The Media in Africa: Beware of Natives

BuzzFeed has photos of 10 signs photographed in South Africa during the apartheid era and it is truly shocking to think that, as the article points out, these signs only became illegal in 1994. But that's why it should be even more shocking that instances of extreme racism and apartheid style thinking should still be so common in the international media today. I have listed a number of examples below, with links to some of the most offensive articles I've read in the past few years.

These are just the tip of the iceberg and a full study would take years. But, in no particular order, let's start with the stories about condom 'recycling' in Kenya and condom 'rental' in Tanzania. Whether the journalists who wrote these stories were bored or desperate is just one question; but what about the media outlet that published them and the public who read them?

One that goes back a few years is the 'story' about starving HIV positive people on antiretroviral drugs eating cow dung in Swaziland. Numerous media outlets echoed that one and it cropped up several times. There was even a story about a woman in Namibia who  claimed to have eaten cow dung but then admitted that she had made it up. She didn't attract anywhere near as much publicity, though.

The ever-popular notion of 'African' sexuality is a trusty tool in the journalist's store of prejudices. Although it has been debunked many times, the media picture of Africans has remained faithful to their apartheid agenda. Africans are truly 'other', that's why there are such massive HIV epidemics in some African countries, isn't it?

The UNAIDS Modes of Transmission analysis, which produces the 'science' behind the media's HIV related racism has also been criticized, but why attack the source of so many stories that everyone seems to enjoy and find so completely inoffensive? UNAIDS even recognizes the true HIV danger in African countries, unsafe healthcare. But they keep that to themselves, publishing advice about avoiding non-UN approved health facilities in a booklet for UN employees, courtesy of the sweetly named 'UN Cares' (about its own employees).

Occasionally a journalist may allude to the use of African participants as research fodder, but people are too used to hearing about the oversexed and feckless African to care very much about such abuse, especially when it can always be dressed up as 'helping'.

It's coming up to about six years since the international media 'discovered' the Tanzanian albino attacks and killings, even though they had been reported in local media for some time. The sloppy and offensive coverage that followed this great 'scoop' for the BBC continues, as do the attacks on persons with albinism. Why revise a story that has won praise and awards? Of what importance are accuracy and insight when opportunities for self-adulation are at stake?

The disgusting US Christian right story of the use of adult pampers as a result of anal sex among men who have sex with men has even done the rounds in some of the local media. We see articles about African countries claiming that homosexuality is 'brought in' by foreigners. But where did the homophobia come from?

There are sometimes instances of the kind of media friendly racism that is 'roundly' condemned, trivial matters that keep readers entertained, much easier to write about than anything that matters. But what the media writes is clearly not yet a source of offence to most people. Perhaps in years to come sites will be able to list some of the shockingly abusive things the mainstream media published about African people, who knows?

We Don't Need Evidence that Health, Education and Other Social Services Are Good

You might think that HIV prevention interventions have some bearing on the context in which they are implemented. For example, you might think that interventions to persuade people to have fewer partners are concentrated in areas where it has been shown that people have many sexual partners. Or you might think that about interventions to persuade people to avoid concurrent relationships, sexual relationships with more than one person at a time.

But in fact, interventions are mostly the same wherever you go, whether it's a developed country or an underdeveloped one. The little research that has been done into sexual behaviour suggests that in some places people have far more lifetime sexual partners than in others and even that in some places people have more concurrent sexual relationships. But no research shows that areas where people have more sexual partners or more concurrent sexual relationships actually correspond closely with areas of high HIV prevalence.

It's just an assumption that if HIV prevalence is high, people there much have more sex, more partners and more concurrent relationships. Some of the research that has been done clearly demonstrates that areas with high levels of HIV have lower levels of multiple partnerships and concurrent partnerships. It also demonstrates that areas with high levels of multiple partnerships and concurrent partnerships have lower rates of HIV. Clearly, unsafe sex is unsafe, wherever it occurs and however, but specific prevention programmes would need to be clear about what kind of 'unsafe' sexual behaviour, precisely, is occurring and how to change that.

But HIV prevention interventions are more likely to be dreamed up by those with political, religious or commercial interests, in complete isolation from anything that could be called evidence. And so far, they have almost all worked equally badly, whether it's in South Africa, which has the highest number of people living with HIV in the world or the US, which has the highest HIV prevalence in the developed world. These failures are not because of lack of available evidence about what would work and what would not work, though there is a lack of evidence. The failure is because HIV prevention funding has been seen as a matter of 'morals', petty politics and a good way to make some money.

If these circumstances were to change, what hope would there be that the high rates of HIV transmission in many countries of the world could be reduced? The issue of concurrent partners is hotly debated by the foremost academics in the field. But what these people don't disagree on is whether condoms work. There is no evidence that condoms don't work, though they are not 100% efficient. There is only a prejudice against the use of condoms because people who use condoms are having sex. But if people weren't having sex there would be no HIV pandemic.

I have never heard an academic, or anyone else, arguing that education, health education and sexual health education are bad and producing evidence to support their arguments. I have only heard bigoted politicians and religious leaders who seem to know little and care less about what their country's children know about sex and sexuality. Over and over again, it has been shown that children who know about sex and sexuality are more likely to delay their first sexual experience and to take precautions against unplanned pregnancy, HIV and other sexually transmitted infections.

Research into sexual behaviour is not just scarce, it's hard to do and the results are rightly hotly debated. But we don't need to wait for this difficult and costly research to be completed to aim to cut the transmission of HIV. It would be immoral to wait for this research. We know now that people have sex and they need sex education and contraception. They need health services, especially sexual and reproductive health services. The majority of new cases of HIV transmission in developing countries are still sexually transmitted, so to those who say HIV prevention is difficult or that evidence is lacking: this is not completely true.

Sure, there are controversies and there is research that badly needs to be done. But ignoring the efficacy of condoms, education, health and other social services in cutting the transmission is not only wrong, it is also disingenuous. Access to education, health and other social services are human rights so no 'evidence' is needed for these areas to be funded straight away. And while we're considering these human rights, we could also take a look at gender imbalances of all kinds, but especially relating to employment, family law, inheritance and marital power imbalances.

High HIV prevalence relates to the broad determinants of sexual and other types of behaviour, to the overall conditions in which people live, to their levels of health, education, wealth and many other things. HIV prevention has mainly concentrated on individual sexual behaviour and this is one of the things that makes reducing HIV transmission appear to be so intractable.

As the authors of a paper published in The Lancet over three years ago conclude: "No general approach to sexual-health promotion will work everywhere, and no single-component intervention will work anywhere. We need to know not only whether interventions work, but why and how they do so in particular social contexts. Comprehensive behavioural interventions are needed that take account of the social context, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour."

The Apparent Irrelevance of Current HIV Prevention Campaigns

It seems extraordinary that after many years of campaigns to get people to use condoms and take precautions against HIV, other sexually transmitted infections and unplanned pregnancies, university students, the (supposedly) best educated people in Kenya, do not consistently use condoms. Many of them do use condoms, or say they do. But usage has to be consistent and only 15.8% say they use them all the time. Most (77%) do sometimes, or have done on some occasions.

My aim is not to criticize Kenyan university students here, though they really should take note of their vulnerabilities. My aim is to question the country's overall strategy to reduce transmission of HIV. For a start, most money that has been spent on HIV has gone to those who are already infected, on treatment and care programmes. That's fine, as far as it goes. But doesn't the Kenyan government want to cut the number of new transmissions so they can afford to continue to treat and care for those already infected?
But even the money that has been spent on HIV prevention doesn't seem to have been spent on effective programmes. Ok, we hear so much about condom social marketing and various programmes that involve slogans and celebrities and sports and various ‘feelgood’ factors. But which of these programmes have been effective? Well, all of them, if you ask their proponents. But why, then, is HIV transmission still so high?

Well, of course, I don't know the answer to that. But I do know that in Kenya many people do not get enough basic education and that many do not have access to basic health care or other social services. Sex education requires recipients to have some basic educational background for it to mean anything. And sexual health requires a good level of general health. So, dealing with education and health in general would probably help specific HIV related health and education programmes to be more effective.

But that doesn't answer the question of why the people who receive enough education to reach university are also not responding to HIV prevention programmes. Well, sex is just not a popular topic for many people; politicians, church leaders, teachers and parents, for example. Even well educated people have very mixed ideas (some true, some confused) about sex and HIV transmission. It's almost as if their sexual behaviour, then, remains completely independent of and unaffected by the various HIV prevention programmes going around.

I would suggest that the exceptionalisation of HIV has not helped in this respect. HIV is presented to people as something separate from their overall health, as something unprecedented, something that requires emergency measures. But HIV it is not exceptional in the sense that it infects more people or kills more people than other diseases. It is a virus, one of many, that happens to be spread sexually (mainly). Given that most young people have sex, many of them are vulnerable. HIV is not a short term emergency, it is an endemic condition in Kenya and many other developing countries in the world. It is not something that can be eradicated in a short period of time.

And it will certainly not be eradicated by separating this one virus from every other health issue. On the contrary, this is one of the things that can lead to people viewing HIV as something 'other', something that affects people who have been 'bad'. Sex is not bad, it is part of human behaviour, always has been and always will be. Yes, people can take precautions and make sure they only indulge in ‘safe sex’. But they don’t seem to be responding very well to the finger wagging, moralising and frankly medieval prevention campaigns that can be found in Kenya. And that’s hardly surprising.

I was in a London HIV clinic yesterday and people all looked furtive, as if they were going someplace they shouldn't be going. Even in a country that likes to think of itself as permissive and liberal, where sex and sexuality are easier to discuss than they are in East Africa, HIV and other sexually transmitted infections are still treated differently. But at least here in the UK, people have better access to education and information pertaining to health. Health services of any kind, particularly sexual health services, can be pretty remote from the day to day lives of most Kenyans.

I think many people just ignore the messages they hear. Their sex life is their business and they consider themselves to be careful and in control. Try telling most car drivers that they are doing something wrong; they see themselves as being in control and if something does go wrong it's got to be someone else's fault. HIV has been too much associated with things that people feel are not relevant to them, such as commercial sex work, men having sex with men, intravenous drug use, etc. Perhaps HIV programmes are not working very well because they have this 'undesirability' factor built in to them.

Sex plays a big part in the lives of most people. Therefore, HIV is just one issue that relates to sex and just one negative issue, for that matter. Sexual health is as much a part of people’s overall health as nutrition, say. HIV needs to be put in a context where it can be seen as relevant to the lives of ordinary people in Kenya, whether they are well educated and comfortably off or less well educated and poor.

The religious and political posturing, that seems to be so influential when it comes to HIV programming, is killing people. Just as sex is a part of people’s lives, sexual health needs to be seen as a part of their overall health.

Calling the (Self) Righteous

Recent research shows that HIV attacks normal, healthy genital tissue in women. Previously, it was thought that skin had to be broken or damaged to be infected. No doubt, breaks in tissue or other damage may increase the risk of infection. But it seems that even healthy women are far more vulnerable to HIV than previously thought.

The researchers conclude that treatments such as vaccine are needed. But they also conclude that condoms are clearly needed as they protect against infection. Those favouring the 'ABC' (Abstain, Be faithful, use a Condom) approach to HIV prevention must take note that abstaining and even being faithful are not enough. Many monogamous women are infected by their husbands or by their partner. Yet some people involved in HIV prevention insist that abstinence on its own or abstinence combined with faithfulness are enough.

Abstinence on its own, or even abstinence plus being faithful (where abstinence alone is not possible), are not enough to protect people from HIV. Abstinence is just not an option in many circumstances and being faithful can also be elusive. Abstinence, faithfulness and using condoms are only three aspects of avoiding HIV, other sexually transmitted infections (STIs) and unwanted pregnancies.

Those working in HIV prevention who are squeamish or downright bloody-minded about the use of condoms need to reconsider their stance. Are they interested in preventing HIV or are they merely interested in prognosticating at the expense of the people whose interests they claim to be protecting? People have sex. They may 'abstain' or refuse to have sex or avoid having sex under certain circumstances. But when they have sex, and most people do sooner or later, they need to know what the dangers are and how to protect themselves.

Those who are forced to resort to commercial sex work will need to be particularly careful, of course. But they will also need the protection of the law against violence, rape and other forms of abuse. They will need access to information, to health care and to legal services. These are not readily available to commercial sex workers at present.

Indeed, they are not readily available to the majority of Kenyans. ABC is not enough to protect most people from HIV and other sexually transmitted infections. It never was enough and it never will be enough. When will the moral crusaders realise that they are wrong and that they are creating and upholding the conditions that allow HIV to spread in Kenya and other countries?

Some argue that ABC and other campaigns are suitable for adults but not for children. I would argue that such campaigns are not enough for adults but also that children are even more vulnerable than adults. Therefore children need, not just more strategies and education, but more protection.

Children themselves, when asked, say they feel they are being denied access to knowledge about how to protect themselves from HIV. Under the UN Declaration of Commitment on HIV/AIDS, 2001, children are those below the age of 15. Most young people over the age of 15 don't even receive the vital information they need but the ones who are not targeted, those under 15, are exceptionally vulnerable.

Many of them are already sexually active, often having sexual experiences that they do not choose to have. In other words, they are being coerced or somehow pressurised into having sex. It seems unlikely that those forcing minors to have sex are taking precautions against HIV. So what chance have those minors?

Questions about how to inform children about sexuality and the dangers involved are difficult and may take some time to resolve. But they won't be resolved by pretending that it is unnecessary to even discuss sex and sexuality with them. The belief that children who are informed about sex are more likely to have sex has long been discredited.

Children who are informed about sex are more likely to put off having sex for the first time till later in life, often till they have finished school. They are more likely to understand risks, for example, the risks involved in sleeping with men who are older than them. They are more likely to know about and use condoms. They are more likely to be able to negotiate safer sex.

Perhaps it's not children who have a problem with knowledge of sex and sexuality, perhaps it's adults; parents, guardians and teachers. This problem is not confined to developing countries. Where I grew up, Ireland, teachers and parents alike had problems talking about sexuality. I suspect that many still do. Having spent much of my adult life in the UK, I know that most people there find sex and sexuality difficult to talk about.

That's a problem that needs to be faced, not denied and avoided. The sooner we, as adults, sort out our problems with the subject, the sooner we can protect our own children and young people.

On the subject of moral crusades and righteous indignation, the Kenyan HIV and AIDS Prevention and Control Act, 2006, worries many people. For many years, those involved in HIV prevention and the care of those infected with HIV have been fighting to reduce stigma. This act may increase stigma. If people are to be encouraged to know their status, which is said to be the first step in reducing the spread of HIV, they need to know that they will not be discriminated against in any way if they happen to be HIV positive.

Once everyone knows about the dangers of HIV, once everyone has access to HIV testing and HIV care, once the health and welfare of Kenyans are adequately accounted for, then the question of willful transmission can perhaps be addressed more equitably. But we are nowhere near that stage yet. It would be a mistake to put any obstacles in the way of wider testing and greater openness.

More women than men are infected with HIV, but also, more women know their HIV status than men. Already, women have been the victims of stigma and discrimination, despite the fact that they are not more responsible than men for the spread of HIV. How will this law affect women, who are usually tested when they are pregnant, and those who are willing to be tested? Whoever the law is designed to protect, it seems likely to fail.

Reducing transmission of HIV requires that the rights and responsibilities of everyone be upheld, not just the rights of those who are uninfected. The fight against HIV will necessarily involve those who are infected, just as much as those who are not infected. If their rights had been upheld in the first place they would not now be HIV positive.

Don't exclude HIV positive people, children or anyone else from the prevention equation.