University of Edinburgh School of Social and Political Science Social Anthropology

East Central Africa Dr. Rebecca Marsland

Assessed Essay: Is it possible for ethnography to be of any use in East Central Africa? Discuss with reference to HIV and AIDS.

Examination Number: 7808463

15 December 2009

Word Count: 3,196

It is impossible to contemplate the shape of late modern history, in Africa or elsewhere, without the polymorphous presence of HIV/AIDS, the signal pandemic of the global here and now (Comaroff 2007:197). HIV/AIDS is a disease that has baffled the best scientific minds of the West due to its incredible and sometimes unrecognized complexity. The portrayal of the disease especially in Africa has for the most part been homogenous: understood as a single, undifferentiated socio-cultural block, despite its rich cultural mosaic and differences in geographical, economic, and historical experiences (Oppong & Kalipeni 2004:48). Africa is continuously over-generalized, which in turn also frequently characterizes research in the continent, in the sense that a study on AIDS in Uganda with a special focus on the Rakai District or Buganda region is plainly called AIDS in Africa (Oppong & Kalipeni 2004:48). Furthermore, mass mediated images of the disease in Western media, portray people as abject, intractable and doomed, epitomizing otherness. Africa becomes depicted as a horrific exemplar of all that threatens the natural reproduction of life (Comaroff 2007:201); death for the most part is treated as a fact of life (Kitznger & Miller 1992:36). Thus the AIDS epidemic, with its genuine potential for global devastation, is simultaneously an epidemic of a transmissible lethal disease and an epidemic of meanings and signification, generating extensive meaning far beyond its biological effects (Paula Treichler 1987). It has given birth to significant forms of sociality and signification, of enterprise and activism, both negative and positive. With the help of social scientists it has increasingly become clear that HIV/AIDS is embedded within social, economic, cultural, political and ideological contexts, specific to each region and area of Africa (Craddock 2004:5). Consequently, anthropological

perspectives have taken a leading role in providing alternative currents of social research in response to HIV/AIDS (Parker 2001:172). The continuous insight the discipline has brought to our understanding of culture and society through ethnography has provided valuable accounts of the impact and significance of HIV/AIDS. Ethnographic accounts stress the need to provide not just quantitative representations of the study but also qualitative data, which is necessary in analyzing the local understandings of HIV/AIDS. Qualitative research, which is primarily inductive and descriptive, provides rich contextual data to further our understanding of social phenomena (Power 1998); it is the special immersion in the data that gives anthropologists a special cache (LeBeau & Gordon, 2002:7). Using ethnographic methods and analysis, anthropologists explore manifold aspects of the disease: experiences of illness and suffering, the logistics of access to treatment, ideologies of shame and stigma, structural inequalities shaping patters of incidence and prevalence, sexual networks, among many others (Parker 1998:692). Ultimately, it can be said that anthropologists offer a unique role in the study of this global pandemic by providing an ethnographic gaze to the study of HIV/AIDS, which may pick up and clarify issues and phenomena. Having said this, the aim throughout this essay will be to reveal, through ethnographic examples, some of the secrets that have been unearthed within the context of HIV/AIDS, specifically in East Central Africa. By looking into the historical progress of HIV/AIDS research and the role of anthropologists, I argue that the discipline is vital and necessary in understanding the epidemic. It can be argued that epidemics in general, and AIDS in particular, give social scientists an unparalleled opportunity to examine the interaction of institutional

practices, social values, and cultural assumptions in a given place and time, particularly those of medicine (Felman 1995). However, like many other disciplines, anthropology was rather slow to respond to the initial impact of the epidemic, largely failing to challenge the dominant Western biomedical paradigm in HIV/AIDS research (Packard & Epstein 1992:354). During the first decade of the epidemic, most social science research focused on the behavioural correlates of HIV infection among individuals, failing to examine broader social and cultural factors. Anthropologists were involved in digging through the ethnographic record on African cultures in order to identify possible patters of behaviour that might facilitate HIV transmission (Packard & Epstein 1992:255). This biomedical paradigm relied on a concentrated Western biomedical emphasis and a largely individualistic bias in understanding HIV/AIDS (Ramin 2007:128). The community paradigm that followed in the 1980s, was characterized by a move away from individualcentric understandings of the epidemic. Pioneering work by anthropologists began to raise the importance of cultural systems in shaping sexual practices relevant to HIV transmission and prevention (Parker 2001:164). What resulted was a growing focus on the interpretation of cultural meanings as central to a fuller understanding of both the sexual transmission of HIV/AIDS in different social settings and the potential to respond to HIV/AIDS through the design of more culturally appropriate prevention programs (Ramin 2007:128). This emphasis on cultural analysis took the shape alongside a growing anthropological research focus on structural factors shaping vulnerability to HIV infection (Parker 2001:163). It became clear that a far more complex set of social, structural, and cultural factors mediate the structure of risk in every population group (Ramin 2007:128). The

structural paradigm that emerged focused on the linkages between local socio-cultural processes that create the risk of infection and global political economy (Farmer 1997). It requires broad biosocial approaches emphasizing structural forces such as racism, sexism and inequality of which structural violence is the pre-eminent model (Farmer 1996, cited in Ramin 2007: 128). Thus, anthropological contributions to the understanding of HIV/AIDS can be seen as twofold: the traditional anthropologists (classically trained anthropologists) adding socio-cultural depth to biomedical and epidemiological understandings of HIV/AIDS epidemic (Ramin 2007:127); secondly, the political economy (PE) anthropologists, whose primary perspective for understanding HIV/AIDS is looking at the political and economic structures in which individuals act and shape their behaviour (Ramin 2007:127). Knowledge of AIDS in Africa is fundamentally about power: the power to name and define; the power to know; the power to attract funds; the power to act to reduce risks of becoming infected with HIV (Schoepf 2004:121). HIV/AIDS is propelled by class, age and gender inequality (Schoepf 2004:131), which in turn is affected by structural and social violence contributing decisively to the dissemination of HIV/AIDS. This new work on social inequality and the political economy of HIV/AIDS has been especially important, as there is a need to integrate both cultural and structural concerns in providing an alternative to previous research paradigms (Parker 2001:163). Disease epidemics need to be seen as social processes; the spread of infection is propelled by history, political economy, and culture (Schoepf 1997). Thus, issues such as social-sexual relations, movement of people, prostitution, sexual relations and marriage; coping with illness, and technical issues of disease transmission are all topics which I wish to discuss in the coming paragraphs.

Since early in the AIDS pandemic, epidemiologists have paid a great deal of attention to urban African women engaged in commercial sex as a core risk and core transmitter groups in the spread of HIV infection (Setel 1999:120), without considering the social factors that power this. In these views, social scientists were quick to point out that the value-laden Western concept of prostitute as employed in these epidemiologic studies added little to our understanding of the sexual and economic lives of women in African cities. This tendency muddied clear thinking about risks with ethnocentric notions of stigma and promiscuity and exaggerated the pervasiveness of prostitution in the Western sense in African sexual cultures (Setel 1999:120). In Unimagined Communities, Robert Thornton (2008) suggests that sex is more than a personal quest for pleasure. It is viewed as an exchange of fluids between males and females, part of a broader flow of objects and services between sexual partners (Thornton 2008). Women and widows gain access to food, cash and consumer necessities through casual sex (Schoepf 2004:374). However, although, these women may be rewarded in cash or gifts for sexual favours it does not necessarily make them prostitutes. Women in economically marginal occupational categories, saw sex trade as ancillary activity. Thus, a good deal of female sexual behaviour in Africa can be viewed as economic survival and adaptation to patterns of male dominance (Green 1988:180). These behaviours must be taken into account in order to understand the sexual networks that are regional and even countrywide. Thornton makes a strong case for uncovering the social factors that power these networks, and for developing new prevention efforts to counter them. This points to the necessity to see sex as a social act, not just a behavioural one; so it follows that social interventions are necessary to curb the flow of infection (Tu1i 2008).

Changes and strategies for behaviour can be analyzed through some of the ethnographic work done by anthropologists. Sexual behaviour and indigenous health practices exist in a cultural context which, along with the behaviour itself, must be adequately understood before attempting to direct behaviour change (Green, 1988:180). Schoepf finds that although in Uganda, there has been notable increase in condom use in recent years, it remains unpopular among many people for numerous reasons attached to stigma and culturally based expectations (Conant 1988:198). To make them popular and acceptable in steady relationships, they must be removed from the realm of moral stigma (Schoepf 2004: 374). This stigma attached to condoms is something, which has for quite sometime been overlooked and needs to be addressed. The stigma and formation of sexual culture is important in the representation and prevention of HIV transmission (Herdt 2000:141). For example, Allen and Heald (2004) compare HIV/AIDS policies in Botswana and Uganda, revealing that the promotion of condoms at an early stage proved to be counter-productive in Botswana, whereas the lack of condom promotion during the 1980s and early 1990s contributed to the relative success of behaviour change strategies in Uganda (Allen & Heald, 2004: 141). For Botswana HIV/AIDS was a topic shrouded in stigma and silence at all levels of society. Part of the problem seems to have been with the health promotion campaigns themselves. In Botswana, there is a deep-seated unwillingness to talk openly about sex, partly due to rules of respect that lie at the heart of family and kinship structures. These attitudes were brushed aside by public campaigns such as the ABC, which resulted the campaigns being ignored or actively opposed (Allen & Heald, 2004). In local terms, condom promotion seemed to encourage immorality; in

addition, condom promotion fuelled an alternative discourse of AIDS, bedded in Tswana beliefs and understandings, which held the condom an agent not in the control of the disease but rather in its very origin and spread (Allen & Heald 2004:1144). In Botswana, sexual intercourse has special value, not only as procreative, but because it sets up a ow of bloods between sexual partners, which is health-giving. Stopping this ow is seen as a possible cause of affliction with the blood becoming hot. From this point of view, use of a condom is dangerous in itself. Additionally, the governments following of an exclusively western model fuelled suspicion. The links between HIV, condoms and immorality remained strong and the stigma attached to infection was considerable. Unlike the population of Botswana, in Uganda people were experiencing AIDSlike symptoms and excessively high mortality at an early stage. Thus, there was evidence to back up the early awareness and behavioural change campaigns promoted, which consequently had a positive effect in quickly increasing awareness of the disease in Kampala and southern parts of the country. As in Botswana, the symptoms of AIDS were often incorporated into local bio-moral interpretations of affliction, but the diversity of Ugandan society mitigated against alternative explanations of the disease found in countries like Botswana (Allen & Heald 2004:148). An important aspect of these campaigns in Uganda was that they involved a variety of institutions and individuals (i.e. President Museveni), both inside and outside of the government sector (Allen & Heald 2004:149). The control programmes in the two countries need to be assessed in the context of the local epidemiology of HIV/AIDS; Reviewing experiences in Botswana and Uganda is revealing to sometimes overlooked cultural and social factors.

An important aspect of anthropological research, lies in our ability to elegantly describe the everyday lives of people who are coping with or simply trying to make sense of AIDS (Kotarba 1990). Communities struggle to find the time and place, and the ritual and financial means, to process the weight of mortality, thus to avoid the ultimate abjection of bare life (McNeil 1998 cited in Comaroff 2007:203). The prospect of being unable to dispatch the dead with due ceremony, marks the null point of social continuity (Comaroff 2007:203). Thus HIV/AIDS consequently, increasingly raises questions of accountability. The disease is many times linked to modernity and urban areas, and to some extent with the West being responsible. For example, Andersson (2002) finds that the high incidence of HIV/AIDS-related deaths greatly enhances the power and pervasiveness of local witchcraft discourse (Andersson 2002:426). Hence, witchcraft discourse is less a device for understanding causes of disease and death than a personified theory of accountability (Andersson 2002:432). We can see that it becomes important to perceive how people respond to the disease, how they attribute the cause of certain trends and events to HIV/AIDS, and how these perceptions and emic attributions are linked to their worldview and own (indigenous) knowledge systems (Niehof & Price, 2008:142). Ethnographic work shows how Western frameworks interact with local ideas and perception of HIV/AIDS. Drawing on ethnographic research in Tanzania, Murchison (2006) for example, deals with stories that have been narrated about a person called Neema and the emergence of ukimwi (AIDS). He finds that these stories stand in stark contrast to scientific and biomedical narratives about HIV/AIDS. In contrast to this, the stories offer alternative ways of seeing and knowing that seem to be counter-hegemonic (Murchison

2006:139). These narratives depend upon presumed boundaries separating traditional healing and biomedicine, but the impetus for the story stems largely from crossing these boundaries by bringing elements and representatives of the two categories together (Murchison 2006:128). The practical concerns involved in the search for health lead many Tanzanians to cross and reshape these categories according to their own experience and needs (Murchison 2006:128); the stories offer a different perspective on experiences with ukimwi (Murchinson 2006:139). These narratives reflect a degree of frustration with biomedicines ineffectiveness in the face of ukimwi on a local level, but, more fundamentally, the narratives reflect a form of local political power rooted in semantic and symbolic control of boundaries and the flows across these boundaries (Murchison 2006:141). The stories about Neema serve as commentaries on local experiences with the HIV/AIDS pandemic and biomedicine (Murchison 2006:130). They are captivating examples of local responses to existential insecurity that exemplify the resilience of humans and the role of cultural creativity in contexts of suffering and uncertainty (Murchison 2006:132). On slightly different tangent, Irving talks about the disruption caused by the illness, transforming pre-existing ways-of-being in time and place (Irving 2005:317). Through his comparison of two persons within different social settings, a blind photographer in New York and a mother from Kampala, he emphasizes how HIVpositive persons are made to re-negotiate the environment and begin to understand body processes in new, sometimes radically different ways (Irving 2005:322). Once-routine practices become increasingly opaque in terms of how each constituent part is ordered into a syntactical chain of action (Irving 2005:326). Irving gives the example of

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brushing teeth and how during an illness, a person become more conscious of the entire chain of action involved in previously taken-for-granted practices. Simple tasks become fragmented, revealing facets and temporalities that were previously hidden (Irving 2005: 326). Thus, while HIV/AIDS is always culturally situated, it involves experiences and modes of action that are particular to persons in search of bodily continuity who are making trails out of the everyday circumstances of their being (Irving 2005:323). When living with HIV/AIDs, periods of illness and fatigue interrupt pre-existing ways-of-being and disrupt temporal structures that have long been ingrained into people bodies through practice. Thus HIV/AIDS not only disrupts time and makes strange the rhythms of habit but also establishes new ways of experiencing and being in time and space (Irving 2005:326). Lastly, it is important to consider the social effects of retro-viral drug as they become increasingly available, looking at the certain problems that emerge with these advances. Anthropologists have pointed out to the setbacks people suffer in keeping to the ideal food intake and rest prescribed to patients, because of the side effects of the medication. It is not enough just offering the drug, people still need to make a living and sustain themselves, which at times can be very hard when suffering from these side effects. Furthermore, although the medication is keeping you alive, HIV-infected people in countries like Tanzania, seem to be located in a category between life and death. AIDS patients are seen as the living dead, the disease signifying death. The medication keeps you alive even though you are still dying; those infected are seen as the living dead because they are terminally ill. Through these associations, people are afraid to talk and test themselves because of the particular relationship HIV/AIDS has to death. These

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ideas further contribute in understanding stigma and the holdbacks in HIV/AIDS reduction. As we have seen, by applying an anthropological lens to the study of HIV/AIDS, we come to understand the hidden meanings of the disease. It is through experiential data collected using participant observation, that anthropology can be argued to be well suited to meet the analytical challenges of HIV/AIDS in East Central Africa. Ethnography provides an essential framework for understanding the cultural context. However, it must be emphasized that anthropology can not merely try a fill in the cultural blacks left over by epidemiologists, physicians, scientists and policy makers (Farmer 1997:524); ethnography only tells part of the story. HIV/AIDS demands broad biosocial approaches no just behaviourist, cognitivist, or cultural reductionisms (Farmer 1997:524). There is a need to link ethnography to systemic analyses informed by history ad political economy. One considerable challenge for anthropologists has been the way in which biomedical models dominate, contributing to the exclusion of socio-cultural approaches. Until current funding patters change, the social studies will remain in the shadow of larger scientifically based epidemiological studies (Craddock 2004:4). It must emphasized that the study on HIV/AIDS should not be one of the scientific versus social research, but one in which they complement each other, in the aim of obtaining a holistic understanding. In conclusion, even if it is impossible to fully predict the way in which HIV/AIDS research will develop in the future, the fact that the epidemic continues to expand and to take its greatest toll in the developing world, suggests that the kinds of approaches that anthropologists have offered for the study of sexuality and HIV/AIDS will continue to be important (Parker 2001:173). An appreciation and understanding of

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cultural and contextual factors are imperative if we are to develop relevant responses (Power 1998: 688).

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