Monday, 17 December 2012

An HIV-AIDS Project in East Africa


Today, I would like to introduce you to my good friend and colleague, Dr Connie Chung, who graduated with a doctorate and two master's degrees in Human Development and Psychology  from Harvard University, USA. In the year 2009, Connie won the Harvard Committee on African Studies project that funded her study on gender and HIV in East Africa and this brought her into close contact with the small town of Iringa, in Tanzania, Africa. She met with Anthropologist Joseph Lugalla, who was part of the Iringa Development of Youth, Development and Children Care and after a thorough research of Iringa and the project’s objectives, began working with the project. I had a conversation recently with Dr Connie Chung regarding her experiences in Iringa and regarding her opinion about women and HIV-AIDS in East Africa. Connie provided me with a keleidoscope of myriad experiences coupled with her inferences from the project and her views. The following is an excerpt of my chat with her………

AB: It is really wonderful chatting with you regarding your experience with the gender and HIV-AIDS project in East Africa. I have been thinking about it and the first thought that comes to my mind is ‘this is such enriching and rewarding experience’. What drew you to this project, Connie?
CC: I was drawn to gender since I had previously worked with young girls who were forced or pressured into prostitution and had volunteered with Aids Project Los Angeles. Some of the girls that I had worked with had contracted STDs during their sex work, and females are more likely to contract HIV through heterosexual intercourse than males.

AB: And what research prep did you do before you left for Africa? What were your expectations?
CC: I wrote a proposal that I sent to my advisor, the Harvard Committee on African Studies, a draft which was sent to an anthropologist who focuses on HIV in Africa and also spoke to an Anthropologist who worked with street youth. I did an extensive literature review prior to coming to Africa.
I was expecting to see a profound level of poverty, given that I was focusing on street children and AIDS orphans. I also expected to have difficulty adjusting to the living conditions and culture.

AB: And did you ? Was it how you thought it would be? How difficult was it?
CC: ……I would say that there are layers to the experience, sometimes painful and at other times joyous.  I had difficulty with the physical conditions of my experience, but over time I grew accustomed to it.  

My exposure to Africa prior to my arrival was very much based on Western media-and sometimes in a way that blended paternalism, sympathy, and/or condescension.  Prior to going to Africa, all I heard about Africans was civil unrest, hunger, apartheid, and memories of commercials showing a destitute or forlorn African child.  These snapshots of Africa are actually very myopic, and often streamed to the West en masse without sufficient education of the complexities of African geopolitics and their culture.  Instead, we lump Africa as some foreign, exotic other,without recognizing its significant internal diversity and the complexities of economic development in the aftermath of colonial rule.  I wouldn't say my experience was as difficult with respect to adjusting to the cultural shock and difference, but I did have individual experiences that were very hard. I was robbed in Kenya, and I remember crying because I woke up in a bed covered with lizards.  The latter story is not typical of what it is like to live in East Africa, but I ended up staying in one house that had a problem with lizard infestation.  I still vividly remember the lizards, and crying because I had never been surrounded by lizards before and thought they would attack me.  Being robbed was an emotional experience too.  I had to grow a thicker skin, and recognize that I was very fortunate to have regular access to basic resources. Over time, I adjusted to the rhythm of meeting my practical needs.  You can be robbed anywhere, so this isn't a statement that if you come to Africa, you'll get robbed.  I know plenty of foreigners who lived in Africa for years on end and have never been robbed.  But those two memories were very difficult for me.

The people were very kind to me.  Many people went out of their way to welcome me to their home, sharing whatever resources they had.  There was a warmth and kindness that permeated my social networks, and I also welcomed the different pace of life and how in tune I felt with my core values.  I did a lot of soul searching in Africa, and I think it offered me a breath of healing. I grew up in Los Angeles, a concrete jungle ripe with the entertainment industry.  Then I moved to Boston, a city with a high proportion of academics who are intensely ambitious and/or competitive.  In East Africa, I lived in a house with chickens, boiled water to sanitize it regularly, bathed in a plastic tub, and sometimes didn't have a toilet, running water, electricity, or a shower.  I passed chickens on the way to work, and sometimes saw monkeys cross my path.  My mom grew up in a similar way, having been raised on a farm.  But I wasn’t.  I loved my new life.  

AB: It sounds like a bittersweet experience in some ways Connie. But considering that you were for a project, let us talk about the project a little. Tell me about the condition of women in general and those afflicted with HIV in Africa. How did the project identify those requiring help? Who were you focussing on?
CC: Tanzania, Africa is a complicated place. I specialized in Iringa, Tanzania which is a major travelling center for migrant workers going to Zambia and other countries. There was a high proportion of men migrating for seasonal labor and contracting HIV and then spreading it along migratory transit routes where sex work was common. Tanzania, Africa also allows polygamy so a man could infect multiple wives at a time. So, the magnitude of the problem is colossal. Education and socio-economic status were big barriers. Most of the cohort lived on less than a dollar a day and condoms were very expensive. Cultural beliefs were sometimes at odds with utilizing condoms and there was still a lot of cultural stigma about HIV and a very high prevalence. HIV/AIDS afflicts a high percentage of various regions in Africa, an anecdotal figure of 16% of Iringa residents has HIV.
From what I understand, the organization had social workers who found street-based children (female and males) who were living in destitute conditions outdoors. Many of whom had been orphaned by AIDS, and sometimes contracted HIV on the streets or from birth. In terms of adult women, we often worked with Masaai women who were semi-nomad tribal women. However, I am unclear as to their HIV status: this was more in the context of  microfinance aspects of the organization with business development models.

AB: What did the project hope to achieve ? And was this feasible?
CC: I think this project was excellent at providing support for AIDS orphans through housing, educational supports and also provided microfinance/business loans and small business developmental training to impoverished women and youth. Once you contract HIV, consistency and availability of ARVs is critical. Some of these people seemed to be able to access ARVS but were not always consistent in taking their prescriptions. However, I personally believe that enriching people's lives by poverty reduction efforts, educational outreach, and social support, the project was able to provide some degree of support and help to the women and children afflicted with HIV-AIDS.

AB: Was anything done at all in terms of medical aid to these women and children? How were the resources and facilities medically? Did these women have access to them?
CC: In terms of medical care, IDYDC provided care and support to HIV positive people across age and gender groups. It partners with Family health International, Football for Hope movements, USAID, Engender Health-CHAMPION project, International Youth Foundation, GrassrootSoccer, and FHI-Tunajali project for more resources that are health-specific.

AB:  What is the understanding of the people and particularly the women afflicted with HIV-AIDS and their knowledge about HIV?
CC: I think that when you are dealing with functionally illiterate women who may be highly intelligent but didn't have the resources to attend school, understanding Western conceptualizations about medical diseases can be very foreign and different. Also, these women are dealing with life stressors that are so intense: 5 or 6 children, living in severe poverty, without clean water, etc. that more information that does not align with their indigenous beliefs can be difficult to adopt or practically enact

AB: Did they volunteer for the HIV test? Did the project offer incentives for these tests?
CC: I do not know.I am not sure if there were incentives for taking HIV tests through this organization. I think testing centers are prolific, but many people are reticent to actually get tested and know their status. There is still much cultural stigma related to HIV status, and sometimes people claim to have malaria instead.

AB: How do you think gender inequality affects a woman with HIV status in Africa?
CC: I think gender inequality affects women's access to health care, education, social support, and making empowered decisions about their sexual health. Encouraging condom use actually
assumes that women have egalitarian stakes and choice in the elective use of a condom.
Sometimes men may forgo or refuse condoms on the basis that it numbs their pleasure, and some women who do not have the resources to survive on their own may simply go along with what their partner says. 80% of HIV infections in Tanzania are via heterosexual sex.
Saying no to sex, using condoms, or limiting sexual partner exposure (such as a man who sleeps with multiple women, or accumulating one's own partners) are contingent on other variables related to power, access, status, and gendered ways of being where women are often in a position of less power yet the irony is that women are more likely to be infected with HIV from heterosexual penetration than men. But sexual decision making is undergirded by so many cultural ways of relating and understanding gendered norms that women may sometimes be put at a disadvantage and then subsequently have less resources once they contract the disease ,even if contracted in a situation of oppression or forced assault.

Gender inequality isn't so always so concrete, or black and white.  The preceding example of not being in a position of reciprocal power in negotiating sexual health precautions, such as condom use should not be exaggerated that African men are mysogynistic or that African women are just victims of gendered and other forms of structural/personal oppression.  That would be an over-reduction of a complex issue, and not the case in many relationships between partners.  However, there are still some deep seated cultural norms about gendered roles, gendered separation of labor, and ways of negotiating relationships-particularly for such a delicate topic as sexual intimacy-that I myself am not privy to, or do not fully understand.  I never dated an African man, and many cultural ways of family/gendered life are still very alien to me.  However, some ways of relating that I did observe, as a cultural outsider, not from a rigorous form of study or investigative research-is that many of the women that I dealt with (which does not represent all Africans, of course)-and who are predominantly very poor and have low education/literacy levels, is that they were often highly reliant on men for basic survival, and sometimes that changes the tenor of how sexual and other personal decisions are negotiated in a way where the women were less advantaged, or in a position of elevated risk for HIV.  

AB: From what you have just mentioned, it sounds like these women have very few choices with regards to their life. Did you have the opportunity to speak to any of these women personally?
CC: Yes I spoke to them personally when I was there. I think that choice and opportunity are not only personal, but structural in nature.  So I do want to underscore that many hard working, highly intelligent African men also confronted significant limitation in their occupational or educational trajectory.  In the areas I visited, the levels of poverty could be very severe.  Poverty is a compounding risk factor-it permeates everything from health care, to education, to literacy, to risk for HIV, to family dynamics, sexuality and gendered norms, family dynamics, and engagement with civil society.  So the range of choices that many (not all) of these women confronted may be very limited in comparison to an African of better economic resources and education, and extremely limited in comparison to many middle class Westerners-however, they still aren't victims.  They still exercise choice, even if these choices are made in extreme challenge, hardship, or duress.  

AB: Do you think you were making any difference to them particularly if they were HIV affected?
CC: Population movement among young men in Tanzania is extraordinarily high and this is also a barrier to health care, medication compliance, and maintaining care. My own feeling is that the biggest difference is when you empower people to empower themselves on a grassroots level. IDYDC staff are primarily composed of local Tanzanians or people who permanently relocated to Tanzania to help out. So any effort that I put in should ultimately be about facilitating indigenous populations to access resources, and thereby build their own networks that heighten social capital to help their own people. If anything, they made a greater difference in my life. They changed my perspective about life and love, what poverty looks like, and how resilient the human vessel is when faced with horrific poverty and abuse

AB: Do you feel considering the multitude of problems we have just discussed, the project was a success? What would you call a success ?

CC: The aim of the organisation is to decreased incidence rate of new cases of HIV infection over a 5-10 year span and to create a greater awareness of HIV/AIDS, destigmatization of the illness and people who are infected and strengthening social support and quality of life for HIV-infected persons. ARVs have changed the quality of life for people with HIV. Encouraging patient compliance, targeting dimensions of health, education and poverty reduction, all strong protective factors for HIV are important goals. If you live without access to clean water, you're functionally illiterate living on less than a dollar a day, if you live on one meal a day, then you have to address success as a whole person-their socio-emotional needs,  improving the health care access and consistency of client use of available medical care in already infected persons, nutrition, clean water, essentials for good health when immune functioning is already suppressed from the virus, and educational needs.

Me: Would you like to share what you learnt from this experience and how it changed you to be a better person?
CC: I learned many personal and spiritual lessons from this experience. I learned the power of human resilience in the face of atrocious adversity. Many of these girls/women still laughed, had families, had friends, tried to do the best with what little resources they had: fighting for a bit of food with whatever skills they could muster. I also learned that by virtue of being born in the United States, I was shielded from many assaults such as starvation that afflict many persons in developing nations.I learnt that I was lucky to have clean water, access to a doctor and was fortunate to be able to read and have an education. Hope takes many disparate forms
and tenacity is often built in the mires of deep and insufferable anguish.
In terms of what I learned about women, I will say that I learned that gender inequality is reified and reproduced in a culture of silence and shaming.  When women don't have access to clean water, regular access to food, proper health care, who cannot read, and who are sometimes reliant on sex work to survive-it may be difficult for them to fully embrace, or practically institute changes, that reflect Western medical notions about health care and safer sexual health practices.  I really believe in the power of communities advocating for themselves on a grassroots level-African women advocating for African women, Africans advocating for Africans, and this should be done in a climate where basic resources and sheer physical survival are not the most pressing concerns of the day.Then as women grow economically, they can charter a different course in how they conduct themselves in sexual/romantic relationships, and how they negotiate sexual decision making.
and make choices about their bodies, their health, their voice, their opinions, and decide on their fundamental core values in a climate of safety, respect, and understanding. I am not claiming that African culture is anti-women, or that I understand the sophisticated, complex and subtle dynamics that subsume gender relations but that gender and how women empower themselves are still issues that need to be debated, voiced, and loudly heard. It is then that HIV/AIDS, poverty, rape, sex trafficking, abuse, (all of these conditions which also affect boys and men) will have less of a chance to thrive in such an environment of openness, destigamatization, and personal empowerment.

Thank you Dr Connie Chung. We thank you for sharing your experience and wish you all the best for future endeavours.

Dr Anusmita Baruah

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