Moving beyond fear

It’s a hot Wednesday in February, the evening rush in Nairobi is just starting, traffic is heavy and I have just swung my Subaru into a jammed-up roundabout in the Westlands section of the Kenyan capital. Most busy intersections in Nairobi feature a roundabout (we would call it a traffic circle or rotary in the United States), instead of traffic lights or stop signs. I’ve more or less gotten the hang of driving in Kenya—keep left, watch out for matatus (the speed demon minibuses that serve as the main form of public transport) and remember that the cars in the roundabout have the right of way. Since it’s rush hour, there’s even a cop directing traffic at this particular roundabout. I slip happily into what looks to be an open lane, but turns out to be the wrong lane for where I want to go. The officer notices my opportunism, looks at me in disbelief and waves me over. I put on my most respectful face and say, “I’m sorry, I’m new in town and still learning about roundabouts.” I hold that this might have worked back home, but the word “learning” only makes him more suspicious, so he rounds the car to speak to my colleague in the passenger seat; he must figure that, as a male, my co-worker is certainly in charge.

“Is this driver under instruction?” the cop asks.

“No, she’s just new in town,” says my colleague, C.Y. Gopinath, better known as Gopi.

“Where are you from?” asks the cop. I lean over and say, “U.S.,” with a big American smile. The cop looks even more suspicious when Gopi says, “I’m from India.”

The officer continues addressing Gopi. “Is she your wife?”

“No, we work together.”

“Where?”

“PATH.”

“What?”

“P-A-T-H. Program for Appropriate Technology in Health. It’s an NGO [nongovernmental organization]. We work on AIDS prevention.”

“You give medicine to people?”

“No, we help keep people from getting infected.”

I decide to pipe up. “We give them information they need to protect themselves,” I say. In fact, a basic tenet of behavior change communication (BCC) is that information is often not enough to change a person’s behavior, but I am trying to avoid a traffic citation, not teach a lesson on BCC theory.

The officer mulls the idea of prevention for a few seconds before returning to known territory. “What are the symptoms?”

“AIDS doesn’t have any symptoms on its own,” Gopi explains. “It’s when your body’s askari goes to sleep.”

We launch into an analogy that has proved very useful here. An askari is a watchman or security guard (very common in this high-crime city). When your askari is asleep, any thug can get into your house. HIV eventually puts your body’s askari to sleep, so any disease can get in unchallenged. One could quibble about the analogy’s accuracy from a scientific point of view, but it helps meet one of my project’s key communications objectives: increasing the perceived distance between HIV and AIDS. The idea is that if people believe being infected with HIV is the same as having AIDS and dying, they are less likely to be interested in being tested and more likely to stigmatize those with the virus. Understanding the difference also makes the point that you can’t tell if a person has HIV by his or her appearance.

Scare Tactics a Failure

In 1999 Kenya’s president, Daniel arap Moi, declared AIDS a national disaster, and prevention and control efforts have been stepped up since then. Since August 2000, when I came to Kenya a few months after finishing my M.P.H. at Yale, I have been working on the communications component of IMPACT (Implementing AIDS Prevention and Care), a global project funded by the United States Agency for International Development (USAID) and managed by Family Health International, a nonprofit based in North Carolina. My agency, PATH, is a Seattle-based nonprofit that employs about 365 people worldwide, with a mission to improve health, especially that of women and children. PATH’s Kenya site, with about 25 employees and still growing, specializes in using innovative communications methods to change behavior, focusing especially on adolescent reproductive health, prevention of cervical cancer, eradication of female genital cutting and HIV prevention. In Kenya, PATH implements the communication and training components of IMPACT.

Though I function as a program officer for PATH, I’m not technically a PATH employee. I’m seconded to PATH Kenya through a somewhat complicated mechanism called the University of Michigan Population Fellows program. Funded by USAID, the program places early-career public health professionals in USAID missions and contracting agencies for two-year assignments; the goal is to provide technical assistance to the agency and professional experience for the fellow. My paycheck comes from the University of Michigan, and the funding comes from USAID, but what’s most important for me is the opportunity to work in the field just out of graduate school. At Yale I had gained a strong academic background in EPH’s International Health Division and learned a great deal about the research, community and policy context of the pandemic while working as community director at the Center for Interdisciplinary Research on AIDS, based in the School of Public Health. But with no experience living and working in a developing country, the fellowship was just the jump-start my career needed. One thing that is clear in Kenya—and in most of sub-Saharan Africa—is that nearly two decades of awareness raising and scare tactics have not done enough to curb the epidemic. People have heard of AIDS. They fear it. Many know AIDS is caused by a virus spread through sexual contact and have some idea of how to prevent transmission. But as my encounter with the traffic cop demonstrated, real understanding is generally poor. Myths and conspiracy theories abound—I recently heard that AIDS stands for “American Invention to Discourage Sex”—and when we ask people at outreach or training sessions to write down their questions about HIV and AIDS, someone always asks, “Where did AIDS come from?”

People do have a strong sense that the AIDS epidemic is a powerful force in the country and on the continent. Kenya has been measuring HIV prevalence since 1985, mostly through sentinel surveillance at prenatal clinics, and the statistics show that an estimated 14 percent of Kenyans aged 15 to 49 are infected with HIV. Though that rate is lower than those in some southern African countries, where adult prevalence may top 30 percent, it still suggests that in Kenya more than 2 million of the country’s 30 million people are living with HIV and AIDS. Hundreds of homeless children roam the streets of Nairobi, many of them AIDS orphans. Kenya’s daily newspapers carry pages of obituaries each day, most with photos. Usually readers are left to wonder whether the young person pictured died of AIDS, but in July, for the first time, one family had the courage to reveal their loved one’s cause of death: the color picture was flanked by two small red ribbons, the symbol of AIDS awareness.

A Landscape of Beauty and Danger

Kenya is one African country most Americans have heard of, thanks to the film Out of Africa and the romantic idea of the big-game safari. Kenya does have spectacular natural beauty. Parts of the country fit the stereotype of the African desert, especially in the sparsely populated north, toward the Sudanese and Ethiopian borders, and the Taru Desert of the southeast. Shaba Game Reserve, in the semi-arid lowlands north of Mount Kenya, was the location for the third installment of Survivor, the popular CBS series. But Kenya also has lush green highlands in its Central Province, gently rolling hills and forests in the west toward Lake Victoria and Uganda, and the steamy Indian Ocean coast, with its distinct Islamic Swahili culture. The Great Rift Valley is home to the earliest human ancestors. Snowcapped Mount Kenya, at 17,000 feet, is the second-highest mountain in Africa, and Kilimanjaro, the highest peak on the continent, is just over the border in Tanzania. Numerous game parks preserve Kenya’s rich wildlife; on my first trip to Masai Mara Game Reserve a year ago last October, I saw elephants, lions, rhino, buffalo, hippos, wildebeest, giraffes, zebra and more, as well as a startling variety of antelopes, primates and birds. Watching a cheetah patiently stalking an impala, or a mama lion playing with her cubs, is unbelievably magical.

Nairobi is a busy, vibrant, cosmopolitan capital of about 3 million people, where virtually any goods and services are available to those who can afford them. Although it sits just south of the equator, Nairobi’s 5,500-foot altitude keeps the climate delightful most of the year, with the chilliest weather in July and August. Despite the country’s natural resources, Kenya’s economy is in trouble; the GNP actually shrank in 2000. The country recently tied with Cameroon, Bolivia and Azerbaijan as the fourth-worst in the world for corruption, according to a survey by Transparency International, a global coalition devoted to curbing corruption. Unemployment is common, crime is rampant and government services are generally poor: roads are in bad shape, many police don’t have vehicles and garbage collection is sporadic or nonexistent. A large proportion of Nairobi’s population lives in slums without running water or sanitation. For most of 2000, the power company was rationing electricity because a drought had reduced the country’s hydroelectric output; in some places, power was cut for 12 hours a day, and water was in short supply. The political climate is uncertain because President Moi, who came to power in 1978, is constitutionally barred from running again in the 2002 elections; some wonder if he will try to run anyway, but in any case the next year is sure to be unsettled.

For people in Nairobi, the terrorist attacks of September 11 brought back the horrors of August 1998, when the U.S. Embassy here was bombed. A total of 213 people, most of them Kenyan, died in the attack, believed to be the work of Osama bin Laden’s Al Qaeda organization. Thousands were injured. Many businesses moved out of the congested city center after the bombing, but since security is already a priority here because of crime, the effect on daily life post-September 11 has been minimal.

In this context, convincing individuals to worry about a virus that may kill them in a decade or so can be a challenge. At PATH, we’re trying to devise new ways to improve the effectiveness of peer education, the centerpiece of the IMPACT project, with the ultimate goal of persuading people to protect themselves by using condoms, reduce the number of sexual partners and learn their HIV serostatus through voluntary counseling and testing. Given that the vast majority of infections in Kenya occur through heterosexual sex, our premise is that AIDS is not the problem, but the consequence: the problem is relationships. That includes relationships between a husband and wife, a young man and woman, a commercial sex worker and her client, a young girl and a “Sugar Daddy.” A key goal is reducing the despair and fatalism surrounding HIV and replacing it with messages of optimism, hope and greater self-respect, as a prerequisite for greater acceptance and involvement with lifesaving messages about HIV and AIDS.

Drama on the Airwaves

The theme of PATH’s communication strategy for IMPACT is “Question Your Relationships.” In every activity, people are encouraged to ask questions, not necessarily to receive the answers from an all-knowing teacher, but to begin thinking in depth about the epidemic, their own risk of HIV, and how the nature and quality of their relationships affect that risk. Rather than imparting information from the top down, we’re training peer educators to facilitate intense dialogue and debate with a relatively small number of people. As the people in those groups raise issues and concerns, and even change their behavior, we’ll magnify the issues and changes on a national weekly radio program we launched in May. The program, called Kati Yetu (“Between Us” in the Kiswahili language), includes a soap opera and a magazine with interviews, panel discussions, music and news. Listening groups have been formed to help spark and deepen debate on issues raised in the program; feedback from those groups, and the peer education groups, will keep the program responsive to community concerns. We depend on IMPACT’s large network of implementing partners to help carry out these activities; the partners, all funded by Family Health International, range from local clinics and NGOs to the Kenya Girl Guides Association and the University of Nairobi and conduct activities such as upgrading health centers and providing voluntary counseling and testing, in addition to peer education and listening groups in workplaces and in the community.

PATH is also producing a comic book for youth, and did a series of murals in schools. For the latter, students developed the content through discussions and role play, then painted the murals with supervision from professional artists and wrote essays based on the topics depicted in the mural. These intense activities are more difficult than producing a poster that says “AIDS Kills.” But we know that fear doesn’t reliably lead to prevention, and despite the probable wider introduction of antiretroviral drugs in Kenya, prevention remains essential.

The challenges to effective prevention are considerable. As in so many places, people are uncomfortable talking about sex and leery of talking to adolescents about sexuality. Years of talking about high-risk groups, instead of high-risk behavior, have led to the idea that HIV is for someone else: for sex workers, truck drivers or “immoral” people. Too many people have decided they simply aren’t at risk. We’re trying out a method of measuring an individual’s perceived distance from the epidemic based on the kinds of questions he or she asks—a “Continuum of Enquiry.” Designed as a matrix, on the far left is someone who feels far from the epidemic and at virtually no personal risk. On the far right is someone living with AIDS. In between are people practicing multipartner sex, people who have contracted a sexually transmitted infection, people who are contemplating a test and people who are living with HIV. Moving from left to right, the questions become more detailed, heartfelt, and personal, and the person’s risk perception increases. As a person feels closer to the epidemic, the possibility of behavior change should increase as well.

For example, a person who asks, “Can mosquitoes transmit HIV?” or “What is the shape of the virus?” probably does not feel at great personal risk. But someone who asks, “If you’ve had gonorrhea, does that put you at risk for HIV?” may be feeling a little closer to the reality of the epidemic. And when a child asks, “Why are people with AIDS so harsh?” we can feel sure he or she has had personal experience. The key is to help the child use that experience to think about risk, protection and a future free from HIV.

At the Westlands roundabout, the traffic has degenerated into merry chaos behind us and the traffic cop is still asking questions—relatively superficial ones according to our matrix, but questions just the same. After a few minutes, he gives us a last probing look, then stops traffic and waves me through.

In only two years here, I can’t really expect to see a noticeable change in the HIV incidence rate, and even if I did I would be hard pressed to say I had contributed to it. But I know that one police officer learned a few things he didn’t know before, and asked some questions that may have made him think. He might talk to others and raise a few questions in their minds, and as they search for the answers they may change their risk perception. I have to believe that every little bit helps. And I did manage to dodge the traffic ticket. YM