Understanding Culture Is Key to HIV/AIDS Prevention

A Kenyan journalist and health communication specialist explains how cultural expectations and practices affect people's perceptions of HIV/AIDS and their ability to change their behavior to reduce the risk of HIV infection.

When I did my first reporting on AIDS for the Radio Netherlands World Service in 1987, part of my research was to find out how big the problem was in Kenya. It was the era of denial, a time when the minister of health could stand up in Parliament and say, "Yes, there's one case of AIDS in Kenya, but it's someone from America." Or someone from Rwanda, or elsewhere -- but it was certainly not a Kenyan problem. I continued to follow the story, and two years later, in 1988, the number of confirmed cases had climbed to around 1,200 -- and denial was no longer possible.

Today Kenyans are aware that we have one of the most serious outbreaks of the epidemic in the world. We find HIV prevalence of up to 20 percent in some antenatal clinics, even in rural areas. Recent research confirms that HIV is now spreading rapidly in rural areas where it had not been such a danger before. The problem is growing more serious for Kenya every year.

Understanding the epidemic in my country requires that one also try to understand the cultural context in which Kenyans live, and how dramatically our society has changed over the past few generations. My grandparents' and parents' generations never faced a situation where, for example, young, unmarried men and women might find themselves together at college, away from the influences of home. They didn't have to cope with those situations. If young people did become sexually active, their parents married them off, even at the age of 14. But we don't do those kinds of things now. Our old ways of dealing with youthful sexuality are no longer acceptable.

Sensitivity to culture is especially important for communicating messages about HIV/AIDS. As a journalist, I thought that all I needed to do was explain that AIDS is a problem caused by a virus called HIV, which goes into the bloodstream and affects your body's immune system. But the first thing I encountered back in 1988 when I was doing some work for the World Health Organization was how difficult it was to translate basic terminology -- like "germ" or "virus" -- into my mother tongue. These concepts simply don't exist in our culture or language -- their closest equivalent is "insect." So, in the early years, even as we thought we were explaining what AIDS is to Kenyans, people remained confused. Today, we've made some progress in communicating these concepts to people.

Culture is also a factor in the high rate of sexually transmitted diseases (STDs) that plague Kenya. The genitals are a very difficult subject to talk about, even with a doctor, and many suffering from STDs cannot bring themselves to seek proper treatment. In rural areas where there's probably only a dispensary, and they don't have the facilities to do all the tests, and the person who works there is probably your aunt, who is a born-again Christian -- you can see how difficult the situation can be.

When I produced a documentary on STDs in Kenya I learned that in some of the hospitals in the western part of the country, as many as 40 percent of the children were born with gonorrhea of the eye, which can lead to blindness if it is not treated. The Ministry of Health, with help from the Belgian government , now has a program to administer tetracycline to the eyes of all newborns before they leave the clinic.

But solutions to cultural practices that put people at risk of HIV infection are even harder to come by. Some months ago I lost someone close to me to AIDS. His wife is a respected member of our community. At the time of her husband's death she faced a great deal of pressure to go through a cultural ritual involving sex called "wife inheritance," which is supposed to cleanse her of her dead husband's spirit. This ritual requires widows to have sex with a brother or other male relative of their husbands, and sometimes to marry them.

Fortunately, this lady is educated, and has been able to resist the terrifying warnings about what will happen if she doesn't comply: that her children will die from the food she cooks, for example. But for those who aren't educated, these cultural expectations are very difficult to disregard. What mother doesn't want to cook for her children?

We need to understand and respect the power of these cultural expectations. I'll give you an example from my own experience that might explain why they are so powerful. I grew up in rural Kenya until age 13, and at age six or seven, we would go into the fields to take care of the goats and cattle. Every time we went out into the field, we were worried that the rain would come. In my part of the country we have equatorial rains, and it pours so hard you can't see 20 meters ahead. As a six- or seven-year old child, you're pretty scared of that rain, and you have 20 to 30 goats and some cows to steer back home.

But I remember in the field there was a guy who could always tell us whether it would rain. On some days the clouds were so heavy we were sure it was going to pour, but when he told us, "No, it won't rain," it didn't. It took me many years into my adulthood to understand how he did this. The trick is that with some amount of accuracy, you can predict whether it's going to rain if you know the direction of the wind in relation to the mountains. But you can imagine how it was imprinted in me at an early age that there are certain people with certain powers to fix certain things, including making the rain go away!

I tell you this story because many educated people in Kenya have had the same kind of scripting. For example, as a journalist in the 1990s, I found that there were people in newsrooms with master's degrees in journalism who would believe claims of some magical cures for AIDS. And our leaders are just like us. That's one of the challenges you have to deal with at the policy level.

There are no simple solutions to problems that are rooted in culture. I'll give you another example: female circumcision. In Kenya the mass media, the medical community and many others all campaign against female circumcision, describing it as horrible, evil and primitive. Yet changing this practice is not going to be simple. It is a very complex thing.

For example, among the Maasai, if a woman is not circumcised, traditional birth attendants will not touch her when she's delivering a baby. They believe that it's a bad omen to help such a woman. Usually they will circumcise her first, then help her deliver. We on our high pedestals may lecture women against circumcision, but what are they going to do when they have to deliver a baby, in a country where 75 percent of deliveries are performed at home?

So that's the challenge. Fortunately, there are solutions. I went to another area, Meru, where members of the community have come up with their own solution -- of course with a lot of help from others who are interested in the problem. They have come up with an alternative ritual which can replace female circumcision. That alternative ritual is becoming accepted and is getting government support.

This example is another small piece of evidence that however difficult a problem may be, there's always a way around it. And that's an important lesson for people working to prevent HIV/AIDS prevention. We must involve local people to find solutions.