HIV/AIDS is a very complex phenomenon which can be defined in both a medical and a social dimension. It influences society on different levels, be it the macrocultural, microcultural or individual level (McElroy and Jezewski, 2000).
This chapter will therefore look at various areas of society and analyse the effect of the HIV/AIDS epidemic on an individual as well as on a broader level. On a macrocultural level the first part of this chapter will confront the reader with statistics, policy development and the history of HIV/AIDS. The second part of this chapter will take the reader into the microcultural level and focuses in particular on the gendering elements of the pandemic. Finally, the third part focuses more on the individual level and the associated sexual culture. It is important to describe the epidemic in such detail that the reader will be able to position the phenomenon disability within the broader problem of AIDS. Disability in the context of HIV/AIDS will be discussed in chapter seven.
“The history of AIDS policy in South Africa is a sorry tale of missed opportunities, inadequate analysis, bureaucratic failure and political mismanagement” (Nattrass, 2004)
AIDS has become one of the greatest killers in KwaZulu-Natal and with this it has become a threat to South Africa’s economic development as well as its educational and health system. With it still being a taboo, the real AIDS related death rate is difficult to evaluate accurately. The Medical Research Council (MRC) has used the death registration system in South Africa to show which diseases are the biggest burden to the country (Brandshaw et al., 2004). HIV/AIDS was amongst the four major diseases that are also described as a “quadruple burden” to South Africa (see feature 6.1).
|Feature 6 1 Estimated mortality rate by disease group in South Africa and KZN (Brandshaw et al., 2004 )|
The research results from the MRC demonstrated the high proportion of deaths due to HIV/AIDS. Statistics South Africa made another attempt to capture the extent of the epidemic, through an analysis of age-specific death rates (see feature 6.2). The mortality profile should be quite accurate as the death registration process has improved over the years and is estimated to be at about 90 % complete.
|Feature 6 2 Mortality rate by age ( StatsSA, 2007)|
Examining the graph one can easily detect the problem. South Africa’s mortality rate of newborns and infants is far too high for a middle income country, part of which can be attributed to HIV/AIDS. Of even greater concern should be the high mortality rate in the age group of 25 to 45 year olds. These are the people that are very likely to be sexually active but should be naturally strong and have a low mortality rate. The high death rates in this age group can surely be attributed to HIV/AIDS, as other determinants like crime or accidents should affect all age groups in a similar way.
The capturing of prevalence rates has provided researchers with more obstacles and difficulties than the statistical measurement of death rates. Some researchers have used antenatal data, others volunteer testing, to measure the prevalence rates. Others refer to AIDS related diseases but all argue about the real infection rate of HIV. Depending on the sample the prevalence rate can differ between 10% and 41% (see appendix 5, 6, 7). Sometimes even prevalence rates of as high as 70% (The Mercury 7.09.2006) have been quoted and this adds to the confusion of the public. Usually lower prevalence rates are measured within a sample that represents different ages and sexes more realistically. Such samples do however depend on volunteer testing and as HIV/AIDS is still a taboo topic it is likely that infected people might not volunteer for the test. Another way of gathering data is through antenatal testing usually in government hospitals. These samples get much higher prevalence rates. It is argued that antenatal testing is not representative of the population as participants in this sample will be poor to middle income sexually active woman, who do not protect themselves against infection. Confronted with such a variety of results, one can only be sure about the fact that the truth lies somewhere in between and that the prevalence rate is high. Considering the increase in prevalence rates in all studies one has to come to the conclusion that the virus is spreading at a tremendous rate.
The rising HIV prevalence rate is however only considered to be the first wave of the HIV/AIDS epidemic. AIDS deaths and the increased burden for the community while looking after the sick and orphaned are seen as the next waves (see feature 6.3). In general the waves are not easy to position, but various researchers have managed to attach a timeline to the scenario.
|Feature 6 3 The three HIV/AIDS epidemic curves (Ba r nett et all. 2002)|
The first wave is seen to have occurred in the 1990s while the second wave has been placed after the new millennium (Veenstra, 2007). Of particular concern for South Africa is the fact that the impact (third wave) of HIV/AIDS on health services and communities has not as yet reached its peak and that further complications can be expected. Looking at South Africa’s social development one could almost conclude that a fourth wave could follow or has already begun. This is the wave of skilled emigration combined with an increase in poverty driven crime. This would be of particular concern as it would destroy already fragile social structures, authority and behaviour control mechanisms. In such a climate civil unrest or dictator-leadership styles could become a threat to the young democracy.
HIV/AIDS has presented itself as an unprecedented threat to the development of South Africa. In the face of such terrifying statistical facts, popular opinion is that this has increased the strain on the health and social system. Research (Veenstra, 2007) however shows that this is not necessarily the case. It is slowly becoming apparent that health care facilities are not swamped with the burden of providing care (see appendix 8a,b). South Africa is in a similar position to other African countries. The relatively stable bed occupation rates in hospitals (see feature 6.4) have led researchers to believe that hospitals have ´rationed´ care as a coping strategy to avoid overcrowding (Veenstra, 2007). This is a fact that can be supported by comments from my interview partners, who expected HIV patients to get less access to health services and to be turned away quicker as there “is not much that the hospital can do”. Thus it seems the strain on health service cannot be captured in numbers.
|Feature 6 4 Inpatient admission over time (Veenstra, 2007)|
Why are people not seeking care? Commonly this phenomenon is explained with the public notion that hospitals have little to offer and are expensive (see above). This may be particularly true for HIV/AIDS as it is often interpreted with the influence of sorcery and pollution (refer to chapter 5). A common notion is that a sorcerer can “bewitch” a person and make that person ill. This will be particularly easy for the sorcerer if his victim is not protected (e.g. by the ancestors) or polluted (e.g. through contact with death or a menstruating women). This notion would classify HIV/AIDS as an African disease which would accordingly be treated only by a traditional healer. People therefore would not see the need to refer to a hospital. Other important reasons given for the present care seeking behaviour are that there is still a stigma attached to HIV, negative attitudes by nursing staff and a ´rationing´ attitude to avoid overcrowding in hospitals.
Hospitals have however operated within their capacity. More useful questions are about the quality of service, the notorious understaffing of hospitals and clinics and the access problems for many potential patients. Human resource (HR) management is an ever increasing problem in South Africa and the effects are also known as “brain drain”. Post vacancy rates are increasing in the health as well as in the education sector. The increase of workload, insufficient skills and experience as well as psychological stress is being experienced by many staff members in these sectors (Veenstra, 2007).
AIDS puts an additional pressure on hospitals and clinics which is not necessarily measurable quantitatively but rather qualitatively. Employees in the health sector are, on the one hand, directly affected through HIV infection44 and are therefore more often sick or have to retire. On the other hand, working conditions are increasing the strain on the workforce which causes a high attrition rate. Skilled people are either emigrating overseas or into the private sector. As Veenstra (2007) discusses in her thesis, HIV/AIDS increases the unfavourable factors for medical staff. She lists four `push factors´ that are influenced by HIV/AIDS:
Poor salaries and an increased workload stand in close relation to each other. The workload has increased through HIV/AIDS, as more medical staff have to take leave while being sick or attending funerals, which leaves the remaining staff under pressure. The lack of success in filling open vacancies, particularly in rural areas, has added to this problem. HIV/AIDS has also directly increased the workload as it added additional work through testing, counselling and treatment. Although HIV patients account for only 12% of admissions, 23% of direct patient care resources were spent on HIV-related illnesses in 2005 (Veenstra, 2007). Nurses and doctors in particular feel that what they get paid is not worth all the effort they have to go through. HIV/AIDS can also limit career options, when for instance a doctor would like to specialise in paediatrics but feels in South Africa he would still spend most of his time dealing with HIV. In addition to the hardships of medical staff, management styles in hospitals are often lacking appropriate HR-understanding. Managers, all too often, will only see themselves as administrators and not as responsible for dealing with the ‘motivation’ of staff or developing staff programmes to assist with workload management or HIV/AIDS related problems (Interview 13). As a result a high number of nurses and doctors are leaving the field. Adding to the problem some medical institutions have issues in employing or working with people of certain race groups, which drives these people out of the profession and they often even end up leaving the country (www.hst.org.za). This could be added as a fifth element to Veenstra’s list.
Another obstacle to people seeking care in the public health sector is access. Particularly, the treatment of HIV with Antiretrovirals (ARVs) has begun very late45 in South Africa due to the dispute about how to deal with AIDS and whether ARVs would poison patients. People therefore have to learn and hear about the option of treatment before they will come and access it. Care seeking could be delayed. In rural areas, but also in townships the access problem might also be of another nature. Many participants in my study, but also in other research, mentioned the fact that transport to particular hospitals is expensive and unaffordable. In addition to this, AIDS patients often have to be accompanied by an additional person as they are too weak to travel on their own. In poor communities this becomes unaffordable and people may therefore not be able to seek care (Interview 18). Another factor is the stigma that is still attached to HIV/AIDS. Due to the stigma, people with HIV might not participate in Volunteer Testing and Counselling (VTC). Ignorant of their status they also do not look for treatment.
HIV/AIDS also has its degrading effects on private households. Already strained through increasing living costs and interest rates, South Africans have to spend more and more of their resources on HIV/AIDS related issues. As a result the individual household has to:
As a consequence the poverty gap between rich and poor has widened and more and more people have to be supported by charity and social grants or need to make a living through begging or crime.
South Africa, like Zambia, can be described as a radical reformer of health care (Veenstra, 2007). The White Paper and its legal companion the National Health Act (2003), outline a very progressive instrument that attempts to overcome previous inequalities, deliver basic services and decentralise health services. The latter, however, seems rather to be an obstacle in HIV/AIDS treatment. As treatment with ARVs is still a very new approach and requires a certain amount of knowledge and training, nurses at the local level did not necessarily have the required knowledge and skills (Veenstra, 2007). An extensive training phase of clinic staff still needs to be implemented. Up until now ARVs have only been available at the district hospitals.
In general the health sector, although it has had its funds increased in recent years, has had to change its focus from Primary Health Care (PHC) to Selective Primary Health Care (SPHC). SPHC is a more cost effective approach and focuses on the major problems, a trend that has also been adopted on an international level. In this context many local based clinics have been built in recent years46 and Home Community Based Care (HCBC) has become an important element in the care for AIDS patients (Veenstra, 2007). Here, I see an important chance for other community structures like CBR (Community Based Rehabilitation) to be integrated and with this to improve the overall health care for a community.
As mentioned earlier HIV/AIDS is not only a medical phenomenon but also a social construction. The context in which the epidemic unfolds shall therefore be discussed in the next sub-chapter.
In KwaZulu-Natal most infections are of a heterosexual nature. Even so the epidemic started, like in many other countries, as a “homosexual problem” in the 1980s. In the 1990s heterosexual transmission overtook homosexual transmission very rapidly (Veenstra, 2007 p. 10). At some point there were two different patterns of HIV transmission, one starting earlier than the other. The transmission amongst homosexuals was characterised by the subtype B of the HIV-1 virus, which is the same virus strain that is also commonly found in Europe and North America. The heterosexual transmission was, on the contrary, caused by the subtype C of the HIV-1 virus strain (Whiteside and Sunter, 2000). Its origin most likely lies within Africa itself. It is the latter that is of interest here, as most infections now come through heterosexual contact. The high rates of heterosexual transmission are puzzling as the chance of heterosexual infection is relatively low47 and can therefore not be explained by an abundance of sexual intercourse. Additional conditions must be present in South Africa and particularly KwaZulu-Natal. This shall be presented in the following chapter.
As described earlier, South Africa and especially KwaZulu-Natal has had a turbulent past, with political violence during Shakas regime, colonialism, the apartheid period, factional fighting in the first few years of the new republic, followed thereafter by a high crime rate. This history of crime and violence as well as the segregation policies of the colonial and apartheid eras planted the roots for the quick and immense spread of HIV. I speak here of roots because the violence and exclusive land policy caused the supporting factors for the epidemic to be common in KwaZulu-Natal. Whiteside and Sunter (Whiteside and Sunter, 2000) call these factors HIV epidemic-determinants.
These determinants are poverty and the big difference between income groups, a highly mobile population, disrupted family relations, the migrant labour system, gender imbalance and a general exposure to violence (see feature 6.5). All of these supporting factors can be found in KwaZulu-Natal.
|Feature 6 5 HIV epidemic – determinants (Whiteside and Sunter, 2000)|
As an example the province has the two biggest harbours in southern Africa and therefore attracts a substantial amount of traffic. The spread of HIV is known to be most pervasive in areas surrounded by heavily travelled roads. High prevalence levels have also been explained through differences in income, education and the different levels of urbanisation all facts that differ enormously in KwaZulu-Natal (Gow and Desmond, 2002). It has to be pointed out that even though poverty is believed to be connected to the spread of HIV, it is not necessarily the poorest that suffer the most. In South Africa the emerging middle class seems also to be affected. They have enough money to entertain and sometimes their career puts them in a position of power (policeman, teacher), so access to various kinds of sexual encounters is much easier for them.
KwaZulu-Natal also has a significant amount of migrant workers, who live for long periods far away from home while they are tending to their jobs. This obviously weakens relationships and encourages multiple partnerships, which are also customary to African life. The gender gap in the province is tremendous, especially when it comes to rural areas or poor communities. Women have a lower socio-economic position and “as a result of their financial dependence on their partners they are unable to insist on safer sexual practises” (Gow and Desmond, 2002). Although most people have access to basic education; sexual education especially through parents and other educators is only slowly developing. Sex is usually still a taboo topic. The traditional “Sex educators” have disappeared (Harrison et al., 2001) and young people are often left behind without guidance (Leclerc - Madlala, 1999).
A theme that is not usually mentioned but emerged in my data, is the theme of “freedom”. One participant of my study explained that with the change of the system in 1994, young “black people” did not want to be told anymore what they have to do. They wanted to experience absolute freedom and this also on a sexual level. They wanted to do what they pleased and just “play the field” (Interview 14). This however also meant exploring sexuality in a risky way, which certainly will have contributed to the fast distribution of HIV/AIDS within the younger generation.
As varied as the HIV prevalence rates are, as various are the messages about ways of infection and protection. In general the South African government has been quite delayed in dealing with the issues surrounding HIV/AIDS (see appendix 4). Confusing and contradicting messages have been sent to their people and even the link between HIV and AIDS has been denied. Through these policies the lives of many South Africans have been risked and lost (see chapter 6.1.1). It was only at the beginning of 2007 that a change in government attitude started to become apparent and the Deputy Health Minister became more active. At this time the infection had already developed into a full blown epidemic and unfortunately after trying to take ‘action’, the Deputy Health Minister was removed from her post.
While looking for an answer as to why the South African government has been so slow to respond, one can press the point that this government had to deal with many issues that emerged through the previous inequalities and that they maybe therefore did not prioritise HIV/AIDS on their agenda. Maybe there was also the naive hope that the problem would just disappear. The new South African government has, for quite some time, hung onto the concept that HIV does not cause AIDS. The president Thabo Mbeki himself, and his Minister of Health Tshabalala-Msimang, advised their people in 1999 to “find out where the truth lies” and to consult the “huge volume of literature” (Nattrass, 2005) that was available on the internet. It is more than likely that they referred here to Duesbergs website (www.virusmyth.com). Duesberg’s theories that drugs and poverty caused AIDS and not the HIV virus were for a long time favoured by Mbeki´s government (Cohen, 1994). It was probably also a romantic notion that ‘western’ drugs and apartheid were to be blamed for AIDS instead of addressing the very complicated subject of sexual culture and its link to HIV. It is also very likely that the leaders of the new republic found it much easier to blame the old enemy instead of addressing the ills within itself.
Up until today, people in South Africa have received very mixed messages about HIV and AIDS. In 2005 the German vitamin entrepreneur Matthias Rath, claimed that he could cure AIDS with his vitamins and that Antiretroviral (ARV) drugs were a form of poisoning (The Mercury, 11.05.2005). The strengthening idea of vitamins fits very nicely into the African notion about diseases (see chapter 5) and he therefore was very successful in distributing his vitamins. Cases became known where people died after they had changed from ARVs to Rath’s vitamins. The South African Minister of Health Tshabalala-Msimang, however, refused to distance herself from the vitamin entrepreneur because it could not be demonstrated that the vitamin supplements were poisonous for people infected with HIV (The Mercury 28.06.2005). In fact, Tshabalala-Misimang encouraged people to try out traditional medicine rather than the poisoning ARV´s. The most prominent case is Fana Khaba, a popular Johannesburg DJ who rejected HAART48. After he had already undergone several “traditional” treatments and its failure was apparent, the Health Minister phoned Khaba´s mother to tell her that she was sending the Dutch retired nurse Tine van der Maas to help them. His CD4 counts were, by that stage, only two49 and he was advised to take a nostrum called “African solution”. Khaba died three months later at the age of thirty-five his body wasted and in agony (Nattrass, 2005). If the Health Minister would have intervened differently the outcome would almost certainly have been different. In her desperate attempt to find an African solution50 to the HIV/AIDS epidemic, the Health Minister made herself look ridiculous in front of the world. In 2006 the same minister represented South Africa at the International AIDS conference with beetroot and African potatoes as the main tool to fight the epidemic. ARVs were only mentioned on the side. The contradicting effects of both were not mentioned at all.51 As a result, 60 international experts on HIV/AIDS called for the resignation of Tshabalala-Msimang after the AIDS Conference (Veenstra, 2007).
It is interesting to note that quite a number of AIDS dissidents who came up with ´African solutions´ can hardly be presented as ´African´ themselves. The German vitamin entrepreneur Matthias Rath, the American scientist Duesberg, the Dutch nurse Tine van der Maas and the Belgian organic farmer Kim Cools have been some of the main advisers to the Health Minister and President Mbeki (Geffen, 2005). They can hardly claim to work from a traditional African perspective nor do their products pass any scientific standards. I therefore can only enforce Nattrass’ argument that so called “African traditional or alternative healing” outside scientific regulations can only too easily turn into a “Trojan horse” open for all purveyors of unproven substances (Nattrass, 2005). In the face of the serious consequences of an HIV infection it is also questionable how important this ´African´ way is for the infected people that must now face premature death. Maybe the desire to find an African solution to AIDS has distracted attention and opportunities have been missed along the way.
Dr. Kevin De Cook, director of WHO’s HIV/AIDS department, highlighted three missed opportunities after the 2006 International AIDS Conference in Toronto and openly criticised the South African government for its response to the HIVAIDS crisis (De Cook, 2006). He pointed out how South Africa could have shown leadership for the African continent, given its economic and political importance. Without its denialism and tactical delaying of actions, the country could have received a tremendous amount of international support for prevention as well as treatment. Success would also have been greater, if the right actions would have been taken earlier.
Instead the late and, as it appears, unwanted52 change in course, seems to have affected other areas of social society negatively as well. The government’s failure to respond to the HIV/AIDS crisis contributed to worsening gender and socio-economic inequities. This is because home care givers are predominantly women and treatment is most unaffordable for poor people as there are often additional or hidden costs like transport.
At the moment there is a clear tension between the immediate need to deliver services, which requires centralisation due to lack of skills, and the longer term development objective of strong local government, which requires decentralisation and more power to local stake holders. The decentralisation has however mainly occurred from the national to the provincial level, while the local level has been under utilised (Veenstra, 2007). Local levels could have facilitated treatment with a better developmental approach to HIV/AIDS, due to their better access to communities and partners as well as their potential to include other community structures like TAC or CBR in their approach. This is particularly important as the number of Home Community Based Programmes (HCBP) has increased over the last 17 years (see feature 6.6) and these could have profited from more empowerment and self government.
|Feature 6 6 Increase in HCBC programmes in between 1990 and 2005 ( Naidoo, 2005)|
One of the initiatives to help overcome the skills shortage in poverty stricken or rural
areas was the recently introduced “rural allowance” and “scarce skill allowance”, which attempt to attract particular medical staff to these areas (Veenstra, 2007). While this has shown success there would also have been a chance of making work placement for young staff on internship positions more attractive. As Veenstra explains in her thesis, these young people often get exploited and therefore leave the area as soon as they finish with their internship. The unfortunate experiences that some young doctors and nurses have had inevitably make their way back via the student grapevine and therefore some areas do not get any applicants for internships anymore (Veenstra, 2007). Another missed opportunity is the wider training of hospital managers and principals. The limiting notion of a manager as a personnel administrator rather than a true HR manager has made people believe that motivation is not a management issue. Old hierarchical and rigid bureaucratic structures are still eminent and are generated by an authoritarian mindset, which in turn, particularly, drives dynamic and creative people away from these areas. The old structures need to be overcome as they are a hindrance to development and are also fragments of the master and slave ideology common in both Apartheid philosophy and the traditional Zulu kingdom.
And then the whole thing about this HIV/AIDS now. This misconception that if you have sex with a virgin then you will be cured of AIDS. … Now our children have reached a stage where they go for blood tests because we see all the signs but when they come back from the clinic they don’t show us their cards. That is the last time we see the clinic card and then we see the signs and inevitably it is followed by death. They won’t tell us that they are HIV positive. (Interview 11, teacher)
Apart from the mixed messages from the Health Minister Tshabalala-Msimang about vitamins, beetroot and African potato treatments there are still many myths about curing AIDS which need to be dispelled. AIDS and sex were taboo for a long time and as the extract above shows are still not openly discussed. Many misconceptions have therefore managed to find their way around. These misconceptions about causes and treatment of HIV and AIDS are various and differ from person to person. One aspect of these notions is connected to the Social Representation of women.
The variety of notions have their roots in the different explanation models that people choose, when explaining disease. In chapter 5, a model was developed about the Subjective Theories that people choose to interpret disability and disease. Just like any other disease, people will explain HIV and AIDS either in a natural or supernatural way. The concept of vulnerability offers the option of taking strengthening umuthi or pleading for protection from the ancestors to prevent misfortune, like HIV infection. The concept of pollution has, on the contrary, developed its own dynamics and influences Social Representations about HIV/AIDS. The concept of pollution is deeply connected to women’s bodily fluid.
Conceptualising the notion of women’s bodies at St. Wendolins, near Durban, Leclerc-Madlala (1999) describes this notion as a “suitcase which conceals and transports disease to others”. Women’s bodies are believed to have more and better hiding places, especially through their wetness. A woman’s vagina and womb is therefore often identified as a place where diseases like HIV/AIDS can hide and grow. Women in this context are seen as permanently polluted53 or “dirty”, carriers of disease and dangerous to men. By the same token pollution is still the dominant theme and an explanation for the cause of AIDS (Mills, 2005), and as a result of this, women are often stigmatised for causing AIDS.
The notion about disease in the context of HIV/AIDS is often shaped through the understanding of biomedical germ/virus theories. Theories of different cultural backgrounds hybridise to a Subjective Theory of the individual. Theories can therefore shift from the supernatural cause to the natural cause. A biomedical explanation gets completed through the concept of pollution or vulnerability. The latter is seen as a transmitting factor.
“Germs” like HIV are seen as dirt that hides in bodily places and can be transported to other organs via blood and other bodily fluid. The polluted “stickiness” of the vagina is believed to hold these germs especially well and is therefore a place a man “would not touch”. As women menstruate and menstruating blood passes through the vagina, some dirt is believed to stick in the vagina and mix with the secretion (Leclerc - Madlala, 1999). A man should therefore rather not have intercourse with a menstruating woman. This may also explain why one of my participants described that she was gang raped specifically because she was pregnant. The men in this instance could be sure that there had not been “dangerous” blood passing her private parts for a longer period. She was therefore considered as being “hotter than all the other women” as being “the best” (Interview 2) and with this as less polluted in the sense of being dirty.
Pollution also influences important events in men’s lives. In a discussion with a traditional healer I was told that the men will not sleep with their women before important events. Traditionally this would be before going to war. Again the re-occurring theme of pollution through women emerged out of my data. The pollution through women was regarded as dangerous and as having a weakening effect on a man’s body. Nowadays however this is transferred to important events like a job interview or a soccer match. Apparently this is the reason why soccer players do not take their girlfriends or wives with them on tour as is the custom of European soccer stars (Interview 20).
Eminent within the concept of pollution is the notion of “cleaning” or purification, which is used as a treatment or protection. There are a number of different “cleaning” rituals that range from deliberately caused vomiting (Ngubane, 1977) to, as has been discussed in recent media events, ´virgin cleansing´. Rituals also shift with modernity. For example, after a funeral people would traditionally dip their hands into a special liquid consisting of bile juice from a slaughtered beast to cleanse themselves of umnyama (Ngubane, 1977). The more modern version however is a plain bucket of water with soap, or the more luxurious version, a shower. The choice of cleaning or purification rituals however depends on the purpose of the cleansing and cultural interpretations of the particular situation. These decisions are often guided by traditional healers or spiritualists who can provide better answers for African people. As it stands today, African people can be quick in pointing out that science provides no sure answers for the origination of HIV/AIDS. AIDS educators still cannot answer the question as to why one person gets infected or sick at a particular time and the other one not. The concept of witchcraft and pollution can provide a satisfying theory of the original causation. People therefore turn to their traditional healers for help. Some ´traditional´ medicine is believed to prevent HIV infection (Marcus, 2001), probably through strengthening the body, while others are believed to heal AIDS. One of the herbalists that I interviewed explained his medicine to me in the following way.
I prepare a special mixture of garlic, African potato, and ginger, isibakla (a bark from the Hluhluwe area) and isihlungu samandiya and fill it in a bottle of 750 ml. They have to buy two bottles and use it within a month. Then they must get tested again and if his HIV is higher (probably meaning CD4 cells) then he is cured, if not he needs to carry on with the treatment. (Interview 20, traditional herbalist)
It should be noted that this herbalist seemed to have some biomedical understanding of HIV/AIDS, but that some basic concepts like HIV and CD4 cells were still being confused. Besides the ´bottle extract´ he also had a stone available, called ´itshe lamalonda´, that could heal boils and abscesses and this was also used for AIDS patients. Asked how one could get infected with HIV he named sexual contact as well as kissing and touching as transmitting situations. He also explained that witchcraft and pollution were factors that were responsible for spreading AIDS.
It must be mentioned that the treatment with African potato is quite a problem. Garlic, ginger and probably also African potato contain Antioxidants, a reactive group that scientists believe to be able to disrupt the virus DNA reapplication (TAC, 2005). On the contrary recent studies have shown that African potato (Hypoxis) and Cancer Bush (Sutherlandia fructescens) interfere with biomedical AIDS treatment and lower the levels of antiretroviral (ARVs). This means that the HIV continues to multiply and weaken the immune system. It also increases the chances of developing resistance to the antiretroviral (TAC, 2005).
Myths seem to be created and disappear, leaving confused people behind, who are looking for a new explanation. Some of the myths that have slowly disappeared over the years include the belief that HIV was injected in Oranges, carried in condoms that are available for free in clinics, that white people brought the virus to kill black people or that the new government purposely let the virus spread so as to reduce numbers (Tillotson and Maharaj, 2001). Even contraceptives like the Depo Provera54 have been blamed for spreading HIV/AIDS (Mills, 2005).
In 2006 a new myth appeared on the scene, when South Africa’s deputy president, during a rape trial, claimed that he had taken a shower after having consensual sex with a woman he knew to be HIV positive (The Mercury 9.05.2006). A participant in my study explained to me that it would be within their culture to take a shower after sexual intercourse. The deputy president however explained that he “knew the kind of woman he was sleeping with and therefore took these preventative precautions”. The shower seems to be the modern purification ritual after having sex with a ´dangerous, dirty woman´ that was obviously ´luring him´ into having sex. The theme of women being dangerous, out of control, loose or seductive is a re-occurring theme in South African society and victims of indecent assault, rape or unwanted approaches by men (at work, home or public places) will be victimised by these notions. Particularly in KwaZulu-Natal, men seem to have the imagination of themselves as being unable to control their sexual desires and that it is a woman’s duty not to seduce them. In this context some high school pupils explained to me, that a “girl is asking for it”, if she is dressed and behaves in a certain way. Men and boys, on the contrary, are believed to follow their natural and uncontrollable instinct. The then deputy president of the ANC had explained that it would be “unzulu” not to have sex when the opportunity arises (The Mercury, 5.04.2006).
The downside of Zumas trial is that it has left the impression in the masses that taking a shower after having sex may reduce the risk of HIV infection. Things could get even worse, if Zuma’s current HIV status was revealed and was negative. This could be seen as a proof that the “shower” treatment works.
You know first of all when you are a girl; you are expected to be a virgin, every time. So the first time, for the most girls, the first time is a disaster. … When you think about it, you don’t agree. You know it is like rape. And in most cases you don’t agree. You have a boyfriend and you say that you don’t like any sex. But when he decides that it is time, that he wants to do sex, he can rape you, he can beat you. Before you even sleep with him. It is a forced thing. It is very rare that you agree on the very first time. Ja, but that creates a habit. You know when you are young, you get used to this, you penetrate this woman who is crying, who is angry, who is dry. Then you enjoy, when she doesn’t enjoy. It becomes a habit, when we are young we become used to that thing. Then you grow with it, even when you are older, even if we agree now, Ok we love each other lets make love, no it is a habit. He will just penetrate you, without even touching without anything. You know and this creates problems. … They think, you know, sometimes they reject too, because you are wet. They reject you; they say what is wrong, because this one was wet. (Interview 1, woman with hemiplegia)
The heading of the Daily News on the 30th of June 2005, referring to new research, claims that HIV in South Africa is spread by sex rather than needles, razors or contaminated blood. This is a fact that was already well known in the world of HIV/AIDS research. Scientists can therefore scarcely ignore the sexual culture and practices as a contributing factor in the spread of HIV.
In chapter 4 basic gender relations were discussed. The patriarchal power relations between men and women have consequently shaped sexual relationships and culture. The history of political and criminal violence in the province has also had a major impact on people and seems to have brutalised gender relations. One of the first things that I had to realise was the fact, that for most Zulu-speaking women, sex was not fun. As a PhD student at the nursing department of the University of KZN put it: “most girls do not experience their first time as fun, in fact they do not even agree, the boyfriend just decides when he wants to have sex, she has no say” (break discussion). She went on to further explain that boys and girls learn that women do not have fun during sexual intercourse and perceive this as normal. Indeed all of my female participants reflected on this during the interviews in one way or another. The acceptance of domination as normal masculine behaviour was very obvious during the interviews. Even a married woman could expect to be abused by her husband. Sexual initiative is taken by men and the needs of women seem to be of no importance. A participant explained to me that “the rules in her house were that when her husband needed her he would make a sign and touch her, and then she would know that she would have to be ready for sex” (Interview 5). When questioned about what would happen if she were too tired from working, she explained that her husband would become angry and “make it roughly”. It is interesting to note that the participant would have never dared to initiate “love”, as this is a male only domain. She was relatively happy with her marriage and would probably never have regarded the “rough sex” as rape.
Rape is very common in South Africa (Wood, 1998) and for some people a very difficult concept to grasp, because the dominating concept of male sexuality paired with the pain and disagreement of the female partner is deeply imbedded in the African way of life. So the question is: when is a rape a rape? Comparable to Europe 50 years ago, women are still judged by their appearance and behaviour and sexual obedience seems to be a duty of marriage. A woman that is wearing a miniskirt or walks around at night close to a tavern is regarded as loose and asking for rape55. No one will stand up for a woman like that.
The male on the other hand is just seen as following his natural instinct, not being able to control himself. This notion became very obvious in the already mentioned rape trial of the then deputy president Jacob Zuma in 2006. The accused claimed that the complainant “had seduced him and that he had to oblige because this was in line with Zulu culture” (The Mercury 5.04.2006). This explanation was accepted by the masses and even by the ANC’s woman’s league.
Another prominent example is South Africa’s worst serial rapist, Mongezi Jingxela, who was jailed in December 2007. Raping and assaulting 60 victims he showed no remorse and explained that he was “falsely accused”. In fact the sexual advances he made upon his victims were not his fault at all as “parents should have ensured that their children were at school and not roaming around the dumps.” (The Mercury 14.12.2007) Although this is an extreme case, it does however mirror the mindset that some men but also women have about women’s sexual rights in South Africa.
Another popular case in KwaZulu-Natal was the assault of a woman in the T-section of Umlazi, Durban. The woman had dared to enter this section with trousers instead of a skirt. The angry mob stripped the poor woman, burned her hut down and assaulted her.
Having this background in mind it is very questionable if local campaigns against rape can be successful. A prominent example is the campaign during the awareness weeks for fighting “abuse against woman” every December. Men are advised on the radio and through advertisements “not to abuse women” without explaining what abuse really is. Although this campaign raises awareness it is very unlikely that men conceptualise this message, because the local culture regards certain types of abuse not as an abuse but rather as the right of man. By the end of 2007 this strategy had still not changed and T-Shirts were being produced, with the imprint “Satyagraha”, “Say no to abuse” ” and similar slogans, once again without explaining what abuse actually is. I am therefore not surprised that journalists like Omeshnie Naidoo observe that the campaign has increased awareness of abuse against women, but that the actual situation has not really improved (The Mercury 14.12.2007).
In the post–apartheid era streamlining and gang rape have become a very common phenomena. While one understands, under streamlining, the sexual disciplining of a women through a group of men, gang rape is usually conducted by a group of men that operate in a gang (Wood, 1998). Streamlining can have different purposes. A man might want to teach his girlfriend a lesson, he might want to punish a girl for refusing his sexual advances or he might simply take advantage of a girl under the influence of alcohol. After he has had his turn on his victim he will then share her with his friends. Streamlining and gang-rape are brutal group bonding rituals that are made possible through deep sexist and discriminatory assumptions. The victim often does not report streamlining as rape, because she fears that people might ask what she has done to deserve it. In the case of streamlining she can also easily be blamed as she is the one that exposed herself to the abusive situation, by for instance following her boyfriend into his house (Wood, 2005).
In the era of HIV/AIDS male/female relationships seem to have been further brutalised. The notion of women being ´dirty´, ´dangerous´ and responsible for spreading HIV´ has been discussed by Leclerc-Madlala (1999). Men fear the wetness of a vagina and prefer women with a tight, dry vaginal channel. Otherwise they might reject the woman, regard her as loose and not trustworthy. Some women therefore use a number of substances to provide the illusion of a clean woman. This is commonly known as “dry sex”. People get these substances from a herbalist or “inyanga” also known as a Zulu doctor. The necessary “umuthi” comes in the form of herbs, paste or powder (Interview 1). Leclerc-Madlala (1999) also names Dettol and Savlon (a tropical antiseptic), snuff, bicarbonate and soda, toothpaste and plain salt as options for a “douche” that will make the vagina ´dry´ and ´clean´. Referring to this “dry sex” habit a participant concluded that this is one reason why so many women refuse to use condoms. As they are already dry the condom causes even more pain. Besides this, it is also very likely that it will break under such conditions, which maybe explains the common argument that condoms are not reliable. The result of dry sex seems to be very traumatic for the sexual anatomy of women and one participant put it quite clearly that a woman can be “limping for a whole week as a result” (Interview 1). Being in KwaZulu-Natal I had always wondered why some women have a trundling walk and sometimes I wondered if it had something to do with the condition of their genitals.
Violent sexual intercourse and the habit of dry sex could also explain why the women who were studied by Leclerc-Madlala (1999) perceived the “whole female crotch area as a large festering sore, occasionally bleeding, often oozing and sometimes painful and itchy”. It indicates that there is a very high incidence of sexually transmitted diseases (STD), which in return encourages the persistence of the notion about the female sexual organs being dangerous, dirty and a carrier of diseases. Indeed a high prevalence rate of STDs is reported for KwaZulu-Natal. I want to emphasise, that this is not only a result of delayed treatment. Dry sex increases the probability of getting infected with STDs. The side affect of STDs and dry sex is an increased permeability of the skin for the HIV virus. It is therefore easier for the HIV virus to intrude into a person’s body.
Protected sex with condoms becomes under the above described circumstances even more crucial. Besides the painful experiences caused through rough and dry sex people refuse condoms for various reasons. Condoms are seen as building mistrust between partners and people believe that they can judge who has got HIV and who has not (Leclerc-Madlala, 1999;Dladla et al., 2001;Tillotson and Maharaj, 2001). Condoms will therefore rather be used with an affair than with a more permanent partner, a phenomenon which is probably spread worldwide. Special to the Zulu culture is the tradition of multiple partnerships (Preston-Whyte, 1996;Dladla et al., 2001), where a man can have several wives. In addition to this the migrant worker system and the ´lobola´ tradition have increased the habit of having several sexual relationships. Migrating to work keeps spouses away from each other for long periods. The African bridal money or ´lobola´ is for many unaffordable. On the one hand the average Zulu-speaking man in KwaZulu-Natal has to pay 11 cows or the cash equivalent (3000-4000 Rand per cow) for his ´lobola´. On the other hand a teacher earns approximately 7000 Rand a month and a labourer 80 Rand a day. Under these conditions it takes decades to save up for the ´lobola´ and this still does not take into consideration the necessary funds for a wedding and the various rituals that accompany the event. It is more than understandable that people still engage in sexual relationships and even have children long before they get married. Unfortunately living apart makes relationships fragile and provides the motivation for affairs (Harrison et al., 2001). For men the idealistic notion of ´isoka´ (Casanova) gives an additional reason to have many girlfriends and is an especially dangerous ´game´ for a young man.
Another theme that emerged in my data is the notion that young women purposely try to get pregnant (Interview 6). The notion of proving womanhood with pregnancy and the access to a child support grant are often blamed as the cause for this phenomenon (The Mercury 20.07.2006; Interview 6, 17). How true this is cannot however be commented upon in this thesis. In any case young people seem to be engaging in unprotected sex and this is not always the result of abuse. This contributes to the spread of HIV in the younger generation.
Although Zulu-tradition embraces multiple partnerships, in the modern South Africa several sexual partners are not necessarily acceptable in a relationship. Men and women complain about the other sex not being trustworthy, but will not discuss this in their relationships. People engaged in a relationship will therefore find it rather difficult to insist on safer sex, as this would send the message that they do not trust their partner. Some people will rather take the risk of condomless sex. Otherwise they would risk an argument with their partner or the break up of their partnership (Tillotson and Maharaj, 2001).
Another reason for refusing condoms is the notion that condoms would cut down sensation (Tillotson and Maharaj, 2001). Some people also fear that the fluid captured in them could be used by sorcerers (Preston-Whyte, 1996). Leclerc-Madlala (1999) describes the fear of some women that the condom could get stuck inside, move up in the body even as far as the heart or throat causing serious damage or death.
Because of this reluctance to use condoms, researchers like Preston-Whyte (1996) and different African leaders wonder if the condom message will work in an African context. This is probably also a reason why the A of the ABC message (Abstinence, Be faithful and Condoms) is often promoted especially by political and religious leaders. My impression is that this does not seem to have the promised effect either. One way of explaining this is that abstinence similar to condoms is not perceived as an African concept either and is also not very practical and therefore encounters the same reluctance as the condom message. In addition to this, condom messages in the past have often been distributed in an, for African people, offensive and sometimes questionable way. In my opinion the problem lies rather with a lack of sexual revolution. Something that the African continent is only just beginning to see. A lack of stable relationships that have been built on equality and honesty is also noticeable.
Unfortunately some Africans could claim that equality, especially in a gender context, is not an African concept either. Here the concepts of respect and tradition seem to be of greater importance. In the fight against HIV/AIDS, gender equality and honesty between partners becomes crucial. European cultures have been lucky as they had their sexual revolution decades ago and at the same time re-valued the position of women in their society. Automatically the sexual subject was lifted out of its taboo corner. The African cultures have not been so lucky. Here HIV/AIDS found its roots first, while people were still busy with reorganising the African continent. They therefore lacked the time to develop a culture that talks about sexual matters and would include the discussions of condom use or the handling of abstinence.
Even though people have started talking about HIV/AIDS, sexual matters are still highly taboo (Leclerc - Madlala, 1999;Harrison et al., 2001;Tillotson and Maharaj, 2001). This contributes to the misinformation of the youth. One participant, who got pregnant as a teenager, explained that this happened because she had no guidance and information in this matter. She pressed the point that this “is still happening, because in the black community parents do not want to discuss relationship things with their children” (Interview 3). Most information young people seem to gather is from their peers, the media and sometimes from school. Concepts are not always fully explained and might be opposing. In the media, messages about safer sex and sexual messages in movies and adverts, might even contradict each other. Through peers, misconceptions can be spread and additionally confuse especially young people. In addition young people rebel to the strict traditions of their elders. Especially African youngsters want to enjoy their new freedom which also includes “playing the field”. Older people find them therefore “difficult to control” (Interview 14) and feel helpless.
Because of this confusion and the desperate need for solutions, people retreat to old values and proclaim for instance virginity as a solution to the spread of HIV/AIDS (King Goodwill Zwelithini about virginity testing The Mercury 12.09.2005). Virginity testing has seen a rapid rise in KwaZulu-Natal. In these tests the hymen is investigated. The young girl has to publicly spread her legs in front of her investigator, who announces the hymen to be intact or missing. It is made perfectly clear, for everyone, who is still a virgin and who not. Sometimes even A, B or C grades are given during the testing (Leclerc - Madlala, 2001). Certificates are handed out or marks are left on the girl’s skin. Lost virginity is punished with exclusion and shame. Because of its intrusive practise and stigmatising results, a ban had to be laid over this practise in 2005. It is however still quite likely that the practise is unofficially carried out in some communities.
As a result of the proclaiming of virginity, virgins have become quite a sought after commodity. To protect their virginity girls will be especially protected and controlled. In KwaZulu-Natal they have even developed a fenced in village where the virgins of a particular Prophet can find refuge.
Men are especially targeting virgins, as they are seen as “pure”, “clean” and “fresh”. While HIV/AIDS is associated with “dirty” women (Leclerc - Madlala, 1999), sexual intercourse with clean women, preferably a virgin, is seen as the appropriate “cleansing treatment” (Marcus, 2001). Leclerc-Madlala explains this with the notion that a virgins vaginal track is ´dry´, ´clean´ and ´uncontaminated´, and a place where the “germs can not stick”. Besides this, the intact hymen is also believed to “seal” the vaginal track, preventing the HIV germ from getting into the girl’s womb (Leclerc - Madlala, 1999). The notion about the good qualities of virginity makes men go out and especially ´hunt´ for virgins. It is suggested that this belief is a significant factor in the high rate of sexual abuse and HIV infection among young girls in the province.
Beside “being a cure” virgins are also regarded as “being safe”. Young women, who “play the field” know this and use this to their advantage. As one informant put it (Interview 3), young girls try to give their boyfriends the illusion of being “dry and clean” with other words the illusion of virginity. This is especially when they have more than one boyfriend and they use ´dry sex´ to prove their truthfulness.
The need for having more than one boyfriend is maybe caused by the need for additional income. This is especially when young girls are looking for entertainment. They may choose to have different boyfriends for different needs (clothing, food or cinema). The custom of playing with older men also known as ´sugar daddies´ (Dladla et al., 2001;Harrison et al., 2001) seems to be widespread. One participant mentioned, in this context, that “teenagers are actually not playing with each other that they are playing with old men” (Interview 6).
Some young men who, on the contrary, were infected from girls that “cheated”, can become very angry about these “loose”, “dirty” women and have in the past taken revenge and deliberately spread HIV to others.
In dealing with the youth there was …a group of boys from Kwa Dabeka who just had that belief that because they are HIV positive, they are not going to go down alone because it is the girls who gave it to them, so they in turn are going to spread it to other people. It was frightening. And just the whole HIV myth, this whole issue of wanting to take others down, is an issue of power, I am the man, I want you, and I must have you. You have no say. (Interview 11, teacher)
In 2008 hardly anyone in KZN can deny the affects of HIV/AIDS anymore or escape the influence of modern living. The hard facts that have been raised by HIV/AIDS and the influence of modernity seem also to have changed the way some people speak about and handle their relationships and with this have started to revolutionise sexuality. Through this relationships between women and men seem to be changing. There are couples in this province, who have gone their own way and with this have begun to revolutionise the local society.
Referring to this change, an HIV positive informant shared with me her life shattering story. Her previous boyfriend had raped her continuously and left her with a child. She was forced to drop out of school and encouraged by her mother to earn a living through prostitution. Somewhere along the line she got infected with HIV. However through the Treatment Action Campaign (TAC) and the influence of the local church she got information about HIV and managed to change her lifestyle. She later got involved with a man who was also HIV positive. Both of them seemed to have a very open relationship with each other. The respondent described how she discussed her sexual wishes and desires with her boyfriend and how they had discussed their HIV status with each other. As a result they protected themselves from re-infection via the use of condoms. The experience of HIV had changed the lives of both of them but they managed to change their attitude towards life positively and have become more open and honest in their relationship. This could easily be true for a number of South Africans that I have not managed to interview during my research. Especially in cities, African couples can be seen holding hands in the street and occasionally a couple is kissing. I make a point of this here as this is apparently not custom in Zulu tradition. The concepts of truthfulness and respect are highly valued virtues for Zulu speaking people. They are being discussed within the background context of gender inequality and there have been some promising changes in power relations. Change is however still very slow and hesitant.
HIV/AIDS is still a mystified topic and people get different messages from different sources. On a macrocultural level the South African response to the epidemic can be discussed by looking at different paradigms and their relative appeal to people in power. A ´mobilisation/biomedical´ paradigm, as used by many scientists, emphasises social mobilisation, political leadership and ART56. The nationalist/ameliorative paradigm however looks at poverty, palliative care, traditional medicine and appropriate nutrition. The political discourse in South Africa seems to have given the ameliorative approach greater viability, which might be an attempt to support the “African Renaissance” and to find “African solutions”. The extent of the epidemic however requires a more holistic approach. Social structures, leadership and the rollout of ARVs have to change in order to achieve this. The latter in particular is believed to have positive effects on the epidemic in general, as people will be more likely to participate in VTC57. It could also decrease risky sexual behaviour as it encourages spouses to discuss sexual matters more openly and decreases the anger of infected young men against women (Leclerc - Madlala, 2001).
Another empowering factor for people in general as well as people with disabilities could be the increase of skills used for subsistence and sustainable farming. This would also be a way of implementing the nationalist/ameliorative paradigm without compromising the ´mobilisation/biomedical´ paradigm. As many people live in rural areas or stay at home with little to do, a way of contributing to the family’s income could be by tending the garden or nearby fields. Schools like the Harding special school in Harding (KZN) (Schwinge, 2001) or the Community Self Help project at the Marianhill mission station (near Durban) can be taken as examples and already inspire other schools and projects in the province. The empowering effect of learning such skills also has a promising side-effect in that it improves nutrition. One aspect that is highly important for people who are infected with HIV.
One opportunity that would bring people more power is the already emphasised method of decentralisation and power distribution to local levels. In the context of HIV/AIDS this is rather a difficult task, but it should nevertheless be given further support. One particular opportunity has opened through the HCBC programmes that may well integrate other initiatives and local structures such as CBR programmes and TAC initiatives. In this regard political will and a change towards greater democracy and participation would need to be followed.
On a microcultural level the tabooing of sexuality provides the perfect atmosphere for the spread of misconceptions, which are various in KwaZulu-Natal. Particularly the notion of being able to protect HIV infection through protective “umuthi” and the imagination of being able to “clean HIV” through sexual intercourse with a virgin have probably led to unnecessary infections. In addition to this the culturally related imbalance of gender relations and the dependency on male incomes have an immense impact on sexual relationships and have made women especially vulnerable to HIV.
On an individual level people need to renegotiate relationships. Notions about female and male sexuality need to be revolutionised. The Zulu conceptualisation of “respect” needs rethinking. If the perception of respect could be transformed into a concept that celebrates womanhood and manhood equally then sexual relationships would have a chance of being reformed.
44 Medical staff get infected either through contaminated needles or from having alternative sexual partners while working away from home. There is a public notion that medical staff should know what they are doing and protect themselves. The stigma attached to HIV infection is therefore very high for medical staff.
45 Brazil as the first developing country in the world began its ARV programme in 1996 eight years before South Africa. Although South Africa is catching up with other countries it still makes less ARVs available (in percentage) compared to other countries in Southern Africa (Veenstra, 2007).
46 KwaZulu-Natal has achieved a tremendous amount in recent years. Left with a very unequal distribution of PHC through the Apartheid system KZN managed to invest in PHC so that it had reached a 95% coverage rate in 2005 (Health Department KZN 2005).
47 1-2 woman for every 1000 exposures get infected with the virus, while it is only 0,33-1 of every man, but 130-480 for every child of an infected mother (Whiteside and Sunter 2000) . This data is based on sexual intercourse under normal circumstances, where both sides agree and no STDs are prevalent.
48 HAART - Highly Active Antiretroviral Therapy
49 A CD4 count of under 200 qualifies for ARVs.
50 Associations with the pre-1994 struggle and the modern idea of an ´African Renaissance´ could be responsible for the desperate attempt to find a solution in Africa. These associations talk about the need for an African solution to an African problem rather than to consult the ´old enemy and suppressor´, who is expected to carry on suppressing and undermining the African way of life.
51 African potato for instance reduces the effect of ARVs (TAC, 2005)
52 Antiretrovirals were only made accessible after TAC took the Minister of Health to court.
53 This is not equivalent with the ritual pollution during pregnancy, after childbirth or death.
54 This is a hormone injection that has a similar effect as a contraceptive pill.
55 It is interesting to note that this opinion is also widely spread amongst white South Africans, who regard their culture as being very different from black people.
56 ART – Antiretroviral Treatment
57 VTC – Volunteer Testing and Counselling
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