World Health & Population
Most who work in international development recognize the importance of implementing locally driven, grassroots initiatives for achieving positive outcomes. Yet, when it comes to HIV prevention strategies in Swaziland, there is a lack of understanding for the cultural and historical influences that determine group and individual behaviour. As a result, prevention efforts have failed to have a major impact on the world’s highest prevalence rate of HIV. Greater understanding and observance of historical influences, local norms and beliefs, and the ongoing processes of adaptation must be incorporated into all efforts if any HIV prevention strategies are to be effective.
Many development professionals today recognize that the most effective aid projects are locally informed, culturally specific and driven by grassroots activists from within that society. To fulfill these requirements, project activities must be divorced from the political agenda of the funding source and focused on the desires of the local people. However, this is far from the reality – especially when it comes to international HIV/AIDS programs. A large proportion of global activity on HIV today is funded by the United States through a 2003 Bush administration initiative known as the President’s Emergency Plan for AIDS Relief, or PEPFAR. This legislation is the largest donor effort to date for a single disease and was constructed with well-defined earmarks for project spending that included prevention and treatment (PEPFAR 2009). While treatment is predominantly focused on making affordable antiretroviral pharmaceuticals accessible to some of the world’s poorest HIV-positive citizens, it fails in many locations to fully involve local and traditional healers, or incorporate local paradigms about Western pharmaceuticals. However, the focus of this article is PEPFAR-funded HIV prevention efforts.
The 2008 bill that renewed PEPFAR stated that 50% of all prevention funds should be allocated to “activities promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction” (Berman 2008). PEPFAR prevention, in another earmark, also incorporates condom education. Combined, these form the “ABC” strategy (standing for “abstinence,” “be faithful” and “condoms”) and have a strong epidemiological basis. Delaying sexual debut, having sex with only one partner – or only one partner in a given time period – and using condoms correctly and consistently will significantly reduce the chances of both individual infection and the rate at which HIV spreads through a population. However, implementing ABC as the only viable prevention option, as has happened in many African nations, is far too narrow to be locally informed and grassroots driven. The focus of these strategies fails to consider the many other factors and influences that determine behaviours at both individual and societal levels. As a US Peace Corps Volunteer (2007–2008) assigned to HIV education in the Kingdom of Swaziland, the nation with the highest prevalence rate of HIV/AIDS in the world, I was quickly confronted with the shortcomings and inadequacies of this approach. Ethnographic research conducted simultaneously during my Peace Corps term revealed several foreign and local influences that impact Swaziland’s HIV epidemic, yet are not documented by any agency collecting HIV data or tracking epidemic outcomes. In this article, I outline these influences and describe how they stifle HIV prevention efforts in Swaziland.
Aiming to Influence
The first detected case of HIV in Swaziland was in 1986. In 1999, King Mswati III declared the epidemic a national emergency (UNAIDS 2006). Although various aid agencies have been present in the Kingdom since the end of British colonialism in 1968, Mswati III’s appeal produced an upsurge of aid activity. In 2002, the Peace Corps was invited to reopen Swaziland as a post, with HIV prevention funded through PEPFAR as the only activity. Yet international funding and attention was not swift or effective enough; the HIV epidemic ballooned to infect 38.8% of the sexually active adult population (ages 15 to 49 years) in 2003, the year Swaziland surpassed Botswana as the nation with the highest prevalence rate of HIV in the world. It peaked at 42.6% in 2007 (UNAIDS 2008). Since then, most discourse surrounding Swaziland’s HIV crisis has been centred among those who hail from outside the nation: diplomats, researchers and international aid workers.1
For fiscal year 2009, Swaziland was delegated a PEPFAR “focus country,”2 one of about 15 that receive the highest levels of funding and guidance for tackling HIV/AIDS. In September 2008, one month prior to the increase, a group of aid professionals and Swaziland government officials met under the leadership of the United States Agency for International Development (USAID) in roundtable discussions to strategize the use of the new funds for prevention activities. I was fortunate to be included, along with Swazi public servants and local citizens working in HIV/AIDS. The meetings reflected an attempt at “locally driven” prevention efforts. However, the local perspective was one that predominately reflected the urban areas, where the selected affluent Swazi workgroup participants lived. Speaking on behalf of rural areas, where 70% of the Swazi populace resides – most in abject poverty – were another Peace Corps Volunteer and me.
Additional efforts also were taken to create culturally appropriate strategies. Among the reading materials for the Swaziland workgroup was a white paper written by American-born anthropologist Suzanne Leclerc-Madlala. Leclerc-Madlala has spent a significant portion of her career living and working in South Africa, where she resided in her South African husband’s township during apartheid. As such, her paper introduces some important emic and etic perspectives,3 organized into cultural scripts4 on sexual paradigms and behaviours that drive HIV in parts of South Africa and Swaziland (Leclerc-Madlala 2008). These scripts brought to light cultural norms and mores that most foreign aid workers had not been able to fully understand and that most nationals could not or would not adequately articulate for the international aid community. While informative, the scripts contributed only as much as could be implemented under the ABC strategies for which the funds had been earmarked by congressional leaders in Washington, DC.
Specifically, this limited activities to the promotion of:
- Abstinence, delaying sexual debut until marriage and the denunciation of cross-generational sex, transactional sex, rape, incest or other forced sexual activity
- Eliminating casual sexual partnerships and sustaining long-term sexual partnerships through partner reduction and marital fidelity
- Correct and consistent condom use during every sexual encounter where partners are discordant or the HIV status is unknown (PEPFAR 2003)
ABC fits within the primary parameters of all health promotion campaigns: to influence knowledge, attitudes and behaviours of individuals and groups. However, ABC fails to adequately influence attitudes and perceptions of risk, which is critical in changing behaviours. Merely expanding lay knowledge about HIV has been found – even in the West – to have little impact on behaviour changes that would be effective in preventing transmission of the disease (Hayes et al. 2005).
In Parker et al. (2000), Diaz, quoted in Parker et al. (2000), further states the ineffectiveness of HIV prevention is that it is centred on an individualistic paradigm. Focusing on individual behaviour “intentions” rather than actual circumstances in which these intentions can, or cannot, be enacted ignores a multitude of interpersonal behavioural factors, including peer and familial pressure, coercion, threat of rejection or the bounds of accepted behavioural norms in a society at a point in time. Diaz notes, “By placing the causes of HIV transmission in individual behaviour, the theorists biased the focus of prevention towards individual responsibility (so true to the American tradition!), minimizing the role of structural and sociocultural determinants” (Parker et al. 2000: 196).
This is notable in the discrepancy between knowledge and behaviour that has been documented in Swaziland. My field notes describe several situations where it was clear that the basic concepts about HIV, such as the four fluids that carry the virus, proper use of condoms, and signs and symptoms of common opportunistic infections, had already been taught repeatedly, memorized and could be regurgitated upon request. Yet these topics remained the primary components for most HIV education programs. Providing food to participants continues to guarantee attendance, while PEPFAR tracks the “success” of “AB” programs by the number of participants counted (PEPFAR 2010).
The gap between knowledge and behaviour in Swaziland was further documented through data collected on voluntary counselling and testing (VCT). In 2007, 51.9% of Swazi adults aged 15 to 49 years had a comprehensive knowledge of HIV/AIDS, and 78.1% in that age group knew where to get an HIV test. Yet only 18.6% of the Swazi population had ever tested, and 1.5% of those never returned for the results (Swaziland Central Statistical Office, 2007).
Part of the discrepancy between knowledge and behaviours is that many components of ABC are counterintuitive for Swazi nationals. Any attempts at teaching outside of the local and cultural paradigms, which are more communal than in the West, polygamist and filled with obligation to hierarchy, were quickly brushed aside and ignored. The reasons for this are elaborated more in the next section. The point here is that focusing solely on behaviour intentions ignores the social, structural and cultural factors that determine behaviour and risk. As Parker et al. explain, this is not new knowledge:
By the late 1980s, therefore, on the basis both of research findings and of practical experience around the world, it was becoming clear that a far more complex set of social, structural, and cultural factors mediate the structure of risk in every population group, and that the dynamics of individual psychology could never explain (or stimulate) changes in sexual conduct without taking these broader issues into account. (Parker 2000: 5)
Therefore, it is critical for HIV aid workers to understand the perspectives that drive group and individual behaviour in a society.
Emic Perspectives on Risk
Individuals and societies have a distinct emic perspective on risk and “risk behaviours” that is central to structural and socio-cultural determinants. Societal norms and mores define social relations, interactions and behaviours, which ultimately determine what is risk. As such, what one perceives as risk or “risky behaviour” is determined by the “cultural response to transgression: the outcome of breaking a taboo, crossing a boundary, committing a sin” (Lupton 1999: 45). In Swaziland, the “possibility of loss or injury” defined as “risk” by Merriam-Webster’s Collegiate Dictionary (2003) is not individual or physical; the disease incidence to be avoided is not viral, as epidemiologists would contend. Risk is understood through communal and social parameters, which are both deeply rooted in history, and historical influences that are capable of mutating as rapidly as HIV. In other words, contracting HIV is less risky than acting against societal and cultural norms and beliefs.
To better understand “risk behaviour” it is therefore critical to look to Galtung’s theory of structural violence, which was first elaborated upon in his paper “Violence, peace and peace research,” (1969). Through this theory, Galtung distinguishes between direct violence and indirect violence, which encompasses hidden constraints to human development and potential, such as limited access to resources, education, political influence and healthcare. The concept has been picked up by many social scientists and advocates examining how individuals and groups identify and persist amidst broad power dynamics and inequalities, whether economic, historical, political or social. Structural violence is best understood when embedded in post-structuralism. Lupton writes:
Individuals are seen not to be fixed in social or cultural identities, but constantly shifting, the products of various combinations of power-knowledge formations. Power is seen as operating through manifold sites, rather than predominantly through monolithic social institutions. Power is seen as not simply coercive or oppressive, as critical structuralism tends to have it, but also as productive and inevitably present in any social relation. (Lupton 1999: 26–27)
Farmer has incorporated the concept of structural violence in many of his writings on HIV/AIDS and health disparities. He states that disease and disparity stem from rights violations, which are “symptoms of deeper pathologies of power and are linked intimately to the social conditions that so often determine who will suffer abuse and who will be shielded from harm” (Farmer 2005: 7). In Swaziland, power, risk and behaviour choice are determined by hierarchy, nationalism and the use of tradition to strengthen the influence of those with the power, both at an individual and societal level. Individual choices focus on immediate needs and survival within the frames of power and hierarchy, both of which are entrenched with gender inequalities and fuelled by Swazi nationalism. How women strive to negotiate risk is thus one of the more critical understandings that should be implemented into prevention models. Many young women in the Swazi peasant class are confronted with the limited choice of having a secure husband or boyfriend and facing greater gender oppression, or remaining unattached with the hopes of reaping any material benefits from men who come and go. Interestingly, older women who have achieved status through marriage, children and decades of subordination are often more likely to perpetuate hierarchy and, to some extent, gender oppression. These women often further gain in status by promoting the “Swazi way” while simultaneously limiting status-gaining opportunities for younger women. Ironically, the model they are perpetuating has evolved; it is much harder for younger Swazi women today to follow the same path because of high death rates caused by the HIV epidemic in the middle generation, decreased participation in the community from men, and the influences of drought and capitalism on subsistence agriculture, the economy and social norms. This is further explained in the next section.
ABC Barriers in Swaziland
In societies with gender inequalities and oppression, the ability for women to delay sexual debut or abstain from sex is not always an available or obvious choice. In Swaziland, a historical precedent of older men seeking relations with younger women makes it nearly impossible for young women to delay their sexual debut when being courted. The foundation of inter-generational sex was established from an economic perspective: men historically could not marry until they were able to build a home on their father’s homestead or originate their own homestead. Today, this paradigm persists despite economic challenges that prevent most men from being able to engage in formal polygamy. Regardless, all romantic relationships have and continue to fall into the Western-defined category of transactional sex. Cultural scripts from Leclerc-Madlala (2008) point out that (i) Sex is a way to show love and get love; and (ii) A woman demonstrates her love and commitment by “giving” sex; a woman does not give sex for free. A man demonstrates love and commitment to a sexual partner by giving gifts of money, goods or services commensurate with his status and wealth. As such, young women expect some exchange of material wealth for sex, whether it is a cellphone, clothing or simply “pocket money” for sodas and snacks at the local sitolo5 (Leclerc-Madlala 2008). In accordance with traditional courting practices, it is older men who are most often able to meet this expectation.
The concept of “be faithful” is interpreted in Swaziland through the cultural lens of polygamy. Maintaining multiple concurrent partners is not only a practice of the majority of Swazi men, young and old, but women expect it of them: “A woman should be prepared for, endure and forgive a partner’s infidelity” (Leclerc-Madlala 2008). However, this custom is changing in some critical ways. Formal polygamy is in decline today because of economic hardship. Yet the long-standing custom of men taking multiple wives has morphed into a new paradigm and practice among the younger generation: maintaining multiple concurrent sexual partners. This practice is in contrast to polygamy as it omits the social security and sustainability created through the establishment of the family unit. In addition, it is not just men practising multiple concurrency: many young women are maintaining multiple concurrent partners. On one hand, this could be a small example of an African-grown woman’s movement, as women are stepping out of their fully subordinated roles to develop a form of financial independence through transactional sex with multiple partners. On the other, it creates a widespread web of relations that has enabled HIV to travel rapidly through the population (see Epstein 2007).
One case study from my thesis research (Peterson 2009) that embodies the challenges of “abstinence and be faithful” campaigns involves Jabu, a teenage girl who was impregnated by the life skills teacher at her high school – the very man responsible for teaching her about safe sex and HIV prevention. Not only was her teacher soliciting behaviour contrary to what he taught, but the messages the girl received from home supported the outcome. Jabu was raised by a single mother. Together, they lived in the teacher’s quarters of the elementary school where her mother taught. Her mother never married, but pursued relations with men to garner new clothing, airtime for her mobile phone and other luxuries. Jabu is now a single mom raising her child, while her teacher and child’s father continues to educate students, with no retribution. This was unfortunately not an anomaly. Stories abounded about both male and female teachers taking advantage of their students in similar ways. In the rare occasion that the teachers were found guilty and punished, they were merely transferred to another high school in a different part of the country.
Multiple complexities also determine the overall effectiveness of condom campaigns in Swaziland. Condoms are available, and are used – albeit inconsistently. When a woman suggests the use of a condom, it is often taken as a sign of mistrust. The request to use a condom simultaneously accuses her partner of infidelity while alluding to her own unfaithful behaviours.6 Traditionally, women were able to acknowledge their husband had more than one partner only if a second (or third, or fourth) woman was introduced formally and accepted into the family as another wife. One older Swazi woman told me a story of the early years of her marriage. Her husband had desired a second wife, but she was “modern” in her viewpoints, protested and ultimately won. However, she was certain of his continued infidelity at the time, and said that even if condoms had been more available, she would not have been able to negotiate use. Another barrier especially impacts Swazi youth. While this population might be more open to the change, unmarried youth – even in their twenties – cannot be found buying or collecting free condoms from the local store or their sexual activity will be noted by an elder and shared with the youth’s parents. It is considered a sign of respect that one’s boyfriend or girlfriend is not introduced to the family until kuteka (the traditional Swazi wedding) or the young woman becomes pregnant. At the same time, it is understood and somewhat expected that youth engage in sexual activities, but it is taboo to discuss when or how, and all young women are considered virgins unless proven otherwise through marriage or pregnancy.
Two of my Swazi bosisi (sisters) from two very different host families further demonstrate the difficulties of implementing the behaviours outlined in ABC. One sisi was 28 years old and from a more modern family residing in a rural community that was relatively close to an urban area. She was unmarried and had first become pregnant at 25, but had a miscarriage; she longed for another child. When she temporarily relocated to South Africa she chose not to use condoms so she could become pregnant. She found out at her first prenatal appointment that she was HIV positive. At one year, her daughter tested negative for HIV. However, the father – who refused to disclose his HIV status to my sisi, now wants little to do with either his daughter or former girlfriend.
My other sisi was 22 and part of a very traditional, polygamist family with a domineering babe (father). When I first moved to the homestead, she confided to me that she had had the same boyfriend for more than a year and was a virgin. She said she was afraid of having sex because of HIV. I discretely gave her condoms, answered her questions, and told her she could come to me anytime she needed more condoms or had other questions. A few months later, we learned she was pregnant. When I asked her why she decided to have sex, she simply told me, “It was him (her boyfriend) who said so.” He also told her that using a condom was not necessary. The cultural paradigm of female subordination that had been reiterated by babe throughout her life prevented her from being able to discuss or deny her boyfriend’s wishes.
Another barrier is that condoms, like HIV and antiretroviral medicines, are seen by many as another form of African genocide. In a conversation on a bus, one male teacher became infuriated by my mere mention of condoms. “On what continent do people not have sexual relations without condoms? Condoms, condoms, condoms! How do you reproduce and have young ones with condoms?” While this particular perspective is not shared by all Swazi, the messages that are received through the ABC campaign are interpreted and either rejected or adapted to fit the Swazi paradigm. Examples of adaptation include colloquial sayings such as, “You have to peel a banana before you eat it” and “You cannot eat a sweet with the wrapper on,” both of which utilize metaphor – a common Swazi communication style – to deter and counter the prevention campaigns for condom use. This process of adapting various influences to fit local belief and desire is not unique to ABC and HIV/AIDS prevention. A brief discussion of Swazi history and foreign contact will demonstrate a long-standing precedent that should be considered in the foreign aid agenda.
Swazi History, Hierarchy and Structural Norms
The Swazi descended from a Bantu lineage that migrated south from the great lakes region of Africa and included the Zulu. As mixed-agriculturists, (as opposed to Khoikhoi pastoralists or San hunter-gatherers in southern Africa) the Swazi were less nomadic and thus marked by more complex political organizations and a “strong sense of social hierarchy” that continues to dictate elements of culture and behaviour today (Thompson 2000: 10). Thompson notes:
The African farming societies, moreover, were far more populous, their economy was far more complex, their social networks were far more resilient, and their political systems were far more durable than those of the Khoisan. They were thus able to resist the invaders more effectively than the hunters and herders had done. (Thompson 2000:72)
Today this is reflected by the strength of the traditional chiefdom network, adherence to a strict hierarchy and reverence for the king as the cultural role model. Swazi political resiliency helped to ensure the continued reign of Swaziland’s natural successive monarch (even if he was rendered effectively powerless during colonialism) and maintained Swazi independence from South African rule. These two historical factors were critical in shaping Swaziland today, as they helped to prevent civil war or the oppression of apartheid among the Swazi, as has been experienced by its neighbours.
However, the strength of Swazi custom and hierarchy is not founded in static durability but in a fluid adaptation to internal and external influences and pressures. As anthropologist Hilda Kuper wrote in 1963, “Striking differences tend to mask the extent of borrowing and adaptation resulting from over a hundred years of white settlement” (Kuper 1986: 6). Kuper (1986) and Sihlongonyane (2003) independently noted that King Sobhuza II, the paramount chief during British colonialism, used his role as traditional monarch to develop cultural identity and nationalism during colonialism and as it exists today – even reinstituting defunct customs to strengthen both the nation and the monarch’s power. Hobsbawm and Ranger, in their classic, albeit contested book The Invention of Tradition, further explain that custom in several African societies has always been flexible and transformed to meet the current needs, despite what colonizers believed or encouraged:
These societies had certainly valued custom and continuity but custom was loosely defined and infinitely flexible. Custom helped to maintain a sense of identity, but it also allowed for an adaptation so spontaneous and natural that it was often unperceived. Moreover, there rarely existed in fact the closed corporate consensual system which came to be accepted as characteristic of ‘traditional’ Africa. (Hobsbawm and Ranger 1983: 247–8)
Macmillan also notes the importance of nationalism for the Swazi: “[M]any traditions are associated with the emergence of nationalism and nation states.… Swazi authorities realized that their last area of independence [during colonialism] was their control over custom” (MacMillan 1995: 546, 555). The traditional importance of the monarch continues to be a prominent fuel of nationalism and identity in Swaziland. The King of Swaziland is heralded as the cultural role model for all Swazi; he is considered the epitome of Swazi identity. This can have positive and negative ramifications with HIV. It further demonstrates that foreign aid workers cannot achieve positive results independent of national leaders, regardless of how much foreign aid is allocated. Yet Mswati III has refused to take centre stage in the HIV agenda, except for securing more aid and foreign influence for his nation. At times, he also has played the hypocrite of HIV prevention. For example, in 2004 Mswati asked the virgin maidens of his nation to submit to a vow of abstinence for five years in an effort to reduce new infections. Such restrictions have been implemented historically in Swaziland – particularly at times of war. However, during that time, Mswati took a teenaged, virgin wife. When the international community cried foul,7 he sanctioned himself in the traditional manner – a fine of one cow to the new bride’s family – and ultimately ended the ban merely six months after it was instituted (Skolnik 2007).
Without the influence and leadership of the most prominent Swazi, foreign aid workers cannot hope or expect to achieve positive results, regardless of how much foreign aid is allocated. This is well known by development professionals, and the importance of partnerships in both the public and private domains is spelled out in the PEPFAR Partnership Frameworks (PEPFAR 2009). However well defined the policy, though, partnerships are lacking in practice. Mswati rarely talks publicly of HIV and the efforts of current and previous US ambassadors to engage Mswati III in HIV prevention, and intervention efforts have resulted in slim success beyond the signing of documents and plans of action, such as the Partnership Framework. In a Q and A session with Peace Corps Volunteers in 2008, Ambassador Maurice Parker admitted that there is rarely a financial match from the wealthy Swazi monarch, and because the fiscal year appropriations of the US government do not always align with the donor country’s, the health department budget is at times built around the annual allocation amounts from PEPFAR and the Global Fund.
With this in mind, I return to the point that tradition and nationalism have been two of the most powerful tools of influence throughout Swazi history – and they are used to promote internal agendas, not external. Throughout history, the Swazi have gracefully adapted new ideas and information – though only in a manner appropriate to the Swazi custom and Swazi needs of a given time. This has often attenuated and frustrated foreigners in their attempts at achieving certain influences and impacts along the way, those working in HIV prevention among them.
Shortly after Swaziland regained its independence from British colonialism, King Sobhuza II, the natural heir to the throne, in an interview on the broadcast news program 60 Minutes, a clip of which is in the 2007 documentary “Without the King” (Skolnik), clearly stated the position of the Swazi to electively incorporate Western culture and values. He said that the turmoil in Africa and Swaziland is “due to the contact with the white man. He has brought his own custom and his own environment....What is good for Africa, I want to keep. But what’s bad for Africa, we won’t keep” (Skolnik 2007). This was a precedent among the Swazi long before Sobhuza II’s time and will likely continue beyond the HIV/AIDS epidemic and the impact of related international aid.
The distinctness of Swaziland is that the government does not monopolize this tool of hegemony. In Swaziland “culture is not only a state instrument but it is used by the general Swazi populace as well to stake a claim in the system” (Sihlongonyane 2003: 162). On frequent occasions, I was told a behaviour, belief or custom existed “because I am Swazi.” In accordance, many external influences that have come into the Swazi paradigm and have been implemented into practice are devoid of the mores and rational for the same behaviour in Western cultures. This value void points out that often the justification “because I am Swazi” and the notion that it is “duty” to perpetuate Swazi heritage has become an excuse to manipulate sexual and societal practices for one’s own benefit, while leaving behind those the Swazi do not find attractive. Through an association with national identity, the Swazi is thus able to perceive him/herself as upholding the values of respect for authority, beliefs and rituals while simultaneously adapting to modernity and personal desires (Sihlongonyane 2003). However, this also has kept individual identity tightly interwoven within the system of hierarchy, and the King’s authority cemented. Meanwhile, opportunities for change abound in this paradigm – though often unpredicted and with unforeseen outcomes than are desired by the influential source.
Historical Influences on Swazi Tradition and Behaviour
The long-standing acceptance of foreigners on Swazi soil is believed to date from the reign of King Sobhuza I. Shortly before his death in 1836, Sobhuza I reported a vision in which he saw white-skinned people bringing umculu and indilinga, translated as “book” and “coin,” respectively. These items were taken to represent the Bible and money. Sobhuza thus told his countrymen that a white man “teacher” will “preserve” the Swazi nation. Matsebula writes:
Sobhuza advised his people to accept [the Bible] but to try and avoid money. He warned them that they must never harm these white people, for if they spilt a drop of the white man’s blood their country would be destroyed and they would disappear as a nation. (Matsebula 1988: 27)
The result was an ongoing string of invitations to or concessions for foreigners. Sobhuza’s son, Mswati II, extended the first invitations to European missionaries in 1840. In addition to religion, missionaries introduced formal education and literacy to the Swazi people, which is said to have contributed to the Swazi rejecting “traditionalist values” and replacing them with Western values (Thompson 2000; Kuper 1986: 58). Today Swaziland is officially a Christian nation, with nearly every Swazi self-identifying as such. Many Swazi professionals relate that they owe their education and the quality of their upbringing to missionaries, some of whom merely provided money for school fees, while others acted more as surrogate parents and took the Swazi children – orphaned or not – into their homes. However, the ideology behind the cosmetic identification is starkly different from that introduced by Western missionaries. The most distinct example is seen in the practices and beliefs held by parishioners of the Zionist Church and the Church of Jericho. Both of these denominations have integrated Biblical teachings and Western paradigms with traditional religion, including ancestor worship. Zionist and Jericho parishioners wear brightly coloured robes to the services, which can include drumming, dancing and running in circles, trances, laying of hands and sometimes beatings. In addition, there has been a great movement toward using Christianity as an HIV prevention and treatment method, with hours-long prayer ceremonies seeking miracles of healing.8
A second example of foreign invitation and behaviour adaptation occurred in 1860 when Mswati II requested that the South African Republic settle white foreigners along the southern and southwestern borders of the Kingdom of Swaziland, as
[t]hey were considered as an effective means for keeping at bay attacks from neighbouring black nations. Mswati accepted them and allowed them to settle as he would accept anybody and settle them for strategic reasons – that is, for defense purposes. (Matsebula 1988: 49)
However, this move also resulted in the settled land being subdivided into farms and deeded to its inhabitants, which went against the tradition of communal chiefdom lands. Kuper noted that these settlements were the “precursors of the spate of concession that led to the final subjugation of [Mswati’s] people” as a colony (Kuper 1986: 12). Nonetheless, Sobhuza II actively campaigned to reclaim as national land some of the private parcels within the modern national boundaries from foreign developers and landowners. Today about 70% of Swazi reside on national land, which is subdivided into chiefdoms and allocated to residents by the chief for a one-time fee. Once a family is allocated a parcel of land, it is theirs indefinitely, if it is used “appropriately” – to build a homestead or for subsistence agriculture. This system allows Swazi peasants of the lowest income level to exist with nominal participation in the cash economy and the nation to remain predominately rural. This fact has reduced the presence of a few key HIV “risk behaviours” that often coincide with settings of urban poverty, including prostitution and IV drug use.
In another example of foreign influence, Swazi leaders recognized that maintaining full autonomy amidst expanding colonialism was not likely, and therefore advocated for what they thought was the best possible scenario: rule of the British rather than the Boors.9 The British granted the Swazi request for colonization in 1902, at which time the main impact was the installation of a small police force “whose primary duty was to restrain the hostility of the Swazi and collect tax” (Kuper 1986: 15). The tax demands were the primary catalyst that pushed the Swazi – even if nominally – into the cash economy, as most sought employment as migrant labourers in South African mines or urban Swazi areas.
Migrant labour continues today and is a key contributor to Swaziland’s HIV epidemic. However, the degree to which individuals recognize and accept this also is determined by cultural norms. In a conversation with a member of local bandlancane (the chief’s inner council) I mentioned the role of migrant labour in Swaziland’s epidemic. Because it is predominately men who migrate for work, the comment insinuated that men have a primary role in the spread of HIV. This community elder corrected me by explaining that women also travel once or twice a year to purchase supplies for their handicrafts. During these trips women have sexual relationships and bring HIV home to their men. Women are therefore equally at fault.
The most recent example of foreign influence is from the humanitarian aid community. The influx of foreigners and funding, while bringing some positive benefits, also contribute to Galtung’s theory of structural violence. The material goods and patterns of lifestyle, brought by those intending to help, contribute to the desire to participate in the cash economy – the ability of which is often attained through transactional sex. In addition, the economy and vast number of local jobs sustained because of HIV humanitarian aid and the accompanying community of ex-pats creates a sort of surreal economic development. As such, the possible benefits from humanitarian aid and international recognition of the HIV epidemic, the presence of UNDP, UNICEF, the World Food Programme, World Vision, Save the Children, the US Peace Corps and many others are countered by an unhealthy expectation of, and dependency on, donor aid.
These interpretations and reinventions of foreign concepts highlighted in this section contribute to “undocumented influences.” In the simplest form, undocumented influences are elements that accompany foreign intervention, peripheral to the primary agenda. These influences surface differently in each society as their impact is rooted in the local history, politics, and economic and social realities and perhaps are most distinguishable in Swaziland at the crossroads between societal paradigms and individual behaviour – the apex of HIV. By definition, undocumented influences are ever-present, ever-changing and therefore tough to identify or monitor. Unfortunately, the impact of the contemporary undocumented influences cannot fully be known and will not be known until it plays out in history. However, awareness of these influences will generate a more thorough understanding of risk, and “risky behaviours,” which ultimately will contribute to better-informed programs and improved outcomes.
It is therefore necessary to recognize the myriad of influences, including the presence of HIV and its accompanying industry of aid, that contribute to Swazi belief, behaviour, and what the Swazi themselves classify and value as “traditional.” While this is indicative that behaviour change is possible, it also is proof that ABC will not translate into the widespread behaviour changes desired by foreign policy makers.
While broader understanding of the sexual experience generated through research and tools such as cultural scripts has reshaped perspectives on what it means to be “at risk” for HIV, few parties at the table of humanitarian aid for HIV are able to fully integrate culture, customs and behaviours into their agendas – with or without local leadership. While knowledge, attitudes and behaviours that HIV prevention experts seek to influence are, in fact, changing, they frequently are morphing in ways not understood or identified by those seeking the change. The result is that countries like Uganda, which once seemed to have HIV tackled by strong local leadership and campaigns derived from local perspective, are facing a resurgence of HIV rates alongside their increase in international aid (see Epstein 2007). In Swaziland many of the changes brought by international aid are occurring outside the scope of HIV prevalence and incidence rates, workshop participant counts, and the number of individuals who know their status. Aid workers are therefore measuring the wrong outcomes while failing to recognize the important changes occurring for HIV and the undocumented influences driving them. In short, real results are contingent on altering the approach and perspectives of donors.
First, foreign HIV education specialists have engaged the Swazi in public conversations about sex and raised awareness about HIV/AIDS for populations rural and urban across the country. This is an important step toward breaking the silence and apathy that often surround taboo topics. However, too often these educators simply do not know the right questions to ask in order to understand the complexities and nuances within Swazi sexual behaviour. Therefore, when local educators are recruited and trained, this information is overlooked and often not incorporated, even by the local educator. In addition, discrepancies in basic education on biology and human anatomy often mean that even while class participants have memorized facts about HIV and its effects on the immune system, the understanding of many lacks the necessary context that would have greater propensity to result in behaviour change. Furthermore, the one group who has greatest ability to influence cultural and individual behaviour has largely not participated in the education and discourse: men. As such, education specialists should transition away from classroom-based workshops to educational opportunities that fit within normal community activity, such as plowing fields. By moving out of a formal environment, the educator will be seen as a greater asset to the community and information shared will be more likely to contribute to a subtle decomposition of HIV stigma and transition of social norms and behaviours.
Second, aid workers must understand that no amount of education and knowledge will ever overpower the need to fulfill basic necessities. In addition, modern influences and capitalism have created great desire for items such as mobile phones and airtime, clothing and “pocket money.” These small luxuries gifted to women by their sexual partners will never subside merely on the basis of knowledge. That HIV education is expected to trump these behaviours reflects a lack of understanding about how local women perceive and negotiate risk. Overcoming this barrier will require greater engagement of Swazi traditional leadership and men at the grassroots level: the King, chiefs and bandlancane, and a cross-section of rural community members.
Finally, and most importantly, aid must be divorced from political agendas, and tied to an ongoing collaborative effort between local and international leaders. To do so, foreign donors should aim to collaborate with local officials to gather knowledge and data from all socio-economic and regional groups within the nation. Programs should be based on this needs assessment and levels of funding tied to real outcomes that are framed from within the local perspective and demonstrated clearly by officials. This is not as detrimental or prohibitive as it may seem. (What if the local officials do not do the work to help their people? If HIV attack rates do not decline, do we restrict funds?) As described earlier, assistance to Swaziland – as well as to many other nations – has historically been solicited and/or welcomed. Asking that the government permit fiscal oversight and demonstrate real changes – whether systemic, social/cultural or epidemiological – merely mirrors the same relationship that occurs between almost all grantors and their grantees, in both the public and private sectors. Anyone who has been on the receiving end of a grant can verify the effectiveness of this approach: no demonstrated outcomes, no money.
In sum, foreigners and foreign aid can have great influence on a society. Cultural scripts, nationalism, hierarchy or other elements that coincide with respect for tradition and contribute to risk analysis and behaviour are in constant flux. The catch is that how they are influenced is uncontrollable – at least from the outside. This should be a source of hope, rather than frustration. While understanding what drives the behaviours and the customs that fuel them is complex, the fact that tradition is constantly morphing through internal and external influences indicates behaviour change is possible. It is when local knowledge and resources combine with foreign skill and experience that we can find the best opportunity for influencing behaviour and ultimately decreasing the rate of HIV.
About the Author(s)Ms. Rachel Lynne Peterson, MA, Programs and Operations Manager, Health Horizons International/Horizontes de Salud; Calle La Maternidad #27, Montellano, Puerto Plata, República Dominicana; E-mail: email@example.com.
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1 To be fair, this paper is a prime example.
2 The term “focus country” is no longer used.
3 “Emic” perspectives refer to meaningful viewpoints of one who is local or an “insider,” while “etic” perspectives refer to the observations of the outsider, often formulated in scientific terms (Pool and Geissler 2005: 24)
4 Cultural scripts are an anthropological technique used to describe norms, values and practices through the use of language that can be expressed equally when translated. (For more on cultural scripts, see Goddard and Wierzbicka 2004.)
5 A small store, often consisting of little more than some canned goods and a refrigerator filled with Coca-cola products.
6 Even though multiple concurrency is known and expected, women must never question fidelity or love (Leclerc-Madlala 2008).
7 Swazi nationals rarely criticize the actions of the king, though political dissidence is slowly increasing.
8 Some of these miracle-seeking practices are, in fact, led by Western ministers.
9 Indeed, requesting British over Boor rule was one of the main factors that prevented Swaziland from being subjected to apartheid
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