Essay -- AIDS in Africa
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Issue Date:  January 21, 2005

African perspective on AIDS crisis differs from West


Americans sometimes think the main question facing those involved with AIDS in Africa is whether they have access to antiretroviral drugs. For American Catholics, it seems the main question is whether or not to use condoms to prevent AIDS. However, these are not the most pivotal concerns for Africans, including African Catholics. It is more difficult to summarize African perspectives in a single sentence, and partly because of this, most of us don’t know what they are.

We should. Two-thirds of the world’s AIDS burden is in Africa. A careful review of African writings reveals that Africans and Westerners do not always view the world with the same questions, concerns and emphases. Before we suggest -- and fund -- programs to control AIDS in Africa, we need to be aware of how Africans understand their own epidemic. A good starting place is the writings of three African priests.

In 1992, Fr. Laurenti Magesa published “AIDS and Survival in Africa: A Tentative Reflection.” This was the last chapter in a collection of essays by African authors titled Moral and Ethical Issues in African Christianity, published only in Africa. Fr. Magesa is a Catholic priest and moral theologian, sometimes serving as a parish priest in Tanzanian villages, sometimes teaching in African or U.S. universities.

He begins with an observation that is still true 12 years later: “Two distinct tendencies characterize discourse on AIDS in Africa. One tendency caricatures the continent and all but defines Africa in terms of the epidemic. … The other [recognizes] AIDS is a problem ‘with social and political causes and hence in theory resoluble.’ ”

He then suggests three ways to understand AIDS in Africa -- three “cosmologies.” The first is the traditional one, where people see AIDS as a matter of magic and taboo, with the appropriate response being ritual. While this view still clearly influences how people behave, it is “inadequate from the contemporary standpoint … There can be no going back completely to that cosmological view.” The third cosmology is the modern view, which sees AIDS as linked to sexual activity, with the appropriate response being sexual continence. While this is clearly a reasonable goal, in 1992 Fr. Magesa doubted that it was the predominant cosmology of most Africans. The number of AIDS cases was -- and still is -- rising across the continent; the direct link between AIDS and sexual activity, and the response to limit sexual activity, had clearly not yet happened.

Between these two cosmologies, Fr. Magesa proposes a second approach, one that sees AIDS as “directly linked to sexual activity,” but with people responding in a “confused” or “muddled” way. “In response to the threat of certain death caused by the disease, [their] behavior is not appropriate; it indicates nonchalance or even helplessness.” It is this cosmology, “the confused view,” that Fr. Magesa sees as predominating in Africa today.

The priest goes on to consider which countries are most affected by AIDS. His discussion of “the AIDS map of Africa” leads back directly to why people might be confused. While “massive sociopolitical upheavals” and poverty both are important in the spread of AIDS, he says, these factors alone cannot account for why some regions are more heavily affected than others. He then proposes that religion is an important factor: places with low AIDS prevalence “have either a predominantly Muslim or a non-Western (deeply indigenous) Christian influence.” In contrast, places with high AIDS prevalence “have a predominantly Western Christian influence.”

The point is not that the doctrines or practices of Islam are more AIDS-protective than those of Christianity; they are in fact similar. Rather, Islam “adapted itself more readily and much more thoroughly to significant aspects of African traditional view of sex and sexuality.” Christianity, on the other hand, “was overwhelmed by its Western cultural medium, and negated and undermined in real life what it taught in theory. Thus, while not consciously intending it, Western Christianity seems to have encouraged in Africa an unprecedented libertarian sexual behavior. Contrary to the African communitarian, taboo and ritual cosmological approach, sexual relations came to be seen as a private matter of the individuals concerned. The consequences of the use of one’s sexual powers to the community of the living and the dead faded into the background.”

Fr. Magesa suggests that behavior modification must be the main focus in the struggle to contain the AIDS epidemic, and that this modification should include two aspects: structural change (economic development, political stability, control of sex tourism, and improved health systems) and a moral or ethical approach. However, this ethical approach must be rooted in “traditional African cosmology” -- it is not meant to “resurrect a dead past” but to use “cultural elements still extant in the African social psyche. … Completely alien, borrowed solutions will hardly work.” He then summarizes, in one sentence, what must be at the core of an African-rooted approach: “Besides the profound sense of God and the hereafter, [there is] the perception of life as the ultimate good and … community as the context of the possibility of human existence.”

Another African theologian who has written about AIDS is Fr. Benezet Bujo, a Congolese Catholic priest who has taught in African universities and is now teaching in Switzerland. In 1993 he published a book in German, which came out in English in 1998 as The Ethical Dimension of Community: The African Model and the Dialogue Between North and South. Near the end of this book was his chapter on AIDS: “The Importance of the Community for Ethical Action: The Example of AIDS.”

For Fr. Bujo, community is foundational in an understanding of African cosmology. “The individual knows him- or herself to be immersed in the community to such an extent that personality can develop only in and through it.” Consequently, “because no clan member can live in unrelatedness, in cases of misfortune the cause is looked for within the community itself. According to African wisdom, a disease is always an indication that something in human relations is wrong.” Later in the chapter, Fr. Bujo makes it clear that since AIDS is an international disease, it is reasonable to apply these principles internationally: “The problem of this disease is not an individual question alone, but possibly first of all a structural one.” The community here is the entire world, and the disordered structures Fr. Bujo sees are ones well-known to NCR readers: unjust economic policies established by the Northern countries, poverty, Third World debt, etc.

Naturally, “the reformation of our society is a task which cannot be mastered by the individual alone.” Yet “in the discussion concerning AIDS, one often gets the impression that prevention of this epidemic is possible if the individual behaves more carefully.” Then, using his own thoughts together with quotes from others, Fr. Bujo shows the inadequacy of an individual behavior-change approach: “ ‘If an information campaign is satisfied with advertising condoms, without exposing the deeper causes and ignoring the ethical questions, then one is merely treating the symptoms.’ Advertising condoms rather promotes the consumer mentality, reducing sexuality to a commodity. … Only an ethical conviction is able to fight this consumer mentality efficiently and to restore sexuality its dignity. … ‘Neither purely technical advice (use condoms, prevent AIDS!) nor moral admonitions (remain faithful!) are sufficient to control the disease. The prevention and stopping of AIDS does not depend solely on the individual but on the quality of our institutions, changes in culture, economy and politics as well.’ ”

Note carefully: Fr. Bujo is not against condoms because the church requires him to be. In fact, neither he nor Fr. Magesa rules out the use of condoms. He is, rather, cautioning against individual approaches to a disease that has communal causes. He is concerned with “condomization” and its effects on Africa. Fr. Bujo puts it this way: “From an African perspective, it is to be stated that an indiscriminate distribution of condoms ultimately wipes out African culture.” He is arguing here as an African, not a priest. In fact, mentioning aspects of African tradition which “prepare for sexual self-discipline,” he says, “colonial policy and European Christianity have already destroyed this cultural background. … If the industrialized nations wish to help Africa, they should offer their support in such a way that the African people can recover their spiritual and moral immunity, which cannot be underestimated even if it does not offer or replace a technical solution for AIDS” (my emphasis).

Ultimately, this loss of African culture hurts not only Africa but the entire world community. “The African community understands itself as a healing community,” but this self-understanding is under threat. When Western medicine was brought to Africa by the colonists, it “was never integrated into people’s consciousness; [rather] colonial systems destroyed the African medical tradition, which could no longer be effectively applied. For even if the Western type of medicine proved to be more efficient in many cases, the holistic approach to medicine was lost, since the modern method of treatment looked at the person merely from the viewpoint of ‘repairing’ one’s organs.”

The third African priest is Fr. Emmanuel Katongole, a Ugandan who teaches part time at Uganda Martyrs University and part time at Duke University in the United States. His contribution is the paper “AIDS, Ethics and Society in Africa: Exploring the Limits of an Ethics of Suspicion,” which he presented at a conference at Uganda Martyrs University in 2000. He begins with the assumption that Western approaches are now preeminent in the fight against AIDS, and asks how these approaches have affected Africa: “As we make particular decisions and choices what sort of people are we becoming?”

He suggests that many Western views of Africa contain misleading and racist attitudes, with the result that the objects of these views -- first the scholars and intellectuals, but eventually all Africans -- become suspicious of the West. He sees this suspicion increasing as a result of the AIDS epidemic and the West’s narrow approach to it, which “narrowly focuses on ‘viral infection’ and overlooks the wider economic and political and general health conditions in Africa.”

Though “we [may] need a certain measure of suspicion as part of the practical wisdom of everyday life and survival,” says Fr. Katongole, becoming suspicious has a cost. Africans have not only become suspicious of the West, he says, but they have also been told by the Western approach to AIDS to become suspicious of each other.

I remember in the early ’80s when, at least in Uganda, billboards warning against the spread of HIV infection carried the picture of what was obviously a married couple with their three young children and bore the caption: “Love Faithfully to Avoid AIDS.” This recommendation was soon replaced by the Uganda AIDS Commission with what was seen to be a more potent picture: two young lovers in embrace, with the caption: “Love Carefully.” What the Uganda AIDS Commission might not have realized, but what in fact it was confirming was the realization that with AIDS even lovers cannot (or is it, should not) trust each other fully (love faithfully), but must learn the art of loving “carefully,” that is, suspiciously. Apparently it did not take a long time to realize that such “careful” love involves regarding the partner as potential danger from which one had to “protect” oneself. Thus, by mid ’90s the captions had changed again, this time from “Love Carefully” to “Use a Condom to Avoid AIDS.”

The West may have long ago adopted this mutual suspicion, but it is new to Africa. This “radical suspicion generated by AIDS gnaws at the very core of our self-understanding, and thus threatens the basic trust on which our individual and societal existence is based,” the priest notes.

Instead of addressing how Africans can rebuild trust, the West has promoted condoms. One of the leading Western brands is even called Trust. This process of sidestepping the fundamental issues Fr. Katongole calls “condomization”: “The issue of course is not whether condoms do or do not protect against the spread of AIDS. … The issue is about the sort of culture which ‘condomization’ promotes, and the sort of people we become as a result.” Condomization becomes a “metaphor for the incursion of postmodern culture in Africa.”

Fr. Katongole, as an African, describes three fundamental problems with that incursion. Condoms are disposable, like so many other aspects of Western culture. But condomization “is not just about the convenience of disposable condoms, but more importantly it is about the popularization of a certain form of sexual activity, i.e., one detached from any serious attachment or stable commitment. In other words, condomization encourages one to view sex and one’s sex partner(s) as essentially disposable, while at the same time parading such lack of attachment as a high mark of freedom and accomplishment.”

This “freedom” is the second problem with condomization. Using a condom seems to confer immediate freedom -- but, of course, “freedom does not come naturally, but is a result of training into the relevant virtues of chastity, fidelity and self-control.” That, at least, is the teaching of church and tribal traditions. Without this training, these “free” people become “free-floating individuals who easily become prey to their own whimsical needs and choices.”

These whimsical choices Fr. Katongole calls “nihilistic playfulness,” the third problem with the incursion of postmodern culture into Africa. When people begin to adopt this postmodern worldview, he says, “we lose not only the possibility of locating ourselves within any meaningful material economic practices and history, but even more crucially, we become increasingly prey to the manipulations and misrepresentations of the media and market forces. … It may not be a long shot to see a connection between this form of nihilistic playfulness and the various forms of desperate violence with many countries in Africa. Such violence may be just an indication that the extreme form of cynicism, namely fatalism, is, for many Africans, just around the corner.”

These views, though presented here in an academic form, are broadly reflective of views I have heard during 15 years of medical mission work in Africa. The questions for these scholars, and for most Africans, are not focused on the microbe, or even how to introduce and fund antiretroviral drug programs. They focus on the overall cultural approach to health and disease. Their concern is not whether or not an individual uses a condom, but rather what is ignored when condoms become the essence of prevention. These people, the ones most affected by this epidemic, have a much broader view than we do. Why don’t we listen to them?

Raymond Downing is an American physician who lives and works in Kenya with his wife, also a physician. He is the author of the forthcoming book, As They See It: The Development of the African AIDS Discourse, which will be published in March by Adonis & Abbey Publishers Ltd.

Learning to listen to Africans

Dr. Raymond Downing and his wife, Jan, have spent 15 years living and working in different countries in Africa. For the last 11 years, they have lived in Kenya, where they currently work in a family medicine program that trains Kenyan doctors. Dr. Downing’s book on the gulf between African and Western perceptions of the AIDS crisis, As They See It: The Development of the African AIDS Discourse will be published in March. In a previous book, The Wedding Goes On Without Us, Dr. Downing describes his and his wife’s working life in Africa. The title story of the book refers to a wedding he attended in Tanzania, which he had to leave early because he became ill.

“The wedding, of course, went on without me,” said Dr. Downing, who saw the experience as a metaphor for how people in mission and development work often try to take over the lives of those they are trying to help, not realizing that they can and will continue without them.

“My contention is that the way people do things traditionally is often very good [those weddings that go on without us], and that I want to learn those ways,” said Dr. Downing, who has worked for Mennonite and Quaker aid organizations in Sudan, Tanzania and Kenya.

In terms of AIDS, Dr. Downing said that means truly listening to what Africans say about the disease and its causes and treatment.

“Obviously not all Africans are saying that condoms and Western-style methods should be prohibited. They do seem to be saying, though, that they should not be the foundations of African approaches. Clearly the ‘ABC’ approach first articulated in Uganda (A=Abstain B=Be faithful C=Condoms) does not prohibit condoms, though it does give them third priority after abstinence and being faithful. Also, new antiretroviral drugs to treat AIDS are sometimes welcomed by Africans because when available and when taken regularly, they can certainly improve a person’s life.”

Dr. Downing said the fundamental question for many Africans is less what technology should be used and more what the foundations of the programs should be and who controls them. He notes that both Fr. Laurenti Magesa and Fr. Benezet Bujo talk about the need for structural changes in society and a moral and ethical approach rooted in African cosmology.

“Their emphases are not on technological quick fixes or shortcuts; they are saying international economic injustice needs to be addressed in order to control AIDS and that behavior-change programs need to be based on the African heritage, not Western commodity-based marketing. Fr. Emmanuel Katongole simply explores what happens to Africans when selling commodities (condoms, drugs) become the foundation of AIDS control rather than economic justice and behavior change rooted in traditional African morality,” Dr. Downing said.

Almost five years ago, South African President Thabo Mbeki make headlines when he was reported saying poverty, not a virus, was the cause of AIDS. Dr. Downing said misinformation and shoddy reporting about the incident -- he notes that in fact President Mbeki never denied the viral basis of AIDS -- was part of what spurred him to write As They See It: The Development of the African AIDS Discourse.

Dr. Downing said poverty is the substrate in which AIDS flourishes and is a large factor in why AIDS is so much more prevalent in Africa than in the West. He compared AIDS in Africa to obesity and diabetes in the United States. The latter conditions are more prevalent among poor Americans than among those better off.

“In the United States, diabetes is our AIDS: the disease of excess in a land of unjust excess; AIDS in Africa is a disease of deficiency in a land of unjust deficiency. And both diseases hit the poor preferentially. Further, the ‘answer’ to our market-driven diabetes epidemic is more market [pills]; the ‘answer’ to Africa’s AIDS epidemic is more market [condoms and anti-retroviral drugs]. It is this ‘answer,’ I think, that a lot of Africans are skeptical of. So am I,” Dr. Downing said.

-- Margot Patterson

National Catholic Reporter, January 21, 2005

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