Damien Rwegera, rwandan anthropologist. Member of Pan-African Aids Organization (Paris, France)
A poster from Burundi.
A Kenyan poster.
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The world spends $1.5 billion each year on Aids prevention. Paradoxically, only $200 million a year are spent in sub-Saharan Africa, which has the highest concentration of HIV carriers. African states provide 10 per cent of this amount. This is a mark of their poverty, but also a mark of their insufficient commitment to a prevention policy Dr. François Chièze, Managing director of the Pan-African Aids Organization |
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HIV/Aids in sub-Saharan Africa The five hardest hit countries… * The term “adults” refers to the 15-49 age group Source: UNAIDS, 1998. |
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It’s an object of our times... An indispensable auxiliary of amorous encounters. A cumbersome companion of passing pleasures. Banal and necessary: the condom. From Sortons couverts! (“Go Out Protected”), Librio/Sidaction, Paris, 1999 |
In the eye
of the global Aids epidemic, Africa has no choice but to organize a massive, multi-pronged
prevention campaign which mobilizes the broadest range of players
The Aids
epidemic raging in sub-Saharan Africa is one of the worst plagues of recent centuries.
The region has only a tenth of the world’s population, but is home to two-thirds
of the total number of people with HIV/Aids. Two-thirds of those infected in 1998
live in the region and the situation is “out of control” in some countries, according
to UNAIDS.
Sub-Saharan Africa is the poorest region of the planet, a fact which deepens the
crisis. In this context, prevention is the only way out and to date, it has been
glaringly inadequate. However, the qualified success of preventive measures in some
African countries demonstrates that actions can be as effective in stemming the crisis
there as anywhere else.
The main problem lies in cultural attitudes to illness, pain and death. Africans
tend to regard disease not as something physiological but as the result of social
or religious factors, such as a curse, poisoning or divine punishment.
More than any other disease, Aids is associated with death and sex. With sperm and
vaginal fluids. It is passed on by blood and a mother’s milk. All this gives it powerful
symbolism while making it a veritable taboo leading people to go so far as to deny
its existence. Out of derision, some young people in francophone countries say that
Sida, the French acronym for the disease, stands for Syndrome Invented to
Discourage Lovers (in French). They are not convinced by scientific explanations
of the disease especially after the bogus reasons trumpeted at the beginning of the
epidemic: namely that Africans were responsible for spreading the disease because
they “had sex with green monkeys”. Africans responded in kind, claiming that “Aids
comes from white people, especially white women who kiss their dogs and sleep in
the same bed with them”.
The main goal of preventive education is to fight such ignorance and fantasies. The
second goal–to explain how to protect against it–runs up against a similar problem
of perception: condoms are a “white people’s thing”. Moreover, they are so expensive
that sometimes a person has to choose between buying something to eat or having safe
sex. For an African earning about $50 a month, paying nearly 20 cents for four condoms
is out of the question.
The effectiveness of preventive education has to take into account these cultural
perceptions and misunderstandings and respect social structures. In Africa, even
in cities, adolescents just cannot talk to their parents about sex. Such discussion
is limited to people of their own age and sex. So Aids education must follow suit:
women, men and teenagers each have to be approached in different ways.
Adults have to drastically change acquired habits. Teenagers have to be persuaded
to adopt safe sexual habits, a much easier task. Yet this is a long-term job operating
on three levels–awareness, information and education.
Despite meagre resources, African countries have made great efforts to raise awareness
and spread information. Posters and radio are the favoured methods. Performing arts
presentations and advertising are also often used. Experience shows that condom sales
increase in the ten days following an awareness campaign. But these campaigns must
happen more frequently to be effective because repetition is the key.
Reaching
young people in hierarchical societies
Educating young people
is still the main challenge because they are the chief victims of Aids. Around half
of the newly-infected people worldwide are between the ages of 15 and 24. In 1998,
90 per cent of the world’s infected people under 15 lived in sub-Saharan Africa where
there is a tendency to engage in sexual relations at a relatively young age. These
relations are often forced, with 12 and 13-year-old girls often the victims of sexual
abuse.
Schools would seem to be the ideal place to reach youth and most countries have at
last included preventive education in the school curriculum (see pp. 30-31). But
in sub-Saharan Africa, about two-thirds of all primary school-age children and 80
per cent of secondary school-age children do not go to school. So while schools must
be part of prevention, it will take some time before they have a real impact. In
Africa, more than any other region, the only way to attack the epidemic is to mobilize
all the major actors in society at every level–the government, civil society, local
communities and foreign aid sources. The higher placed they are, the greater impact
they will have given the fact that African societies are so hierarchical.
At the top are those with political power. They bear considerable responsibility
for the spread of the pandemic.Their only excuse for inaction is that the continent
is beset with terrible problems. In countries at war, Aids is hardly a priority.
And when there’s no war, poverty is people’s main concern–not Aids. After all, the
disease has never come up as an issue at election time.
The self-criticism of the continent’s heavyweight, South Africa, has had quite an
impact. President Thabo Mbeki publicly admitted when he launched the Partnership
Against Aids project on October 9, 1998, that “for too long we have closed our eyes
as a nation, hoping that it was not really true”, while “every day another 1,500
South Africans were infected in South Africa.” He appealed to young people and to
the population at large to use condoms.
A campaign will obviously not work unless the battle against Aids is a top priority
for governments and given ongoing attention. This has happened in Uganda which has
been the most successful African country in terms of Aids prevention.The initiative
for the all-out battle came from President Yoweri Museweni, who understood the extent
of the disease from the day he came to power in 1986: out of about 60 army officers
sent for military training in Cuba, where Aids tests are compulsory, 20 were HIV-positive.
Without further ado, he earmarked funds for a large-scale national prevention campaign.
Uganda has since made considerable gains. For example, between 1989 and 1995, the
proportion of teenage girls (between 15 and 19) who remained virgins increased from
26 per cent to 46 per cent. They had the courage to refuse sexual relations.
In Senegal, prevention has also been boosted by top-level political decisions, with
clear results. In 1998, the government of Côte d’Ivoire earmarked $1.6 million
for a prevention campaign and recently the president set up a nationwide fund, containing
an equal sum for taking care of the ill.This represents a huge amount of money in
Africa.
Bilateral and multilateral aid agencies are more likely to help countries which make
their own financial commitments to prevention. Beyond that, international organizations
like UNAIDS, WHO and UNESCO can and must convince African leaders
of the extent of the problem. In 1996, the countries of Africa as a whole, except
for Botswana, Kenya, Malawi and Uganda, spent less than $1 million each on Aids prevention.
Spiritual leaders and traditional chiefs, widely respected and obeyed across the
continent, represent another key set of actors. Since the epidemic started, religion
has hindered rather than helped the fight against Aids. A devout Catholic will not
use a condom if he is told it is a sin, any more than a Muslim will if the imam does
not even deign to talk to him about Aids.
The lessons learned from a conference on Aids held in Dakar (Senegal) in 1997 are
revealing. About 300 participants from Africa, Europe and the Middle East, represented
the two main religions of those regions–Islam and Christianity. Just getting people
together to talk about such a delicate topic was an achievement. After some stormy
discussions, everyone agreed that Aids was a disease and had to be viewed in strictly
medical terms. If it did not remove all the obstacles to prevention campaigns, the
conference at least managed to persuade participants to stop opposing the mere idea
of them. Across the continent, religious leaders are now starting to join the fight
against Aids–for example, Caritas International, one of the world’s biggest networks
of NGOs, as well as the group Christians and Aids and Uganda’s Islamic Medical Association
(see
p. 33) have become
involved.
With doctors powerless to cure or effectively treat the disease, people are turning
to the symbolic authority of the ancestors, embodied by traditional chiefs. They
are directly concerned by preventive education because some customs run the risk
of spreading Aids–such as marrying the sister of one’s late wife or the brother of
one’s dead husband and taking part in certain ceremonies which involve washing the
dead. There is an alternative to every custom, as long as the head of the family
accepts it. If the traditional chiefs were to decide to do more to help prevention,
they could speed up the process of changing certain practices.
Risky
customs
Equally formidable
are the traditional healers and practitioners, who have a leading part to play since
most Africans consult them. Nigeria has 700,000 such healers but only 20,000 doctors
for 120 million inhabitants. Involving the healers in the fight against Aids not
only draws on their prestige but also lessens the harm they can do: namely by admitting
the disease exists and claiming they can heal it. Various projects have targeted
healers by providing them with training and instilling them with a greater sense
of responsibility. For example, in 1995-96 the Aids Foundation of South Africa was
in contact with about half a million healers and 650 associations, all of which admitted
that even if they could sometimes treat the symptoms, they could not cure the disease.
Before that, 75 per cent of them said the opposite.
The Zimbabwe National Traditional Healers Association, with 50,000 members, has over
the past decade run about 500 workshops which deal with all social groups (teenagers,
polygamous families, healers, traditional chiefs) as well as members of parliament.
The aim is to make people aware of the dangers involved in traditional rites such
as circumcision, female excision and cures involving incision.
Preventive education in Africa remains the only way of combating Aids, but prevention
must not exclude medical treatment. Africans cannot be told forever that “medicine
is for others but condoms are for you”. There is no underestimating the importance
of a French initiative in May 1998, which was favourably received by the G8 (Group
of Eight Industrialized Nations), and led to the creation of the International Therapeutic
Solidarity Fund. Supported by rich countries, the fund aims to make anti-Aids drug
treatments more available in developing countries. Better access to treatment will
not only help save patients but reinforce prevention efforts. Experience has shown
that infected people with no hope of treatment are more likely to have unprotected
sex than those with medical support.