Failure of Food Security Programs in Humanitarian Response: A Critique Based on Social Science Theories – Jo Fan Shen

U.S. Agency for International Development (USAID) refers to food security as “when all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life (1).” The discussion of food security problems revolves around three key constituents: food availability, food access, and food utilization. One of the most significant impacts of food insecurity is malnutrition. As stated by Rossi et al., malnutrition continues to claim a massive cost of lives owing to the effect of widespread food insecurity that follows a circular cause-and-effect pattern of very low food production and extreme poverty (2). The unbreakable cycle results from the effects of mismanagement, war and chronic insecurity, and lack of geographical access to land and markets (2). According to Maxwell et al., humanitarian crises with food security dimensions are increasing in frequency, scope, and complexity (3). The increase can be attributed to the futile attempts of existing interventions to resolve insecurity. In fact, the programs failed to meet the standard measures of the Millennium Development Goal to reduce hunger. The first Millennium Development Goal aims to halve the proportion of “hungry” people from the 1990 level by 2015 (3). However, with less than seven years until the deadline, “we are confronted with the sad reality that virtually no progress has been made towards that objective. Compared with 1990-92, the number of undernourished people in developing countries has declined by a meager three million – a number within the bounds of statistical error (3).” Such dismal results demonstrate the need for a reformed approach to address food insecurity.

Food security is affected by the interaction of a range of factors, including socioeconomic, biological, agricultural, and physical; therefore, effective food security programs should be context-specific in order to address the issues that lead to insecurity: chronic poverty, rapid population growth, declining per capita food output, poor infrastructure, ecological constraints, limited arable land, inappropriate policies, disease and epidemics, poor water and sanitation, inadequate nutritional knowledge, civil war, and ethnic conflicts (2). This paper will have three sub-sections, and each will argue why food security interventions have failed to address the needs of people affected by humanitarian crises. The three arguments are titled Analytical Capacity, Programmatic Practice, and Role of Stakeholders.

Analytical Capacity

According to Riely et al., monitoring and evaluation systems are key instruments for strategic and operational management of food-assisted programs (1). The systems that should be included are program monitoring and impact evaluation, food security assessments, needs assessments, targeting systems, and early warning monitoring (1). Current food security programs either lack these components or the existing systems are sub-par. Therefore, I argue that one of the reason food security interventions failed is because of poor analytical capacity. Programs from the Great Lakes region of Africa demonstrate how approaches that are based on questionable assumptions can result in a misuse of food distribution and an imbalance of resource allocation (4). I will conclude this section by reasoning that the same stereotyped interventions are presently used and food insecurity remains rampant due to the inadequacy of analytical capacity (4).

Currently, food assistance is given as a “knee-jerk reaction to people’s suffering, rather than a measured response to assessed need (4).” The seven case studies described by Levine and Chastre fall under three separate categories: displacement, rural context, and urban context. Despite the difference in circumstances, the humanitarian response was same across the board: free food assistance, seeds and tools distributions and feeding centers (4). In other words, the relief agencies through all the cards they had at the Great Lakes and hoped one would work. The responses were general and non-specific despite the presence of complex, multi-factorial constraints and challenges facing food insecurity. Moreover, due to the lack of situation assessment, agencies distributed foods to “needy” groups without knowing to what extent the lacked food. Such questionable targeting results in overlooking groups who are truly in need and is simply a waste of funding. Another example is the allocation of seed protection ration. Levine and Chastre found that seeds were allocated for no apparent reason and directed at the wrong population (4). Even though the intervention lacked a food needs assessment, the agencies continued to infer seed needs from food needs. The cycle of faulty assumptions and wrongful distribution illustrate one of the flaws of food security interventions.

Due to the misuse of food distribution, the problem of funding and cost arises. Just as situation and need assessment were missing, cost-benefit analysis, environmental assessment, and impact assessment were also lacking. How do the interventions hope to gage the extent of its success without such monitoring and evaluation? Impact assessment is especially important because the results allow programs to recognize mistakes and strive for reform and improvements. Furthermore, the assessments allow agencies to justify funding needs.

At the moment, rather than taking an analytical approach that assesses both socioeconomic and psychosocial needs of the affected groups, the food security interventions are based on assumptions and “deal with symptoms not causes (4).” In other words, present responses do not address the real issue because assessments were not performed to conceptualize the issues (4).
Programmatic Practice

In this section I will continue to argue food security interventions are flawed. As a direct effect of inferior analytical capacity, food, whether pertaining to consumption needs or production, dominates current approaches. Food-focused programs ignores actual constraints to food security, such as access to land, markets, freedom of movement, ethnic factors, support institutions, loss of labor, lack of capital, diseases, and epidemics to name just a few (4). An effective intervention should address all these issues and treat the cause of insecurity rather than its symptom, or the lack of food. For example, in Eastern Masisi of the Democratic Republic of Congo, road construction made a “significant impact on household food security, through direct employment, improved security of movement, reduced transport costs and improved marketing,” thus, brining higher prices to producers (4). This example illustrates that food insecurity is a result of numerous factors; therefore, a non-food rationing approach more effectively improve security than food-oriented methods. Levine and Chastre claim existing programs lack economic thinking. With “greater use of market and cash interventions and reduce the use of food-based interventions,” food security has a chance in emergency situations.

Another aspect to the flawed practice is the separation of emergency and development response. Consider the case of Congo: Rossi et al. describes Congo as “a long-term forgotten crisis that is still characterized by short-term funding and long-term needs (2).” And also Ethiopia: Maxwell et al. states that “Ethiopia, despite record production, and despite billions of dollars worth of assistance devoted to alleviating chronic food security over recent years, nearly one person in eight required external ‘emergency’ assistance to achieve adequate food consumption this year (3).” What do these two statements reveal? A need to resolve the gap between response and prevention. As mentioned earlier, food assistance is a knee-jerk response to emergency; however, the overemphasis on response causes agencies to lose sight of its long-term goals: help the developing countries to independently support themselves. Most of the poverty-stricken countries have become dependent on specialized agencies, such as the United Nation World Food program, but these are all short-term policies (2). Without a preventive component in the food security interventions, these countries remain trapped in the cycle of extreme poverty and food insecurity.

Role of Stakeholders

My last argument will discuss the role of stakeholders in the food security interventions. The stakeholders involved are donors, operational agencies, non-governmental organizations, national governments, and affected groups. According to Levine and Chastre, communication and coordination between agencies remain limited or nonexistent because of reluctance to share information about their respective activities (4). Maxwell et al. attribute the unwillingness to funding competition among non-governmental organizations. The competition causes “private, voluntary actors to behave more like for-profit businesses, and led donors to behave in a oligopolistic manner (3).” How could an intervention that is created for the benefit of the needy be effectively implemented if the actors all have different mandates?

As mentioned in Programmatic Practice, the food-aid focused programs cause the affected groups to become donor dependent; however, the donors and agencies are fighting over who gets what. Instead of supporting programs that need the most help, the donors give to programs that will “make people happy (3).” The politics behind humanitarian appeals to donors contribute to the flaws of the food security interventions. Such impartiality exists because of the lack of evidence-based intervention and attention to the policy process. Both the actors and donors should generate attention to influence the policy process and work towards social mobilization of society to resolve the flaws and constraints that haunt current programs. Social mobilization is suggested because human beings do not operate in a vacuum. Each of our actions affects one another; therefore, addressing the complexities of food security requires the coordination and cooperation of all the players: donors, non-governmental organizations, national governments, and the affected groups.

Missing the Point

As Levine and Chastre cleverly titled article suggests, existing food security interventions in humanitarian response is “missing the point (4).” Current programs remain flawed due to inferior analytical capacity, antiquated programmatic practice, and confused role of stakeholders. While the flaws stay unresolved, new challenges to food insecurity are emerging, such as pandemic diseases, growing water insecurity, threats on labor productivity pertaining to obesity epidemic, global climate change, and increasing food and fuel prices (3). To address these challenges, food security interventions need a whole new transformation. A couple of proposed solutions include improve analysis, enhance allocation of resources and coordination, promote institutional learning, and support social protection (3).

Addressing the Failures of Food Security Programs in Humanitarian Response: A Proposal Based on Social Science Theories – Jo Fan Shen

Before describing the alternate approach, I will provide a brief recap of the previous essay Failure of Food Security Programs in Humanitarian Response: A Critique Based on Social Science Theories. I argued that current food security programs remain flawed due to three main reasons: inadequate analytic capacity, antiquated programmatic practice, and ineffective role of stakeholders; and in order to address these faults, food security interventions need a whole new transformation. Therefore, the proposed alternate approach will consolidate the short-term protection of food consumption with long-term improvements in production and access (3).

The alternate approach is a two-tiered system with a focus on prevention. Before an emergency situation and response take place, a disaster surveillance system will continuously analyze factors such as available pasture, agricultural production, population movements, market prices of staple foods, and water sources (5). The system will utilize the results to monitor emergency hot spots, build buffer stocks of potential supplies, and deploy an emergency relief team – all before a crisis occurs (5). However, in the case that a crisis does occur, the first tier of the system will dispatch a basic emergency package to the affected population; then, the second tier moves in with initiatives to transition the affected population from “emergency to self-sufficiency (5).” The basic package aims to fulfill distributive justice while the second tier initiatives expect to change the norm of a donor-dependent mindset. The initiatives include micro financing, construction of infrastructure, and school programs.

In addition to the disaster surveillance, another aspect of the alternate intervention involves the role of policymakers. The new approach re-frames the need of the affected population to effectively communicate the basis of destitution to the non-governmental agencies, donors, and the government. In effect, funding conflict is reduced while implementation of context-specific policies is increased. The last part of the new approach involves an international-based campaign to raise awareness about food security issues in emergency situations and to garner support toward ending malnutrition. This final installment will unite the activities of various agencies and donors, thereby, further reducing miscommunication and funding conflict.

The body of the essay will examine in detail how the new approach resolves the flaws of the current programs. Specifically, the first section will explain how implementation of the extensive emergency surveillance and situational analysis system will reduce the misuse of food distribution and enhance resource allocation. Section two will follow by describing the benefits of moving away from a food-focused, donor-dependent approach, to a more market-based, self-sufficient program. Finally, the last section will discuss how redefining the role of non-governmental organizations, donors, and governments can clarify the need of an affected population and influence the general society to care about food security issues. At the end of the essay, the missing point expressed by Levine and Chastre will finally be resolved and founded.


Improve Analytic Capacity

The implementation of an emergency surveillance system directly addresses the problem of poor analytic capacity. Not only does the system provide a baseline analysis of the current food security situation, such as the needs of the affected population and at what stage the agencies can intervene, but also, the system provides a continuous analysis that updates the programs; therefore, the programs avoid becoming obsolete and break the cycle of faulty assumptions and wrongful distributions.

But how does the affected population benefit from the new disaster surveillance system? The existence of a needs assessment and situation assessment program allows for proper distribution of food and resources; therefore, those experiencing food insecurity can receive the correct aid faster and utilize the aid efficiently, and in effect, be able to focus on other socioeconomic factors for long-term improvements. In other words, the affected population cannot achieve love and esteem needs without first meeting the biological needs of food, water, and shelter (6). The emergency surveillance program helps to monitor “hot spots” and maintain a stock of potential supplies to prevent recurrence of food insecurity; as a result, the affected groups can be empowered to go higher up on the hierarchy of needs.

Reformed Programmatic Practice

According to the Failure of Food Security Programs in Humanitarian Response: A Critique Based on Social Science Theories essay, another problem with existing programs are that the approach is overly food-focused, not context-specific, and lack self-efficacy. The new intervention is constructed in such a manner to address the current problems. As mentioned in the critique essay, food-focused intervention is a knee-jerk response to emergency situations. However, aspects of the food-focused programs do contribute to relief; therefore, the new approach includes the relief aspect of food-focused interventions by offering a basic emergency package during humanitarian responses. While the affected population is temporarily relieved from the crisis at hand, a second package, or the second tier, aims to provide community-centered initiatives and to encourage the affected groups toward self-sufficiency. The micro financing workshops and road infrastructure construction are two examples of what a secondary package may include. These initiatives will reduce food constraints to prevent future food insecurity reoccurrences.

The ultimate outcome is to change the current societal perception that the affected population is helpless and donor-dependent. By building this population’s self-efficacy with the second tier package, the donors and relief agencies will reduce the distorted perception of the affected group’s dependency. The reformed mindset will mobilize the affected groups toward self-efficacy. As a direct effect, the same population will be able to manage future emergencies independently.
Redefined Role of Stakeholders

Currently, the needs of the population are framed form the point of view of those in power, “private, voluntary actors behave more like for-profit businesses (3)” than relief agencies that serve to improve the lives of the needy. The new approach reframes food insecurity problems in terms of how the emergency situations affect the social, economic, religious, political, and cultural aspects of people’s lives. A new point of view forces the policymakers to recognize the problem at large – malnutrition and poverty – instead of bickering over fund donations and allocations. The alternate intervention replaces the litany of “we promise to reduce hunger and decrease poverty” with a story (7): You will eat three meals-a-day, you can shop and sell foods at the local market, and your children can attend school. A well-framed approach can empower the stakeholders to implement better, more effective policies that result in long-term improvement in production and access.
The last component of the alternate intervention entails a worldwide awareness campaign to put food security problems in humanitarian response on the international agenda. By mobilizing the masses, the result is increased funding and support for the policies. Food security does not happen over night (5). In order to reach out to all populations suffering crisis, continued funding is needed to support the second tier programs that will promote long-term improvement and self-efficacy.

Conclusion

Does the new intervention address the missing point? Will the alternate approach be able to face current and emerging challenges to food security, such as pandemic diseases and obesity epidemic? Yes and no. The proposal does address the missing factors in old interventions: assessment system, non-food-oriented initiatives, and united relief agencies. Even though the alternate intervention attempts to resolve the cause of the problem, until a proper testing phase and result analysis, the proposal cannot be generalized as a cure-all solution. Any modification to the new proposal will revolve around USAID’s definition of food security: when all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life (1). Currently, the world is still far away from satisfying “all people at all times,” but the mini-successes of the Farmer Field Schools in Cambodia and Malawi prove self-sufficient food security attainable and sustainable (8).

References
1. US Agency for International Development. Food Security Indicators and Framework for Use in the Monitoring and Evaluation of Food Aid Programs. Washington D.C.: Food and Nutrition Technical Assistance Project, Academy for Educational Development; January 2009.
2. Rossi L, Hoerz T, Thouvenot V, Pastore G, Michael M. Evaluation of health, nutrition and food security programmes in a complex emergency: the case of Congo as an example of a chronic post-conflict situation. Public Health Nutrition. 2005; 9(5): 551-556.
3. Maxwell D, Webb P, Coates J, Wirth J. Rethinking food security in humanitarian response. In: Food Security Forum; April 16-18, 2008; Rome, Italy.
4. Levine S, Chastre C. Missing the point: An analysis of food security interventions in the Great Lakes. Humanitarian Practice Network. 2004; 40: 1-30.
5. Action Against Hunger Web Site. http://www.actionagainsthunger.org/. Updated n.d. Accessed December 10, 2008.
6. Maslow’s Hierarchy of Needs. Businessballs Web Site. http://www.businessballs.com/. Updated n.d. Accessed December 10, 2008.
7. Wallack L. Framing: more than a message. Longview Institute Website. http://www.longviewinstitute.org/research/wallack/levels. Updated n.d. Accessed December 10, 2008.
8. Success Stories. Special Programme for Food Security. http://www.fao.org/spfs/spfs-home/en/. Updated n.d. Accessed December 11, 2008.

The ABC Approach to HIV/AIDS Prevention: How Anthropology, Political Science and Sociology Point to Interesting Flaws in the Approach- Kate Mitchell

The ABC approach is well known for its brilliant success in significantly reducing HIV/AIDS in Uganda from 1991 to 2001. The approach consists of three main messages: Abstain from having sex until marriage, be faithful, and if all else fails, use condoms. In a ten-year period under this strategy, HIV infection rates in Uganda fell from 15 percent to 5 percent. Perhaps even more striking was the decline in HIV among pregnant women. “In Kampala, the country’s capital, HIV among pregnant women dropped from 30 percent to 10 percent”(Lopez, 1). Uganda has been widely celebrated for achieving such striking reductions.

With numbers like these, it is no wonder the ABC approach has generated a faithful following of politicians, policy makers, clinicians and public health professionals. With HIV/AIDS prevalence in Africa rising at an alarming rate, many are eager to follow in Uganda’s footsteps and adopt the ABC approach to HIV prevention. Many believe that Uganda’s, “standout results [from the ABC campaign] present a model for attacking the African pandemic”(Lopez, 1).

Not so fast. There is another side to this story. A body of critics, also made up of politicians, policy makers, clinicians and public health professionals, has been very vocal about their opposition to the ABC approach. A quick internet search brings up article after article questioning (if not outright denying) the benefits of the ABC method of HIV prevention. They have bold titles such as, “Abstinence programmes do not reduce HIV prevalence in Uganda,” “Uganda’s HIV rate drops, but not from abstinence” and “Uganda’s war on AIDS: Candor more crucial than abstinence, officials say.” Some critics have argued that reductions in Uganda are clearly attributable to other causes that are not so easily reproduced. Others point out that aspects of the program are effective while others are not. Yet others have bones to pick with how the program has actually been implemented. The critiques go on and on.

With such competing views, and HIV rates climbing, key players in the field of International Health have some interesting and tough decisions to make. The question remains: Should this approach be applied elsewhere? Should ABC serve as the gold standard for HIV/AIDS prevention throughout Africa and beyond? Or, could the critics be right? While ABC seems to have yielded extraordinary results in Uganda, can we even be certain that the drops in HIV prevalence are direct results of ABC programming? If the results are directly related, will the approach work elsewhere? Will it even continue to work in Uganda? Should we also consider if the approach is flawed in very fundamental ways?

Using three separate social science fields to examine the ABC approach and the impact it did (or did not) have on Uganda, provides interesting insight into the shortcomings of an approach focused exclusively on abstinence, fidelity and condoms. By utilizing various social sciences to analyze the ABC method, we go beyond infectious disease epidemiology and biostatistics. We also step beyond the conversation of morality and faith that so often dominates the debate of abstinence focused interventions. Through the frameworks of Sociology, Anthropology and Political Science the discussion shifts to issues of gender roles, culture, leadership, social mobilization, power and influence.

Sociology

Sociology is the study of individual behavior within society. It can also be defined as the “study of companions or associates.” When considering ABC methodology from a sociological perspective, gender issues cannot be ignored. In sociology, human behavior is often predicted by the role the individual plays within their society, their community or even their relationship.

The ABC approach does nothing to address the social inequity between men and women in many parts of Africa and the role that women tend to play within relationships. The approach assumes that abstinence, fidelity, and condom-use can be negotiated equally by men and women when in fact they cannot. The following statement clearly illustrates the lack of negotiating ability women often feel: “Abstinence is not an option for a girl married at 13 in Uganda, for the woman whose husband beats her regularly, or for the girl who is raped on her way to get water in Botswana. Men are the only ones who can abstain in these circumstances”(Marton, 2). This lack of negotiating power that women feel in their relationships is also true in terms of fidelity. Alarmingly, married women have one of the fastest growing HIV rates. Marriage is actually beginning to be thought of as a risk factor for HIV in many parts of the world. While a woman may choose to be faithful, she has little to no say in whether her husband makes the same choice (NPR). Condom-use is also difficult and often impossible for women to negotiate in settings where their roles are subordinate. Simply telling the population to choose abstinence until marriage, be faithful to one partner, or use condoms is inadequate when women do not have the ability to adopt these behaviors (assuming they were convinced to do so) because of the social situations in which the women live. Gender inequities put women at greater risk of HIV/AIDS and from a sociological perspective, consideration of these inequities in society are fundamental to the success of a prevention program.

Anthropology

Anthropology is the study of human behavior within a cultural context. This discipline has a strong focus on, “the role that culture plays in what people, groups and societies do”(Edberg, 73). An analysis of ABC strategies for preventing HIV/AIDS from an anthropological perspective demands consideration of the, “complex whole that includes knowledge, belief, art, morals, law, customs, and any other capabilities and habits acquired by man as a member of society”(E.B Tyler). The idea of using the ABC approach across the board as a universal method for preventing HIV/AIDS fails to consider many aspects of culture and the specific contexts in which people live and make health behavior decisions. In a course on Reproductive Health in Disaster Settings taught at Boston University’s Summer Institute, Monica Onyongo talked about some of the problems with an ABC approach to HIV prevention in relation to culture. She talked about parts of Kenya where polygamy is a cultural norm and posed the question: How do you ask a man with 3 wives to be faithful to any one of them? Monica also talked about the tradition in parts of Kenya for men to marry their sister-in-law if their brother dies. This cultural norm poses a very interesting challenge for Public Health professionals, especially in settings where chances are that the brother died of AIDS. An approach to HIV prevention based on abstinence, fidelity and condoms does not even begin to consider these cultural practices and ignoring these practices in prevention efforts leads to catastrophic consequences.

Political Science

At the core of political science thinking is the study of human behavior in relation to the exercise of power and influence (Fairbanks, 1). An analysis of the HIV/AIDS pandemic and the ABC approach from a political science perspective explores the political climate in which the problem exists. This sort of analysis also relies on the following questions: Who are the political leaders involved? What level of power do they have? What level of influence do they have? In the case of Uganda, 2 political leaders (among others) have played very significant roles.

In the early years of the AIDS epidemic in Uganda, President Museveni played a strong and influential role in creating awareness about HIV/AIDS. “At a time when many African leaders were in denial about AIDS in the 1980s, said Green, Museveni spoke to crowds through a bullhorn, stating point-blank that they would die unless they changed their behaviors” (Cohen,1). President Museveni heavily promoted early sex education, mutual respect in relationships, female autonomy, abstinence before marriage, fidelity and condom-use. He also influenced an open dialogue about the disease even among young children right from the very beginning. Some consider “candor more crucial than abstinence” as a contributing factor to reducing HIV (Wax,1). This candor came directly from the influence of President Museveni. “The entire country, from the president to grandmothers and first-graders, has mobilized over the past 11 years in Africa’s most successful fight against the epidemic” (Wax, 1). Some go as far as to say that, “Uganda has waged a successful fight to reduce its infection rate by enlisting the entire population in a frank discussion about sex” (Wax, 1). From the political science perspective, it is clear that President Museveni’s role in the implementation of the ABC program was essential and that his charisma led to significant behavior change in the population. This sort of analysis leads to the question of whether an ABC approach or a charismatic leader is important to HIV/AIDS prevention.

It should also be noted that further analysis of the ways in which the population actually changed their behavior showed that abstinence and fidelity had little to do with the reductions (Roehr, 27LB). A recent longitudinal study showed that while many Ugandans were inspired to change their behavior by the president, the adoption of condom-use played a significant role—over abstinence and fidelity (Roehr,27LB). Recent rises in HIV/AIDS in Uganda have been directly linked to a shift in focus from an even A, B and C approach to a strong emphasis on A for abstinence. Central to the political analysis of ABC prevention in Uganda is an examination of the role of President Bush. Recent pressure from the Bush administration has lead to a lopsided approach—almost exclusively focused on abstinence. In fact, Bush has directed, “about one-third of new AIDS prevention money for Africa to groups that advocate ‘abstinence-only before marriage’ messages”(Wax, 1). This new focus with the help of conservative religious groups has lead to condom shortages throughout Uganda and a silencing of information about the benefits of condom-use. Uganda, once a place where the entire population mobilized and engaged in “frank discussion about sex” and condom use, now faces a political climate where condom-use is considered “a last resort for the immoral.” President Bush had an, “unprecedented opportunity to provide leadership by talking about men’s behavior, and women’s needs to African leaders and the public” (Marton, 2). However, based on his personal moral beliefs and agenda, he failed to go beyond the A in the ABC approach by allocating such large portions of funding to abstinence only programs.

It is clear that ABC can unfold in very different ways in different political climates. It is also clear that the individuals who prove to be powerful and influential in the political arena have a profound effect on how a program is implemented as well as how it is received by the population.

Further political analyses beg the questions: what about countries like Kenya and South Africa where leaders have at one time or another openly denied the existence of AIDS? With a void of political leadership and support around HIV and AIDS, could ABC even stand a chance? Based on the above arguments, it is clear that the ABC approach to preventing HIV/AIDS is a flawed approach but the numbers remain. Uganda has achieved major successes in fighting the spread of HIV/AIDS. While some aspects of the campaign have contributed to the decline in HIV/AIDS, it is also clear that other aspects are directly linked to increases in HIV/AIDS. The new questions become, what can Uganda’s achievements be attributed to and can they be replicated in different societies, cultures and political climates?

A new and compelling argument against the ABC approach is that it is actually an outcome, not a strategy. “One important point is that abstaining from sex, being faithful, and using condoms—ABC-related behaviors—are outcomes of prevention strategies, not strategies in themselves” (Murhpy,1444). I would have to agree. Abstinence, fidelity and condom use are far more likely to occur when women gain autonomy, cultural nuances are considered and the political climate is conducive to the success of the program. This suggests that perhaps abstinence among young people, fidelity in marriage and condom use should be three of many objectives of a new sort of HIV/AIDS intervention that is based on fostering female autonomy, consideration of cultural contexts, open dialogue, social mobilization and capitalizing on supportive and influential leaders (political or not).

If ABC is not the Silver Bullet For HIV/AIDS Prevention, How Should Public Health Agencies Approach Prevention? Anthropology, Sociology and Political Science Provide a Framework for Success- Kate Mitchell

Some have argued that the ABC (Abstinence, Be faithful, and if all else fails use Condoms) approach to HIV/AIDS prevention is the silver bullet, citing success in Uganda and boasting it to be the one proven tool. Others say that ABC has not worked anywhere and certainly did not work in Uganda, where critics claim that massive reductions in HIV/AIDS prevalence were actually due to a lack of treatment resulting in extraordinary numbers of deaths over the decade marked by ABC rollout.
While it is evident that a great deal of the decrease in HIV/AIDS prevalence in Uganda can be accounted for by deaths, it is also apparent that Uganda has achieved some significant results in preventing new infections. In the first part of this assignment (assignment 3), I called upon three social science frameworks to critique the ABC approach to HIV prevention. Through the lenses of Anthropology, Sociology and Political Science, I concluded that while aspects of this program appeared to work in Uganda, ABC cannot be universally applied throughout the world or even throughout Africa. I did not argue with the epidemiological or scientific soundness of the approach. Instead, I argued with the actual feasibility of using this approach as a universal silver bullet applicable in any setting. Variations in culture, gender equality and political will in different parts of the world demand approaches that are unique to each community. I also concluded that in Uganda several interrelated factors worked together to produce an environment in which ABC could achieve some results—but ultimately ABC was less of an approach and more of an outcome of various factors coming together in the right place at the right time.
There is more to be learned from the factors that yielded Uganda receptive to HIV prevention methods than there is to be learned from the ABC approach itself—mainly cultural considerations, improved female autonomy and the use of political will and influence.

It is clear that HIV is a sexually transmitted disease and therefore, promoting abstinence (or delayed sexual debut), fidelity and condom-use must be integral parts of any HIV/AIDS prevention program. Establishing that populations must adopt these behaviors (either in part or in whole) in order to prevent the spread of HIV is inarguable. The challenge is creating an environment in which populations are able to adopt these behaviors, want to adopt these behaviors and actually choose to adopt these behaviors.

I don’t presume to develop any one silver bullet or gold standard for success. I do propose, however, an adaptable framework for success—a framework based upon Anthropology, Sociology and Political Science that can be modified in various settings to establish environments that are receptive to HIV prevention methods. This framework takes into consideration cultural variations, gender inequalities and the importance of political will and public policy.

Anthropology says, “Do NOT ignore culture!”

In my critique of the ABC approach, I pointed out that the approach cannot be universally applied throughout the world or even throughout Africa. I argued that it does not take into consideration cultural factors that often serve as barriers to abstinence, fidelity and/or condom-use. Is it plausible to ask a man within a polygamous society to be faithful to one woman? The field of Anthropology guides Public Health professionals to realize that culture must be considered in the design and implementation of health interventions. To address this issue of cultural variations that do not allow for one prescriptive tool for success, I propose that Public Health organizations implement community-planning strategies. This means that agencies working towards HIV prevention must provide individual communities with the facts and basic knowledge about HIV transmission, methods of prevention and consequences of not adopting new health practices. The agency must then work collaboratively with the community to develop a plan that is culturally specific and scientifically sound for the particular community. Often when health interventions are introduced into communities without consideration of the culture, one or more aspects of the program is not seen as feasible by the community. When this happens, the community often rejects the entire intervention as unattainable. By utilizing community-planning strategies, communities are given the opportunity to articulate what works for them and what does not work for them—within the context of science and facts. While being faithful to one woman might not be possible in a community where men are expected to have up to three wives, it is possible for a community like this to develop a prevention plan that involves condom-use, regular testing and being faithful to three women. Community-planning is important because it involves men and women. It involves community members and Public Health experts. All are seen as equal players in the prevention process. This leads to community buy-in, a concept essential to the success of any Public Health intervention.

Sociology says, “Do NOT ignore gender inequalities!”

In my critique of the ABC intervention, I pointed out that the ABC approach assumes that girls and women have equal capacity to negotiate abstinence, being faithful and condom-use. This is simply not the truth. Throughout much of Africa and much of the world, girls and women are marginalized. They are forced to marry as early as 12 years of age, they are not allowed to stay in school, and ultimately they become highly dependent on men for survival. According to a recent UNFPA article, “…women and girls face a range of HIV-related risk factors and vulnerabilities that men and boys do not--many of which are embedded in the social relations and economic realities of their societies” (UNFPA). In addition, “Violence against women is highly prevalent throughout the world. Girls and young women acquire HIV an average of 10 years earlier than men of similar ages. This is related to early marriage, rape and being compelled into transactional sex for economic reasons” (Roberts, 1). It is due to this range of factors that, “In sub-Saharan Africa, 76 per cent of the young people (aged 15-24 years) living with HIV are female” (UNFPA).

These inequities cannot be ignored. The field of sociology highlights the importance of considering gender inequities when planning a health intervention. I propose that agencies committed to HIV prevention shift some of their efforts towards creating access to primary and secondary education for girls and reducing the disparity between girls and boys in secondary school. While this will not necessarily yield immediate reductions in HIV/AIDS prevalence, it will improve female autonomy. Many Public Health experts have argued that successes in Uganda have been falsely attributed to the ABC approach—when in reality the successes were largely due to increases in female autonomy. It is clear that women who stay in school longer choose to marry later. They are also equipped with additional skills that make them less economically dependent on men and less likely to engage in transactional sex as a means of survival (strongly associated with HIV/AIDS transmission). “Boosting women’s economic opportunities and social power should be seen as part and parcel of potentially successful and sustainable AIDS strategies” (UNFPA). It has been shown that in societies where women feel a sense of empowerment, they are far more likely to choose to wait longer to have sex, engage in monogamous relationships and feel capable of negotiating condom-use. They are also far more likely and able to demand monogamy of their spouses. A large part of improving female autonomy is dependent not only on increasing access to education for girls but also on reducing violence against girls and women. Violence reduction programs should be an integral component of HIV prevention. The UNFPA goes as far as to say, “If HIV-prevention activities are to succeed, they need to occur alongside other efforts that address and reduce violence against women and girls” (UNFPA).

Political Science says, “Do NOT ignore health policy!”

In assignment three, I demonstrated that achievements in HIV/AIDS reductions in Uganda were in large part due to political will. President Museveni traveled to remote villages with a bullhorn, mobilizing the population to change their behavior. His support early in the campaign of ABC methods (advocating equally for A, B and C) lead to frank conversation among Ugandans of all ages about HIV/AIDS and prevention methods. In time, as his support for condom-use dwindled and the national HIV/AIDS prevention strategy became almost entirely focused on abstinence, the country followed suit and discussion of condom-use became taboo. It did not take long before the country faced a national condom-shortage and HIV rates began to rise again.
By examining HIV/AIDS prevention through the scope of Political Science, the importance of charisma, leadership and political will become very clear. Often Public Health implementers see politics and public policy as beyond the scope of their work. As Mervyn and Ezra Susser have argued that Epidemiology has become too narrow, too focused on individual risk factors and has forgotten it’s role as the basic science of public health—implying that Epidemiology is failing the field of Public Health by neglecting to focus on populations, Public Health professionals working towards HIV prevention have also become too narrow, too focused on the silver bullet (a vaccine, circumcision, microbicides or the ABC approach) and have forgotten that Health Policy is one of the subfields of Public Health. It is essential that Public Health practitioners address health problems at the policy level as well as at the community level. Many Public Health professionals have chosen not to play the political game but hope to enact changes in the health of populations outside the realm of politics. This is a big mistake and the consequence of this mistake is the loss of life for millions. By choosing not to participate in public policy and politics, Public Health professionals are making a challenging battle far more challenging. By enacting change at the policy level, Public Health practitioners have the chance to create health interventions that are supported by charismatic leaders. With this support, these health interventions are likely to be adopted as part of the national healthcare system—thus rendering them far more sustainable and culturally accepted.

This approach does not provide a single prescription to prevent HIV/AIDS transmission on a global scale. It does offer an approach to HIV prevention that considers culture, gender inequality and the power of political influence. In order for populations to accept and adopt behaviors that are critical for HIV prevention, the community must be involved in designing the prevention plan for their specific cultural context, female autonomy must be increased allowing women to negotiate their own sexuality and public health professionals must engage in Health Policy reform. This framework, a framework grounded in Public Health, Anthropology, Sociology and Political Science, has the potential to yield HIV/AIDS prevention programs that are holistic, sustainable and achieve measurable results.

References
Cohen S Beyond Slogans: Lessons From Uganda’s Experience With ABC and HIV/AIDS The Guttmacher Report on Public Policy, December 2003
Hampton T Abstinence Only Programs Under Fire JAMA Volume 299, Issue 17, Pages 2013-2015
Lopez K The ABCs of fighting the spread of AIDS in Africa The Seattle Times, June 2005
Marton K Bush in Africa: Saving women from AIDS International Herald Tribune, July 2003
Murphy E Was the “ABC” Approach (Abstinence, Being Faithful, Using Condoms) Responsible for Uganda’s Decline in HIV? The PLOS Medicine, Volume 3, Issue 9, Pages 1443-1446
NPR Uganda, Abstinence and the Spread of HIV (pod-cast accessed on November 17th, 2009)
Roberts J HIV Prevention: Are We Making Progress? www.Medscape.com Accessed on December 10th, 2008
Russell S Uganda’s HIV rate drops, but not from abstinence San Francisco Chronicle, February 2005
UNFPA The Gender Dimensions of the HIV/AIDS Epidemic United Nations Population Fund www.unfpa.org/gender/aids.htm Accessed on December 10th, 2008
Wax E Uganda’s war on AIDS: Candor more crucial than abstinence, officials say The Washington Post, July 2005

It’s Not As Easy As ABC: Abstain, Be Faithful, Use Condoms in Africa – Antoine Longuet

It’s Not As Easy As ABC: Abstain, Be Faithful, Use Condoms in Africa – Antoine Longuet

AIDS is known to be one of the worst pandemics since its discovery in 1981 (1), particularly in Africa, where the spread of its infection has amounted to 24 million in 2007, with over the 33.8 million infected individuals around the globe (2). A number of organizations have launched intervention initiatives to stop its spread, one of them being the ABC program launched worldwide in the 1990’s by governments of affected countries such as Botswana, Uganda, Mozambique and by the UN which has created the UNAIDS department to deal with this crisis (3). The name of the ABC program is an acronym for the messages it wishes to promote: Abstain, Be faithful, and use Condoms. Recently, the United States Bush Administration launched the President’s Emergency Plan for AIDS Relief (PEPFAR), which endorses the ABC program and increased US funds for AIDS relief (4). The ABC initiative has come under considerable criticism since the early 2000’s by scholars for its ineffectiveness in understanding the complex cultural and sociological factors that lie between the program’s objective and its actual intervention. The ABC intervention has also been criticized for its lack of marketing research to promote itself, incapacitating the effectiveness of its message.

ABC And Local Cultural Factors:

ABC has primarily been promoted in Africa in the 1990’s, where it was believed to have a great success in Uganda (the number of infections dropped from 15% in 1992 to less than 5% in 2006) (5). However, this was often not the case in other countries, where there is still a staggering number of infections, which keep rising.

Misconceptions of the ABC program are based on assumptions about the different ways through which the disease is spread. This intervention focuses primarily on heterosexual transmission via conventional intercourse. However, the program ignores the many other ways through which the disease spreads. Surprisingly very little research has been done on homosexual transmission in Africa, while it is an important debate topic within the First World to prevent the spread of AIDS. Also, the program ignores local cultural factors, which often move against the efforts made by the ABC program. Sociological factors, particularly polygamy and sexual violence, are another larger issue, which truly affect the success of the ABC program. In this sense, it can be said that the ABC program is based on analysis of individuals within a vacuum, without taking into account socio-cultural factors.

Local cultural practices involving sexual relations and defining socially acceptable sexual activities have often hindered the efforts of the ABC program. Just as “Ethnographic research […] often reveals how deeply sexual intercourse is enmeshed in meaning and social experience”. It is only recently that “researchers are […] turning their attention to little-known sexual practices”, as Erik Eckholm noted (6), which “might also raise transmission odds” (6). Such practices include female circumcision, which is often forcefully done upon women in South Africa, and usually in a non-sterile environment with tools used on women who have been previously infected. Other such practices include anal intercourse, particularly between men, which often leads to HIV transmission. A more obscure practice involves sexual intercourse with monkeys (6), which are known to be HIV carriers and is believed to be the origin of the virus. However, the ABC program is primarily directed towards regular heterosexual intercourse, and surprisingly contains very little research on homosexual activity or other kinds of sexual activities in which the HIV virus can be transmitted. The fact that the ABC program targets conventional sexual relations, through which the disease is most spread leaves “gaps” through which the virus can continue to infect the African population and proliferate within it.

Another cultural issue, to which the ABC program is confronted, is myths about the HIV virus as a whole. Alma Gottlieb documented “rumors connecting AIDS to vampires” (6). Such myths distort the definition of HIV transmission that needs to be assessed on a local basis where the myth is present. Other less obscure myths involve misunderstandings of the inner-functioning of AIDS and its transmission. Older seropositive men often believe that sexual intercourse with virgins or minors, which are considered “AIDS-free” would “wash-out” HIV from the body (5). This particularly poses a problem to the ABC program in terms of abstinence and condom use as many of the older seropositive men either rape their victims, or provide food, clothes and education to women and girls of poor backgrounds in exchange for sexual favors. The men who demand sexual favors in exchange for economic support are often termed as “sugar-daddies” (5). In such as case, not only do these young women not abstain, but also due to the “body-cleansing” myth that is involved, condom use is inexistent. This is particularly threatening for virgins where the rupture of the hymen, at any age, is involved with vaginal-bleeding, and causes automatic HIV transmission if the sexual intercourse involves a seropositive mate while not using a condom (6). It has also been noted that within a couple in which both partners are seropositive, men tend to die before females do. Locals have addressed this by assuming that women are more resistant to the virus because they eliminate the infected blood through the menstrual cycle, another reason why virgins are considered to be “virus-cleaners”. The true explanation to this is earlier male extra-marital affairs than for females (6), which poses a serious challenge to the ABC program.

The main cultural problem that ABC faces in Africa is the widespread belief that condoms actually spread AIDS, and therefore a general male resistance to use condoms. Other males are against the use of condoms because they consider this to diminish the sexual pleasure that is involved in sex, and the simply do not consider the practicality of its use. African males have often been noted to believe that condoms are “like taking a shower with a raincoat”, or “eating a candy with the wrapper” (6). Conferences in which AIDS is discussed are often met by male responses, which involve little interest about why such phenomena occur, and “the production of knowledge and ability to distinguish [the use] of condoms as correct or incorrect in this sense [is] taken for granted” (6).

ABC And Local Social Factors:

The ABC program is proven to be inefficient when facing cultural problem due to the fact that it gives narrow alternatives to prevent the transmission of AIDS, which are culturally unfeasible. Furthermore, this intervention is inflexible because of its inadaptability to local cultural-conditions. The ABC intervention also faces many social challenges on a variety of levels going from the simple one-on-one sexual interaction to post-colonial stereotypes that apply to the African population as whole.

First of all, heterosexual relations within a couple are often stricken with sexual violence and marital rape in Africa. Thirty three percent of women in Uganda suffer from sexual marital violence, while eighteen percent of married women experience sexual violence with seropositive men who blame them for their condition (7). Studies have shown that men are twice as likely to die before their spouse due to AIDS due to extensive extra-marital sex (5). Women in poorer areas of Uganda and Africa as a whole claim to marry men who travel extensively along trading routes, and very often have sexual relations with other women (6). This particularly becomes difficult for ABC when such marriage conditions involve men who not only have affairs, but also are also polygamous. African countries in which the Islamic tradition of polygamy is widely socially accepted and permitted by authorities, such as Ethiopia and Nigeria, are a haven for HIV transmission (5). Within such conditions, not only do married women not abstain, but do not use condoms during intercourse because of the taboo involved with its use in a married couple, even polygamous. The use of the condom is often looked down upon, and when suggested in a couple, this often leads to suspicions of infidelity (5).

Cases of marital rape and violence clearly show that there is a gender inequality within certain regions of Africa where women not only are marginalized for their gender, but are even more so if they are seropositive. South Africa is known to be one of the countries in Africa in which gender marginalization occurs to the extent that it has the highest reported rape rate in the world (7). Not only does gender inequality push women on the margins of social and economic life, thus increases their dependence on their husbands, but it makes the ABC program entirely ineffective. Marginalized women, particularly in South Africa, are submitted to the will of their husbands or mates by socio-economic, even cultural factors, which render the discussion on condom use inexistent due to the fact that the ABC initiative is directed towards the male condom, ultimately giving the male gender the choice of its use. The fact that the ABC program specifically targets the male use of the condom, as opposed to the female one, undermines its effectiveness within regions where women abuse is common. As noted within the Review of Concern on Women & HIV/AIDS study: the “combination of poverty, unequal access to basic needs and resources, oppressive cultures and traditions, the denial of sexual and reproductive choices and the absence adequate heath-care and information” (7) render the ABC program entirely ineffective in region where female discrimination is actively performed.

The Church has also played a controversial role with regards to the ABC program in Africa as it has actively promotes the A and the B of the program (Abstinence and Being faithful) but discredited the use of Condoms, suggesting that it interfered with the natural order of things and that it is an immoral object (8). The Church has actively been opposing the use of the condoms through church sermons, as well as in catholic schools for decades due to its belief that it promotes “immorality and sexual promiscuity” (8). Furthermore, the Islamic community in Kinshasa also condemns the use of the condom, claiming that it “wages sin” (5). Edward Green has actively fought the use of condoms, convinced with the fact that “HIV incidence began to decline [in Uganda], primarily due to reduction in partner numbers” (5). He also claimed that condoms are not 100% effective and that Ugandans dislike the use of the condom. He even coined the use of the condom as a “western, technological solution inappropriately exported to Africa” (5). As a result, women who propose the use of the condom, while not being married, are often considered “free-women” who actively have sex with multiple partners, and are thus considered to be unfaithful, even prostitutes (5). However, Dr. Serwadda, a researcher on AIDS, claims that although abstinence and faithfulness in a relationship, promoted by the church, has played a major role in diminishing the extent of the Ugandan AIDS crisis, “it has not been a magic bullet” (5). He also noted, just as said before, that abstinence is not always an option, and neither is faithfulness in certain conditions, such as in the case or rape and sexual marital violence. Furthermore, while taking into account the discrimination of condom use, women who abstain from having sex till later may only push back to a later time their risk of infection due to the bleeding caused by the rupture of the hymen during loss of virginity if their partners were not to use condoms (5). Until recently, even UNICEF, while intervening in Uganda, made no mention of the use of condoms (5). However, this has changed in the recent years as President Bush made an address in June 2004, backing the use of the condom in the US as well as in Africa, suggesting that the “United States should “learn from the experience” of countries like Uganda”(9). Since, the US and other AIDS program activists have changed their point of view on the use of the condom. President Museveni of Uganda, who had actively opposed the use of the condom for many years, changed his opinion on this issue in an address on Monday, July 12^th, to the International AIDS Conference in Bangkok, despite his personal religious beliefs: “Abstain from sex or delay having sex if you are young and not married, Be faithful to your sexual partner (zero-grazing), after testing, or use a condom properly and consistently if you are going to move around. This has now been globally popularized as the ABC strategy” (10).

Post-colonial stereotypes that remain within the African territories are another obstacle that the ABC initiative has come challenged. Most of these revolve around ideas that women are passive, and that “people of color are undependable, uneducated or nonliterate, [and] cannot understand complex messages (6). These stereotypes underline post-colonial racism, which is still prevalent in African countries and work against the ABC initiative as it dilutes and distorts the effect of the messages that are directed towards the African population. On one hand, a similar narrative can be seen within AIDS media coverage, which often leads to conspiracy theories about interventions performed by post-colonialist countries. Eurocentric media is often “biased, [with a] doomsday mode of reporting typical of Western AIDS coverage, [and afflicts] African people [who] appear as the passive recipients of internal and external help, while Africans at large are charged with failing to address the epidemic, even failing to be aware of it” (6). On the other hand, the African press reports constantly new efforts made to fight the epidemic. This discrepancy in media coverage only accentuates stereotyping, and thus not only creates a reticence from the part of the aid recipients who perceive the ABC message as aggressive and imperialist, imposing upon their way of life. This underlines the C of the program, which is one of the western solutions to stop the spread of HIV/AIDS and other STDs.

The final sociological factor that the ABC program faces is based within the legal systems of African countries such as Uganda, which have no definition of what westerners call “prostitutes” (6). Since prostitutes are one of the many ways through which AIDS spreads, the A and the B do not apply, and the C only applies in some cases. In order to effectively apply the A and the B within HIV/AIDS stricken countries, the definition of prostitutes must be put in place within their laws, and therefore either outlawing or the regulating this business. Furthermore, in order to fight the spread of this virus within sexually abused minors by “sugar-daddies”, there needs to be a strengthening of laws against minor defilement. This, however, is now out of reach of the ABC program, which needs to be stretched in order to allow legal enforcement.

ABC and the Health Belief Model:

The issue of culture makes it even more complicated for the ABC program, which promotes itself through a health belief approach, assuming that the population is concerned with its health. The Health Belief Model is an individual based model in which it is assumed that the individual perfectly weighs out the costs and the benefits associated with performing a health related behavior. The outcome of this analysis is an intention, which the model assumes to lead necessarily to the performance, or not, of the behavior depending on the intention. Here, the ABC assumes that the individuals involved in a sexual relation are devoid of social pressures, and that each individual perfectly balances out the health costs and benefits of abstaining, being faithful to their partner, and using condoms. However, as proven in the analysis above, each individual is constantly under immense social and cultural pressures, which ultimately lead to their decision rather than their belief. The health practitioners that have developed the ABC intervention have done so without including socio-cultural factors while basing themselves on the belief that each individual evaluates abstaining, being faithful to their partners and using condoms, according to their health concerns only. Yet cultural and social factors have been proven to drive the decision making process of individuals within these three subjects.

Furthermore, the ABC program focuses primarily on the individual, assuming that his or her decision process occurs without social interaction, in a vacuum. The reality of this is very different, particularly for marginalized and abused women who have no choice with regards to their health decisions. We can therefore say that these decisions are made on a group basis, such is the case for women on whom female circumcision if forced. Finally, the ABC program assumes, just like the HBM model over which it is based, that the intentions of the individual will lead to the action. This is clearly flawed due to the fact that even though men and women have the intention of following the ABC program, they might not due to socio-cultural decisions and inherent impulses. Decisions that involve sexual relations and health are often very delicate due to innate human impulses and socio-cultural factors, particularly in uneducated groups of individuals about the risks of HIV/AID transmission.

Flawed Marketing And Advertising:

In order to be delivered to the population, the ABC program needed to be marketed and tailored to the local crowd of each region within Africa towards which the program was directed. Marketing programs were fragmented into three separate types of projects according to the three objectives of the ABC program: one for abstinence, one for being faithful, and one for condom use. However, the ABC marketing program particularly focused on the condom use. During the 1960’s and 70’s Pentecostalism and the Catholic Church have greatly expanded within Africa, promoting messages that involved abstinence before marriage and faithfulness in relationships (8). However, these religious groups actively opposed the use of condoms, which was in direct opposition to the ABC marketing program focus. One of these programs, called Jeito, was launched in Mozambique in the mid 1980’s promoted the use of condoms through a Condom Social Marketing Program (CSM) (8). This program, like many other CSM programs, did not involve dialogue with the local population on their perception of condom use, and did not analyze in depth the local socio-cultural underpinnings. This was primarily due to the fact that the Jeito program was put in place urgently to quickly address the spread of HIV/AIDS. Furthermore, there was locally a widening gap between the classes, which often translated in the poorer population into survival by prostitution. This was not taken into account when the program was designed. The result of this program was not only strong clash between the messages of the churches and the Jeito program messages, but also a total misinterpretation of the Jeito program’s messages by the local population. While the program was promoting the use of condoms, the reliance of sex work by the poorer population translated into a perception of the use of condoms reserved to prostitutes, who were often infected by HIV/AIDS. Thus, many associated the use of condoms with HIV/AIDS itself (8). This program developed into a political downplay in which the program was unsuccessful. Once more ABC program, through Jeito, has proven to be ineffective not only because it does not take into account local perceptions on sexual activity, cultural and social factors, but also because it offers no dialogue with the local population in order to tailor its message according to the regional socio-cultural conditions. According to James Pfeiffer, the failure of the Jeito program “reveals the striking dissociation that is produced between the aid world and poor target populations when community participation and dialogue are disregarded” (8).He therefore suggests that there should be a “creation of frameworks for long-term dialogue between health workers and communities to establish trust and channels of communication” (8), which would allow the programs to tailor their intervention to the local population rather than imposing a top-down intervention according to pre-packaged interventions that have been put in place in many affected regions.

The failure of the Jeito program illustrates an overall failure of marketing interventions that have been put in place based on the ABC program, which is not designed to local population dynamics. This also illustrates the lack of data that such programs have collected within their regions of intervention, which have lead to misconceptions of the extent to which AIDS have affected the population. These misconceptions therefore “[obscure the] details of degree and specificity” about the perception and extent of the HIV/AIDS crisis (6). Africa is composed of forty-five countries, where seven of them are affected severely by the virus, and only of these are considered as high-risk countries. However, media coverage and general misconception of AIDS have led to think of Africa as a “Continent of Agony” (6). Conversely, such fallacies can also be seen in the other extreme where half of the new infections in Uganda occur within regular marital relationships, but are entirely ignored by local FBO’s (Faith Based Organizations) (5). To a further extent, African male speakers in HIV/AIDS conferences have made claims about the conditions in Africa while undifferentiating women, prostitutes and mothers, thus distorting definitions over which the ABC is based (6).

Conclusion:

The ABC program, which has started in Africa in the 1990’s promoted a message throughout HIV/AIDS stricken African countries of Abstaining, Being faithful in a relationship, and using Condoms in order to fight the spread of the virus. However, this program has been proven to be flawed, particularly on its account of lacking knowledge of the local socio-cultural factors, which have often led to the misunderstanding of the program’s messages. Local cultures, which promote polygamy, have greatly hindered the effectiveness of the ABC intervention. Furthermore, local social factors, such as violent marital sex, rape and the existence of men called “sugar-daddies” have rendered the ABC program ineffective due to the marginalization and submission of women within such conditions. It is therefore evident that this program based on the HBM ignores all socio-cultural factors, putting forth a health based conception of the performance of A, B and C. However, the local conditions illustrated above have made this type of intervention irrelevant. The HBM based ABC program is also an individual founded intervention, while local conditions clearly need a population or group founded intervention. Finally, the marketing programs, such as Jeito in Mozambique, have met serious local resentments due to their lack of knowledge of local conditions, which have perceived ABC messages, particularly the use of Condoms, as manipulations of post-colonialist countries. The use of condoms has predominantly been misunderstood as a western tool to be used by HIV/AIDS carriers and individuals of immoral sexual activities. The ineffectiveness of the ABC based interventions show that a larger approach needs to be put in place within HIV/AIDS stricken African countries, which take into account socio-cultural factors, which play an important role in shaping the perception of such programs, and that demand large scale social reform. Therefore, an ecological approach seems appropriate for such an intervention, which would allow the program to tailor effectively its messages and campaigns to local conditions and thus assess more powerfully the spread of the virus. However, such an intervention will still meet a certain amount of challenge as “conclusions of ethnographers [about] the “risk group” categories produced by epidemiology often have little to do with the lived realities of human experience” (5), and thus will ultimately lead to future misinterpretations of messages sent by public health interventions. Ecological model based interventions will face challenges by the local population due to possible target population misclassification, but will ultimately lead to more effective interventions.

Resolving the ABC Program’s Flaws:

As suggested before, and ecological approach to this issue would certainly allow a program such as ABC to effectively tailor its messages and intervention to the local conditions. This, however, requires the program to change its philosophy with regards to the individuals it wishes to target by assuming that group based intervention in which sociological and cultural factors are key to determining individual’s health related behaviors. The ABC program therefore will need to research the local population on multiple levels in order to create an ecological intervention that effectively reaches the target population on several levels. In order for this program to effectively design interventions to local population conditions, the program needs to stretch out into domains out of Public Health, such as law enforcement, which would effectively back-up this program and thereby provide it policy cushion. This approach will thereby not only use Public Health measures to assess the population internally, but it will also use binding policies in order to enforce certain aspects of the intervention.

The Use Of Surveys:

An ecological approach to this issue not only requires the program to assess the target population in terms of a group rather than in terms of individuals, as dictated by the HBM, but also to intervene upon multiple levels, assessing sociological as well as cultural factors that need to be determined beforehand. An effective intervention would require a certain amount of research to be done within each particular region, especially in terms of the cultural factors, which have constantly impeded the progress of this program. In order to effectively research the population and understand the underlying factors, a series of studies through one-to-one surveys need to be done on multiple levels of the population. In hindsight of the problems the ABC program faced in Mozambique (8), Nigeria (5) and Uganda (6), the three main levels of the population can be surveyed: the population itself, subdivided according to SES background, the local authorities, and the religious groups. In Mozambique, the main issue was the population’s SES conditions, which at the time of the Jeito intervention, had plunged, and therefore forced many members of the lower SES classes into sexual work. Local religious beliefs were in full change the moment of the Jeito intervention, and in coordination with the socio-economic instability, caused the intervention’s message to be entirely misunderstood (8). In Nigeria, the fact that polygamy is legally accepted is one of the most complex issues with regard to the ABC program. Surveying local authorities might be able to suggest solutions to the problem and help shape the ABC program’s intervention with regards to the issues of polygamy and AIDS. This would allow the intervention designers to understand the official stance of local authorities on the HIV/AIDS issue. Finally, as seen in Mozambique (8), local religious groups such as the Pentecostal Church have clearly a different stance on the issue of intervening on HIV/AIDS, and would be worthy to seek an opinion from to understand how its position affects the local population perception of the virus. Also, in order to effectively understand the evolution of local cultural conditions, research needs to be done on a long-term basis, even while an intervention is already in place in order to constantly shape it to the evolution of the population’s cultural condition.

Local myths are particularly problem for ABC and are representations of the misinterpretations about the origins of HIV/AIDS and its inner functioning. Alma Gottlieb acknowledged “rumors connecting AIDS to vampires” ^vi, while Schoepf showed that older seropositive men believe that sexual relations with young women, and particularly virgins would allow them to clear their blood of impurities. Such misunderstandings can be assessed explicitly by addressing the victims of such abuse through sexual education at a very young age to inform them about the realities of the transmission of this virus. However, the fact that many of them do not attend schools and live in a close knit-community often prevents them from discussing such taboo subjects. The most practical and direct solution would be public campaigns using billboards upon which the “story” of HIV/AIDS transmission can be personified. Furthermore, public speakers need to be recruited in order to publicly inform the people as a whole, and not only these young girls, about this virus.

Approaching The Population:

In order to successfully reach the population, these speakers need to have knowledge about the cultural practices and beliefs of the region in which they are intervening; which is why they should be either from that region, or go through local cultural or religious authorities. In a sense, the origin of the speakers and the appearance of familiar cultural ties between the speakers and the population would lean on framing theory (11). These speakers and billboard ads, while still pushing for an HBM approach, which informs people about the basic health concerns of HIV/AIDS, need to use at the same time a marketing theory based approach (11). This will permit the messages of that the speakers and the billboards are sending to not only give health related information about HIV/AIDS to the population, but also package this information in a way that would appeal to the people’s desire. In a sense, by combining the HBM with marketing theory, the speakers and the billboards will present the issue of health through the use of condoms, faithfulness, and abstinence as a socially and through time, a culturally positive object. However, if the program has enough funds, it may even combine an HBM based approach with Advertising theory through the use of more advanced, and more expensive media, such as radio and television (12). Advertising theory would virtually play the same role as marketing theory in these adds, while appealing to the population’s social and cultural aspiration. The use of the advertising and marketing theory thereby necessitate the use of surveys in order to adequately pinpoint the social and cultural aspiration of the population, which need to take into account the religious and governmental positions on the HIV/AIDS issue in order to further the effectiveness of the intervention.

The Use of Dialogue:

The use of surveys to develop effective interventions based on the ABC program which use speakers may not adequately allow the population to effectively feel addressed about the issue. One the main issues with the Jeito program, as determined by Pfeiffer, was its lack of dialogue with the target population (8). Dialogue, through group speakers or through one-to-one surveys, would not only bring information to the target population, but also to the designers of the intervention who, through dialogue, may constantly monitor the changes in the population comportment and perception of the ABC messages. The use of dialogue with the local population will also allow researchers to be able to “think outside the box” in a way that they are not constrained to ask questions to their audience that is restricted to certain guidelines. Such freedom of expression would permit researchers to acquire more in depth information about the socio-cultural background information about the population, such as obscure sexual practices to which Treicher referred, such as homosexual practices and sexual relations with monkeys (6). Dialogue with the population has particularly become important with regards to the religious factors, which are intertwined with the cultural ones. Religious factors are often very complex and are perceived and explained quite differently by the religious authority and the population that follows it. Surveys and dialogue would therefore be appropriate to target the religious authority and the population of followers as not only is this a very delicate and complex subject, but it is also ever increasingly volatile to events.

From a socio-economical point of view, dialogues are not as important as surveys due to the fact that the raw data, such as the state of the economy and how it affects the population, are more readily transcribed and analyzed using this type of research method. However, from a sociological point of view, the dialogue with the population is just as important as from a cultural point of view. Sociological factors depend on the SES status of the group as well as the its cultural attributes, making it also very volatile. In order to assess the problem of HIV/AIDS in women, which are known to be the target to sexual abuse, particularly in South Africa, which has been reported to have the highest rape of rape in the world, the most effective way to address them is to operate a constant dialogue with them in female social events in which they would be allowed not only to speak up and be heard, but also be educated about such concerns. By directly targeting women, who are the victims of sexual abuse, they will have the opportunity to be educated, and thereby by able to make educated choices about their husbands, or their partners, whichever applies best. However, interventions upon women need to be carefully tailored as they are the segment of the population that have been the most abused due to their often marginalized position within society. Women’s position within society has often pushed them to be the target of sexual abuse (13). One of the many ways, which could help women, is the use of the female condom. Even though women who are sexually abused are often do so with no condoms, the use of the female condom will help those who are not being abused, thus giving them a larger leverage when the issue of the use of the condom is being put in question.

Assessing ABC From A Legal Point Of View:

The very fact that women are the targets of sexual abuse not only reveals sociological underpinnings which need to be addressed through dialogue, surveys, and marketing programs in order to change the perception of women and of HIV/AIDS, but also reveals the lack of enforcement of already binding laws. Policies in countries such as South Africa, which has the largest reported rape count in the world, are often key locations for sexual abuse due to the lack of enforcement of the law. This is often due to either corruption, or lack of governmental funding. However, funding may be able to at the same time eliminate corruption, and help enforce the law if they are adequately managed. Furthermore, in order for these laws to be enforced, new elements need to be added to civilian codes of conduct, and rectifications need to be made. The fact that Uganda does not have the definition of what a prostitute is, in western terms, complicated judicial decisions with regards to rape or sexual abuse. This is also makes it very difficult for governmental organizations to control prostitution and women abuse. Outlawing prostitution, or at the very least require a list of declared prostitutes in the country would help authorities and humanitarian organizations help prevent the spread of HIV/AIDS. Polygamy, however, is a much more delicate situation as not only is outlawing polygamy virtually impossible due to the fact that it is deeply engrained within the population’s cultural identity, but it is not easily enforceable. Therefore, the question of controlled polygamy seems to be a quite delicate situation, which can only be assessed on a local level in coordination with governmental and religious authorities.

Conclusion:

The main issue with the ABC program was its lack of analysis of local socio-cultural factors due to the fact that it was an HBM approach, thereby causing its marketing approaches to be flawed. However, an effective research through the use or surveys and dialogue with the different groups of the target population will allow the designers of the ABC program to clearly understand the different social, cultural and economical elements that shape their population’s attitude and perception of health related interventions. Furthermore, dialoguing with different target groups of the population will allow localized interventions rather than a broad and imprecise one. The presentation of the ABC program’s campaign through speakers, adds, billboards, and advertisement appropriately tailored to the local population conditions and target groups would allow the intervention to incorporate the HBM approach into a more appealing message in which the issue of health not only becomes less taboo, but also, for the lack of a better term, “looks good”. Finally, the use of legal and constitutional enforcement of sexual abuse through adequate funding and policy modification would allow authorities to regulate to a larger extent the spread of the virus.

References:

1) Discovery Channel. Sexual Health Center: HIV/AIDS. http://health.discovery.com/centers/sex/sexpedia/hivnaids.html

2) Anup. S. AIDS in Africa. Global Issues. 2008. http://www.globalissues.org/article/90/aids-in-africa

3) United Nations. Acquired Immune Deficiency Syndrome Department. New York, NY: UNAIDS. http://www.unaids.org/en/

4) United States President’s Emergency Plan for AIDS Relief. 2008 Annual Report to Congress. Washington, DC: United States Congress.

http://www.pepfar.gov/documents/organization/100029.pdf

5) Schoepf. B. G. Lessons for AIDS Control in Africa in Review of African Political Economy. Taylor & Francis 2003; 30: 553-572.

6) Treicher. P. A. AIDS, Africa, and Cultural Theory. Indiana University Press 1991; 51: 86-103.

7) Statement of Concern on Women & HIV/AIDS in Review of African Political Economy. Taylor & Francis 2000; 27:590-593.

8) Pfeiffer. J. Condom Social Marketing, Pentecostalism, and

Structural Adjustment in Mozambique: A Clash of AIDS Prevention Messages. Case Western Reserve University 2004; 18: 77-103.

9) Sanger. D. E., D. G. Jr. McNeil. Bush backs condom use to prevent spread of AIDS. New York City, NY: New York Times, 2004.

10) Museveni’s ABC. New York City, New York: Wall Street Journal, 2004.

http://www.aegis.com/news/wsj/2004/WJ040721.html

11) Seigel, M. Developing Interventions: The Role of Social and Behavioral Sciences Models of Individual Behavior Change: Are they Helping Us or Constraining Us? – III. Boston University, November 9^th, 2008.

12) Seigel, M. Developing Interventions: The Role of Social and Behavioral Sciences Models of Individual Behavior Change: Are they Helping Us or Constraining Us? – IV. Boston University, November 16^th, 2008.

13) Why we are failing African girls. London: BBC News, 2004.

http://news.bbc.co.uk/2/hi/africa/4052531.stm