Among AIDS Derivatives in Africa

In 1978, Anne Retel-Laurentin published a memoir about her experiences as a medical doctor, anthropologist, and white woman doing research on sexually transmitted diseases in 1950s Ubangi-Shari, now the Central African Republic.

In the midst of recollections about field work among Nzakara suffering from the sequelae of STDs, Retel-Laurentin described a sumptuous meal in Bangui, at which French officials quizzed her about her research while domestic servants circled the table with wine. This dinner scene, in which French men blamed Nzakara infertility on lazy men and loose, self-aborting women, was not incidental, but rather an integral part of the colonial social field in which Retel-Laurentin labored.

In November, 1996, I spent six nights in a beach resort hotel in Saly Portudal, Senegal, with about 125 other researchers from Africa, Europe, and North America, for a conference on AIDS and the social sciences in Africa. The hotel was part of a concentrated, insular site of hotels, restaurants, boutiques, and "traditional village" structures which cater to European tourists seeking a theme-park-like tropical holiday in Africa. We found ourselves, AIDS researchers in professional wear, mingling with scantly dressed tourists in the hotel's hallways and at daily breakfast buffets.

The conference was the first large meeting located in Africa devoted entirely to social scientific research about AIDS on the continent. It was jointly sponsored by ORSTOM [formerly Office de la Recherche Scientifique dans les Territoires d'Outre-Mer; presently Institut Français pour le Développement en Coopération], CODESRIA [Conseil pour le Développement de la Recherche en Sciences Sociales en Afrique], and the main Senegalese AIDS organization; funds also came from the European Community, French cooperation and development sources, and the Ford Foundation. I thought of Anne Retel-Laurentin in Bangui as I sat down for meals in Saly Portudal. I also remained haunted by her canny words about how a young, sterile Nzakara couple had welcomed her, a French M.D. and ethnographer, to their village household as "a derivative of their tedium."[1]

How do Africans greet the tedium and suffering surrounding AIDS and the derivatives of this disease that crosses sex with death? The derivatives are human and material, Saly Portudal taught me, ranging from AIDS researchers and conferences, prevention devices like condoms and dildoes, to organized ¾ or arbitrary, chaotic, violent ¾ forms of AIDS-related programming and investigation.

Post-Colonial Missionaries

The most striking social fact in Saly Portudal, in my mind, was the bringing together of francophone and anglophone Africans and Africanists for five days of simultaneously-translated deliberations. Anglophone/francophone - not Euro-American/African - was the most striking divide in style and approach, especially among anthropologists. This divide went with another: between the applied, action-oriented research emanating from largely anglophone Africa and a more ethnographic and contemplative genre of studies emerging from research in francophone Africa. Only the anglophone researchers declared their work to be gendered, feminist, empowering, enabling. Christine Obbo, a Ugandan anthropologist based in France, argued that AIDS had changed social scientific research; it should be action-oriented, participatory, involved in social change. Elizabeth Reid, Australian director of the United Nations Development Program's HIV and Development Office in New York, argued for "enabling," "transformative" research practices.

There are at least two new types of what I began to call "postcolonial missionaries" in the anglophone AIDS industry in Africa, fervent "experts" itinerating in foreign lands among people who inspire pity and seem to need new family forms, subjectivities, and bodily practices. First, there is a new generation of feminists who are active in formulating participatory and action-oriented research strategies for empowering local women and understanding gendered dimensions of AIDS in Africa. Connections between research and provision of AIDS-related care are not always clear in their projects. Nor are they clearer in the programs of their equally ardent counterparts: Euro-American, also primarily anglophone, gay men who are also involved in grassroots research and consciousness-raising prevention work. One presentation by a Euro-American gay activist, in particular, shifted my sense of the material culture surrounding AIDs programming and "transformative" consciousness-raising actitivies within Africa. Condoms are part of these new development encounters in Africa. Dildoes, the speaker made abundantly clear, are too.

Both of these types of gender experts mixed platitudes about meaningful research dialogues and condom-teaching encounters with international organizational techno-speak. Feminists and gay activists were not alone in speaking this reifying code, but they knew this lexicon of packaged diminishment mighty well: "PLWHAs," for people living with HIV/AIDS; "IEC" and "IEC consultants," for a form of AIDS programming (information, education, communication), and its relevant experts.

Finally, besides feminists and gay activists, there are those I came to call "the confessors." They seem to move between workshops and conferences in francophone and anglophone Africa, as confession emerges as a new mode of participatory, action-oriented research in Africa. There were a few African persons with HIV or AIDS present at Saly Portudal to provide the perspective of the suffering. Yet are these well-dressed, extremely well-travelled men and women not also derivatives of AIDS in Africa? After all, no one hesitated to refer to these people as "PLWHAs," including the "PLWHAs" themselves.

Tensions of Translation

Anglophone/francophone tensions were most evident during an early workshop on the cultural constructions of AIDS. The francophone papers preached less than their anglophone counterparts and described more. Three French women delivered their papers first, followed by a Senegalese man. These papers were of one cloth, that of semantic, symbolic anthropology of language and the body. All concerned local representations of AIDS, including the lucid, perceptive paper by Aboubacry Mbodji on popular Wolof language surrounding AIDS. He made clear that his key questions concerned how people think Sida (the French equivalent of AIDS), and how these representations relate to how people behave. Each presentation provoked queries from anglophone women, especially Ugandan feminists, about the relationship between these semantic analyses and another kind of practice Ñ not the behavior of the studied, but the kind of AIDS programming that had been adopted. Noorine Kaleeba (now of the United Nations UNAIDS Office in Geneva, and a founder of TASO, Uganda's famous feminist grassroots AIDS organization) also suggested that what was missing was "a face" for AIDS, intimating that a confessional contribution by a PLWHA was in order.

Must all AIDS research be "action-oriented"? This insistence on "action" is dangerously close to the imperative of "concrete efficacy" in social scientific research on AIDS, invoked by Peter Piot (formerly a major player in Projet Sida in Kinshasa, now director of UNAIDS, Geneva). Indeed, some of the most important insights made in Saly Portudal were made by participants, francophone and anglophone, who do not depend on AIDS-related funding for their daily bread.

Françoise Héritier of the Collège de France, for example, baffled many anglophones as she made use of an analytic vocabulary of symbolic, binary terms, in historically concrete and politically astute ways. What makes AIDS such a terrain for violence, she explained at one point, is the intersection of the rapport femme/homme ("female/male relation") with the shame associated with a victim of this sexually transmitted disease. She interjected in pointed terms when several Senegalese men expressed outrage that one ORSTOM-funded epidemiological project in Abidjan (Ivory Coast) was organized so that women receive their serostatus results (as well their newborns') in confidence, indeed without any obligation that their husbands ever be informed. Such a policy ran counter to Senegalese law on male authority in the family, the men argued. Héritier pointed out the shame implicit in their anger and in other conference revelations that suggested men violate women through willfully silencing their seropositivity. Indeed, one Nigerian doctor present reported that many more Nigerian men (some 60 percent) anticipated withholding knowledge of their seropositive status from their spouses, than did women (some 30 percent).

Coming Out and Autogestion

The new approaches and vocabularies that are developing in AIDS programming were highlighted in a rather hollow - or at least acronym-driven - success story reported from Zambia. The country had begun AIDS programming in "organized panic" and the first efforts had been intrusive, expert-oriented, and consisted of free handouts, we were told. Soon, however, AIDS workers discovered the importance of PLA (participatory learning and action) and IEC (information, education, communication) messages. These new approaches led to empowerment and self-management ( autogestion in French). Soon people were "coming out spontaneously" as seropositive persons.

"Coming out"? Yes, "coming out" is part of anglophone AIDS code in Africa. This echo from gay speech was just one reminder about how vocabularies, dispositions, and techniques surrounding this disease in Europe and North America — and developed among the most well-organized of those hard hit by the disease and its stigmatizations in the West, male homosexuals Ñ are wending their way into Africa.

Many of the people involved in AIDS programming in Africa came to the work after enduring AIDS care-giving and funerals of spouses, kin and friends. Many have experienced stigmatization, whether as gay people, HIV carriers, or AIDS widows. Confessional methods associated with safe self-disclosure, consciousness-raising, and social support - developed among the middle classes in North America over the last 25 years or so by feminists, Alcoholics Anonymous, gay HIV/AIDS support groups and others - are now actively at play within AIDS programming in Africa.

The rhetorics of autogestion and "coming out" are linked in these programs. The context for understanding the meaning of autogestion is structural adjustment (SAP), a set of austerity programs which the World Bank and the International Monetary Fund have imposed on debtor countries as a condition for receiving credit since the 1980s. The idea of SAP is, simply put: no more free lunches, no more free drugs. These measures have disabled the access of Africa's poor and disappearing middle classes to good nutrition and health care by cutting back public welfare expenditures, increasing food prices, privatizing health care, provoking pharmaceutical shortages, and imposing health cost recovery through user charges. Autogestion is a euphemism for such conditions, one that slyly turns austerity into a virtue by suggesting empowerment. "Coming out" is anglophone gay code for self-acceptance and self-realization, saying no to shame. "Coming out" can also take on a more collective meaning, indicating proud struggle against discrimination and violence. The Euro-American gay activists present seemed to take inspiration more from depoliticized condom and dildo sex education workshops for gay white men in the West than they did from ACT-UP's well-choreographed, media-grabbing, theatrical forms of rebellion, by shaming the powerful and evil. Autogestion and "coming out" - in its less politicized variant - have accomodated each other in African AIDS programming, aquiescing to the austerities imposed by the "new world order" of "development."

Colonialism repeats itself under these conditions. Good intentions are not enough. Post-colonial AIDS missionaries in Africa who are satisfied with individuals "coming out" as PLWHA and using condoms under SAP-imposed conditions - conditions which are horrific for basic human health - repeat colonizing practices of charity and pity. The danger is that, much like British feminist parliamentarians and missionaries who spoke against clitoridectomy in colonial Kenya and widow-burning in colonial India, these post-colonial AIDS workers risk finding in these "native" victims bad copies of their own aspiring identities, and affirmation for their own benevolent, emancipating effects.

Public voices of outrage were rare at Saly Portudal. One Nigerian woman stood at one point and declared that "food or sex?" is the question most Africans ask when faced with the impact of SAP in the era of AIDS. As subsidized food prices are replaced by subsidized condoms, they say: "If sex will kill us in ten years time, O.K. But give us food now." This woman shifted the debate from a naive politics of locating potential victims in order to give them condoms, a politics of getting the pitied to "come out" as the rescued, to a politics of refusal and justice, of mocking indignation, scorn and laughter. Her anger was not far from Paul Farmer's (M.D. and anthropolist of AIDS, and author of AIDS and Accusation (Berkeley, 1992)) who argued that the number one co-factor of AIDS was "social inequalities," an expression he equated with structural adjustment. What is at stake in the social sciences in Africa, he argued, was not permitting inquiry to reduce HIV to "life style" and behavior. "Is gender inequality a 'life style'?" he asked. Achille Mbembe, historian and CODESRIA director, echoed by asking (just minutes before he and other organizers announced that a crate of free condoms had arrived for conference participants), "how can we prevent the history of AIDS in Africa from being reduced to a history of the condom?"

Extreme Situations

Most of the contributions during an evening round table on "extreme situations" and AIDS in Africa concerned Rwanda, one of the most important sites for AIDS programming before the genocide began there. The sudden disruption in HIV screening capabilities and condom availability was more visibly traumatizing for many Rwandan soldiers, Elizabeth Reid reported, than the genocide itself. Suddenly plunged into a state of emergency where they could no longer find out if their lovers were seropositive or not, these men were more worried about this new sexual vulnerability than the possibility of massacre. Panic about the vacuum in AIDS-testing capabilities, she suggested, was an important part of the context of civil strife that fostered such high rates of politicized rape of women by men at war.

Civil strife and political repression, like structural inequalities and poverty, tend not to fit into most epidemiologies of AIDS. STD-related suffering, research projects, and conferences are an integral part of the social field requiring study. We need to understand how institutional and social derivatives of AIDS are conforming to the social realities imposed by global regulatory organizations. We need to know who is doing innovative, ethical, thoughtful work, and who is not. We also need to understand the sudden evaporations and mobilities of these derivatives as "extreme situations" render AIDS work impractical and condom distribution frivolous.

Zaire is a key example of an AIDS research capital that evaporated overnight, due to civil unrest and looting in Kinshasa in 1991. A Zairian presenter, MBATA Betukume Mangu André, argued that his entire country has constituted an extreme situation since international assistance was drastically cut following the expatriate flight of 1991. Projet Sida, a major collaborative research umbrella, collapsed. So did Brooke Schoepf's CONNAISSIDA, an alternative, feminist research project. Now hospitals are ever more overburdened and depleted and simply send AIDS patients home to die.

The French were not big players when Kinshasa was the capital of AIDS research in sub-Saharan Africa. Americans and Belgians based at the U.S. Center for Disease Control in Atlanta and the Institute of Tropical Medicine in Antwerp were. The big AIDS program funders, it seems, exited as did the big men Ñ Jonathan Mann and Peter Piot Ñ who launched their stellar AIDS careers there. Since Kinshasa's Project Sida folded, Kampala (Uganda) has become anglophone Africa's major AIDS research capital. Abidjan is the capital of francophone AIDS research in Africa, as a major ORSTOM-funded research installation there suggests. Abidjan also had a preponderant position within conference presentations as a whole.

Obscene Spectacles and Moral Diagnoses

A European man working on a CEMUBAC (Centre Scientifique et Médical de l'Université Libre de Bruxelles pour ses Activités de Coopération) project in Southern Kivu intervened to say that it was an exaggeration to call all of Zaire an "extreme situation." Even though he himself had fled war in Bukavu that same week, he said he represented an AIDS project that continued to operate effectively and invited everyone to watch a film about it the following evening. The first scene depicted a gathering on Bukavu's streets. A male nurse spoke to a group of men, apparently all married. He asked why they thought their wives cheated on them, and received some lame answers to his leading question. The nurse offered to do a survey among the married women of the city to find out why. The film cut to his return with the "results." The wives complained, the nurse reported, that their husbands were not sweet enough with them, not greeting them affectionately with names like sweetheart and "carrot" after a day's work. Wives were going elsewhere for love and satisfaction, the nurse concluded.

The film soon cut to a scene inside a hospital office. A female health practitioner was giving a private lesson to a lone man about how to use condoms; between them was a table on which rested a condom-dressed dildo. The lesson did not end quickly. She showed him how to properly put a condom on, in this case, an extra long, dark, wooden model of a penis that she caressed with long, sweeping movements and used as a pointer to underline important issues. The film audience had already had a good, long laugh over the pet name of "carrot." The dildo demonstration led to near pandemonium, as everyone joined in uproarious laughter at this spectacle, intended, so it seemed, to provoke laughter.

A third part of the film turned to a special public presentation in a Bukavu movie theater. Three women wore evangelical-like uniforms with large letters sewn on them, in an acronym announcing they were "apostles" of a group of persons living with HIV. Their act? The women stood before the group of male spectators and confessed that they were HIV positive.

As soon as the film ended, I expressed outrage at the ambiguity surrounding the kind of spectatorship and reading the film was intended to create. The film had rolled simultaneously as documentary and didactic lesson, never making clear its anticipated audience(s) nor purpose(s). Its effect is to evoke, depending on the position of its spectators, amused prurience or uneasy -perhaps embarrassed, perhaps scandalized - laughter. The CEMUBAC-affiliated Belgian who had invited us to witness the film insisted that absolutely nothing in the film had been staged, as if the presence of a filmmaker holding a video camera did not alter practice. He also declared that there was nothing wrong with a film eliciting laughter. Laughter was a good method to break down barriers about forbidden subjects and get people to begin to talk about AIDS, he argued, as if the film was made solely for didactic rather than for fund-raising, grant-justifying, and self-entertaining purposes as well. The confessors' uniforms suggested to me that fundamentalist, evangelical Protestant money was likely behind the uniforms and the confessional mode. This was never confirmed, nor completely denied. The women were from Kinshasa and CEMUBAC had flown them to Bukavu, hundreds of miles away; this much was clarified. A Zairian woman lawyer based in Kinshasa explained to us that the women were accustomed to speaking in front of respectful, quiet, all-female audiences in the city. They came back to the city from their confessional trip disturbed by the reception they received from the many rude and raucous young men in the Bukavu theater.

The film did not contextualize a thing, though it edited out conflict and suffering. Yet its refusal to contextualize suggested that a prurient Euro-American imagination, convinced that Africans are hypersexual and need only be provoked to get them to speak openly about sex, lay behind its production. This CEMUBAC project has been taking place in an area where tensions among Catholic and Protestant approaches to AIDS control, as in most of Zaire, are rife. The film clearly towed a pro-condom, anti-Catholic line, as would be expected of this Brussels organization, founded in the colonial period under the auspices of the city's anticlerical university. Yet the film hardly replaced anti-condom approaches with anglophone feminisms. Nor did it suggest any sensitivity to gender relations or the potential for violence and shame - structural, social, individualized, filmic Ñ to emerge out of AIDS programming. This film reinforces shame; it is violent. Why should there be women apostles who confess their HIV status and implicitly their moral transgressions? Because this is what PLWHAs are supposed to do, the film seemed to say, while providing unmediated representations for spectators who are left to determine the politics and meaning of such obscenities and laugh as they please. The making of this film was also violent; the spectators within the film were moved to abuse these women with HIV. As I expressed horror at this confessional scene, the African man sitting next to me said: "Yes, but they have sinned." "Is that what you think?" I asked. "I am not supposed to say that, I know," he said, "But, yes, I am a Christian."

References to Sodom and Gomorrah and divine punishment are common in Zairian popular opinion. The internationally famous musician Franco LUAMBO sang: "AIDS is a punishment from God; it resembles Sodom and Gomorrah in ancient times; use your prayers to ask God the way to salvation." These biblical references circulate alongside ideas of sorcery, envy, and unjust human agency. In the early 1990s, the following mixture of ideas was active: Sida is an imaginary disease invented by corrupt doctors who go after women in bars. It is an imported sickness created in the laboratories of white men. Sida is a new manifestation of an incurable, ancient deadly diarrhea provoked either by a particular spirit that lives in anthills and attacks thieves; poisonous mushrooms which snakes eat to intensify their venom; or by other particular bitter foods, types of yams, fruits, meats, or caterpillars. Old people say that Sida is punishment for the acceptance of the colonial occupation of Zaire by Europeans and continuing mimicry of their ways. Sida is a disease of someone who had good luck and became rich; indeed AIDS funeral rituals in Zaire are often designed to capture back the wealth of the person who has died. Others blame white tourists who have traveled through, sleeping with Zairian girls. [2]Since Franco LUAMBO died, quite possibly of AIDS, people say that they are afraid to say or sing the word Sida as doing so may "entrap" them with the disease that entrapped the superstar musician who sang about AIDS.

This popular language about AIDS suggests that it is critical to take account of the severity of the social and economic crisis in Zaire in this post-1991 period, where hyperinflation and dollarization have combined with diamond smuggling, cholera, alternate-day meals, pyramid gambling scams, and now war. Zairians have been associating the increasing "apartheid" in wealth and justice, in creative writer YOKA Lye's words, with "malediction." Sida, like ebola (and likely now war, too), remain "terrible signs of divine punishment against unrepentant initiates" - like President Mobutu and his entourage - Òof artificial paradises which suspect windfalls seek to conquer in vain." [3]These local understandings of AIDS are on target, not unlike the Nigerian woman's intervention about sex and food, because they make historical and political judgments about the value of colonial "development" and nationhood as they equate them with theft, misfortune and injustice.

Evoking Sodom and Gommorah is an ambiguous, prophetic moral diagnosis, susceptible to apocalyptic political visions of Mobutu's dictatorship and the IMF going up in flames. Yet it is also the kind of diagnosis that may be allied to narrow, insidious forms of blame and shame - a useful rhetoric, therefore, for insensitive AIDS parasites living off Eurocrat salaries and preserving 19th-century stereotypes of Africa, as well as for fundamentalist, post-colonial missionaries who equate the disease with sin. Zaire is a country where new churches have flourished. Some Zairians at Saly Portudal celebrated a new prophetic church in Kinshasa with lists of AIDS victims and of those cured. Its prophet and confessional therapies may be, they argued, the only media in Zaire, even in the world, capable of curing AIDS. Such new churches in Africa -and they exist elsewhere than Zaire - are derivatives of AIDS suffering, SAP, and "extreme situations." These derivatives are as "action-oriented" as any AIDS programming on the continent, and they too beg for serious ethnographic research.

Used Condoms or Toy Balloons?

Consider, finally, a representation of AIDS painted by the world-acclaimed Kinois painter, Chéri SAMBA. The painting, Les Capotes Utilisées (1990), is a vision of "used rubbers" and everyday city life in Kinshasa. Condoms were introduced on a massive scale, especially under the brand name Prudence, in Kinshasa in the late 1980s. The painting depicts several Prudence condoms, being thrown by unseen lovers from the windows of a Hotel Prudence, while children turn this detritus of AIDS prevention work into toy balloons. It is a half-mocking, half-condemnatory moral commentary about changing material culture, sexual habits, and city children in Kinshasa.

AIDS researchers and workers in Africa too often content themselves with success stories, produced in countries where expatriates feel welcome and can easily get around and out again, and where functioning medical systems provide amenable working conditions. Yet AIDS research capitals keep shifting in relation to stability, access, and crises. Few have attempted to understand the so-called extreme situations, which are too often read as tenable forms of suffering, but avoided as chaotic hardship posts. Chéri SAMBA's painting, like the CEMUBAC film, suggests how urgent it is to undertake critical social analyses of AIDS languages and derivatives, especially as the latter interact with transnational forces that fixate on condoms, dildoes, and organized confessional therapies.

Chéri SAMBA's painting is a reminder that global AIDS workers should take seriously and meet these local politicized consciousnesses. Zaire is a country where people interpret AIDS as a disease that is not transmitted, but caught by the rich and those unfortunate others who, entrapped by the malediction of their greed, join them in shitting themselves to death. It is a strange, excremental world we live in, the painting suggests, where local people's lives, sufferings, and conflicts get ricocheted in and out of dark-continent, postmodern africanisms associated with slavery and debt, libido and disease, where people are held hostage by international contracts and unjust global and local deals. Meanwhile children and painters frolic with new toys, these reified signs called Prudence, expressing laughter and disdain at the seeming futility of HIV prophylaxis for those who will die poor in a lopsided world.

This brief foray remains impressionistic and thus will necessarily read as caricature for many post-colonials working in AIDS care in Africa. I could not have written it if I had not read Veena Das on suffering (especially her ÒMoral Orientations to Suffering: Legitimation, Power, and Healing,Ó 139-67 in Health and Social Change in International Perspective, ed. L. Chen, A. Kleinman, and N. Ware (Cambridge MA, 1994), pp. 139-167; and Critical Events: An Anthropological Perspective on Contemporary India (Delhi, 1995)). Many of the ideas here emerged from conversations with Paul Farmer and Christine Obbo in Saly Portudal, and especially with Vinh-Kim Nguyen then and since; insights from Alice Desclaux, Mamadou Diouf, Jean-Pierre Dozon, Achille Mbembe, Ernest Wamba-dia-Wamba, and Grace Bantebya Kyomuhendo were also very helpful. None of them, however, should be presumed to agree with my constructions here.

Nancy Hunt is a historian of gender, health and popular culture in Africa. In September 1997 she will take up a joint position at the University of Michigan, established through the International Institute, in the Department of History and the School of Medicine's Department of Obstetrics and Gynecology.

1. Anne Retel-Laurentin, ÒLes soleils de lÕombre,Ó in La natte et le manguier (Paris, 1979) 113.

2. BASUAKUAMBA wa Bashipayi, MBU Mputu, TAYAYA Lumbombo, WAYIKAMBA Sylvain, WENDO Nguma, Croyances populaires concernant les épidémies (Rép. Zaore) (Bandundu, Zaire, 1995).

3. . YOKA Lye M., ÒMythologie de lÕargent-monnaie ^ Kinshasa: Culte de la débrouille,Ó paper presented at the LÕargent, feuille morte? conference, Katholieke Universiteit Leuven, Belgium (June, 1996).