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On-line version ISSN 1678-4464
Cad. Saúde Pública vol.25 no.3 Rio de Janeiro Mar. 2009
Abordagem de gênero em projetos comunitários de combate à AIDS em Moçambique: convergências e desencontros entre governo e sociedade civil
Wilza Vieira VillelaI, II; Rosemary Barber-MaddenIII
IUniversidade de Franca, Franca, Brasil
IIUniversidade Federal de São Paulo, São Paulo, Brail
IIIMailman School of Public Health, Columbia University, New York, U.S.A.
This article discusses some areas where government and civil society converge and clash in their gender approaches in community HIV/AIDS projects in Mozambique, based on an evaluative study conducted in 2006 encompassing 160 of the 1,124 NGO projects undertaken with the support of the country's national AIDS council, known as the Conselho Nacional de Combate ao SIDA (CNCS). An analysis of projects and official documents shows that, for the CNCS, the term "gender" represents a way of underscoring the epidemic's impact on women. In community projects, the gender approach often times finds expression in initiatives to mitigate the economic impact of the epidemic on widows. Initiatives aimed at men and at the population as a whole generally pay little attention to power relations between men and women or their affect on the epidemic. This suggests that any endeavor to transfer Western analytical techniques or forms of intervention for coping with the HIV/AIDS epidemic to other regions of the world demands painstaking efforts to translate these and adapt them to local cultural standards.
Acquired Inmunodeficiency Syndrome; Sexually Transmitted Diseases; Gender; Africa
Este artigo discute algumas convergências e desencontros entre governo e sociedade civil na abordagem de gênero de projetos comunitários de enfrentamento do HIV/AIDS em Moçambique. Baseia-se em material de pesquisa avaliativa realizada no país em 2006, incluindo 160 dos 1.124 projetos de organizações não governamentais desenvolvidos com apoio do Conselho Nacional de Combate ao SIDA (CNCS). A análise dos projetos e de documentos oficiais mostra que para o CNCS o termo gênero aparece destacando a dinâmica de epidemia em relação às mulheres. Nos projetos comunitários a abordagem de gênero muitas vezes será traduzida em ações de mitigação dos impactos econômicos da epidemia sobre viúvas. Atividades voltadas para a população masculina e para a população em geral pouco abordam as relações de poder entre homens e mulheres e suas conseqüências para a epidemia. Isto sugere que a transferência de tecnologias de análise e intervenção sobre a epidemia do HIV de países do ocidente para as demais regiões do planeta exige um cuidadoso trabalho de tradução e adaptação aos padrões culturais locais.
Síndrome de Imunodeficiência Adquirida; Doenças Sexualmente Transmissíveis; Gênero; África
During the 1980s and 90s, two things became clear: the HIV epidemic was spreading among women, and it was following a different path than among men. Women were contracting HIV through sexual relations with stable partners or their work selling sex, while for men, the epidemic was spreading primarily through recreational sex with other men 1. Comparing the two paths to infection has shed light on the differing ways in which men and women experience their sexuality and has shown how gender stereotypes and attendant inequalities, pressures, and oppression in the exercise of sexuality act as vectors of the HIV epidemic 2. As a result, researchers, activists, and financing agencies have begun suggesting that proposals intended to halt the epidemic take into account the dynamics of gender relations within different cultures and the ways in which these dynamics impact the practice of sex 3.
The validity of this suggestion does nothing to make it easier to put into practice. The notion of "gender" as a social organizer, the emergence of research into how gender inequalities impact health, and the development of HIV-prevention interventions based on the gender approach all came from the Americas and Europe. There the epidemic involved gay men and injecting drug users at first, only later extending to women. The disease took another route in most of sub-Saharan Africa, gaining ground from its very start through heterosexual relations, through the sexuality and conjugality rites and norms specific to each ethnic group, and owing to extremely deficient healthcare resources 4. Yet the features of transmission are exactly the same for women: unprotected sex with a stable partner or with a client. In other words, the perception that the epidemic spreads among women because of their subordination to male decisions about sex and because they lack autonomy (financial, emotional, and social) holds true even in distinct cultural contexts. Nevertheless, initiatives to contain the epidemic among women cannot be universal, for they require an analysis of the dynamics of gender relations within each context, along with an analysis of the context itself in terms of its socio-cultural, political, and economic features and access to resources for empowering women 5. The support women need to break free from dependence on their partners (education, income, health care, work, and social valorization) is related to available material and symbolic resources and to decisions on how to allocate and use these. As Mann & Tarantola have urged 6, "thinking globally, acting locally" is the best guiding principle for AIDS policies and initiatives.
Countries like the US, France, Spain, and England introduced the ideas of using the gender category to guide policies and of analyzing how gender inequalities impact the spread of HIV as a reflection of women's social and sexual subordination and of the epidemic. In these regions, the social problems that contribute to relegating women to subordinate positions have been addressed more effectively and resources are more readily available. This means that any proposals for sub-Saharan Africa must take into consideration the culture, poverty, illiteracy, and poor access to health care that have fueled the expansion of HIV and the epidemic's disproportionate impact on women in these places.
There has been no "feminization" of the epidemic in sub-Saharan Africa, because it has hit large numbers of women there from the very beginning. In Mozambique, for example, 1998 estimates of infection rates among those aged 15 to 49 indicated a higher percentage among women, a situation that held steady for the following years 7. Since this is a feature of the region's epidemic rather than a process, analyses of the feminization of the epidemic and proposed interventions based on the Western world's so-called gender approach, while valuable, must be complemented by analyses of how this same approach is understood and applied in the African context.
The gender approach in AIDS proposals in Mozambique
The material discussed in this article was drawn from an evaluative study conducted in Mozambique in 2006 to ascertain the efficacy of civil society projects put in place with the support of the country's national AIDS council, known as the Conselho Nacional de Combate ao SIDA (CNCS). Through on-site visits and interviews with project workers and beneficiaries, 160 of the country's 1,124 active projects were analyzed. Interviews were also conducted with CNCS staff and management and with provincial departments of the Ministry for Women and Social Action; official documents on the anti-AIDS effort were likewise analyzed 8.
Mozambique's AIDS policy for 2005-09 is outlined in the National Strategic Plan, or the PEN II (Plano Estratégico Nacional). The document assumes that "the gender perspective was present through this entire planning process" 7 (p. 14). This finds expression in the gender breakdown of data on the incidence and prevalence of HIV (although no such breakdown is provided for STDs or behavioral studies); in the recognition of women's subordinate position as a facilitator of the epidemic; and in its analysis of the representations of female and male sexuality within the country's sub-cultures. As strategies for combating the epidemic, the PEN II lists reducing women's vulnerability by decreasing poverty and financial dependence, fighting violence, and overcoming myths and biases against women. The CNCS is the agency responsible for implementing the PEN II and includes under its umbrella the Ministry of Women and Social Action, whose top focus is violence against women and social protection for orphans and widows. In its text, the PEN II places great emphasis on blood transmission, mirroring the emphasis found in interviews with activists, the general population, and CNCS staff alike, even though a comparison of transmission rates via sexual and blood contact indicate that the latter is not very significant.
HIV scenarios in Mozambique
Before proposing any HIV initiatives from a gender perspective, we must first understand the status of the epidemic in Mozambique and its impact on the reality of a poor country still recovering from a civil war, devastated by natural disasters, and characterized by great ethnic, cultural, and linguistic diversity.
A large part of the population does not believe in the existence of HIV or that AIDS is the result of a virus. Sickness in general and AIDS in particular are interpreted from the prism of logic systems and cosmovisions that exclude the notion of an external causal agent and the possibility of human intervention, thereby hampering prevention or treatment activities 7,9. At the same time, the entire country is absorbed in the work of national reconstruction, with implicit ideas about the division of labor, collective work, and the socialization of its results. Maternity is of central importance - like any process that produces or reproduces things of nature, something common in agricultural countries - and in conjunction with the notion of the collective, this breeds ambiguous, contradictory feelings about femininity and even about power differentials between men and women.
The country's numerous languages, religions, ethnic groups, and cultural practices engender a broad gamut of costumes, traditions, and social significances when it comes to sex, conjugality, and relations between men and women. This demands the use of an equally broad gamut of HIV-prevention approaches and tools, as well as accuracy in interpreting the power relations and "power games" found where sex and gender interact. Such diversity notwithstanding, poverty is a homogenizing factor in Mozambique, with 70% of the population living below the poverty line 10. This acute poverty facilitates a scenario in which sex is exchanged for money or goods, without this being seen as prostitution.
Agreement and disagreement between the government and civil society in using the gender category
According to the PEN II, government guidelines require that civil society projects funded through public resources adopt the gender approach. What does this mean? From the text of the plan, we can conclude that this implies understanding the social dimension of sexual relations between men and women and the need for action that will transform these relations. Can such a transformation be accomplished fast enough that efforts to rescue the country from the devastation of war, drought, floods, and malaria will not be undone by HIV?
Condoms are readily available in Mozambique. Yet there is also much resistance to using them, in part for the same reason as in other countries: "it's like eating candy with the wrapper on". But this resistance also reflects distrust of a "white man's" product that keeps babies from being born, that is distributed in order to prevent a disease allegedly invented or imported by this white man, and that may in itself carry HIV 9. These fallacies concerning the origin and even existence of HIV are basically no different from similar fallacies once, or still, circulating in Brazil and other countries: that the AIDS virus came from abroad, that it was produced in a laboratory for the purpose of genocide, and so on 11. It is worth remembering that this kind of conspiratorial fallacy about HIV acts to obscure the social relations driving the epidemic, including gender relations. In fact, an important part of the work by community organizations in Mozambique focuses on convincing the population that HIV actually does exist, with no room left for addressing native sexual cultures or the barriers these create to the use of condoms, especially through constructs involving masculinity 9.
Governmental guidelines are in part a response to pressure from the bilateral and multilateral agencies that finance the CNCS's HIV initiatives, which want these to be based on a "gender approach". However, there is no clear definition of what this would mean in actual fact, nor are there any strategies for training activists in designing proposals that combine this orientation with practices that encourage the use of condoms and with the norms and costumes governing the exercise of sexuality within the country's various linguistic and religious groups 10.
Further, while some proposals are aimed at preventing violence against women and at enhancing their power within communities where women are not part of decision-making processes, such efforts are not always coordinated with efforts to fight the epidemic or with analyses or assessments of their efficacy or impact on HIV. In the international realm, the same parallelism between agendas is seen, as is the effort to link gender violence with the HIV epidemic 5,12.
Given the extreme poverty and social abandon that women face, community projects actually end up placing greatest priority on providing them with the means to guarantee their immediate material survival and that of their children and of the country's countless orphans, who depend entirely on community institutions or family arrangements. For community organizations, protecting poor women, widows, and/or women with HIV is understood as a gender approach, and one that is more effective than seeking autonomy in sexual relations with men. In the case of many projects, activities that generate income or provide free food, seeds, and tools prove more important to their beneficiaries than HIV prevention. For example, when asked what a given project had brought to or taught the community, the answer was more often about material support than about the virus or epidemic 10. Although this may be interpreted as a reluctance to voice the name of something considered an evil 13, we must also consider the possibility that satisfying immediate needs and living with other infectious diseases - like malaria, which is more common than HIV and the number one cause of death in the country 14 - may make HIV less relevant. So priority is not placed on thinking about patterns of male-female relations or the exercise of sexuality, particularly if this reflection will not offer immediate alternatives that make daily life easier.
Projects therefore tend to link initiatives to mitigate the epidemic's impact with dissemination of the idea that HIV is an avoidable virus and that infected people should be cared for, without getting into the topic of sex or of power differences between men and women and without devising activities tailored specifically to each gender. To the contrary, the spirit is to create a collective sense of urgency about the epidemic 8. When a discussion of gender relations does come up during an activity, it basically comes linked to issues of power or violence, without touching on the question of sex, something that remains quite cloaked in silence. In other words, gender relations are addressed in a desexualized manner, and condoms are talked about without reference to desire and its inherently transgressive nature. It has been argued that sex and gender are articulated, interdependent and not juxtaposed realms of human experience 15; in order to prevent HIV infection and diminish the stigma attached to its carriers, a specific approach to sexuality must therefore be accompanied by a discussion of power relations between men and women.
Outline of a gender approach to the HIV/AIDS epidemic in Mozambique
For community organizations in Mozambique, the notion of "gender" and of vulnerable women is most often understood within the context of the poverty in which widows, HIV-positive women, female heads of family, and orphans live.
Women with HIV suffer greater discrimination than men, hampering their access to treatment and prevention methods, but there have been no specific initiatives to reduce this discrimination. For those who do believe in the existence of HIV and in its sexual transmission, what comes into play is prejudice against female sexuality; for those who believe the symptoms of the infection come from supernatural sources, what comes into play are beliefs and myths that see women as the source of all evil and are also part of gender inequalities 13. So however one looks at it, HIV infection and its consequences are blamed on women, leaving men free to engage in unprotected, casual, commercial, or ritual sex and virtually turning them into victims of women - a potentially dangerous reversal of the situation for these women.
There is no denying the gender dimension that drives the HIV epidemic in Mozambique or the fact that recognition of this dimension should guide the design of proposals for dealing with the epidemic and with its impact on the country's female population. Creative alternatives must be sought to transform ideas into concrete actions that are meaningful to the population and therefore can overcome the damage done by the epidemic. In doing so, the ethical and technical attitude should be that the application of experiences, activities, and ideas that have proven successful in other contexts should not obscure the sociocultural traits that will underpin construction of the national or regional identity needed in order to solidify a collective commitment to combating the epidemic.
Analysis of the social relations of sex finds a place on the agenda when and where women have already achieved greater autonomy in the exercise of their sexuality and enjoy a greater role on the labor market and in public life. This increased autonomy is what makes it possible to reflect critically on women's social position and to analyze how such features as domination and oppression are subjectivized and translated into behavior and feelings; this in turn lays the ground both for behavioral interventions that help women protect themselves from HIV as well as for initiatives and development policies for women.
Yet even these initiatives have achieved only relative success. Brazil, for example, is considered an exemplary model in the fight against the epidemic. But its successful program notwithstanding, the country has failed to contain the slow yet steady advance of the HIV epidemic among women, especially the poorest 16.
The recognition that women's subordinate position makes them more vulnerable to the virus must be conjoined with broad development policies that will reduce poverty among women and gain them rights similar to those enjoyed by men.
Gender is an idea that embraces individuals and socially organized collectives at one and the same time. The use of such an approach should inform analyses and initiatives involving both individual behavior and practices as well as collective ones, while simultaneously informing policymaking that seeks to reduce women's inequality through access to education and income. The expectation is that this social equity will redound in less submission to men in general and to each woman's partner in particular.
In the realm of individual initiatives, the category of gender has proved quite valuable in academic work and in interventions based on the notions of self-esteem and self-valorization and on challenging certain norms, especially those concerning partner submission. In the context of HIV prevention, this has been manifested in the idea of "demanding a condom" and, in the aid context, in terms of endeavoring to reduce discrimination in healthcare settings. While these strategies are useful and necessary, they have fallen short of the mark in cases where they have already been applied for some time now. Within the sphere of collective initiatives and of policy implementation, the gender approach has not yet achieved the desired results, precisely because of the problems encountered when translating proposals from paper into concrete, broad, and meaningful action 12.
The magnitude of the epidemic in Mozambique requires swift, efficient responses. Trusting in adoption of the gender approach without any concomitant efforts towards development and poverty reduction, the valorization of national identity and culture, and solutions based on dialogue with those affected and on recognition of their creativity and intelligence may delay the engineering of an effective national response in the HIV/AIDS battle, with clearly deleterious implications.
Mozambique's gross domestic product has grown steadily 10; as promising as this is, the increase in national wealth has yet to reverse the epidemic's tendency to spread, especially among women. In countries whose culture differs from those of the modern Western countries where the notion of gender was forged, use of this concept should entail a process of adjustment and adaptation, including initiatives for and about individuals - both male and female - and for and about collective groups, as well as broad social policies. As in other African countries, women hold major posts on Mozambique's national political stage. This may offer a valuable window of opportunity when it comes to implementing policies and actions that contribute towards gender equity. Yet we must underscore the apparent ambiguity that pervades the social valorization of women in Mozambique, where the presence of women as community leaders, heads of extended families, and holders of public offices comes hand-in-hand with sex trafficking in young girls, rituals of purification through sex, violence, and rape. Consequently, any proposed practices or policies for containing the expansion of HIV based on the gender approach should take into account the tight link between culture and development. The cultural patterns adopted by any given society, including social gender relations, are interdependent on each society's development model. So preventing HIV/AIDS requires the implementation of initiatives aimed at reducing poverty. It is within this context that reducing social inequalities between men and women can make sense.
W. V. Villela and R. Barber-Madden share equal responsibility for the writing and editing of this text.
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W. V. Villela
Universidade Federal de São Paulo
Rua Alarico Franco Caiubi 347
São Paulo, SP 05330-011, Brasil
Submitted on 25/Aug/2008
Approved on 04/Nov/2008