All over the developing world there are various sorts of homeopathic medicines for any kind of illness. Some of these actually work, most do not. As Peace Corps volunteers in Africa, we receive a well-worn but complementary copy of “Where There is No Doctor”. Concerning such folk-medicine it provides a rough metric: if the “dawa” in some way resembles the ailment, it is probably not genuine. If the kenyeji (village) witchdoctor seeks the root of a plant that has thorns resembling an inverted sore throat in order to cure that ailment you can generally dismiss it and not look back.
Where there is No Doctor (Swahili)
The typical approach to AIDS in the last twenty years has been a frustrating complex. For years it the world was holding its breath and waiting for it to erupt across the globe. It did not. When I accepted my invitation to go to Tanzania I was not sure what to think about the disease. As we were leaving the US, one trainee offered tales of preventative successes during our collective, frenetic rush around the globe as we got to know the 40 people we’d spend the next two months with. She explained the dynamics of community theater and how it has been used to fight AIDS in East Africa. Another trainee wondered at the profoundly low chance to transfer the disease listed on Wikipedia. For a long period this was most of what I’d heard about it. We were quite busy with adjusting to the facets of culture on the surface.
The entry on ineffective homeopathy in WtiND Swahili.
Eventually we had a section in our Pre-Service Training Swahili language text about UKIMWI (AIDS) and spent a week in PowerPoint presentations with somewhat different perspective on facts than we’d heard online. Like the false wives-tale cures that resembles their symptoms, they were biased for hyperbole instead of attempting to root to the core issue. All Peace Corps volunteers have been through college and most of the individuals in group of teachers had been through quite good ones–a constructively critical bunch. Over and over, my colleagues noted peripheral issues in the approach of PEPFAR (President’s Emergency Plan for AIDS Relief) and Peace Corps. Things like:
“why isn’t more focus being placed on malaria which kills very many people and can be prevented”,
the naïve “how is farming related to AIDS”,
How come teachers are some of the most affected?
or “why don’t we give free condoms”.
The presentations were so surface-oriented. The disease transmission were worst-case without qualifications. There were no references. They didn’t provide much for us to get our teeth into so we could really feel out the issues. Most of us were going into science, math or computers teaching, with degrees & backgrounds in Engineering, Physics and Biology practically all of us had read and used scientific papers. Little of the training required these skills and they went unutilized rightly but in this corner they would have inspired us. I asked why we couldn’t read some substantive research on the subject of AIDS and prevention. It was not yet time.
In the unending summer before I left for Tanzania, I had read a review in the New York Review of Books on AIDS. It sounded pretty solid but it was one entry in a vacuum of knowledge. I emailed my friend serving in Peace Corps Lesotho but didn’t hear anything back. I placed an order for the book and though I didn’t crack the cover before I departed, I felt that at some point I might be inspired to tap it. Even as we arrived at the AIDS section of training I couldn’t find the time. Training is intense and I read slowly. Finally, as I travelled across half the country to my Peace Corps PEPFAR conference concerning AIDS in February, I started reading.
The book “The Invisible Cure” (2006) begins with anecdotes about the Biologist author’s ill-fated quest for an AIDS vaccine back in 1993 which began in Uganda. She walks through essentially the same culture which we have been living through. Generators burn out and hundreds of cell samples are ruined, boxes containing critical research supplies shipped from America are lost in a closet next door to her house for six months, and refrigerator prices rise 200% because she is white. Still she is piqued. The taxi driver who delivers her to her research hospital is informed enough about AIDS that she wonders if he had read papers on the disease. Others in the community too. Ugandan radio programs discusses the evolution and difficulties of creating a vaccination. In about 1990 the AIDS epidemic was taking a downward turn in Uganda and taking a devastatingly upward one elsewhere all along the East coast of Africa. The UN promotes a report which credits condoms, a single false lead which probably has widely mislead aid until very recently.
Every bit of the book seems to be well researched. With twenty years of data around the world in publications it is surprising that few other observers had drawn together so many points. Perhaps it is Epstein’s personal touch in cultural brooking and willingness to follow through with footwork that made it possible. From 1993 until 2006 she travels around Sub-Saharan Africa–South African miners from Mozambique, Tanzanians in Kagera region, Zambia, Zimbabwe, farmers in Kenya–each with a different perspective on AIDS, few so united against AIDS as Uganda in the 1990s. She meets peoples divided over AIDS by globalization, inadvertent stigmatism spawned by existing campaigns, corruption, funding, religion, government lies and tragically flawed research.
At my PEPFAR conference I was about a third of the way into the book. I found myself disappointed: I wasn’t yet far enough to rework her deft analysis within the imperfect framework created by our government. In the face of such a detailed analysis I was even more let down when the weak statistics from the same powerpoint slides showed up again. The trouble with a complicated thesis with non-obvious supporting data is it is not simple to express. Epstein suggests that a combination of women rights, traditional support networks, and partner reduction (”zero grazing”) were in large part responsible for the Ugandan drop. ABCs is a popular way to promote AIDS “behavior change”: Abstinence (A) and condoms (C) were both overemphasized by their respective camps at the expense of faithfulness. The Be Faithfulness (B) message was a casualty of over cautiousness by white policymakers concerning the stereotyped African image.
Voodoo? (WtiND Swahili)
So again, for so many years, the world waited for a global outbreak. The reason it did not come is that Africa is culturally, sexually different. Epstein strongly argues that because of weak economies and different cultural background many (not all) young men and women pursue multiple concurrent relationships. Note this does not mean more partners in a lifetime, just that instead of it being a scandal to have more than one boyfriend or girlfriend it is tolerated on either sides as long as transactional signals are lovingly affected. It is not best compared with prostitution but does obviously run counter to Western (and Eastern) norms. The reality of multiple partners in both genders creates a natural environment for HIV and AIDS to spread based on its somewhat unique epidemiology. In this environment all of the individuals are connected in a network of concurrent long-term sexual relationships.
A single HIV encounter is highly unlikely to precipitate the disease but the connection to all the other routine husband-and-wife and extended girlfriend-boyfriend interactions approach certain transmission to all parties without reliable condom use within most pairs. Studies cited show HIV spreads at much higher rates, perhaps 1000% greater than average, during the first months because the immune system is yet to respond. This is perhaps a side note if you don’t notice this multiple concurrent relationship wrinkle.
Answers to our HIV questions from training were laid out with scientific thrift. Giving away free condoms makes people utterly devalue them. Concurrent relationships are at the heart of the disease in Africa. As biased PCVs we need to stay away from going the liberal, condom advocacy path to balance the perceived faith-based PEPFAR abstinence campaigns, all missing the resonance of teaching faithfulness. Rote teaching young students even more statistics and transmission details that they can already impressively rattle off is ineffective. Life skills lessons are important but still don’t inherently get at the root cure. When multiple concurrent relationships are status-quo they need to be explicitly addressed with explanation of their dangers. We can’t keep ignoring what has not worked for twenty years. Even HIV tests are relatively impotent when the first months, when it is still undetectable, are the most crucial in the spread and male-circumcision has its own problems, also addressed.
(Photo attrib)
The dawa we need to introduce is a focus on faithfulness to a few partners. The valorous abstinence and the phallic shaped condom are powerful symbols, like those roots, but distract us from the real, root cure.
Today, Uganda is trying to return to its strategy as it has strayed since 2000 toward focusing on abstinence with devastatingly few successes. Malaria is now being dealt with by the recently renewed PEPFAR (and related projects). Also notable: Very recently, researchers discovered a non-dominant but significant genetic problem that arose for Malaria resistance hundreds of years ago which accounts for approximately 11% of the total HIV infected population.
