AIDS Prevention

[Edward C Green <EGreendc@aol.com>]

Culture Clash and AIDS Prevention
---------------------------------
 
Dear AFRO-NETS
 
Perhaps I could share this essay that was just published:
 
Green, Edward C., "Culture Clash and AIDS Prevention"
The Responsive Community Vol. 13(4); 4-9 2003.
 
While attending a recent international health conference, I sat 
in on a session on AIDS prevention. Out of the four scheduled 
presenters, only one, an American, showed up to speak; the other 
three, all African, could not attend due to travel problems. The 
American speaker spoke about HIV transmission among gay men, us-
ing the word "homophobia" about a dozen times. The audience, 
mainly from Africa, Latin America, and the Caribbean, seemed un-
responsive, and while there was at least 90 minutes left for a 
Q&A session, no one said a word. The situation seemed a bit awk-
ward. 
 
The session moderator knew me, and perhaps because I was sitting 
near the front of the room, she asked me if I would like to open 
up a discussion about AIDS prevention. So I commented on the dif-
ferent patterns and dynamics of transmission between AIDS in 
America and Africa, and told the audience a little about Uganda's 
simple, low-cost ABC program, led by President Museveni: Abstain, 
Be faithful, or use Condoms if A and B are not practiced. The ab-
stinence message urged youth to delay having sex until they were 
older, preferably married. There was a deliberate attempt to 
fight stigma and discrimination associated with AIDS, and to gen-
erate open and candid discussion about the epidemic everywhere, 
down to the village level. Information about AIDS and how to 
avoid it reached local communities through culturally appropriate 
means of communication involving local leaders, indigenous heal-
ers, drama, and song. There was AIDS education in the primary 
schools. Christian and Muslim faith-based organizations were in-
volved from the beginning of the national response, and they were 
particularly adept at promoting abstinence and faithfulness. The 
government took concrete steps to empower women so that they 
could refuse unwanted sex.
 
The result? Since the program's inception, Uganda has experienced 
an unparalleled two-thirds reduction in national HIV infection 
rates, and in 1989, the new infection rate began to decline. 
Western experts began showing up a few years later.
 
The audience was immediately full of questions: Why had they not 
heard more about these interventions? Why don't we involve reli-
gious groups and schoolteachers more in AIDS prevention? How can 
we prevent seduction of schoolgirls by older men? How can we get 
husbands to stop running around and then infecting their wives? 
Just as the audience had no comments about the presentation they 
had just heard, the American who had made the presentation had no 
comments about this new topic that so animated the audience.
 
This illustrates not only the very different types of epidemics 
found in two regions of the world and therefore the different re-
sponses needed to address them, but also a clash of cultures and 
values between the West and Africa. Africans and others in the 
audience thought that promotion of fidelity and abstinence was 
exactly the right response to AIDS, whereas this is usually 
thought by Westerners to constitute unwarranted infringement in 
people's personal lives. Some of my colleagues call this approach 
"missionary terrorism," designed to interfere with people's right 
to experience having multiple sexual partners. The American and 
indeed Western model of AIDS prevention is to leave sexual behav-
ior alone, but reduce risk by promoting condoms and treating the 
curable STDs (since these facilitate transmission of HIV).
 
How has the Western risk-reduction model fared in Africa? There 
is no evidence that mass promotion of condoms has paid off with a 
decline of HIV infection rates at the population level in Africa, 
according to a new UNAIDS assessment of condom effectiveness. In 
fact, countries with the highest levels of condom availability 
(Zimbabwe, Botswana, South Africa, Kenya) also have some of the 
highest HIV prevalence rates in the world. Still unknown is the 
impact of the other relatively expensive AIDS prevention programs 
we now fund, namely widespread treatment of STDs or voluntary 
counselling and testing. We know that these programs, along with 
condom social marketing, had not yet started in Uganda when in-
fection rates began to decline. This does not mean they might not 
have contributed to HIV prevalence decline in later years. In 
fact, even though only 8% of Ugandan men and women were using 
condoms regularly by 2000, those who were using them were exactly 
the ones that needed them: sex workers and the few men who still 
had multiple partners.
 
To understand why the major donors continue to pour millions of 
dollars into risk reduction while largely ignoring the evidence 
from Africa, it is useful to review some recent history. Western 
donor organizations and the groups they fund began implementing 
"behavior change communications" programs in the Third World in 
the mid-1980s, soon after American AIDS activists felt they had 
discovered how to defeat AIDS in San Francisco and New York. Of 
course, the very term "behavior change" suggests that outsiders 
know what is best for Africans, that Africans are misbehaving and 
need to change their behavior, and that outsiders will show them 
the way to behave. Yet now that we have comparative data, we know 
that African and American sexual behavior is not very different. 
There are subgroups of Africans an Americans who have a great 
many sexual partners, but most people in both populations do not.
 
When Americans designed interventions for Africans, the only pre-
vention model available was the risk reduction model that had 
been designed in the United States for special high-risk groups. 
The model's premise was that we cannot change the behavior of gay 
men (or drug addicts), therefore the best we can do is reduce 
risk through condom promotion (and needle exchange for addicts). 
This model seemed to work relatively well in the 1980s, although 
infection rates are rising again among gay men in America. Never-
theless, since the mid-1980s, this model has been applied to 
populations where most of those infected are not in special high-
risk groups but instead in the majority population. In short, we 
provided American solutions for Third World populations. Once the 
risk reduction model was launched in Africa and the developing 
world, it assumed a life of its own and became the unchallenged 
paradigm for global AIDS prevention.
 
The risk reduction approach also involves the promotion of "safer 
sex" practices such mutual masturbation and oral sex, if not 
male-to-male sex, even though all these practices seem to be com-
paratively rare in Africa. Some Westerners see this as liberating 
Africans from outmoded and perhaps repressive sexual norms. What 
Americans and Europeans forgot when designing these approaches is 
that African cultures are still largely bound by tradition and 
religion, and that they have not undergone the general sexual 
revolution, and certainly not the gay-lesbian revolution, of the 
West. This should have been Anthropology 101.
 
In the minds of Western AIDS activists and public health profes-
sionals, no one should judge someone else's sexual behavior. This 
leads to "moralizing" about behavior, and which should not have 
any place in public health. Yet Ugandans who turned around their 
AIDS epidemic did not know they were supposed to remain value-
neutral. In a BBC interview in August 2002, Museveni recounted 
how he talked about AIDS at every meeting with the public: "I 
would shout at them: you are going to die if you don't stop this 
[having multiple sexual partners]. You are going to die."
 
Forms of sexual behavior highly relevant to HIV transmission, 
such as rape, coercion, and seduction of minors, take us into the 
realm of morals or at least ethics, whatever our objections. Is-
sues involving questions of right and wrong may well require an 
ethical or value-related answer. Ellen Goodman has wondered 
whether in the American transition from a more religious to a 
more secular society, we have somehow given ourselves a "moral 
lobotomy." She asks whether, due to our reluctance to being con-
sidered judgmental, "are we disabled from making any judgment at 
all?" To avoid a fatal disease fuelled by having multiple sex 
partners, good judgment dictates that people have fewer partners. 
Common sense should not be dismissed as moralizing.
 
Apart from Western values and biases, there are economic factors 
to consider. AIDS prevention has become a billion dollar indus-
try. Under President Bush's global AIDS initiative, the US will 
spend US $15 billion, partially on prevention. It would be po-
litically naïve to expect that those who profit from the lucra-
tive AIDS-prevention industry would not be inclined to protect 
their interests. Those who work in condom promotion and STD 
treatment, as well as the industries that supply these devices 
and drugs, do not want to lose market share, so to speak, to 
those few who have begun to talk about behavior. Put crudely, who 
makes a buck if Africans simply start being monogamous?
 
Financial interests aside, it is tempting to rely on quick tech-
nological fixes to complex problems involving human behavior. 
Condoms and STD drugs can be procured, promoted, and distributed, 
and all of this can be counted easily. With condoms and pills we 
have ready-made monitoring and evaluation measurement units, and 
these units are already familiar from decades of experience with 
family planning programs. USAID often comments that it has a 
"comparative advantage" in the condom supply and promotion part 
of AIDS prevention. Yet other major donors could also make the 
same claim, leaving no one with a "comparative advantage" in pro-
moting non-contraceptive, non-drug interventions focused on sim-
ple behavioural change. In fact, faith-based organizations have 
exactly this interest and capability, but they are usually ex-
cluded from donor-funded participation in AIDS prevention. West-
ern experts, who often have backgrounds in AIDS activism and con-
traception, are predisposed to be suspicious about religious or-
ganizations. There is a long history of antagonism between family 
planning organizations and certain religious groups, notably the 
Roman Catholic Church, and more recently, the "religious right" 
in America. Some of my family planning colleagues fear that rais-
ing any question about condom effectiveness for AIDS prevention 
is evidence of a larger agenda to cut off funding for all contra-
ception and to oppose the advancement of women's rights.
 
Part of the whole problem is precisely the "ever-increasing po-
larization between left and right." Some in the religious right 
have in fact attacked broader contraception and progressive so-
cial programs in the same breath as they have attacked the condom 
distribution (or "condom airlift") solution to AIDS. This has put 
liberals so much on the defensive that they will simply not lis-
ten to logical public health arguments on the need to address 
risky sexual behavior in a pandemic driven by risky sexual behav-
ior. Partisans on the left and right are currently fighting over 
how the newly promised billions for AIDS prevention will be 
spent. The fight seems to have once again been reduced to condoms 
versus "abstinence," forgetting that the lesson from Uganda is 
that a balanced, integrated approach that provides a range of be-
havioural options is what works best.
 
 
Edward C Green, PhD
Harvard Center for Population and Development Studies
9 Bow Street
Cambridge, MA 02138 USA
mailto:egreen@hsph.harvard.edu
mailto:egreendc@aol.com

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