It is time to turn our attention away from academic debates and look to the role of men in the spread of the disease
Suzanne Leclerc-Madlala There is a mystery at the heart of the Aids epidemic in Africa that scholars have explored but have been unable to explain. This mystery has nothing to do with how or when the virus crossed the species barrier from ape to human, or why our variant of HIV is different from that most prevalent in Europe. It has nothing to do with whether HIV and Aids are even linked, whether Aids is just another of Africa’s multiple diseases of poverty, or whether it is possible to develop an effective vaccine in time to save the next generation, and indeed, save Africa from the economic ruin and social chaos predicted. Ironically, all this debate does very little to break the multiple silences that surround HIV/Aids in this country. Arguably, it compounds the problem, as it takes us on an intellectual journey far beyond the dark mysteries that lie at the heart of this epidemic.
The mystery of which I speak has to do with that stubborn and multi-layered Aids silence, or what the professionals call “the denial” that has consistently characterised the Aids pandemic in Africa from the very beginning. Let me risk making myself very unpopular and suggest that the silence has much to do with heterosexual power and sexual lifeways, the structure and meanings of which are contoured by what is often termed “culture”. In the two weeks following the Aids 2000 Conference, three related incidents impressed upon me, once again, the hopeless situation of women in the face of Aids. The first one involves our maid’s 29- year-old sister, who died silently in a back room in Sydenham, which she shared with her Malawian boyfriend of several years. Every time her boyfriend went home to his wife and family in Malawi, Thembi would visit her sister and talk about her deteriorating health. Before two months had passed, Thembi started shedding weight, had lost her appetite and felt too weak to get out of bed. Her elderly mother was called from the farm in Transkei to nurse her, for her boyfriend had returned home to Malawi. A few weeks ago, Thembi started urinating in the bed, displaying memory loss and talking unintelligibly. Did her mother from the farm know anything about infection control? Did she know anything about the danger of HIV transmission through body fluids, if indeed Thembi was dying of Aids? Of course not. Moreover, nobody dared to mention the dreaded word “Aids”, although her sister offered the possibility that it could be “this new sickness”. Alternatively, it was blamed on witchcraft, widely perceived as one of the specialities of people “from Africa”, meaning: beyond our national borders. Thembi died without ever having received proper medical attention. She pinned her hopes on healer friends of her boyfriend who came to cut her skin and rub herbs into the wound in an effort to “chase the demons out”. Thembi’s boyfriend arrived just in time to bury her and give her mother R200 for transport back to the farm with a suitcase of Thembi’s clothing and a radio. The second vignette concerns a cousin from Umlazi whom I will call Thandi. Shortly after her wedding, she inherited two orphaned children from her sister-in-law who had died of Aids. Now, a second sister-in-law is dying of Aids and her sickly baby has constant diarrhoea. What bothers Thandi is the fact that she is a trained nurse, equipped with knowledge that might be helpful, but as a makoti (sister-in-law), in her husband’s home, and one without a child of her own no less, she dare not open her mouth. How could she suggest that there might be something seriously wrong with the baby? They would say that she is jealous. How, at the end of the day, does she talk about her fears and reluctance to clean up the infectious fecal matter that has leaked through the nappies and soaked into the carpets while she was at work? She doesn’t. She keeps quiet. Perhaps she herself will be the next sister-in-law in that home to go down in silence. The third story is my friend Fikile’s plea that we make a video, a tape recording, something, anything, to document local women’s tragic experiences and anger about their inability to prevent themselves from becoming infected with HIV. Her plea came after a week-long stay in Umbumbulu where she buried a young cousin, and saw the burial of four other young women, all of whom were rumoured to have died under similar circumstances, with a similar set of symptoms: the “new sickness”, “Helen Ivy Vilakazi” (HIV), the “three words”, umgulazi. People in KwaZulu-Natal are dying like flies. Going to funerals has now become the premier weekend activity, as it was in the late 1980s to early 1990s during the “total onslaught” years. Admittedly, this epidemic is not only affecting women, but their stories have a special poignancy that is embedded in a kind of silence and helplessness that does not affect men. Millions of women are being squashed under the weight of the compounded multiple silences of Aids. Has the Aids 2000 “Break The Silence” Conference really helped them? Having recently completed a comprehensive review of the existing social science literature on Aids in Africa that addresses attitudes and behaviours related to sexuality, gender and HIV/Aids, there are clearly discernible patterns that emerge and shed light on the peculiarities of the African Aids pandemic. I think they also help to explain our silences. More than anywhere else in the world, the advent of Aids in Africa was met with apathy, or what some researchers have called “an under-reaction”. This was noted at all levels of society, whether individual, communal or national. This under-reaction stood in stark contrast to responses in other parts of the world. In Europe and Australia, for example, markers of sexual behavioural change indicated drastic developments in the first year of HIV/Aids being seriously discussed. In Thailand, the first evidence of the arrival of Aids saw a rapid dwindling of clients at brothels, to the extent that many were forced to close due to lack of business. The scenario for both North America and parts of South America was similar, although it was also recognised that prevention-education campaigns would have to constitute a sustained effort. These reactions occurred as a response to HIV levels that were a fraction of those found in Africa. Yet, no such reaction was recorded for Africa. Only now is there some evidence of the beginning of sexual behavioural change in Uganda, and one wonders to what extent this is due to a “seeing is believing” phenomenon. Back in 1996 I read a paper at a conference in Harare wherein I reported my findings of young people’s apathetic and reckless attitudes towards Aids in KwaZulu-Natal. While some delegates from South Africa seemed genuinely shocked by these findings, the delegates from Uganda, Kenya and Zambia merely shook their heads. They were impressed by the similarities of attitudes expressed by their youth. Essentially, their view was: “Don’t worry, our youth reacted in a similar manner and it was only when they started to see the coffins and had to attend countless funerals that they started to wake up”. Perhaps that time has finally arrived in South Africa. The general lack of behavioural change was once attributed to scant information. Over time, this explanation has become less tenable, as ongoing studies demonstrate a combination of adequate knowledge with continued high-risk behaviour. Today, there is hardly any doubt that more intensive or better constructed information campaigns will do little to change behaviour. We need to reflect with seriousness on what makes the African Aids problem so stubborn, so unrelenting and so smug in its silences. Some researchers have drawn our attention to the social acceptance of death, the idea that the cause and time of death are at least partly predetermined and highly affected by super- natural forces. They point out that the health transition in the West over the past 200 years largely has been a process of people, communities and nations devoting ever more time and care to reducing the risk of death, and to deepening the conviction that the avoidance of death and personal responsibility were linked. Obviously, this was a historical, long-term process, but the point made is not that the message about risk of death from Aids has not had adequate impact, but that the message about the high priority it should be accorded has not reached a sufficiently receptive audience in Africa. These ideas are very provocative, but one has to consider what death and risk mean to someone like, for example, a truck-driver who drives a 20-year-old vehicle without brakes or headlights on some of the most dangerous roads in the world’s poorest and most war-torn countries. More provocative still is the evidence that has been gathered since the Aids epidemic began in Africa on the sexual culture that characterises much of sub-Saharan Africa, specifically with regard to levels of premarital sexual relations and extramarital relations. There is a significant body of well-researched and well-documented social science studies that points to high levels of premarital sexual activity, extramarital relations and sexual violence, making African societies, taken as a whole, more at risk for both STDs and HIV/Aids than those in other parts of the world. In many communities, women can expect a beating, not only if they suggest condom usage, but also if they refuse sex, if they curtail a relationship, if they are found to have another partner or are suspected of having another partner, or even if they are believed to be thinking about someone else. It is worth noting that African researchers have been the principal investigators for many of these studies. The notion and practice of reciprocity and gift-giving is a pivotal feature of sexual relations that has been documented in most parts of Africa. “Gifts for sex” is a practice that expresses itself most strongly in premarital and extramarital relationships.Writers argue that such a practice cannot be equated with Western notions of prostitution. They note that only recently, with Christianity, has sexuality become bound up with religious belief systems that imply sinfulness, and it has never been bound up, as in Europe, with the refinements of romanticism. Sex, then, could be viewed rather more objectively and instrumentally in an African context. Selling sex for money or other material benefits in the face of Africa’s entrenched poverty and women’s continued financial dependence on men is one form of transactional sex. >From my own research with young people in townships around Durban, there is quite clearly another prevalent form of transactional sex. This one has little to do with poverty per se. It involves girls eagerly and easily exchanging sex to pay for chain-store accounts, cellphone bills, designer- label clothing and buckets of take-away chicken brought home for sharing with friends in university residences. Sex with a nameless “Mr Bee-Em” helps the girls to become popular and stay in fashion. As one young woman commented: “If I want jewellery and other nice things, I must get them now. After we’re married, forget it! Our men are awful.” The exchange nature of sexual activity in much of Africa puts girls at increased risk of HIV and plays a major role in sustaining the Aids epidemic in Africa. Along with the general under-reaction to the growing epidemic that characterised Africa’s response, there was, and still is, a great reluctance (that some scientists have called “a refusal”) by Africans to come to terms with the real sexual cultures of their societies. For a variety of reasons, all strongly rooted in the continent’s unique political, economic, social and racial history, there are layers of denial and silence that preclude a serious grappling with sexual cultures. There are widespread beliefs that males are biologically programmed to need sexual relations regularly with more than one woman, and often concurrently. Such beliefs are logically consistent with societies that were traditionally polygamous.
Research has found that these beliefs are held almost as strongly by women as by men. Studies consistently suggest that sex is regarded by the young as necessary, natural and an expression of love, as well as an activity that their peers expect of them if they are to be considered “normal”. Failure to consummate a relationship is often interpreted as a lack of love, and to suggest the use of a condom is taken as a sign of mistrust, as well as the hallmark of one who indulges in casual sex. Condom use in marriage is almost unheard of. Partner dynamics are characterised by an avoidance of direct communication, with the assumption that men should control the sexual encounter. Common to both young men and women is the belief that a man has a right, or even a duty, to force himself on to a woman who displays reluctance or shyness. Gender-based violence itself is often seen as a sign of affection, showing how deeply the man cares. Sex in marriage is simply expected as part of the marriage “deal” whenever the husband demands it. Indeed, even in cases where the woman discloses her HIV-positive status to a husband, studies show that the husband is likely to continue conjugal relations with her while refusing to be tested himself. Often, the husband will insist that the wife should not worry about falling pregnant and passing the virus on to the child because she has a marital duty to produce children.
What emerges most clearly from all these studies is the fact that there is an urgent need to recognise and accept the nature and shape of contemporary sexual mores that have dire consequences in the wake of Aids. By turning our collective attention to academic debates on the origins or existence of Aids, we are conveniently avoiding facing up
to sensitive issues around sexual culture. By pinning our hopes on vaccines and cures, we risk “over- medicalising” our engagement with Aids. We simply cannot afford to get lost among the trees and lose sight of the forest, the latter being the socio-cultural-sexual context that provides such a fertile breeding ground for HIV/Aids.
This points to the crux of the heavy silences that nourish Aids in Africa, including the silences and denials of the government. What needs to be addressed is the role of men, particularly in attitudes and behaviours that reflect their sexual irresponsibility and a certain death sentence, not only for themselves, but also for millions of women and children. For African leaders, perhaps the face that reflects the image of where decisive action is most urgently required in terms of attitudinal and behavioural change looks far too familiar: it possibly resembles the face in the mirror. Worse than appearing as a “kill-joy”, firm measures on the part of the government to foster the transformation of the sexual attitudes and practices of young and middle-aged men will run the risk of inciting the hostility of, politically, the most dangerous section of the population. Perhaps this explains why the issue is so carefully avoided. But until such measures are taken, and our leaders speak out with vigour and determination, as the Ugandans did, we will continue to re-enact the high- risk sexual culture and the silence that enshrouds it. The much-
lauded social transformation that everyone professes to desire, and the “breaking of the silence” will remain elusive. Dr Suzanne Leclerc-Madlala is a medical anthropologist and lecturer at the School of Anthropology and Psychology, University of Natal