Sunday, September 23, 2012
One might be shocked at the Victorian prudishness to be heard in discussions about HIV throughout East Africa. I was at a meeting of young peer educators, who should already be in a position to know better, they are in their late teens and twenties. But several of the male educators agreed that HIV is 'women's fault' because they only wear two layers of clothing below the waist, underwear and trousers or skirt. The other layer they are 'traditionally' (amazing what is referred to as tradition) supposed to wear are either 'cycles' (shorts that go to just above the knee), or a petticoat (so perhaps even trousers are deprecated).
Those who agreed with this, when pressed, said that they and others were tempted by women who did not wear the requisite number of layers. Considering we were supposed to be discussing modes of transmission, the phenomena involved in HIV transmission, blaming it on the way women dress seems a bit far removed from helpful details of what to avoid and why such things should be avoided. Eventually people moved on to 'sharp objects', but eliciting what kinds of sharp objects and explanations of precisely why sharp objects should be involved in HIV transmission took a lot of prompting.
Even then, there was a lengthy discussion of whether 'deep kissing' can transmit HIV if one or both parties was bleeding profusely from the mouth, and another about whether HIV really 'dies in seconds' or if it can survive for minutes, or longer. There was no mention of blood borne diseases aside from HIV, or of whether it was vital to avoid having the blood of other people introduced into your own bloodstream via some kind of sharp object, whether it was from a medical injection with a reused syringe, a razor, a tattoo needle or an infant's teeth. In case you are wondering, it is prudent to avoid having contaminated blood in your blood stream. It may sound obvious, but people do seem a lot more worried about things like underwear and kissing.
The conversation moved on to 'idleness', perhaps continuing the Victorian flavor. People should not be 'idle' because 'idle people' have unsafe sex and 'spread' HIV. Far from advocating for economic interventions on the grounds that people are poor, unemployed and unable to provide for themselves, unemployed and underemployed people are in need of something to do to help them resist temptation. The discussion was long and tedious, as they tend to be, and I eventually had to move on before the idleness discussion ended. But I was sorry I didn't have the time to say that HIV prevalence tends to be higher among employed people, often among the best educated and wealthiest employed people.
For example, the latest HIV related statistics I could find are for Uganda, and prevalence is 8% among the employed, but only 5% among those who are not employed. Indeed, the biggest differences seem to relate to what kind of employment a person is engaged in. Other figures find that HIV prevalence is lowest among those in 'domestic employment'; 'housegirls' (often being blamed for 'bringing HIV into the house', echoes of Charles Dickens?), at 6.9%. But it rises to 16.3% among public administration workers. I may be missing something, of course. 'Idleness' may be more prevalent among those in employment, and far more prevalent among those in certain types of employment.
I was asking a lot of people about the current voluntary medical male circumcision (VMMC) program, of which most people seem to be in favor, and the subject of hygiene arose repeatedly. Perhaps this moves us on from the Victorian era to herald in a more 20th century obsession with hygiene, especially popular among many of the big philanthropists, Carnegie, Rockefeller and others. But it's difficult to see what kind of hygiene the VMMC program hopes to promote, even the obvious, genital hygiene. I was taken to slum areas, where the most obvious lack in hygiene include large pools of stagnant water, piles of smouldering rubbish, mud houses, open defecation and the like. It will take a lot more than circumcising men to improve even genital hygiene.
It may seem shocking to those who have been to slum areas, where the vast majority of urban dwellers live, that proponents of VMMC think circumcising men could come anywhere close to being a priority. If seeing the conditions people live in is not enough, they should have a look at the conditions in hospitals and hear about the amount of disease and injury that comes from the very places where sick people are supposed to be attended to. Even street kids, who sleep rough, often in wet, filthy places and struggle to feed and cloth themselves have been targeted by the current program. Is it even ethical to carry out an operation on someone that you know lives in such conditions, where they are susceptible to all kinds of infection, probably for months?
Moral and even religious associations are often close to the surface when talking to people about HIV. It doesn't take much to prompt reactions suggesting that many people have little time for talk about the viral explanation of AIDS. A few mention taboos or 'chira', but others talk of or hint about the 'low morals' of people who are infected with HIV. This may suggest that, although they all say 'safe sex' can protect you from HIV, ultimately they may not really believe that safe sex is enough! Some appear to believe that people's levels (and type) of religious faith determine their likelihood of being infected, protected, perhaps even of being cured of HIV.
I interviewed a Pastor who belongs to an indigenous Kenyan Church that circumcises boys on the eighth day (following Leviticus 12). He seems quite convinced that circumcision reduces HIV transmission, citing all the publicity that everyone else seems to be able to recite like articles of faith. But others have pointed out that HIV prevalence is also high among his church members and among some circumcising tribes. The pastor, seemingly being prompted by his bishop, concluded that people must accept that HIV is being caused by unprotected sex, so they must decease from their bad behaviors and that they should also accept circumcision.
I'm not faulting the pastor on his biblical interpretation. But the relevant chapter has more to say about cleanliness than just circumcision. If cleanliness and hygiene are so important, the highest priority would seem to be the provision of clean water and sanitation for everyone. Circumcising all the men who live on the street, work in the lake, live in slums and face so many preventable health and HIV risks in their daily lives (to say nothing of the risks women face) could do a lot more harm than good. Without clean water and sanitation, lack of hygiene will continue to be behind much of the morbidity and mortality among people, whether they are circumcised or not, even whether they are male or female, adult or child.
The problem with all the talk about sin, idleness, evil, immorality, bad behavior and the rest is that it seems to miss the biggest denials of human rights that most people in Kenya face: the rights to health, education, water and sanitation, infrastructure, employment and many more. Given the conditions people have to live in, the explanatory power of individual sexual behavior in HIV transmission is completely deflated. Perhaps the pastor and others are looking for splinters, rather than beams. Walk through a slum, and I don't think the need for circumcision will be the first thing that strikes you. And if you see street kids, even the ones who don't (yet) sniff glue, you will probably think that circumcision could not possibly be safe for them, given the conditions they have to live in.
Those wielding their scientific data (and scalpels) are happy to bully anyone who threatens to get in their way, and everyone is happy if they are recipients of donor largesse. Even those cajoled into being circumcised by promises of '60% protection' (whatever people think that means), of being 'men' and of making the wise/smart choice (according to the billboards), free healthcare (as long as it's just circumcision), protection from various other sexually transmitted infections, better sex for them and their partners (yes, this claim is also used) and the endorsement of Luo politicians and elders, seem to be happy.
Most of those who have had the operation under the current program so far are not sexually active adults (or would have been circumcised anyway, but are availing of the free option), and therefore are not likely to face high risk of being infected through their sexual behavior. But all circumcision operations are being counted towards the (movable) target, any drop in HIV transmission can be attributed to the program and any increase in transmission can be attributed to the individual behavior of those infected, to the fact that they did not practice 'safe sex', as they were advised to do. Meanwhile, appalling living conditions, hazardous healthcare, poverty and lack of opportunity, low levels of education and multiple other factors ensure that people's lives remain blighted, with HIV being only one of many sources of the blight.
[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]