Sub-Saharan Africa has two-thirds of the world’s HIV/AIDS cases. So you would think that Western journalists and politicians might condescend to ask us what we think about how to fight AIDS. But they haven’t. A pity, because they would have found that many of us support Pope Benedict XVI’s scepticism about the effectiveness of distributing condoms.
A few days ago, The Lancet, a leading British medical journal which regularly pontificates about public health, slammed the Pope for making “a false scientific statement that could be devastating to the health of millions of people”. I wonder if the editor of The Lancet has ever visited rural areas of Nigeria or South Africa. If he did, he would begin to see why fighting AIDS with condoms is like extinguishing a fire with petrol.
First of all, many rural Africans are illiterate and proper use of condoms cannot be relied upon. In any case, many men think that it compromises sexual pleasure. “Would you eat sweets with a wrapper on?” is a common objection.
Secondly, social organisation in rural Africa is quite unlike sedate suburban life in Sussex, or wherever the editor of The Lancet lives. In villages here there is often a low standard of moral behaviour. Men don’t get married but they do want children, so using condoms does not even come into their minds. They sleep with whomever they like until they are very old and need someone to cook for them. A man might be sleeping with six different women in a year. And the women often don’t mind whether a man will marry them or not.
Day to day life is unlike the West. The huts are open and at night there is no electricity to supply light. Anything can happen. Thus rape of children as young as six is not uncommon. As most of these go unreported, the aggressors go scot-free. Even when the rapist is known, nothing much is done.
In South Africa, which has some of the highest rates of AIDS in the continent, researchers claim that half a million women are raped each year. Journalist speak of a “rape epidemic”. More than a quarter of all the females can expect to be raped at least once in their life, even in infancy. Half of the victims are under 18. It is hard to get hard figures, because most attacks go unreported. Tell me, how do you persuade a rapist to use condoms?
If condoms are so effective why is HIV still on the increase in Africa? One factor is certainly that people with condoms are emboldened to take more risks. Part of the counselling of people living with AIDS is “try not to spread it” -- in a word, to live abstinence. But before they got the disease they were told “hey, no need to curtail your libido, just use condoms.” If personal control is not achieved before contracting HIV/AIDS it is often impossible afterwards. I overhead a chilling conversation once of a boy planning to sleep with a girl. “What if she has AIDS?” his friend asked. “Well then, I have seven years to live and I will enjoy myself to the limit,” he replied.
There are even more basic obstacles. Many villagers are unschooled and know little about modern science. Poisoning or sorcery is suspected when people fall ill. Western medicine is often seen as a last resort after traditional healers have failed. So doctors find it difficult to explain to HIV/AIDS patients the cause of their illness. It is not uncommon for them to go to their graves with the stubborn belief that an enemy cast a spell on them. The more serious and "treatment defying" an illness is, the more it confirms the malignant power of the sorcerer.
Villages are often cut off from distribution networks for goods and services because of difficult terrain. You can’t jump into your car and make a midnight trip to the pharmacist to buy a packet of condoms. In fact, you might be cut off from condom suppliers for weeks at a time. One doctor related to me a typical example. A youth in a village explained why he did not use condoms with his girl: “well, I had to convince and convince, and when she finally said yes, I could not risk going outside to buy condoms since she might change her mind before I came back.”
And people are not just careless, they are ashamed. Here’s another story from the same doctor. A woman came to him for an antenatal check of her second child (the first was a year old). She discovered that she was HIV positive. She was terrified of what her husband would do to her. The doctors called the husband and tried to break the news gently. To their amazement he told them that he was HIV positive and had been on treatment for over a year -- without telling his wife. Why? “Well, someone gave it to me,” he said. Many infected people deliberately spread the disease, thinking; “I can’t be the only one. Since someone gave me the disease, I will give it to someone else.”
Plus, there are other means of transmission of AIDS which are unfamiliar in the West. One treatment you will not find in Cleveland is medical scarification. A traditional healer in a village will make an incision over the affected area to discharge fluid or blood. The healer uses the same implement to cut different people, leading to the spread of HIV/AIDS and other infections. Traditional scarification for aesthetic or cultural reasons also exists and is no more hygienic.
It is true that in rural Africa HIV/AIDS spreads mainly through heterosexual relationships. But it is also transmitted by intravenous drug users. African villagers prefer injected drugs to tablets because, so they think, it is better value for money. So the local chemists (who are seldom trained pharmacists) oblige them. Sometimes they save money by reusing syringes and not swabbing the skin with disinfectant. The resulting infections sometimes create huge abscesses.
The Pan African Health foundation (PAHF), a non -profit HIV/AIDS prevention charity, is building a factory in Nigeria with a capacity of 160 million syringes a year. This will supply 20 percent of Nigeria’s needs and, when fully operational, most of sub-Saharan Africa. Inexplicably, American and British foreign aid agencies which doled out lavish donations for condoms to fight HIV/AIDS were not interested in supporting the foundation. The local state government finally gave some funding.
UNAIDS, the international agency which coordinates research and treatment for AIDS around the world, is a strong supporter of condoms. Its official position is that: “The male latex condom is the single, most efficient, available technology to reduce the sexual transmission of HIV and other sexually transmitted infections.”
Note the stress on the word “technology”. The condom is just a technology. And technology is not much good for changing behaviour.
The West is addicted to technology as a substitute for free will and moral effort. If you eat too much, you get gastric banding surgery. If you’re depressed, you take Prozac. If you’re a smoker, you wear nicotine patches. Here in Africa, this fantasy has collided with the reality of the AIDS crisis. There is no technology to tame sexual desire. There is only self-restraint and faithfulness to your partner. These will eventually rein in AIDS; condoms won’t.
- Chinwuba Lyizoba
Chinwuba Iyizoba is an electrical engineer in Enugu, Nigeria
This article is published by Chinwuba Iyizoba, and MercatorNet.com under a Creative Commons licence.
Tsandra said... Italy | Wed, 8 Apr 2009 at 1:32 am
A great article: also goes to show that we need to stop berating the men we have over here in the West (now that we’ve succeeded in educating them). Just look at the men in the rest of the world: in the East they tend to be drunk half of the time. In Muslim countries we know what a woman is worth. This piece here tells you what they’re like in Africa. And feminists would have us be indignant with “white males”? Gimme a break.
mac said... United States | Wed, 8 Apr 2009 at 12:05 am
Thank you Dr. Anegbe! This is what we need: people doing their best to solve the problem. One important thing I got from your experience, is that we really should use everything in our arsenal of prevention to control the disease: focused group discussions, counseling, and yes even condoms. We can work on behavioral modification (which is the key) but since this may take time, we can also make use of whatever protection condoms may provide particularly in discordant & monogamous couples. Hopefully we get good results from the new microbicide trials that are currently enrolling for these may further help us in preventing transmission.
Let us concentrate our energies in working on what we believe will solve the problem rather than spend our precious time thinking of ways to discredit other researchers’/health care workers’ solutions. Together we can achieve something.
Dale O'Leary said... United States | Tue, 7 Apr 2009 at 11:55 pm
Maybe we aren’t asking the right question.
Maybe the question should be: Why have massive condom education and distribution campaigns failed to slow the AIDS epidemic in Africa, while a campaign stressing abstinence before marriage and fidelity in marriage has had positive results?
Both require substantial changes in behavior. The difference is that while the decision to practice abstinence and fidelity is made with your clothes on, the decision to use a condom is made with your clothes off, in the heat of passion and often under the influence of alcohol or drugs. The decision not to engage in sex requires will power, but it is supported by religion and tradition. While the condom promoters encourage people to use a condom every time, the fact is that if both partners are HIV free and monogamous, the risk of infection is zero.
Sexual Transmitted Infection epidemics are driven by multipartner sexual activity. The epidemic isn’t driven by monogamous couples not using condoms, but by those who engage in relations with a number of different people. Those pushing condoms as the only solution for the AIDS epidemic, ignore the psychology of multipartner sexual activity. Those most at risk engage in sex with people they don’t know very well. Insisting on condom use in such situations implies a lack of trust, it breaks the mood, it interferes with the seduction that is part of such encounters.
Condom promotion campaigns necessarily spread a false sense of security. The campaigns don’t say that condoms, even used every time and correctly will only reduce your risk of infection, and you may still contract HPV, which causes cancer and warts. Instead the paint a picture of fun and freedom. According to the Lancet article; “A vigorous condom-promotion policy could increase rather than decrease unprotected sexual exposure, if it has the unintended effect of encouraging greater sexual activity.” And since those who are encouraged to engage in multipartner activity even if supplied with condoms and educated on how to use them inevitably slack off after a few months, the problem gets worse not better.
According to study published in the Int. Journal of STDs & AIDS, the researchers were able to get more men to take condoms, but those who did also engaged in high risk behavior, increasing not decreasing the risk of infection.
Condoms may sound like the solution, but Africa needs programs with a proven record of success.
Bruno said... Nigeria | Tue, 7 Apr 2009 at 6:05 pm
I know Spain is a beautiful country but I don’t understand this Spaniard Antonio Uceta. The inefficacy of condom usage is something we already know, both from facts and research result. I Think Antonio has to read more, and discover himself
Dr Ambrose Anegbe said... Nigeria | Tue, 7 Apr 2009 at 5:57 pm
I am a medical Doctor. For my national youth service program I was posted to a rural community in the area of Nigeria that has the highest incidence of HIV AIDs infection. 50% of the patients occupying our beds in the hospital had HIV AIDs. It didn’t take me long to know why the incidence of HIV was so high in this community. They had a very low moral standard, high rape incidences, and the people believed that someone was after them( trying to kill them) when they fall ill. I beg to say that what Chinwuba Iyizoba wrote is very true. In addition I was in charge of ultrasound in the hospital and thus had a lot of dealings with the pregnant women in the village,this gave me the previlage knowledge that most of them ( the pregnant women) where not married, many got repeatedly pregnant by different men. I was always encouraging them to go and get married. Not satisfied with what I was doing in this village clinic, i started making regular trips to other communities very far from my own hospital. I visited 13 communities and as a doctor I reviewed the medical history of over 800 villagers. because of this I was given the National honorary award For Community service by my country Nigeria, I also got the merit award from the National Drug law enforcement( NDLEA) for procuring through donation drugs,syringes and other medical disposable severely lacking in clinics these communities.
Bill Rohan said... United States | Tue, 7 Apr 2009 at 12:59 pm
Perhaps the discourse here, with the many perspectives expressed, not only reflects part of the problem, it is also, hopefully, part of the solution. The structures of any society and the established behavior patterns and beliefs, can, through the exchange of ideas and related actions, be changed. A society becomes other than the way it is as each member, by hi/r speech and actions, shapes social reality, for better or worse.
Mal said... Australia | Tue, 7 Apr 2009 at 10:21 am
(Well, I guess that’s the way it is and nothing can be done about it.)
Bill Rohan, in one sentence you have summarised the attitude of many in the West. No wonder they get it all wrong.
Dale O'Leary said... United States | Mon, 6 Apr 2009 at 11:50 pm
Those who believe in condoms should look at the research. While correct use decreases the probability that an individual sexual act will transmit the virus, massive condom distribution has not been effect against an established epidemic.
“Massive increases in condom use worldwide have not translated into demonstrably improved HIV control in the great majority of countries where they have occurred.” “A vigorous condom-promotion policy could increase rather than decrease unprotected sexual exposure, if it has the unintended effect of encouraging greater sexual activity.” (Richens et al, (2000) “Condoms and seat belts,” Lancet, 355, p. 400.)
“In many sub-Saharan African countries, high condom use has yet to produce demonstrable benefit...sad experience shows that high HIV transmission can coexist with high condom use.” (Hearst, Chen (2003) “Condom Promotion for AIDS Prevention in the Developing World,” Geneva: UNAIDS)
Consistent use is the exception. “Consistent condom use peaked at 62% in the first 6 months, but declined to as low as 8% in the second year of follow-up.( Taha et al. (1996) “Lack of association between reported condom use and rates of sexually transmitted diseases in Malawi,” AIDS, 10, p. 207-212.)
Several studies have found that inconsistent condom users have higher rates of STI and/or HIV infections than condom non-users.( W. W. Darrow et al. (1989) “ Condom use effectiveness in high–risk populations,” Sexually Transmitted Diseases, 16, p. 157-160)
Among men who have sex with men those who did not use condoms were less likely to be infected, than those who did.("A prospective study of condom use in Baltimore found no differences in STI infection rates among those who reported using condoms 100 percent of the time versus 0 percent of the time."Zenilman et al. (1995) “Condom use to prevent incident STIs,” Sexually Transmitted Disease, 22, p. 15-21)
A study of HIV in Zimbabwe found that: “HIV risk was elevated among those who had used condoms consistently with their most recent partner.” “Irregular condom use was not protective against HIV or STI and was associated with increased gonorrhea/Chlamydia risk.” (Ahmed et al (2001) “HIV Incidence and sexually transmitted disease prevalence associated with condom use,” AIDS, 15, p. 2171-2179.)
Audrey E said... Australia | Mon, 6 Apr 2009 at 2:04 pm
This article was so interesting and was very enlightening taking a “behind the scenes” look into the problem of AIDS in Africa. As has been mentioned below, the Pope has copped quite a bit of criticism from the public for his comments. If only more articles like this were published - I think the world needs to know what Africans think.
Fr. Larry Gearhart said... United States | Mon, 6 Apr 2009 at 2:01 pm
Mr. Rohan, I’m not sure what you mean by “excus[ing] member[s] of a culture from being responsible for preventing the spread of a life threatening disease because it is difficult to change their established beliefs and behavior patterns...” I didn’t detect any effort to excuse anyone, merely a reporting of facts regarding beliefs and behavioral trends and their consequences, together with an effort to explain cultural background of the resistance to condom use. We find similar culturally motivated resistance in many teenage populations in the U.S. and Europe, along with many other pathologies such as substance abuse, suicide, etc.
The effective use of condoms requires many things, including education in their use, cultural change, enough self-control to interrupt the heat of passion long enough to take “protective” measures, and, of course, much greater quality control in the production and distribution of condoms than is normally available in any cultural context.
Similarly, the effective practice of monogamy requires many things, including sufficient self-control to restrict one’s practice of sexual intimacy to one partner [self-control that, like in the case of condom use, requires cooperation from one’s partner], sufficient memory and candor to recognize when past behavior may be an indicator of risk, sufficient recognition of the utility of modern medicine to recognize when HIV testing is indicated, etc.
The latter requires greater application of individual reason and free will than the former, while the former requires greater application of reason and free will at the level of enterprise and governance. Both have major pitfalls, and most of these relate to the fallible self-interest of people, institutions and nations.
All of this applies and is readily discernible without any consideration of morality or the actual nature of free will.
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