Modern Dilemmas

HIV/AIDS Prevention Efforts in Northeastern Tanzania

Eileen Moyer

The primary research for this paper was conducted over two months during the summer of 1996 along the northeastern Swahili Coast of Tanzania, and extending from the capital of Dares Salaam to the northern port of Tanga town. In this paper, I will provide basic information concerning the continued efforts to educate about and further prevent the spread of HIV/AIDS in Tanzania. I will examine some of the underlying concepts of such approaches and will attempt to shed light on ways in which they can be improved.

The Tanzanian National AIDS Control Program (NACP) estimates that about 800,000 people, or 3.2 percent of the population, are infected with HIV (World Bank 1991 :xxi). Among those infected, approximately 160,000 have already developed AIDS, and the rest will presumably follow suit in the next twenty years. In Africa, the average time between onset of symptoms and death is a year, or two. Right now, AIDS accounts for approximately 20,000-30,000, or 5-7 percent of annual deaths in Tanzania. Despite local beliefs that AIDS is not the number one cause of death in Tanzania, studies by the World Bank indicate that it has "recently surpassed malaria as the leading killer among diseases in adults, and is likely to do so for children in the near future" (Ibid.). Current epidemiological models suggest that infection rates may reach as high as 17.4 percent of the total population by the year 2010 (World Bank 1991:xix). These figures become even more disturbing when one considers that most of those who will die are in the prime of their lives. The economic results of such demographic changes will be devastating: the work force will become younger and less experienced, and those who survive will be responsible for taking care of the children left behind by those who have perished.

The World Bank report has suggested that the most important indicator for determining the rate at which HIV infection rates will increase is dependent upon "sexual behavior patterns, and in particular, to the proportion of the adult population with multiple sexual partners" (1991 :xxi). 

If, for example, both partners in 45 percent of married couples are "sexually monogamous", it has been estimated that, by the year 2000, about 1.2 million people will be carrying the virus and another 450,000 will have died of AIDS, with these numbers growing to about 2.3 million and 1.7 million respectively by the year 2010. If, on the other hand, only 15 percent of married couples are mutually monogamous, as many as 3.6 million could be infected by 2000 and AIDS deaths could be as high as 1.6 million, growing to 6.1 million infected and 5.6 million deaths by 2010 (World Bank 1991 :xxii). 

This report, which is backed by the World Bank, World Health Organization, and the government of Tanzania, suggests that the "most important issue" concerning the spread of the epidemic is the sexual behavior of the Tanzanian people. This statement indicates that the ultimate goal of these organizations is to halt all sexual unions that are not monogamous. Although this approach would make sense epidemiologically, in truth, it is unrealistic, moralistic, and perhaps worst of all paternalistic. The report does not state that this goal is likely to be possible, and in fact does go on to make numerous other valuable suggestions to limiting the spread of HIV. But, I believe it is important to understand that major donors of international aid such as WHO and World Bank, often referred to as the gate keepers of international investment, believe that they have the right to demand changes in the sexual lives of Tanzanians in the name of public health.

It was clear to me during my field research in Tanzania that people were not dying of AIDS (the same could also be said of numerous other diseases) because they did not know what caused it, or because they were sexually promiscuous. They were dying due to a series of complex reasons directly related to poverty and a shared lack of individual and communal power in an increasingly global economy. In this respect, the poor of Tanzania are not unlike the poor of the rest of the world, whether living in so called developing countries, or in ghettoized urban areas of the "developed" United States. Many are dying of illnesses and diseases that are easily preventable and treatable because treatment is not available, they are unable to afford it, do not have the insurance to pay for the treatment that is available, or because the health care facilities that do exist are culturally alienating to the poor.

Since the end of socialist president Julius Nyerere's term in 1985, Tanzania has gradually moved toward a formal capitalist economy. The International Monetary Fund (IMF) awarded Tanzania a newly enhanced structural adjustment facility loan worth $ 234 million on November 8, 1996, to signify the agency's satisfaction with Tanzania's willingness to respond to their demands (Wallengren 1997). This award is expected to encourage renewed donor support and investments worth hundreds of millions of dollars from other worldwide funding agencies and businesses. The practice of the IMF is to impose large scale structural adjustment policies on the Tanzanian government to encourage the development of sound macroeconomic practices that theoretically will improve the standard of living for the average Tanzanian (Lugalla 1995:9). As Lugalla points out, however, the average Tanzanian is defined as "poor, "a term which he argues is never satisfactorily defined by the IMF or the World Bank (1995:12). In an attempt to define poverty in the context of Tanzania, he reminds us that a definition which does not recognize that concepts of basic needs change depending on the social settings, and that the "nutritional needs of a nomadic Masai [sic] ... may be different from those members of an African rural and agricultural settled community" (Ibid.). Differences in what are perceived as basic needs also exist between rural and urban communities. Lugalia suggests the following definition of poverty:

... a situation or condition of life or living that is insufficient to meet minimal necessities of life, like food (nutrition), housing, safe water, protection from disease and struggle against ignorance... [and] that poverty is a material condition as well as a power relationship (1995:12). 

Lugalla's definition is similar to the one that I will use to discuss the institutional poverty in Tanzania that results in many people being exposed to a greater risk for contracting HIV/AIDS. This definition provides a flexible framework, that allows for discussion of the ethics of human dignity and human rights, as opposed to one that obscures the realities of daily living by relying on statistical measures of poverty (Lugalla 2995:13). 

Modern Choices? 

There is nothing wrong with underlining personal agency, but there is something unfair about using personal agency as a basis for assigning blame while simultaneously denying those blamed the opportunity to exert agency in their lives (Farmer 1996a:29). 

"Chaguo la kisasa" is a Swahili phrase that can be translated as "the modern choice." It is the advertising slogan used by Salama Condoms, the primary retailer of condoms in Tanzania. The ideological concepts involved in the notion of selling modernity as a way to encourage condom use to help prevent the spread of HIV/ AIDS and other STDs is somewhat problematic in light of Tanzanian ambivalence towards Western modernity. Many Tanzanians are aware that numerous factors associated with modernity, including urbanization, marginalization of the poor, and increased demands for migrant labor have contributed to high HIV infection rates in Tanzania. The effects of modernity have caused a disjunction with past rural based economies.

I would now like to examine some of the advertising techniques employed by Salama Condoms, in an attempt to understand the concepts that inform the assumptions behind Salama's approach. To begin, I briefly discuss the implications of the words "chaguo la kisasa" that are somewhat representative of the marketing goals of Salama Condoms. The word chaguo, or choice, suggests an element -- perhaps an exaggerated element -- of individual agency. The implication is that people can "choose" to be modern, and further that if they decide against this choice, and become infected with HIV, or any other STD, then the blame lies with them. The issue of personal agency in making hoalth care, or "lifestyle" choices is a loaded one. By willfully perpetuating a romanticism of Africa that fails to recognize that many Africans are caught up in a global system that has produced institutionalized poverty throughout much of the so-called developing world, some academics and many development agencies are irresponsibly overstating the agency of individuals to make everyday healthcare choices. It is too easily forgotten that certain parts of the world were purposefully underdeveloped to benefit those who live in the "developed" world (see Rodney 1981; Wallerstein 1979; Wolf 1982; and Mudimbe 1988:3).

Situating individuals within a global political economy that produces institutional poverty, and the illnesses associated with it, is a primary tenet of critical medical anthropology (Baer, et al. 1986; Singer and Baer 1995; Singer 1983, 1992, 1994a, 1994b, 1996a, 1996b; Scheper-Hughes 1990, 1996). To ignore the local implications of poverty can result in blaming a victim who suffers from AIDS, something which has become a recurrent theme in the history of Western epidemic disease (Polakow cited in Farmer 1996a:32). Development agencies sometimes blame the individual for failing to drink pure water, failing to use condoms, and failing to use knowledge regarding public health and hygiene, rather than acknowledging that the larger political and economic systems that include a lack of economic opportunities for the oppressed, and an unfair distribution ofthe world's resources (Farmer1996a:32). This mentality ignores the realities that basic needs differ according to social circumstances, such that what might be defined as in'ational behavior in one circumstance is completely understandable when one is able to adopt an emic point of view (Lugalla 1995). "Exaggerations of poor [peoples' ] agency are consonant with many core U.S. values. In a classless meritocracy of self-sufficient individuals naturally dominated by self-made multi-millionaires who profess family values, it's easy to blame poor [people] for their personal misfortunes" (Farmer et al. 1996:202). This quote illustrates how propagandized notions of American "values" can be used by those with a conservative agenda to condemn people who have failed to live up to those "values" due to economic imbalances.

In our role as educators and intellectuals, Africanist scholars are constantly being forced to challenge myths about Africa (Mudimbe 1988). The media are filled with images of Africa that mostly portray warfare, starving children with distended bellies, and people living in abject poverty. Rarely do those who live outside of Africa witness the spirit and perseverance of its people. In response to this, many anthropologists, including me, in an attempt to represent the silenced subjects and friends who have made our research possible, may occasionally be heard to utter phrases such as, "oh they may not have much, but they sure are rich in spirit." Phrases like this, while well intentioned, may in certain circumstances be viewed as romantic, paternalistic, and even dangerous. Poverty of economic circumstances should not be equated with poverty of spirit, but in emphasizing the "happiness" and "spirit" of Africans we may be encouraging the status quo ideas that we set out to challenge. The fact is that most Tanzanians are poor, and many of those who are "rich in spirit" will die this year as a result of that poverty. To imply that Tanzanians have a choice when it comes to protecting themselves from AIDS, misses the point that having the ability to make a choice does not mean that one has the power to make that choice.

Kisasa, or modernity, is an adjective formed from the noun root sasa, meaning "now," and belongs to the noun class associated with abstract concepts. Kisasa means modern, and is essentially linked to the concept of the present and "nowness." During my time in Tanzania I quickly learned that to demand that things be done fight now, or sasa hivi, is very rude. It is commonly believed that all things will come in good time. Patience is more than a virtue in Tanzania, it is a way of life. In light of this knowledge I question the value of anything that is associated with "nowness." The past in Tanzania, as in many societies, is romanticized, and things associated with modernity are often considered a passing phase, or as fads that have not withstood the test of time. There is also the notion that if one chooses to embrace modernity one must turn one's back on the past, or zamani. Zamani was used by many with whom I spoke to indicate a connection with the past. Medicine which I referred to as "traditional" was sometimes described by them as dawa ya zamani. I do not think they were implying that they believed that these medicinal practices were disconnected from the present, but rather that they were a continuation of the past into the present. This is not to say that I never encountered people who believed that things from the past should be discarded in favor of modernity. Tradition and modernity, rather than existing as opposite concepts, live side by side in Tanzanian society, and it is necessary to resist the temptation to create a false sense of order where in reality one does not exist. This apparent contradiction is anything but a contradiction. In regards to healing, people routinely make use of more than one medical system. Competing medical systems coexist, and patients are often willing to try all of them when they, or their family members are ill.

Despite the reality that modernity offers little by itself, Salama Condoms continues to sell modernity, as opposed to a balance between old and new with a healthy respect for the past. Salama Condoms are distributed by Population Services International (PSI), an international development organization that receives funding from numerous sources throughout the world, but most significantly from USAID. This is important because many of the decisions made by the organization are directly in accord with USAID policies. Indeed, one could describe PSI as a subcontractor to USAID, acknowledging that they must adhere to USAID guidelines in order to retain their contract. PSI is also behind the marketing of numerous other healthcare recommendations, including the distribution of insecticide impregnated mosquito nets, rehydration salts and various forms of birth control in many African and developing countries throughout the world. One of their primary goals is to reduce birth rates in Africa and elsewhere in the developing world so as to improve the standard of living. Tanzania is a country where children are considered a sign of wealth, honor, and prestige, and agencies that aim to decrease the number of children born are often considered threatening and untrustworthy. The following statement shows why women in Tanzania may be unwilling to embrace family planning strategies which attempt to limit the number of children: 

Successful marriage bonds in Africa are cemented with the bearing and rearing of children. A childless couple is often shunned and ridiculed. More often than not, the woman is blamed for the failure to have children, and is assumed to be infertile. It may be suggested that the woman misbehaved in the past and engaged in risky practices that have caused her infertility. This is often grounds for abandonment or divorce (Lwihula 1994:60). 

The move toward monogamous marriage, which has occurred under the guise of modemity in Tanzania, has resulted in unspaced families, neglected children, and maternal weariness (Tumbo-Masabo and Liljestr6m 1994). Nationalized education programs, combined with other factors have often ended, or at least abbreviated, initiation processes that in the past had provided young adults with education about sex (Ibid.). In recent years, family orientation has shifted from the extended family to the immediate family as pan of the urbanization process. Often grandparents, aunts, and uncles, who had been responsible for educating children about sex in the past, no longer live in the same town as the immediate family, and parents often are unwilling to talk to their children about sex (Ibid.). These are only some of the dilemmas of modernity as it pertains to high HIV/AIDS infection rates in Tanzania.

Salama Condoms, the primary retailer of condoms in Tanzania, uses social marketing techniques to sell their products. The objective of social marketing is not only to sell the product, but also to sell social change through the use of Western marketing techniques (Andreason 1995:3). The ultimate goal of Salama Condoms is to modify the behavior of the people of Tanzania to halt the spread of HIV. The philosophy of the director of the Salama organization is to make Tanzanians want to use condoms, and to create a demand for condoms.. that will not go away once the development organizations pull out. His philosophy, and that behind social marketing in general, is that since most outside health care agencies give their products away for free, they do not create a demand in the capitalist sense of the word. Salama Condoms are sold at the modest price of approximately US 30 cents each, and the agency maintains its nonprofit status by pumping its income back into the project. The condoms are sold wholesale to local stores, pharmacies, clinics, hospitals and traditional healers, who in turn sell them to the public. In order to get people to buy them, condoms and the health messages that go along with them are advertised over the radio, on television, in newspapers, and through posters and signs. Philip Setel (1997, personal communication) has pointed out that in Moshi town, Kilimanjaro Region, name brand condoms which must be purchased in local stores are often considered more trustworthy than free condoms that are distributed by development projects. He suggests that in buying name brand condoms people make a statement about their willingness to invest in erotic pursuits. Essentially, all condoms are not created equal. Free condoms are often described as being too thick and less effective in preventing disease than the name brand condoms. 

It is true that most development projects fail to create a sustained interest in their product, whether the products are consumer goods such as medicines, mosquito nets, or condoms, or whether practices that encompass behavioral modifications, such as boiling water, practicing safer sex, or avoiding undercooked meat. Some development and structural adjustment projects have instituted social changes that have fostered an environment which encourages the spread of AIDS and other diseases. Brooke Schoepf, an anthropologist working on AIDS related topics in Zaire, has described AIDS as follows: 

Globally, AIDS is best regarded as a "disease of development" and "underdevelopment." It has struck with particular severity in communities struggling under the burdens of economic crisis caused by stagnation in the global economy, distorted internal production structures inherited from colonialism, unfavorable terms of trade, and widening disparities of wealth fueled by the channeling of public funds into private pockets (Schoepf 1993:55). 

Schoepf's observation illustrates the degree to which outside forces, often under the guise of development and structural adjustment programs, have played a role in institutionalizing the poverty that increases Tanzanians' risk of contracting AIDS. Development projects which encourage men and women to leave their families in search of work are rightly perceived by Tanzanians as often doing more harm than good. To illustrate the degree to which mistrust of development agencies is felt in Tanzania, I quote an excerpt from Philip Setel's description of a local response to the efforts of MUTAN (Tanzanian-Norweigian AIDS Project) among the Chagga of Kilimanjaro region. 

For those who are not directly involved, these [development] projects can easily be seen as temporary and ineffectual additions to the local landscape. They are all but openly said to be scams for rewarding a handful of influential local people with new cars and big salaries. In the case of AIDS, it is not uncommon to hear whispered suspicion that the national AIDS control effort is either underwritten or heavily subsidized by condom companies in Europe and America. The cynics say that the AIDS workers are in it only for the money, not because they believe in what they are doing (Setel 1995:66). 

In another account of the activities of MUTAN, Eli S. Heguye (1995) illustrates how the agency began supplying free condoms in Oria village, Kilimanjaro Region as part of an HIV/AIDS study. These free condoms flooded the market, forcing the two shops and private dispensary that had previously sold condoms to discontinue carrying them. When the study was completed MUTAN pulled out of the village, taking their supply of free condoms with them. Without a local supply, young people reported traveling as far as 30 kilometers to Moshi town in order to buy condoms (1995:118). In light of these observations it is not surprising that Salama Condoms tries to disassociate itself from the development projects that have made mistakes in the past.

My intention here is not to imply that international development organizations are intentionally acting against the best interests of the people whom they are trying to serve. Instead I would argue along with Farmer, et al. that the solutions offered to health problems, while well intentioned, are often shortsighted, and that their efforts often "obscure the roots of health problems rather than directly address them" (1996:293). This observation is made in light of the fact that WHO studies have shown unequivocally that power and economic imbalances are the primary risk factors for predicting vulnerability to AIDS, and yet intervention programs and recommendations continue to target the individual without addressing the larger structural problems that have resulted in poverty (Ibid.).

Salama Condoms, in encouraging individuals to embrace "chaguo la kisasa, "is subtly selling social changes that promise to deliver relief from poverty in exchange for a willingness to embrace modemity. This is not a new concept. European colonial and neocolonial presence in Africa has been justified by the paterealistic insistence that Africa needed to be enlightened and civilized, to be encouraged to move towards Western ideals, world religions and capitalism, in order to achieve equal status with the already "modemized" and "developed" Western world. The irony, of course, is that much of the wealth of Europe and the United States was built on the backs of Africans, and that if Africa were ever to achieve an equal voice in the world market, European ideas of wealth would have to be redefined. Moreover, this argument completely overlooks the fact that the international market may not be able, or willing, to absorb the products that Africa has to offer. Salama Condoms is merely the latest in a long line of projects that have sought to entice Africa with promises of the ostensible benefits of Western modernity.

Entering Dar es Salaam from the north one is confronted by a barrage of advertisements, for products like Coke, Pepsi and various pharmaceuticals. Among the billboards is a prominently displayed Salama Condoms sign, declaring "Chaguo la Kisasa" (figure 1 ). It is ironic that many who come into the city traveling along this road do not have the luxury of making the choice do as this sign implies. Rather, economic circumstances directly related to modernity, often force them to leave their homes in search of employment to feed their families. This sign is also ironic because it is in the city, the icon of modernity, that people are at the greatest risk for contracting HIV.

The most recent advertising campaign sponsored by Salama Condoms employs a more subtle approach than simply stating "choose modernity." A primary goal of this particular campaign is to empower women to tell men that sex without a condom is out of the question. In recent years it has become apparent to many AIDS prevention programs workers that it is necessary to provide people with more than just factual knowledge regarding AIDS if the hope is to achieve a high degree of compliance with preventive measures. A recent survey carried out by researchers at the University of Dar es Salaam has shown that over 97 percent of respondents were aware of AIDS and over 80 percent were aware of its major modes of transmission. Despite this knowledge, condom use was negligible (World Bank 1991 :xxxii). 

Women's Choices 

Many people have argued that a primary reason for noncompliance with condom use is that women cannot insist on condora use in domestic situations. This argument assumes that women would in most circumstances want to use condoms, and that it is only men's resistance that results in non-compliance. While in Tanzania, I often heard two sayings in response to the act of wearing a condom during sex. One compares having sex with a condom on to taking a shower while wearing a raincoat, and the other compares it to eating candy with the wrapper still on. It is generally argued by many development agency prevention proposals that men will not initiate condom use, and unless women insist upon it, it is unlikely to happen. Even if one were to accept this argument, the problem remains that women must first have the power to make such demands.

The women portrayed in the Salama Condom posters are shown as quintessentially modern. They all appear healthy and thin, wear Western-style clothing, and many have light skin and straightened hair. I was told by people at PSI's main office in Dar es Salaam that the women used as models for the posters, many of whom looked like contestants in the Miss Tanzania contest, were purposefully selected from the Kilimanjaro Region, women I am told who look like they are Chagga. I was told that this was done because Tanzanians associated this region and this ethnic group with wealth and modernity. It is, in fact, the wealthiest region in the country, producing great quantities of coffee and attracting millions of tourist dollars a year.

The annual Miss Tanzania contest, a national beauty pageant, was held while I was in Dares Salaam, and many Tanzanians with whom I spoke were privately outraged by the appearances of the women who supposedly represented the ideal Tanzanian woman. Several people remarked to me that all of the women were "too skinny," and that they were trying to deny their "blackness" by lightening their skin and straightening their hair. The images of modern "Chagga" women that PSI uses in its posters raises an interesting point about economic and social class in Tanzania. The women in these posters clearly belong to a higher socio-economic class, while PSI claims that it is trying to empower women of the lower classes. Is it possible that the light skinned Salama women may in fact alienate poor women simply because of their class? Burke has noted that "skin lighteners," and hence light skin, "demonstrate the inextricable intertwining of consciousness about class and race" (1996:188). Further, that "use of lighteners attract[s] vociferous criticism both from political activists and from self-identified 'traditionalists,' who view the products as the most potent and immediate embodiment of elite ... submission to the corruptions of modemity. (lbid.y' Advertisers, including those of condoms, must observe a fine line between people's desiring to be part of the upper classes and their despising of the upper classes because of their superior social and political positions. Advertisers must acknowledge that people choose to use certain products, and that the incorporation of manufactured goods into daily life is rarely indiscriminate (Burke 1996:189). A decision to use skin lighteners or condoms may be directly related to notions of class identity. If condoms, like skin lighteners, are seen as an embodiment of modernity, it may not necessarily be a good thing.

One Salama poster (Figure 2) depicts a mother and daughter sitting on a bed in a modest Tanzanian home. Emblazoned across the top in red is "Mueleze.t" -- "explain it to him!" One assumes that the mother is offering this advice to her daughter. At the bottom appears the catch phrase, "Bila Salama?" --"Without a Salama (condom)? .... Hata Siku Moja" -- "not even once." The wagging of the finger is associated with the line hata siku moja. Once when I was wearing a Salama condom T-shirt in Dares Salaam, I noticed a couple of men talking about it and laughing. I looked at them with a serious face and said "Bila Salama." They both laughed, waved their finger at me and said "Hata siku moja. "

Although the advertisements never mention AIDS or condoms directly, everyone I asked could tell me what the poster was about. The word salama, meaning peace, safety and tranquillity, is equated with condoms, much as Coca-Cola is associated with a carbonated beverage. It is clear from such responses that Salama Condoms has attained a high degree of product recognition, at least among those living in the cities which have been highly targeted by the advertising campaigns.

Another set of posters (Figure 3 and Figure 4) portray young successful couples wearing very modern clothing. The woman in figure 4 is carrying books that identify her as a college student, an educated modern woman who knows what she wants. The man is clearly on the defensive in both posters. The posters evoke experiences that play upon stereotypes regarding the male pursuit of the opposite sex. One can almost imagine from the looks on their faces the sort of line that he might be feeding her right now.

Another poster shows a date scene (Figure 5). This setting is a very posh restaurant, the likes of which very few Tanzanians could afford. This image questions notions that assume that if a man buys a woman dinner he is entitled to demand repayment in the form of sexual favors. The answer the poster provides is "no way." But it is clear from the expressions on the faces of the models, that it is the woman who is setting the ground rules.

Looking at these posters, it is also clear that something else is being promoted along with condom use. Modernity in the form of books, nice clothes and fine dining is all part of the package. One advantage to this marketing approach, of course, is the simultaneous development of Tanzanian markets to consume Westem imports. This is the paradox, or dilemma of modernity. The very media which purport to be interested in stopping the spread of HIV are in fact encouraging behavior that most people inrural areas associate with the cause of AIDS. Kisasa or modernity is "killing" people in Tanzania and the health organizations are paying for the advertisements which promote it.

Although I laud the efforts of Salama Condoms, and any other organization that attempts to empower women in social situations, I question their methods. Women may look at these posters and acknowledge that they would like to be like the women portrayed, but they are not provided with a way to do so. In order to make demands, women must first have power, and a failure to recognize this allows development agencies to continue acting upon the myth that building a woman's self-esteem is all that is necessary to get her to make behavioral changes.

A poster produced by DANIDA (Danish International Development Agency) in conjunction with World AIDS Day attempts to address some of the social prejudices experienced by people with AIDS (Figure 6). It says "World AIDS Day, December 1 st: Equal rights and responsibilities to all. A person who has AIDS has equal rights like anyone else. Therefore he deserves to be given love, care and various family services without discrimination." The woman in the poster is saying, "These days men just pass us by without even a greeting." The man is saying "We must understand that the only way of avoiding AIDS is to avoid casual sex and to respect yourself."

On the surface this seems like a straightforward public service poster. I found, however, upon questioning several people about it that it was also seen as carrying an underlying message about prostitution. Many men viewed the woman in the poster as either a prostitute or a loose woman. I asked, "Why is that? Is it the clothes she is wearing, or the way she looks"? The responses were in general agreement that it was not her appearance that made her seem like a prostitute, but instead, the words she was using. My interpretation had been that the woman in the poster was complaining that men are often too busy to get to know a woman, and they are only after one thing. The men with whom I spoke, however, said that this kind of talk indicated that she was looking for sex, and that the man's comment about avoiding casual sex was a direct reference to the woman. She was seen to personify casual sex. I have no way of knowing for sure whether the designers of this poster intended it to contain this subtle subtext, but I highly doubt it, given that they have clearly tried to confront the social problems associated with AIDS.

The image of the modem woman as prostitute and transmitter of HIV is a common one throughout Africa, and one that has recently been at the center of the debate concerning the approaches of AIDS researchers and development projects. Schoepf (1995) has led the argument against blaming women who are forced to sell their bodies in exchange for food and meager payment for becoming infected with HIV. Drawing on examples from her work among women in urban Zaire, she notes: 

The [economic] crisis has fostered risky situations and forced numerous women to use sex with multiple partners to provide for themselves and family members. Adolescents from poor families are especially vulnerable to offers of gifts. Some exchange sex for food, clothes, or grades in school. Fear of AIDS promotes older men to seek out youngsters whom they reason are unlikely to be infected (1995:31). 

Even the term prostitution has become problematic in light of the current debate. The word prostitution, it is argued, connotes Western ethical and moral values which are out of place amidst the economic realities of Africa (Day cited in Haram 1995:47). Some would argue that this response is simply one of semantics, and that anyone who is involved in commercial sex is engaging in prostitution, or "the transaction of money for sex" (Talle 1995:25). But Talle misses the point that transactional sex does not always involve the exchange of money. The greatest increase in HIV infection raises in the United States in recent years has been among young women of color, many of whom have been similarly forced into situations where they must prostitute their bodies in order to meet life's basic requirements. Poor women in the United States and poor women in Africa often share many of the same race and class variables. Adding gender to the equation compounds the effect of their compromised position within social power structures. Although there are sound arguments which state that some women engage in prostitution as an act of free will, most would not choose to expose themselves to HIV if there were more viable economic opportunities available. Women who engage in commercial sex because they are in need of 'money are highly vulnerable to HIV infection. They are not always able to negotiate safer sex because they often cannot be as selective as they wish, and they cannot afford to turn away customers who insist on sex without a condom, especially if the men are willing to pay more for such an opportunity.

Foucault has argued that prostitution has emerged in the Western mind as an example of deviant behavior to be relegated to the realm of otherness (1990:4, first published 1976). Prostitutes are social outcasts who have been falsely blamed for spreading the AIDS epidemic throughout the world. Prostitutes lose their identity and become pan of a homogenous, devalued group. 

This assumption directs attention away from the fuzzy boundary between 'normal' women and prostitutes, away from the context of poverty and disempowerment underlying many women's decision to engage in sex work, and away from the variation within the field of prostitution in terms of working conditions and for transmission of HIV (Sacks 1996:65). 

Sacks' point in this statement is that women from all levels of society will at times engage in sexual services for material goods and access to men's resources. Oversimplifying the boundaries of commercial sex fails to recognize the variety of forms and circumstances of sexual exchange for many women struggling to survive with limited resources (Strebel 1994:39). Women of Africa are no different from women throughout the world who are in inferior positions, and prostitutes, rather than being singled out for their "deviance," should be recognized as rational players in a game where they hold little power.

There is a sense of ambivalence towards prostitution in Tanzania. Although most would agree that it is immoral, most would also recognize that it is often a necessary part of modern living. In Tanzania, poor urban women who trade their bodies for material benefit are perceived as being modern, and as consumers of condoms. Talle argues that among female bar workers in Namanga, a town in northern Tanzania, women who engage in sex work out of economic necessity are "detaching themselves from constraining gender roles and institutional family authorities and marking their own individuality, [they] act within a modern paradigm" (1995:22, my emphasis). Prostitution is seen as a way to gain access to modernity, or kisasa. Talle further suggests that a prostitute is able to increase her street value by increasing her heshima, or respect. In order to do this, she must be selective in her sexual partners, and she must insist on men using condoms (lbid.) This seems to suggest that there is a certain desire among men to engage in safer sex with a prostitute on some occasions, and also that some women who already posses a degree of social power are able to further exploit it in order to demand condom use.

In many ways condoms are seen as a product of the modernity characterized by prostitution, and this sort of modernity is not something to which most women would aspire. If prostitutes are recognized as being modern consumers of condoms, and one can make the assumption that most women do not aspire to be prostitutes, then it would be unlikely that most women would insist on condom use for fear of being associated with prostitution. In fact, women are unlikely, and indeed unable in many circumstances, to ask their partners to use a condom. Even women who use condoms with customers are unlikely to use condoms with their boyfriends or husbands, for fear of insulting them by implying that they might already be infected (Lwihula 1994:63; Strebel 1994:41). It also serves as a way for the women to separate the business of prostitution from their domestic sexual lives (Schoepf 1995; Bourgeois 1996; Farmer, et al. 1996). As one woman has said, "if you want to get a divorce, try asking your husband to use a condom" (Mhloyi and Mhloyi 1994:18). 

Building Bridges 

Singer (1994:933) argues that it is necessary for those working on AIDS related issues to resist the temptation to exoticize the Other. This can best be accomplished by looking at both local and global power relations that have contributed to the explosion of the AIDS epidemic in Africa. Singer outlines ways that prevention programs might best respond to HIV in developing nations where there has been a strong mistrust of large development projects. He suggests that community residents should be trained and then permitted to institute local prevention programs based on their knowledge of the community; that local actors must be employed to dispense information about AIDS; and that it is necessary to address health problems beyond HIV, something which is especially important in Tanzania where most people are more concerned with the possibility of dying from malaria and diarrhea than from AIDS (Singer 1996:490). Having spent several months conducting research in Tanzania I agree with all of Singer's suggestions and observe that where these approaches were best employed relative success was encountered in the form of increased condom use (see Moyer 1997). Although it is too early to determine if such use will result in decreased HIV infection rates, it certainly seems promising.

The epidemiology of AIDS in Tanzania is complex and it is impossible to provide broad explanations of causality without looking at the cultural, political, and economic factors which contribute to increased infection rates. It is necessary to examine the larger political economy dictated by Tanzania's position within the global market in order to understand why people living in conditions of extreme poverty may be at a greater risk for exposure to HIV; why these same people, due to malnutrition, may already have weakened immune system; and why other diseases, such as malaria, tuberculosis, and cholera might contribute to shortened life spans for those already infected with HIV. Macro-level social processes including education, urbanization, and economic development must be recognized as factors which contribute to the spread of infection (Ware et al. 1992:23). The economy of Tanzania, like many other African countries, has been "underdeveloped" as a result of the demands of Western capitalism (Rodney 1982:14), and as such, it should be recognized that only revolutionary political and economic changes will allow for the future "development" of Tanzania. 

In the mean time, however, people continue to die of HIV related infections and numerous other diseases at startling rates. Development agencies such as PSI are working hard to decrease new infection rates. At the same time, local actors and grass-roots organizations are doing their best both to prevent new infections and to treat those who have already contracted the disease. For the immediate future, it will be necessary to continue building upon the groundwork of such grass-roots organizations in an effort to curtail the spread of the disease. Microsocial factors including the way people define HIV/AIDS, when and how people seek treatment for infection, the degree to which they comply with prescribed treatment, ways that the chronic nature of HIV limits an individual's ability to participate in daily communal and family activities, and gender and power relations within the community all must be examined in order to understand how best to affect positive changes. Nearly everyone I interviewed understood that HIV is most often transmitted through sexual intercourse, and many knew that biomedical and development agency personnel recommended condom use as a means of protection. But most also had valid reasons for questioning the efficacy of condoms and the intentions of development agencies. It is only through understanding such reasons, and through a willingness to reply to such questions that condom use can be effectively encouraged. 

Works Cited 

Andreason, Alan R. 1995. Marketing Social Change: Changing Behavior To Promote Health, Social Development, and theEnvironment. San Francisco: Jossey-Bass Publishers.

Bourgois, Philippe. 1996 (1995). In Search of Respect: Selling Crack in El Barrio. Cambridge: Cambridge University Press.

Burke, Timothy. 1996. Lifebuoy Men, Lux Women: Commodification, Consumption, and Cleanliness in Modern Zimbabwe. Durham: Duke University Press. 

Farmer, Paul. 1992. AIDS and Accusation: Haiti and the Geography of Blame. Berkeley: University of Califomia Press.

________. 1996a. "Women, Poverty, and AIDS." In Women, Poverty, and AIDS: Sex, Drugs, and Structural Violence.

Farmer, Paul, Margaret Connors, and Janie Simmons, eds. Monroe, Maine: Common Courage Press. 1996b. "Rereading Social Science." In Women, Poverty, and AIDS: Sex, Drugs, and Structural Violence. Farmer, Paul, Margaret Connors, and Janie Simmons, eds. Monroe, Maine Common Courage Press.

________. 1995. "Culture, Poverty, and the Dynamics of HIV Transmission in Rural Haiti." In Culture and Sexual Risk: Anthropological Perspectives on AIDS. Brummelhuis, Han ten and Gilbert Herdt, eds. Amsterdam: Gordon and Breach Publishers.

Farmer, Paul, Margaret Connors, and Janie Simmons, eds. 1996. Women, Poverty, and AIDS: Sex, Drugs, and Structural Violence. Monroe, Maine: Common Courage Press.

Foucault, Michel. 1990 (1976) The History of Sexuality Volume 1: AnIntroduction. New York: Vintage Books.

Haram, Liv. 1995. "Negotiating Sexuality in Times of Economic Want: The Young and Modern Meru Women." In Young People at Risk: Fighting AIDS in Northern Tanzania. Klepp, Knut-Inge, Paul M. Biswalo, Aud Talle, eds. Oslo: Scandinavian University Press.

Heguye, Eli S. 1995. "Young People's Perception of Sexuality and Condom Use in Kahe." In Young People at Risk: Fighting AIDS in Northern Tanzania. Klepp, Knut-Inge, Paul M. Biswalo, Aud Talle, eds. Oslo: Scandinavian University Press.

Lugalia, Joe. 1995. Adjustment and Poverty in Tanzania. Müinster: Lit Verlag.

Lwihula, George K. 1994. "Gender and Acceptance of Medical Innovations and Technologies Related to STDs and AIDS in Africa." In Gender, Health, and Sustainable Development: Proceeding of a Workshop held in Nairobi, Kenya, 5-8 October 1993. Wijeyaratne, Pandu et al. eds. Nairobi: International Development Research Centre.

Mhloyi, Gilford D. and Marellous M. Mhloyi. 1994. "Socio-Cultural Determinants of HIV Infection in Zimbabwe." In Gender, Health, and Sustainable Development: Proceeding of a Workshop held in Nairobi, Kenya, 5-80ctoberl993. Wijeyaratne, Pandu et al. eds. Nairobi: International Development Research Centre.

Moyer, Eileen. 1997. Dilemmas of Modernity: AIDS Prevention Strategies in Northeastern Tanzania. Unpublished Master's Thesis: University of Iowa.

Mudimbe, V. Y. 1994. The Idea Of Africa. Bloomington: Indiana University Press ________. 1988. The Invention of Africa: Gnosis, Philosophy, and the Order of Knowledge. Bloomington: Indiana University Press.

Rodney, Walter. 1982.How Europe Underdeveloped Africa. Washington, D.C.: Howard University Press.

Sacks, Valefie. 1996. Women and AIDS: An Analysis of Media Misrepresentations. Social Science and Medicine. 42(1):59-73.

Schoepf, Brooke Grundfest. 1995. "Culture, Sex Research and AIDS Prevention in African" In Culture and Sexual Risk Anthropological Perspectives on AIDS.

Brummelhuis, Hanten and Gilbert Herdt, eds. Amsterdam: Gordon and Breach Publishers. 1993. "AIDS, Sex and Condoms: African Healers and the Reinvention of Tradition in Zaire." In Rethinking AIDS Prevention: Cultural Approaches.

Bolton, Ralph and Merrill Singer, eds. Amsterdam: Gordon and Breach Publishers.

Scheper-Hughes, Nancy. 1996. Small Wars and Invisible Genocides. Social Science and Medicine. 43 (5):889-900.

________. 1990. Three Propositions For A Critically Applied Medical Anthropology. Social Science and Medicine. 30(2):189-197.

Setel, Philip. 1997. Personal communication, April.1996.

AIDS as a Paradox of Manhood and Development in Kilimanjaro, Tanzania. Social Science and Medicine. 43(8): 1169-1178.

Singer, Merrill. 1989. The Coming of Age of Critical Medical Anthropology. Social Science and Medicine. 28(11): 1193-1203.

________. 1996. Preventing AIDS in Communities of Color: Anthropology and Social Prevention. Human Organization. 55(4):488-492. ·

________.1994a.. AIDS and the Health Crisis of the U.S. Urban Poor: ThePerspective of Critical Medical Anthropology. Social Science and Medicine. 39(7):931-948.

________.1994b. The Politics of A1DS. Social Science and Medicine·38(10):1321-1324.

________.1992. AlDS and Ethnic Minorities: The Crisis and Alternative Anthropological Responses. Human Organization. 51 (1):89-95. · 1990. Reinventing Medical Anthropology: Toward a Critical Realignment. Social Science and Medicine. 30(2): 179-187.

Singer, Merrill and Hans Baer. 1995. Critical Medical Anthropology. Amityville, New York: Baywood Publishing Company, Inc.

Singer, Merrill, and A. Baer, and Ellen Lazarus. Critical Medical Anthropology in Question. Social Science and Medicine. 30(2):v- viii.

Strebel, Anna. 1994. "It's Difficult to Leave your Man over a Condom." In Gender, Health, and Sustainable Development: Proceeding of a Workshop held in Nairobi, Kenya, 5-8 October 1993. Wijeyaratne, Pandu et al. eds. Nairobi: International Development Research Centre.

Talle, Aud. 1995. "Bar Workers at the Border." In Young People at Risk: Fighting AIDS in Northern Tanzania. Klepp, Knut-Inge, Paul M. Biswalo, Aud Talle, eds. Oslo: Scandinavian University Press.

Tumbo-Masabo, Zubeida and Rita Liijestr6m. 1994. Chelewa, Chelewa: The Dilemma of Teenage Girls. Stockholm: The Scandinavian Institute of African Studies.

Wallengren, Maja. 1997.Tanzania Returns to the 1MF Fold. African Business. January.

Ware, Norma C., Nicholas A. Christakis, and Arthur Kleinman. 1992."An Anthropological Approach to Social Science Research on the Health Transition." In Advancing Health in Developing Countries: The Role of Social Research. Chen, Lincoln C., Arthur Kleinman, and Norma C. Ware, eds. New York: Auburn House. World Bank. 1991. Tanzania: AIDS Assessment and Planning Study. Washington, DC: The World Bank.