|AIDS and society in Tanzania|
A Plague of Paradoxes: AIDS, Culture and Demography in Northern Tanzania. By Philip W. Setel. Chicago and London: Chicago University Press, 1999, 308 pp
Reviewed by Robert Darby 
Archives of Sexual Behavior, Vol. 34, No. 6, December 2005, pp. 707–714
How a disease afflicting thousands of homosexual men and intravenous drug users in developed nations became an epidemic affecting millions of heterosexual men and women in Africa is one of the great puzzles of epidemiology. In hindsight it will probably eclipse the centuries-long debate over whether syphilis and gonorrhoea were different diseases or phases of the same one. It may well be seen to have elicited many of the same explanatory efforts, moral judgements and therapeutic or preventive responses as the syphilis epidemic of the eighteenth and nineteenth centuries; then, as with AIDS today, many schools of thought contended, some stressing behavioural, some socio-economic, some micro-biological, some moral and some anatomical factors.  Philip Setel’s aim in this richly textured and illuminating study is to historicise the impact of AIDS in a region of Tanzania – to move away from a narrow focus on virus particles, receptor cells and body parts, and to consider the broad social and human environment which has enabled the disease to exercise the effects it has. He thus seeks to explain both why its spread has been so fast and so terrible and to illustrate the ways in which it has been perceived and experienced by Tanzanian men and women. While not denying the centrality of sexuality in the process, Setel insists that it is mediated by its social context: “AIDS in Kilimanjaro has been an outgrowth of culture, history, demography and political economy. … It has been a disorder of social reproduction that emerged through the intersection of HIV with people engaged in a conscious struggle with forces both impinging on and internal to their cultural worlds. Sexuality … has been framed as an outcome of socio-cultural change in productive and reproductive regimes.” (p. 236)
The region studied is occupied by the Chagga people, living in the north of Tanzania, on the slopes of Mt Kilimanjaro, near the border with Kenya. The main town in the area is Moshi. Among the paradoxes which give the book its title, Setel notes that contemporary sexual ideologies (lamenting the immorality or bad character of modern youth) have been based on nostalgia for a vanishing demographic system. He emphasises that “traditional” Chagga culture was not static, but constantly evolving under internal and external influences, such as other ethnic groups, Arab slave traders, and of course European colonialism. The latter brought new diseases, but also new economic opportunities, such as coffee, cultivation of which transformed the vegetable plots traditionally farmed by Chagga families. Rapid population growth led to massive emigration from the region after World War II, especially of young single men, who naturally sought sexual contacts wherever they went, but who were not able to marry until they had accumulated the resources needed to buy a wife (the bridewealth).  From its earliest appearance, HIV was associated with mobile men, especially itinerant businessmen (often just petty traders), whose proliferation in the 1980s was itself a sign of structural changes in the world economy, Tanzania’s failed development strategies and shrinking economic options in other areas. The disease spread fast. In 1992 Kilimanjaro was listed as the seventh most severely affected region, with 134.2 cases per 100,000; in 1994 the fifth; and in 1997 the third. In 1991 over 70 per cent of self-identified prostitutes tested sero-positive. Setel points out that these figures are not confirmed by the lower level of sero-prevalence measured among blood donors, suggesting either that AIDS detection in the region is more thorough than elsewhere in Tanzania, or (more probably) that many infected people are returning home to die.
A welcome focus of the book is its stress on women’s experience. Setel points out that the high level of HIV infection among women is an effect of both their economic and social subordination as much as of their sexuality. He particularly mentions female poverty and economic insecurity, leading many into various forms of prostitution; their dislocation from cultural institutions which could protect them from unwanted advances from husbands or former lovers; and their general lack of rights and subordination to male power. As in Victorian England, the double standard on sexuality morality is strongly in evidence: one man made no apology for his own fondness for screwing around, yet criticised the looseness of contemporary youth and insisted that any future wife be a virgin. It is this moral environment, far more than their expense, which explains the low level of condom use in the region. Even though many women knew about them and wanted their protection, as respectful wives they could not make the suggestion to their husband; yet men did not want to put them on because they were uncomfortable and reduced sensation. On top of that, the local Christian churches preached against their use, and other opponents spread the rumour that they had actually been impregnated with HIV. Not that condoms alone are the answer: as Brooke Schoepf has argued, “Failure to recognise the economic causes of prostitution, to address the structural causes of under-development, poverty and joblessness, builds resentment … and resistance to advice such as the need for condoms” (quoted, p. 237). The lesson is that any program to combat AIDS in Tanzania must also aim to raise the social status and economic security of women.
Setel is critical of accounts which identify “African sexuality” as the main culprit in the spread of HIV, agreeing with Schoepf that it is not sexuality per se which is the problem, but “situations of risk produced by intersections of biology, political economy and culture”. He points out that there is no such thing as “African sexuality” and that such explanations can easily stereotype Africans as being unusually randy and promiscuous, as well as more generously endowed – a trope with a long history in envious European discourse. Yet his own study does bring out very clearly that traditional, no less than modern, Tanzanian culture was marked by a high level of sexual activity (promiscuity by any other name), involving sexual liaisons soon after puberty, multiple partners at any one time, various forms of polygyny and polyandry and more casual relationships in adulthood, a strong preference for vaginal intercourse over other (safer) forms of enjoyment, and a high valuation placed on fertility. A successful man wanted to advertise the fact by having as many children by as many women (both wives and “girlfriends”) as possible, and that meant a lot of unprotected fucking. A carpenter in Moshi regretted that the saddest effect of AIDS had been to lessen the amount of fun people could have: “AIDS has ruined their way of life. The greatest achievement here is sex. Our way of life has been very seriously affected. Even with one girl there is not much fun. You need to have several to have a good time. … Life has become very miserable”. (p. 179) It hardly needs pointing out, as all studies of HIV have shown, that frequent unprotected sex with multiple partners is the most important risk factor for infection. As Setel himself writes, “where there has been historically low condom use, poor treatment of STDs, and a general preference for penetrative vaginal sex … multipartner sexuality among some can be statistically related to increased risk of being infected with HIV.” (p. 201)
Circumcision not a significant factor
There is no comfort here for the small band of researchers from circumcising cultures who are seeking to prove that the male foreskin is the decisive factor in the high incidence of AIDS in the Third World, supposedly because it is uniquely vulnerable to penetration by the virus. Given the pre-existing ubiquity of both male and female circumcision in Africa, it seems an eccentric argument, and it is a sign of the cultural bias of such researchers that they make no attempt to suggest that, or to test whether, female circumcision might be the key factor – that the labia or clitoral hood might as treacherous a pair of Trojan horses as the prepuce.  It is certainly not an issue in Kilimanjaro, where both boys and girls are circumcised as part of a complex sequence of initiation rites at puberty. His foreskin gone, the former boy is visibly different and now both subject to adult responsibilities and entitled to adult privileges, such as the right to seek sexual opportunities and economic advancement in the village. Initiation for girls used to involve excision of both the labia minora and the clitoris, but now appears to involve only the latter: whatever the details, the adjustment likewise marks their transition from girl to woman, with attendant rights and responsibilities. There is no suggestion in this book that circumcision or lack of it could have anything to do with the prevalence of HIV among males, though one man interviewed asserted that the discontinuation of female circumcision was a factor in rising rates of both immorality and HIV infection: “This is all because Chagga culture has been polluted and mixed with European ways. … In the past there was initiation and puberty training. Men learned their age sets and women were circumcised. … The youth of today are tied up in the profligacy of the disco, bearing children out of marriage, and so on”. (pp. 59-60) It is the sort of conservative lament for lost virtue common to all societies in the throes of change.
A Plague of Paradoxes demonstrates the value of an anthropological approach to the question which is generating more literature each year than anybody could read in a lifetime: how to explain, and thus contain, the high incidence of HIV infection in Africa, so much worse than anywhere else. Several types of theory have been proposed, variously emphasising genetic susceptibility, patterns of sexual behaviour, iatrogenic misadventure (non-sterile medical procedures), failure to institute effective programs or to do so in time, and even anatomical variables, such as male and, to a lesser extent, female circumcision. Setel’s argument is that any mono-causal account is missing the point, and that explanations (and thus effective control strategies) are to be sought in the peculiar combination of social, demographic, economic, cultural and behavioural evolution in each African region. Such an approach requires a lot more than just the counting of foreskin-free penises or herpes lesions which has become fashionable in some medical circles. He shows clearly, and often in moving detail, how demographic patterns, social change, economic need, cultural understandings, sexual behaviour and medical responses created an environment in which HIV was sure to thrive. Tanzanian sexual practices (frequent unprotected intercourse with multiple partners) would have been enough on its own to ensure the spread of the virus (as it was among homosexual communities in the USA), but it is these broader factors, coupled with the tardy response to the problem by medical authorities  and limited resources, as a consequence of poverty, when they did, which explains why the epidemic has had such a devastating impact on the lives of African people.
References and notes
1. Visiting Fellow, School of Social Sciences, Australian National University, Canberra, ACT 0200, Australia
2. Peter Baldwin, Contagion and the State in Europe, Cambridge University Press, 1999, ch. 5; Robert Darby, “Where doctors differ: The debate on circumcision as a protection against syphilis, 1855-1914”, Social History of Medicine, Vol. 16, 2003, pp. 57-78
3. A remarkably similar situation in Victorian England was blamed for the proliferation of prostitution and consequent high level of syphilis and other venereal diseases.
4. It is only a few doctors from Moslem countries practising female circumcision and some conservative Africans who assert that failure to be circumcised makes women more vulnerable to infection and that the operation is therefore a valuable prophylactic. While western researchers on this issue have generally seen female circumcision as a means of spreading AIDS, they have, rather inconsistently, seen male circumcision as a means of stopping it.
5. The first HIV cases were noticed in 1984, the first death in Moshi was in 1986, but it was not until “the early 1990s” that meaningful preventive programs were in place. Such a delay gave the virus an enormous head start in which to establish itself throughout the population. This situation contrasts with countries such as Australia and Britain, where the response was rapid, moralism was avoided, and effective education programs stressing safe sex were developed with the full involvement of, and thus acceptance by, the at-risk communities. That such an approach is working in Africa is suggested by David Moore and Robert Hogg, “Trends in antenatal human immunodeficiency virus prevalence in western Kenya and eastern Uganda: Evidence of differences in health policies?”, International Journal of Epidemiology, Vol. 33, 2004, pp. 1-7
Update 2006: Toronto AIDS conference refuses to embrace circumcision as miracle prophylacticWhile the huge AIDS conference in Toronto in August 2006 produced the familiar calls, from the usual suspects, for mass male circumcision as the great surgical hope against HIV in underdeveloped countries, the conference as a whole remained sceptical of this approach and did not endorse Mr Gates’ stress on this strategy. Although his keynote speech and a few papers advocating circumcision received disproportionate publicity, most of the conference focused on the need for education, encouragement of safe sex, the development of topical applications and the empowerment of women. This was the most valuable suggestion in Mr Gates’ presentation, since it is the subordinate position of women in many traditional cultures which prevents them from refusing sexual advances, or insisting on condoms or safe sex when they consent.
There were even papers on the irrelevance of circumcision and the importance of condoms, regretting the fashionable stress on the former and the incomprehensible neglect of the latter. They pointed out that it was irrational to promote a risky and harmful surgical operation such as circumcision, offering at most a 60 per cent reduction in risk, clinically shown to be effective over only 20 months, in the much-hyped study by Bertran Auvert, the extravagant claims of which have been criticised by Michel Garenne at the Pasteur Institute. Consistent condom use provided 90 per cent protection over a person’s lifetime.
A thoughtful critique of Auvert
Michel Garenne paper
Condoms the best defence
Further information on condom use in underdeveloped countries
Circumcision not so protective after allMale Circumcision May Not Protect Against HIV Infection:
Paper by Dr Vinod Mishra, Presented at AIDS 2006
By Danny Kucharsky
TORONTO, CANADA -- August 17, 2006 -- HIV prevalence is not necessarily lower in populations that have higher male circumcision rates, according to findings from a study of African countries presented here at the 16th International AIDS Conference (AIDS 2006).
The study, which examined the association between male circumcision and HIV infection in 8 Sub-Saharan African countries, contradicts the findings of previous research and the opinion of several prominent personalities active in the fight against AIDS, such as former US President Bill Clinton.
While several studies have indicated that male circumcision has a protective effect against sexually transmitted infections (STI), including HIV infection, the evidence is inconclusive, said investigator Dr. Vinod Mishra, director of research, ORC Macro, Calverton, Maryland. “We’re just questioning that push,” he said of the optimism displayed by Clinton and others.
The study used demographic findings from recent demographic and health surveys in Burkina Faso, Cameroon, Ghana, Kenya, Lesotho and Malawi, and AIDS indicator surveys from Tanzania and Uganda. The surveys were conducted from 2003 to 2005 and sample sizes ranged from 3,300 men in Lesotho to 10,000 men in Uganda. In survey fieldwork in each country, men aged 15 to 59 gave blood for anonymous HIV testing. Information on circumcision status and on STI/STI symptoms was based on men’s responses to questions in survey interviews.
Prevalence of male circumcision ranged from a high of 96% in Ghana to a low of 21% in Malawi. Among the other countries, circumcision rates were 84% in Kenya, 89% in Burkina Faso and 25% in Uganda. HIV prevalence was markedly lower among circumcised than uncircumcised men only in Kenya (11.5% among uncircumcised men vs. 3.1% among circumcised men). A small protective effect of male circumcision was also seen in Burkina Faso (2.9% vs. 1.7%, respectively) and Uganda (5.5% vs. 3.7%).
In the other countries, there was either no difference in HIV rates between circumcised and uncircumcised men or circumcised men were more likely to be HIV-positive than uncircumcised men. For example, in Lesotho, HIV was seen in 23.4% of circumcised men compared to 15.4% of uncircumcised men.
“If anything, the correlation [between circumcision and HIV infection] goes the other way,” in most of the countries studied, Dr. Mishra said during his presentation on August 15th.
When adjusted for sociodemographic and behavioral factors, a small protective effect was observed in 6 of the 8 countries, but it was not statistically significant in any country, Dr. Mishra said.
In Kenya, and to a lesser extent, in Ghana, Malawi, Tanzania and Uganda, circumcised men were less likely than uncircumcised men to report having had an STI or STI symptoms in the 12-month period prior to the survey (2.1% vs. 5.4%, respectively). The relationship was reversed in Cameroon (8.0% vs. 2.5%) and Lesotho (12.1% vs. 7.5%). With other factors controlled, male circumcision had some protective effect in 5 of the 8 countries, but the effect was statistically significant only in Tanzania.
In addition, “circumcised men tend to have more lifetime sex partners, so there’s some [high-risk] behaviors that go with circumcision status,” he said.
A study limitation is that it was based on self-reported information on circumcision status and STI/STI symptoms. It also lacks data on age at circumcision and degree of circumcision, which might influence susceptibility to HIV infection. However, Dr. Mishra said the study is consistent with other research that has failed to find a protective effect of male circumcision on HIV and STIs.
Dr Vinod Mishra, “Is Male Circumcision Protective of HIV Infection?”
(Conference abstract TUPE04010
Wot, no condomsCondoms Still Out in the Cold at Toronto AIDS Conference:
Emerging Prevention Technologies Take Centre Stage, Proven Condom Given Short Shrift
16 August 2006
TORONTO, Canada — “Prevention” and “new technologies” are the buzzwords at the XVI International AIDS Conference in Toronto, but UNFPA, the United Nations Population Fund, is calling attention to the fact that millions of people still lack access to the most basic and available preventive method of all—the male and female condom.
The Conference, which has attracted 25,000 scientists, activists and policymakers from all over the world, marks the first time the international community has seized upon prevention as the most cost-effective and sustainable response to the global pandemic. Keynote speakers former United States President William Clinton and Microsoft co-founder Bill Gates both emphasized the need for female-controlled methods, such as microbicides to halt the virus’s spread—particularly among young women and girls who now make up the fastest growing proportion of the newly infected. The potential of vaccines and male circumcision to slow transmission rates have also grabbed the lion’s share of attention.
Steve Kraus, Chief of the HIV Branch of UNFPA, asserts that, while discussions around new prevention technologies represent an important step in the evolution of the global HIV response, all of them are still years away from becoming widely available. “People are getting infected now,” he says. “While we applaud discussion and research into new technologies, we are still not using what we have available today. The condom already exists and it hasn’t been delivered. It works and represents the best tool we have in the fight against HIV/AIDS,” says Dr. Kraus.
Today, an estimated 8 to 10 billion condoms are being used in low-and middle-income countries. This represents only half of the total need. In sub-Saharan Africa, where HIV prevalence is highest, African males have access to only 10 condoms on average—per year. While female condom distribution is increasing, the total market share remains woefully low—at only 0.3 per cent—despite rising demand in high-prevalence settings such as Zimbabwe and Malawi. To meet increased demand, UNAIDS estimates, resources will have to double from about $320 million a year today to between $500 million and $630 million by 2015.
UNFPA, the United Nations Population Fund, is an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal opportunity. UNFPA supports countries in using population data for policies and programmes to reduce poverty and to ensure that every pregnancy is wanted, every birth is safe, every young person is free of HIV/AIDS, and every girl and woman is treated with dignity and respect.
Cell Phone: +1 917-535-9508
Email: leidl (AT) unfpa.org
Tel. +1 (212) 297-5031
Email: dungus (AT) unfpa.org