Collective Efficacy

“The ability of people to join together and help one another…collective action and mutual aid, a spirit that is impossible to measure or quantify, but that is rooted in a sense of compassion and common humanity”
-Helen Epstein

I cannot take credit for the following post. I have been reading Helen Epstein’s, “The Invisible Cure” which has created a shift in not only my thinking but also mood and outlook as I ponder the remaining 18 months of my Peace Corps service in Botswana. If you want to understand why HIV/AIDS is so widespread in Southern Africa and as Helen states in the title of her book, why we are losing the fight against AIDS in Africa, you need to look no further than to navigate the chapters of her text. I have quoted her in several places in this post. I urge all readers of this blog to read her book to fully understand the context in which I hope to convey her many important points of view and investigative findings.

Important Terminology:

Multiple Concurrent Partners (MCP): having more than one sexual partner at the same time.
PEPFAR: President’s Emergency Plan For AIDS Relief; initially a 15 billion dollar U.S. HIV/AIDS funding package that primarily caters to African nations. Provides money for ARV treatment programs in Botswana, testing centers and some preventative programs geared towards abstinence only education.
Batswana: the people of Botswana

I’ve been agonizing over how to update my blog since my last entry in early August. Nothing came to mind. I thought about incorporating my daily activities and struggles and illustrating the memorable stories that I’ve experienced thus far. I even thought about how I should detail the goals that I set for myself, in so far as adapting to living in a developing country, giving everyone back home a feel for how my time in Botswana was difficult and yet rewarding at the same time. Unfortunately, and to my own detriment, I also rejected any blog posts that didn’t convey a more uplifting and cheery side of Botswana and the culture. I changed my mind yesterday when I had one of the most uplifting days thus far during my Peace Corps experience and it occurred, though only partly from my acceptance that a lot of what I am doing, what I want to achieve, and more so, what many aid agencies and government officials are attempting to accomplish with regard to Botswana’s HIV/AIDS epidemic, is misguided. Maybe I should retract that last word.

When 60 of us began our “pre-service training” (PST) for Peace Corps six months ago, I began wondering if there was anything we could really do to help. I am referring to all of the following: Peace Corps, white-westerners, developed countries, 60 two-year volunteers, “makoa”. Can we make a difference? Are we even wanted here?

During the time that I was beginning my high school years in Idaho, Botswana was seeing HIV rates soar, along with the rest of Southern Africa. This was the early 90’s and ARV treatments were nowhere in sight of being introduced for those who were infected, let alone being subsidized by the Botswana government as they are today. The nation and the continent were inundated, much like HIV attacking CD4 tells of the human immune system, by those affected by the death of a loved one, friend or neighbor to AIDS. This has been my bewilderment: How could a nation and a continent not consciously tackle behavior change and more importantly, decrease their prevalence rates with this level of influence from AIDS and its wake? With so many people dying in small villages and the urban centers of this country, why were Batswana not emotionally triggered to take action? Why was the Peace Corps invited back to Botswana to strictly address HIV/AIDS capacity building; in a country that had seen it’s fair share of HIV related deaths? And ultimately for my part, what can I do to “help” when real life trauma can’t propel the behavior change train?

Here’s the catch, they didn’t know about HIV/AIDS. More precisely, they didn’t want to know. This statement may sound a little naive at first but let me clarify. HIV/AIDS has a history of stigmatization and discrimination behind it. Simply remember back to the propagation of homophobic connections between HIV and gay men; the “gay man’s cancer/plague”. Stigma and discrimination are nothing unique to western cultures in relation to this disease. What’s noteworthy however, and replica table here in Africa, are the responses taken by the gay community in the states during the 80’s and 90’s; community mobilization.

Botswana is still addressing stigma of those with HIV/AIDS and I believe this is the direction the government must fully address and finance. As I discussed in an earlier blog post, I had to temper a lot of my expectations joining the Peace Corps and especially once I arrived in Botswana. I haven’t done as well at it as I would like to believe. I had grand notions of implementing like-minded programs that I ran in the states. I looked at my previous work experiences and kept drawing upon them for inspiration. A myriad of projects and proposals glittered in my head as I drafted GAANT charts and calendars for programmatic implementation plans in notebooks and on scraps of paper whilst sitting in workshops. Not only did I begin to look at how these programs would be successful and meet some nation-wide strategic framework but that by the time I finished my stint in Francistown, I could be proud of my accomplishments; accomplishments that would speak for themselves on my resume.

What if the answer is rather simplistic in nature though difficult in execution? What if people became emotionally invested in their neighbor’s life or felt a collective urgency to do battle with a virus, a disease, a chronic illness that doesn’t discriminate whether you are a child, a prostitute, a virgin, a circumcised male, a political figure, a mother, or a frequent condom user. These “what if’s” revert back to individuals and community members wanting to know their own HIV status along with caring for those who are living positively with the virus or dying from opportunistic infections that plague those with full blown AIDS. How is this done? How did Uganda appear to do it 20 years ago? And why can’t Botswana and the rest of Southern Africa do it today?

“In 2003, the only African country that had seen a nationwide decline in HIV prevalence was Uganda. Since 1992 the HIV rate had fallen by some two-thirds, a success that saved perhaps a million lives. The programs and policies that led to this success… was played by the ordinary, but frank, conversations people had with family, friends, and neighbors – not about sex, but about the frightening, calamitous effects of AIDS itself. These painful personal conversations did more than anything else to persuade Ugandans to come to terms with the reality of AIDS, care for the afflicted, and change their behavior… researchers found that people in other sub-Saharan African countries were far less likely to have such discussions.”

With so many Batswana dying years earlier, obviously they must have had an emotional connection and response, right? This is where stigma and discrimination in Southern African has played an enormous role in the spread of HIV. Even when family members were dying, their children, cousins, nephews, aunts & uncles didn’t “know” they were dying from AIDS. If individuals got tested for HIV (and that’s a big “if”) they probably didn’t return to the clinic for the results. During the 90’s, rapid response tests were not available. Usually a two-week turn around time was standard, “if” your blood tests were handled properly and tested in a timely fashion. Plus, clinics and hospitals were not prolific in nature with regard to providing HIV tests. Thus, a person may have to travel a great distance to get tested, especially in rural areas, which constitutes most of Botswana.

As an example, a women may have to hitch a ride to Francistown from a surrounding village, costing a great deal of money in Botswana terms, find someone to look after her child or more likely than not, take them along with her. This may also take place secretly from her husband or parents. Upon completion of her blood test, she is told to come back in two weeks to get the results. More money, time and crafted excuses to her family. In the end, she doesn’t make it back. Also very likely is the possibility that even if these obstacles weren’t grand in their nature, this women may not want to know her status because the truth could be traumatizing and subsequently not offer any solution or treatment anyway. If she is positive, and her family finds out, she risks being kicked out of the house, shunned by neighbors for being seen as “cursed” and/or “morally destitute”. She keeps her status unknown or if known, secret from everyone in her life. Assuming she is positive, she become sicker and eventually develops AIDS. Her family doesn’t know what’s wrong with her and as she is dying, she complains of debilitating head-aches, one symptom of an opportunistic infection of AIDS patients, When she actually passes on, in a remote hospital ward- removed from view and thought of those in her community, people ask her family why she is “late”, they say from head-ache. No autopsy is done, as so many cases like these are happening throughout her village and her death certificate reads: cause of death – unknown. The family doesn’t pursue the issue because even if they know that it was AIDS related, conveying that to the rest of the community still brings shame to them and possible discrimination; neighbors stop interacting each other and in some cases assault and vandalism occurs. If a generation learns to ignore, live in denial and close off the realities that HIV/AIDS brings to their lives, then its no wonder why there hasn’t been an emotional component in Botswana; a tipping point that prompts behavior change and reduces Botswana as having the second highest prevalence rate in the world.

Other Peace Corps volunteers have shared their experiences with me of living in rural villages and detailing the low levels of understanding of how HIV is spread. The Botswana government is bolstering resources for a nation-wide life skills curriculum geared toward furthering HIV/AIDS education in the schools. In fact, roughly one quarter of Peace Corps Volunteers (PCV’s) in Botswana are working in schools; capacity building this program. However, many youth and adults in urban centers and larger villages can adequately explain the modes of HIV transmission and offer up methods of prevention; abstinence, faithfulness, condomizing to name the heavy hitters. This regurgitation of scientific facts and debated protective measures doesn’t appear to be the problem or the solution.

Botswana is one of the main recipients of PEPFAR funds, UNAIDS support, and Global Fund interventions. Why don’t we see dramatic shifts in incidence rates? One of many reasons is arguably due to the poor monitoring and evaluation programs tied to gathering data of HIV infection rates. Nevertheless, one would think that the massive HIV/AIDS industrial complex that exists in Botswana and elsewhere in the world, would somehow be able to illustrate some dramatic shift in new infections; some measurable shift due to well funded preventative measures. Are we making things more complicated than they need to be? Are we focusing too much on the abstinence versus condoms arguments? I have no doubt that Multiple Concurrent Partnerships (MCP’s) are the primary factor behind Botswana fighting out the number one and two slots for highest prevalence rates with Swaziland. But, are MCP’s merely a symptom of a larger problem? Are MCP’s happening, not just because of so-called cultural practices and history, but because there is “no sense of collective urgency to rouse people into action…their compassion and hard work bringing the disease into the open, getting people talking about the epidemic, reducing AIDS-related stigma and denial and leading to a profound shift in sexual norms.” At present, it seems more commonsensical than spending millions on advertising campaigns and slogans. So, what to do now? Though I doubt that the answer is staring back at me in my fantasy basketball league, I think having a positive coping mechanism at least delays this answer for the time being and helps me get some semblance of accomplishment out of my daily activities.