Community, Culture and HIV

Last week's readings and class discussion touched upon a topic that is very central to me.  How do we explain the failure of multimillion dollar interventions in decreasing the HIV epidemic both here and abroad?  Are people simply ignorant?  Are cultural practices simply backward, retrograde and in need of change?  Is HIV only the result of poor individual behavior choices?  These are the questions that I hoped to begin to explore in the set of readings that I have assigned to students over the last few weeks.

Traditionally, I feel that discussions of HIV spoke at communities rather than working with communities.  The difference is subtle but important.  Interventions developed from completely outside of communities that are targeted toward changing behavior in my estimation pathologize and "other" the very communities that they are supposed to serve.  Furthermore, "behavior" as the sole education and prevention mechanism of HIV prevention obscures the structural and systemic causes of disease and death.

Toward that end, I wanted to offer the students a set of readings that challenged the traditional approach to HIV and AIDS in Botswana.  Saturday is For Funerals presented an account of HIV/AIDS that in my opinion marginalized the voices of those most affected by the disease.  That the Botswana government has relied primarily on outside advice to tackle the HIV/AIDS epidemic can be interpreted in a multitude of ways and I will leave that up to the students to decide.  

What I hoped the readings for this week did (See Week 4 of the syllabus: readings posted on www.netvibes.com/adpbotswana : See class Wiki Section) was to offer the students an alternative explanation for the continued high rates of HIV infection in communities most at risk.  While much  is made of the unacceptably high rates of HIV infection, it must be remembered that the majority of people in Botswana are HIV negative?  What are the ways in which communities negotiate risk? How do they understand disease and the body?  How are communities coping with the sense of crisis? What are the mechanisms for care and well-being?

What I hoped to focus on was the idea that there are some things that communities are getting right and that more attention needs to be paid to how they approach illness, disease, and care.  A paradigm of HIV education that suggests that communities have nothing whatsoever to  offer to researchers is a paradigm that is doomed to fail.  Simply put, people either tune out or dismiss information when that information presents them, their bodies, their communities, and their sexual practices in a light that suggests that they are ignorant, backward and uneducated.

Ideally what the readings from this week did was to examine various different communal conceptualizations of care and disease.  Ultimately, I hoped that students would be able to think critically about how these communal conceptualizations could be harnessed in order to develop more effective strategies of prevention, care, and treatment.

The discussion in class for this week seemed to suggest that my attempts to foster this debate met with mixed success.  Certainly, some of the students appeared to understand the point of the readings, which was not to question the efficacy of the causal agent of HIV or AIDS.  Rather it was to suggest that communal understandings of illness and disease needed to be accounted for in the development of prevention mechanisms.  Others, seemed frustrated and concerned that Western "science" was being ignored in favor of unproven and untested "traditional" conceptualizations.

Unfortunately, this is not a winnable debate.   What I would also encourage students to think about however, is that Western science is far from unbiased particularly when it comes to the study of populations that are disempowered and the diseases that disproportionately effect them.

I think that as researchers it is imperative to see research with communities as a collaborative practice and not a top down approach that suggest that these communities have nothing to contribute to the discussion. Furthermore, the weakness of the ABC model, which is based overwhelmingly on behavior modification and change is that it does not allow us to account for structural and systemic mechanisms that contribute to high rights of HIV infection.  To focus solely on behavior modification (which I must clarify is an important and necessary mechanism for reducing HIV infection) is to also absolve society of the forms of inequality that it allows to continue to exist that make particular populations more vulnerable to HIV infection and less likely to live should they become infected.