Culture is Key

“Culture is the way we do things here”
Blog Jan 26 2009
I am writing about HIV/AIDS in Botswana in order to clarify what I have learned as the result of having lived and worked here for the last nine months. What follows is eclectic version of what I have seen and heard while in interacting with students, teachers and villagers, as well as other Peace Corps volunteers.
The government of Botswana has dealt with the existence of HIV/AIDS for the last 20 years. The rate varies today between more and less than 25% depending on the age, location, education, and gender of individuals. It has hindered the economy, overburdened the health system, destroyed families, created a large number of orphans and affected the entire country.
The government has responded with many national programs. These included free voluntary testing, free distribution of three lines of ARV drugs to suppress the disease, a comprehensive parent to child program to prevent the transmission of the disease from positive mothers to their newborns, an extensive prevention program of outreach and prevention from the top to bottom of the country in the workplace, schools, community and in the healthcare system. In addition there have been extensive public information campaigns in print, on the radio and the television. Although less than two million people live in the country over 60 million condoms have been distributed in two years. While these programs are currently being implemented, they have not effectively stopped the spread of the disease. Why is accurate and inaccurate information on HIV still prevalent?
AIDS is often called, the disease. It is a fairly new disease in the country. Its appearance is considered by some to be caused by the Western world. Its source and cure are considered to be from a foreign culture. The disease is historically not part of the Batswana or traditional culture. Condoms and modern medicines are not part of the culture either. Men have multiple concurrent partners. That fact that men can score with a considerable number of women is a source of pride. Women want to have children to prove their fertility, to attempt to keep men, to receive money and gifts from older men and other reasons. Many people do not have enough to marry for a number of reasons. Sometimes it is because the bride price is very high in terms of the number of cows it costs to obtain your fiancé. This price is usually paid for in terms of cows. Without marriages, the women end up raising the children whether they are mothers and/or grandmothers. Wearing a condom (sock in Setswana) is often considered unnatural because it interferes with trusting your partner and physical intimacy. Certain women advocate not using condoms with their partners out of fear, the lure of more money and proving their loyalty and trust. Rape occurs frequently and goes unreported. Young women often are scared to report it. The theory is that they bring rape on themselves by the way they dress. Therefore, young girls can by their parents or fear punishment by the perpetrator. HIV testing is not often considered an option for young women since they need the consent of a parent.
Some people are willing to take the risk of acquiring the disease because they feel they will get the disease eventually. Others feel that they personally will not be affected by it. Others say you can always tell if their partner has the disease and they can avoid those with the disease. In any case, it appears that the local culture wins out over the new English speaking, foreign culture. Cultural pride is very strong here. The Setswana language is talked by the majority. In one memo that went around my school, it stated, “Culture is the way we do things here.” This might be one determining factor.
Testing is not usual before sex. Sometimes testing after sex or by married couples is a problem. For example, which partner acquired the virus and how? Teachers have died among others. They are role models and do not want it known that they have the disease. Young folks can not test without their parents consent so they do not know their status. Also because the HIV stigma is so great, people really do not want to know their status in part out of fear.
The present HIV prevention approach I am involved in with requires schools to inform and create peer educators among the students. These students are to inform their fellow students, families and the local community. The grassroots approach has worked in Uganda and other countries. The large public media campaigns are thought to have less impact and less credibility.
In general, I find the disease is not talked about in public. People who die of AIDS are said to die of TB, pneumonia, or other opportunistic diseases that kill people with the HIV/AIDS. There is an AIDS fatigue. People have gone through long periods of burying friends and relatives. Now people live with the disease due to new anti retro viral medications. It is often assumed that the disease is not life threatening any more. But there are only three different lines of drugs here as compared to many more available in the US. Because of the lack of strict adherence to the medication, the first or second line of medication can be ineffective. Hence, people on the medications can die. The prevalence of alcohol and alcoholism as part of the traditional cultural seriously impacts the prevalence of the disease and the adherence to the medication.
In short, I am making a guess as to some of the problems associated with preventing HIV even though the country has a goal of no new infections by 2016. As an outside observer who does not understand the local language, I am passing on information from a variety of personal and professional sources. From what I understand Botswana is not alone. Southern Africa in general has a very high incidence, including South Africa, Swaziland, Lesotho and several others. Part of this regional problem is in part due to the lack of ritual male circumcision which is performed in other parts of Africa. While male circumcision has been shown to reduce the spread of HIV and is encouraged here, as yet is not as yet wide spread.
The answers to the pandemic appear elusive even though the treatment and prevention effort is so huge in this country. Any comments and observations would be appreciated.