Sm. Sci. Med. Vol. 36, No. 3, pp.

175-194, 1993 Printed in Great Britain

0277-9536/93 66.00 + 0.00 Pergamon Press Ltd

THE COMPETING DISCOURSES OF HIV/AIDS IN SUB-SAHARAN AFRICA: DISCOURSES OF RIGHTS AND EMPOWERMENT VS DISCOURSES OF CONTROL AND EXCLUSION
GILL SEIDEL University of Bradford, Bradford, West Yorkshire BD7 IDP, U.K.

Abstract-The competing discourses of HIV/AIDS circulating in sub-Saharan Africa are identified. These are medical, medico-moral, developmental (distinguishing between women in development and gender and development perspectives), legal, ethical, and the rights discourse of groups living with HIV/AIDS and of African pressure groups. The analytical framework is that of discourse analysis as exemplified by Michel Foucault. The medical and medico-moral are identified as dominant. They shape the perceptions of the pandemic, our responses to it, and to those living with HIV/AIDS. However, dissident activist voices are fracturing the dominant frameworks, and are mobilising a struggle for meaning around definitions of gender, rights, and development. Key words-HIV/AIDS, sub-Saharan Africa, discourse/language, gender, rights, ethics development

1. INTRODUCTION
This

paper

seeks

to identify

the major

discourses

on

HIV/AIDS circulating within sub-Saharan Africa. It is concerned with the ways in which HIV/AIDS is talked about, how it enters into discourse, how it acquires other meanings which both preceded and inhabit the AIDS discourse that derive from dominant institutional frameworks and categories. And, in a dynamic perspective, it focuses on the struggle for meaning engaged around definitions of gender, rights and development. A number of distinctive yet overlapping discourses contend for hegemony. The dominant discourse, identified here as medical and medico-moral, have shaped the AIDS agenda. They have had a considerable impact on policy design and intervention in the national and international arenas, on the perception of people with AIDS, and those seen to be at risk. Dissenting voices seek to challenge and fracture the dominant medico-moral representations which constitute a source of power. These dissident voices are articulating a discourse of rights and empowerment from a southern, developmental perspective. The discourses identified, deconstructed and contextualised are medical, medico-moral, development, legal, ethical, and the rights discourse of
groups living with HIVJAIDS and of African pressure groups. The discourses fall into two categories: discourses of control/exclusion vs discourses of rights/ empowerment.

2. THE ANALYTICAL

FRAMEWORK: ANALYSIS

DISCOURSE

The analytical framework, more familiar to social scientists in continental Europe and particularly in

France, is that of discourse analysis [I]. Its basis is in social semiotics. Discourse is used in the sense that encompasses entire texts and different signifying systems. It is used in a primarily interactive sense. It is an elaboration of the dialogical principle [2] in which a text, or utterance, may be defined in relation to other utterances, that is, in terms of its intertexuality [3]. Discourse analysis shows how social and institutional values, or ideologies, may be constructed, and circulated. Foucault has shown how the body is caught up in a political field of power relations. He has sought to identify the polymorphous sites of power and the interplay between modes of domination and various forms of classification [4, 51. Following Foucault, our concern is with how discourse functions and how power is exercised through discourse, not with ideology as reflection. This study represents a preliminary mapping and complex contextualisation, pinpointing the linkages and intersections of the different discourses and uses of AIDS. Discourse analysis is necessarily an interdisciplinary endeavour, with significant contributions from critical anthropology [68]. Concerns with the politics of meaning, with language as a political object, as a political resource, or as a control, identify the ways in which the linguistic and the political have been connected [8, pp. l-24; 9-l 11. The most illuminating studies derive from a minority perspective [12]. They are concerned with the ways in which minority and powerless groups are constructed and oppressed through discourse [13-161, and with modes of resistance [17-191. This is the interactive process. These include studies of medical settings, and images of gender and science within medicine [ZO] and religion. As an example of

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GILL SEIDEL

analytical resistance [21] to dominant discursive practices this study also shows how hitherto muted speakers [22, 231 are attempting to fracture and challenge the dominant institutional voices. There is now a considerable literature on AIDS discourse in the North, on the social and media representation of AIDS and of people with AIDS. However, there has been no attempt to analyse the principal and intersecting discourses on HIV/AIDS in the African regions as a locus of power and struggles; or of the implications of the struggles engaged around particular meanings, and the material outcome for women and for the Continent.
3. COMPETING DISCOURSES

There is a short-term explanation, or account of HIV spread in Africa, and a long-term, contextualised, developmental perspective. I refer to the medical and development discourses respectively. These contrasting accounts correspond to different paradigms which construct their object in totally different ways; and as knowledge and disciplines they occupy a different rank and prestige. They enjoy a differential access to public policy and funding. They also have significantly different outcomes. 3. I. Medical The
medical discourse

may predate colonialism [30]. At times these have been contained and resisted. Medical discourse has shaped the cultural agenda of AIDS in which the Person with AIDS, as a full human person, is absent. To quote Watney, it has fixed and reinforced a rigid network of heavily medicalised perceptions [3 11. This conceptual rigidity frozen into fixed categorial frameworks has had damaging material effects. These are immeasurable. First, it has further marginahsed vulnerable communities. Second, it has impeded the design and implementation of effective HIV intervention throughout the world: to think in terms of exclusive, fixed categories, of a fixed relationship between sex and gender, and to advance monocausal explanations for extremely complex social phenomena, is to be blind to the flexibility of sexual behaviours and to the interrelatedness of risk [32, 331. The introduction of more appropriate and more sensitive interventions have been hampered by the hegemonic medical paradigm which has been deaf to womens voices, and altogether reductionist. 3.2. Fracturing
carrying the medicaI category of risk groups:

the critique forward

view, a hegemonic view, is the This account of AIDS dates from the recognition of AIDS by the medical establishment [24]. It is the authoritative voice, usually mediated by the Ministry of Health. This is an organ of state, answerable to no particular constituency, and often highly bureaucratic. Yet it has the power to make and execute decisions, determining policy priorities and appropriate interventions, and fix the level of funding. Medical discourse is concerned with symptoms, with depersonalised seropositives. These are seen to be typically prostitutes or promiscuous people, members of so-called high risk groups, or core transmitters, or control populations, all epidemiological equivalents, linked to reservoirs of infection. In the professional AIDS discourse of the North, the stigmatising and misleading high risk groups has been more widely replaced by risk behaviours. But elsewhere the initial language and conceptual frames set by the early WHO statements, and epidemiological explanations inviting these moral judgments, have not generally changed [25]. The limitations and effects of these categorisations have been analysed and combated in the North and South by cultural analysts and AIDS activists [2&28]. In the South the labelhng of sexworkers and free women (femmes libres) generally as high risk groups (and of course gay [homosexual] men in the North [29]) has resulted in their further harassment, control and medicalisation. The mass harassment and calls for expulsion of independent women are not a new phenomenon, and
moment.

short-term

A more context-sensitive categorisation has been advanced by two health policy specialists from Southern Africa, that of situations of risk [34], with an awareness of contexts of violence. This new categorisation shifts the focus to include displaced and refugee populations suffering from the effects of war, destabilisation, and natural disasters. It is a useful categorial refinement. However, the gender dimension is obfuscated-as long as it assumes that women and men are at equal risk. Beyond the obvious disymmetries of power and knowledge, there are sociological and epidemiological considerations. The populations of refugees in displacement camps-in Zimbabwe, Somalia, and elsewhere-are predeominantly women and children. Contrary to widespread belief, it is women and children who regularly account for the largest numbers of casualties in war. War is constructed as a male activity-with the result that women as guerrilla fighters and political activists (refugees from Mozambique in Zimbabwe camps, for example) [35] and as farmers growing the regions food, are doubly absent as subjects. In Uganda, reports suggest that HIV has increased dramatically in the north in the wake of military intervention. Furthermore, there is an epidemological disymmetry: epidemiological patterns have stressed the considerably more effective transmission from men to women. 3.3. The construction
of African AIDS

A key dimension and construct of medical discourse is its categorisation of disease. In the South, both Northern and Southern aetiologies contend for political space and prestige. Traditional medical practitioners knowledge and cooperation is being actively sought in some AIDS control programmes.

The competing discourses of HIV/AIDS in sub-Saharan Africa This is the case, for example, in Zimbabwe and where traditional practitioners are registered, and in Zambia. However, there can be no doubt of the centrality of the biomedical categorisation of disease in HIV intervention, particularly after May 1984, following the publication of the Gallo/Montagnier studies, with power shifts, competition and interaction between AIDS as an epidemiological issue and a biomedical paradigm. These battles continue, within and between paradigms, and between powerful research institutes and particular scholars. There have been very particular consequences for Africa. The WHO had produced a geographical categorisation of HIV infections, ostensibly on the grounds of viral transmission patterns (homosexual, heterosexual and through contaminated blood supplies, etc.). This categorisation is extremely problematic in a number of respects. Sub-Saharan Africa is seen to represent Pattern II countries, where HIV is being spread primarily through heterosexual contact, unscreened blood supplies, and by perinatal transmission. Firstly, this authoritative categorising obscures the fact that the virus affects heterosexuals in Europe and North America (Pattern 1); and where the increased spread may be explained primarily by IV drug users, (as in Italy, for example) and by heterosexuals generally. Evidence would suggest that many heterosexuals unlike the gay community have not modified their sexual behaviour-because they still cling to the belief that straight sex is not a high risk activity. This is the result of homophobic reporting and earlier categorisation of the disease (as a gay plague). It is also due to the filtering down of the medical construct of Pattern I countries and Pattern II into the popular press. Secondly, the effect of constructing the Pattern II type is to invent African AIDS [28, 36-381 as if it were a totally distinct tropical disease. If African AIDS is constructed as a tropical disease, and this is legitimised by the discourse of the Northern medical establishment, then this has profound implications for funding and for international solidarity. It is a new, very authoritative and sophisticated variety of the discourse of control and exclusion, which, because of its medical and scientific stable, passes as neutral and non-ideological. This, it seems, was the subtext of the Seventh International AIDS Conference held in Florence, Italy in June 1991 [39]. 4. DEVELOPMENT DISCOURSE Development discourse is by no means unitary. It draws on different theoretical frameworks. Different hypotheses are put forward to account for the interrelated patterns of underdevelopment. Some of these explanations include the development efforts themselves and the rapid growth of urban centres destroying the existing networks [40]. The very concept of development is a hotly contested area. Develop-

177

ment, originally a biological metaphor in the 18th century, has transferred into the social sphere, and became part of ordinary language towards the end of the 19th century. It is a metaphor at the centre of a web of meanings. It acquired a particularly important dimension of meaning in the 1930s with the association, in legal and constitutional texts, between development and colonialism [41]. Development as distinct from medical discourse cultivates a diachronic, historical perspective. In an anti-colonial perspective, with labour migration as an important variable, it addresses the socio-economic determinants of health and health care [4245]. It is this long-term view that has been largely absent in the sensational, often racist and voyeurist reporting of so-called African AIDS in much of the British and international media, as well as in the monocausal medical accounts. But African journalists and communities neither have the right of reply or equal access to the international press. The long-term view is concerned with articulating the problems of underdevelopment, a no less disputed concept. This analysis has produced a historically-constituted development discourse related to calls for international and North-South solidarity. Within this development framework, President Museveni of Uganda has emphasised that the AIDS threat to public health is a developmentally linked disease with deep historical roots [46]. In his address to the Seventh International AIDS Conference meeting in Florence in June 1991, which was also markedly moralistic, he quoted some salient and sobering statistics. In 1987, the average per capita health expenditure in sub-Saharan countries was U.S.$3.50 per year, as compared with U.S.$ 1000 in the U.S. and the Scandinavian countries. He reflected how these and other factors detract from the treatment of endemic sexually transmitted diseases, an accepted co-factor in HIV transmission. 4.1. Constructing tvomen and gender in development discourse Another strand of development discourse constructing explanations for HIV spread and making policy recommendations is concerned with womens experiences and womens work. There are two distinct paradigms. However, as with so many sites which construct women and womens issues within the frames of patriarchal discourse, there are inconsistencies, subterfuges and contradictory ideologies. The paradigmatic change and accompanying shift in verbal strategy occurred in the early 1980s. There was a move from Women in Development (WIDta source of contradictory policies, favoured by such institutions as the World Bank and some African military presidents and their First Ladies-to gender and development [47-511. Until recently, women were not recognised as being economically active, despite the fact that on a macrolevel they constitute the continents food producers. In effect, they have been

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GILL &DEL of sexual behaviour or operate in isolation of the need for action on poverty and gender inequality 164.651.
5. MEDICO-MORAL DISCOURSE

excluded from particular sectors. Within the functionalist paradigm of complementarity, this is euphemistically termed a division of labour: it obscures the sex division of control of production and resources. Mechanisation processes and technological innovations, even when introduced into traditional sectors of womens work, and addressed to women, have tended to be appropriated by men in both the South and the North. Within the new paradigm, development data is disaggregated in terms of gender. Gender and development [52-541 holds out the promise of more informed research and intervention in HIV and sexual behaviours as in other important areas. It builds on womens experience of mens control over womens sexuality and over their productive and reproductive work. It has the potential of challenging the dominant construction of sex (biological) and gender (cultural) as opposites as decreed by nature [Y-59, 233-2361, and the structure of male power. Some perceptive analysts, like Ankrah [60], a Ugandan-based social scientist-whom I would now situate in the gender and development frameworkare giving increasing importance to gender and gender oppression. This follows Obbos pioneering insights in Uganda [61]. Ankrah has been critical of other social researchers in the continent, including the Society for Women in AIDS in Africa (SWAA) and what she sees as their softly-softly approach to mens privileged access to women. This is often defended in the name of African tradition or African culture. Far more controversially, however, in gender terms, she is promoting the notion of male empowerment as primarily a function of legislation. The advocacy of male empowerment is somewhat surprising. It is usually a strategy advanced by heterosexual men to defend their power and privilege in response to womens analysis of male power and the need for womens empowerment. In this dominant perspective, it is a lexical and symbolic subversion to justify both their continued sexual harassment of women and their multiple female partners. This rather startling advocacy needs to be situated in the current Ugandan context and the changing ideological stance of the government [62]. The aim is to impose (and police) monogamy as a means of reducing HIV risk. This includes the emphasis of new legislation in an attempt to sanction under-age sex and sexual harassment of minors. A strict moral code to be adopted towards women has been part of Musevenis National Resistance Armys Code of Conduct from its inception [63]. Arguably, this has been difficult to enforce, particularly in the northern war zone. Standing and Kisekka have soberly set out the necessary gender priorities and their relationship to development, in the context of the pandemic: in situations of deepening economic crisis which disproportionately affect women as provider, no AIDS prevention programme can afford to ignore the socio-economic aspects

Some meanings within development discourse intersect with moral and medico-moral discourses in the HIV context. These are primarily Christian interventions. As distinct from most development discourses, the medico-moral discourse is frequently judgmental; and AIDS has been represented by some as Gods punishment. Medico-moral discourse shares features of the older public health paradigm which created social categories of disease identified with disorder. These assume considerable importance in predominantly Christian communities. Their impact on national AIDS programmes in Christian contexts should not be underestimated [66]. Furthermore, there is an upsurge in fundamentalist faiths in which women are called upon to conform to a domestic and reproductive existence (although bornagain practices seem to vary within and between communities) [67]. In many African contexts. early missionary activity meant the establishment of hospitals and schools. In Uganda, the missionary hospitals account for an estimated 42% of hospital care, despite the separation of church and state and Ugandas history of religious wars. With the virtual collapse of Ugandas superstructure, their role is crucial. The Catholic mission hospitals in southern Uganda, around Masaka, and in the Rakai district, organise essential outreach activities. This means that any challenges to the Christian truth and practice cannot be articulated in the public arena. It is another case of double bind. High-profile Christian HIV interventions mobilise sets of meanings primarily around sexuality and the body, such as the value of chastity and fidelity before and within monogamous marriages (predominantly for women-a guarantee of paternity in patrilinear societies where children brought up by women belong to the fathers). Christian discourse on the importance of motherhood merges with older. indigenous values: in the grass roots perception, womens status in much of sub-Saharan Africa is intimately tied up with motherhood and a large family. Widely shared values of what constituted good conduct also prescribe general behaviours for women. 5. I. *Chastity inter~~mtiorrs Some chastity interventions endeavour to support young womens voices and deal with sexual intimidation and harassment. Examples include Girls have a right to say no to sex, a church hospital programme in Zambia [68], and the non-denominational Action Health Incorporated supporting teenage girls in Lagos, Nigeria, concerned with limiting unwanted teenage pregnancies. These important initiatives may clearly intersect with other non-stigmatising

The competing discourses of HIV/AIDS in sub-Saharan Africa discourses which seek to construct women as subjects. However, they also intersect with Christian Pentecostal discourses of the born-again community. These patriarchal discourses locate women within the strict domestic setting, but in ways in which young urban women, constantly pressurised for sex, may find attractive [67]. 5.2. Christian chastity us condoms in Uganda Condoms and condom distribution remains a highly complex and controversial issue in Uganda [69] and elsewhere. They engage a web of meanings and sites of power. Catholic, Protestant and Muslim leaders have condemned condom marketing or distribution initiatives as encouraging promiscuity [70]. However, non-denominational NGOs continue to quietly promote and distribute them in their training sessions [66]. This may be read as a confrontational strategy or subversive act. It may also be read as a distinctive contribution to public health, separating the discourses on community and public health from older public health discourses and those constructing traditional Christian morality, with a view to minimising conflict. The Presidents position on condoms has shifted. It is now indistinguishable from that of the current Pope, although he claims that his position is practical, not ideological, suggesting that it is largely a problem of distribution, cost and access in rural areas [46]. It could be said that rural access to aspirins present altogether similar problems, but no argument is being advanced for avoiding aspirins . . . On an earlier occasion, adopting a nationalist culturist stance, the President criticised condoms as non-Ugandan. This discourse was challenged by a Ugandan nurse living with AIDS in a corridor discussion during a training session in Kampala (July 1988): Ugandans will have to change their cultureor theyll die [66]. Such critiques must necessarily be elusive. While some Catholic missionary doctors and nurses permit condom use between established couples, where only one partner is infected, this represents exceptional pragmatism. But one report suggests that a new section of The AIDS Support Organisation (TASO), which hitherto has regularly made condoms available, is now controlling their distribution [71]. It emerged from discussions with leading Catholic missionary healthworkers in Uganda, who are very much on the frontline and are those coordinating HIV intervention programmes throughout the continent, that the AIDS pandemic represents an extraordinary opportunity to reaffirm their most deeply held values concerning the sexual order. These include the Medical Missionaries of Mary. Such views may be seen as part of a cultural system, or ideology in Geertz sense [72], which is mobihsing behaviour. In both Kampala and in southern Uganda, in the Rakai region, recent popular religious activities have been exceptionally contained within the Catholic Church. These include a number of women seers in

179

the Catholic parish of Mbuye delivering messages from the Virgin Mary preaching sexual chastity and morality in relation to AIDS [73]. Some Christian-based NGOs in Uganda and elsewhere more actively address interrelated concerns, including the historical roots of poverty and related morbidity patterns. They do not restrict their concerns, to one-dimensional issues. They give priority to the social justice dimension of the Gospels as consonant with a human rights discourse. The paradigm is that of liberation theology. This creative theological project is developed from the perspective of the poor and oppressed by the Dominicans (Order of Preachers) in the Americas. This theology explores topics seldom addressed by traditional theology. While the Dominicans have appointed African promoters of Peace and Justice on the continent, liberation theology has failed to flourish in Africa [74]. Other Christian interventions are more authoritarian, dismissing grass roots participation and concerns, such as the high bride-prices; while some priests are reported as justifying glaring gender oppression and male violence as a cross to be born. The intertextuality is very apparent. The various subtexts on the religions and cultic agendas, part of world and state ideologies, have shaped the already intermeshing development and AIDS discourses. These are also competing in the religious and political arenas to construct and regulate the category of woman. 5.3. The gender construction of national programmes The ubiquitous slogans from east Africa are now very familiar and form a chorus within most National AIDS programmes: Stick to one sexual partner, Zero grazing or the stricter Churches version: Love faithfully [66]. This is useless advice for women in heterosexual relationships who have no say over their partners fidelity (reports of women being infected by their husbands are commonplace). Furthermore, the increased level of domestic violence inflicted by men whose extra-domestic freedoms, either through economic hardship, or fear of AIDS, have suddenly been curtailed, is still to be recognised as an issue [75], and a further dimension of male violence. Rape must also be recognised and addressed in situations of peace, as common practice; also, in very early arranged marriages, according to experiential accounts [76], as well as in situations of destabilisation and war. The vast majority of sexually active women and their needswomen as a class at risk-with or without children, have been completely overlooked in most National AIDS programmes. Instead, they have chosen to target urban elites and harass the more identifiable female sexworkers. The major shortcomings of these intervention programmes and their implications for women have been summarised by Longwe and Clarke [77] in an extremely valuable series of tables which have received scant attention. Of the many creative

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care and support programmes already in operation and in the planning stage in Uganda, Rwanda, Zambia and Zimbabwe, not one is concerned specifically with organising support for women. The medico-moral discourse on AIDS (in common with other sexually transmitted diseases, like syphilis) involves blaming others [78]. The location of blame for disease in immorality or sin of the Other is part of the older, religious tradition of using sexual taboos and prescribed behaviours to reinforce existing sexual orders, and other order patterns in the interest of the well and powerful [79]. The category of the other take on a variety of disguises in time and space. It accumulates stigma through a selection and combination of cultural devices, calling on homophobic, xenophobic, sexist and racist stereotypes and representations. Most enduringly, however, in the South it is the female sexworkers and women in general who are blamed, as is the case for sexually transmitted diseases in both the North and South. In Nigeria, in each of the three major regional languages, Hausa, Igbo and Yoruba, corresponding to different ethnicities, the phrase used for STDs may be translated as womens diseases [80]. This is a strikingly poignant and condensed symbol in which the vagina and womens hidden secret areas more generally, the symbolic inversion of the penis, are seen as shameful, and both polluted and polluting. In many cultures on the continent, they are also unspeakable, other than in the crudest of terms. Drama is a way round, and particularly puppetry [81, 821. 5.4. Deconstructing the category of prostitution What is a prostitute and what constitutes prostitution, or sexual services? Dominant assumptions from Europe, uninformed by sexworkers organisations and voices (now networking after the Second International Conference for AIDS-related NGOs in Paris in 1990), are still largely projected on to African urban contexts [83]. It is necessary to see it as work (not as feminine social pathology), but with a clear recognition of its location within wider historical processes. Gender-sensitive ethnographic studies have analysed the contexts of sexual servicing in different regions where few jobs are available for women [30,76,84-891; and where women have limited access to the cash economy. These services are extremely complex, have ethnic specificities, and are by no means static; and nor are their clients. Earlier studies include those of White [90] in Nairobi, appropriately subtitled domestic labour. She identified a number of different modes of work, all survival strategies for women. Often, there is no dichotomy between marriage and other relations implying sexual-economic exchange, but, rather, a continuum of forms of sexual service. This is the case among the Mongo in southern Zaire where there is no prostitution in the conventional Northern sense; and where young women, single or married, or whose regular partner may be away, are

given money or presents for un coup presi (a quick service), une nuit blanche involving a whole night [91]. In the course of their lives, women frequently alternate periods of marriage with periods of sexual service to one or more clients, or friends, who pay with gifts or money. The Karuwai Hausa women living independently with other women in Katsina, northern Nigera, practice karltwanci [92]. Particular forms of sexual service have different names in different communities [90,93]. However, sexual servicing does not necessarily distinguish a free woman from a wife, or from a repudiated woman, or widow. A free woman can become a wife, and a wife a free woman. In a recent study of sexual networking in a Yoruba community in Ekiti in Ondo State, southwest Nigeria (1989-90) [94,95], women interviewed were most indignant when it was suggested that they took lovers for any other than an economic motive [96]. In East Africa the Swahili term, malaya (used as a general term, though it has cultural and professional specificities) [89,90], is an expression of reprobation, or abuse, used to control relatively independent women. The use of this derogatory term conceals the fact that these relationships are often experienced by women as distinctly advantageous and more congenial. This is the case in Uganda where the increasing number of female-headed households, and of women living alone, in southern rural and semi-rural Uganda, is readily admitted by women in single sex group and individual discussions in Kampala (1989). This trend was documented earlier by Obbo [61], but is generally denied or minimised by men. In informal discussions, men insisted that women are always looking for men and husbands as a means of support; and that women can and should be encouraged to (re)marry at any age. The fact is that in marriage, the husband acquires sexual and reproductive rights as well as an unrestricted right to his wives labour [97]. Furthermore, in much of East Africa, he has the right to any additional income derived from petty trading. (And marriage as a second and particularly as third wife carries a very low status position.) These are crucial considerations when in Uganda, as in Nigeria, and in most of Africa, the object of political power is wealth. The control of women and mens access to women, particularly as wives, provides an endless resource of labour. An altogether exemplary piece of action research by Schoepf [98,99] and colleagues for CONNAISSIDA in Zaire, taking account of vulnerable womens own assessment of risk, using experiential training methods, has been influenced by the theories of the Brazilian Christian educationist, Paulo Freire. A number of recent studies point to the effects of structural adjustment policies in the continent and the deepening crisis. They show that the structures of employment inherited from colonial times have contributed both to the weakening of the extended family and to the feminisation of poverty [lo&1031. To quote Schoepf: Linking macrolevel political

The competing discourses of HIV/AIDS in sub-Saharan economy to microlevel sociocultural analysis shows how womens survival strategies have turned into death strategies [98, p. 2011. This embeddedness of dominant sexuality, the images of gender and illness in the cultural and political matrix and the different meanings attached to wetness and dryness partly explain mens resistance to condoms in many parts of Africa (in the few urban contexts where supplies are available and affordable)---particularly as proposed by female partners; and already largely associated with STDs. Apart from diminished penile pleasure (as frequently reported), it would also seem to be a confirmation of the presence of pollution and disease, of STDs and HIV carried by/in women-rather than the best means available for staying healthy, for protecting others, or for avoiding reinfection, other than abstinence or non-penetrative sex. These are entrenched, cumulative discourses [ 1041 which are not easily disrupted-because of the linked mechanisms of sanction. But that does not of course suggest that culture is unchanging. Women health workers, including some sexworkers as resource persons seeking to change sexual behaviours and to encourage condom use, find that they need to use more explicit sexual talk. In so doing, they are dubbed shameful women and may be shunned. Life-saving strategies, negotiation and self-expression need to come through demystification and empowerment, and through economic and political leverage. Despite enormous odds, cultural and sexual behaviours are clearly capable of change; and a number of NGOs in the AIDS field have made this an article of faith [105-1071. However, in the context of development in particular, and with due sensitivity to different cultural contexts, and difference, human rights issues are being played down.
6. LEGAL DISCOURSE AND HUMAN RIGHTS COVENANTS

Africa

181

tionality [109], was the lone Commonwealth voice vigorously opposing South African sanctions and categorising the ANC as a terrorist organisation? In other fora, these issues need to be clearly addressed from the perspectives of popular sovereignty [11 l-1211; and this is already happening. 6.1. Human rights covenants underpinning AIDS rights discourse We may now turn to the human rights covenants which underpin the AIDS rights discourse and which inform public health policy on AIDS. The legal discourses on AIDS in relation to rights, dignity and civil liberties derive from the main human rights covenants, principally from the UN Universal Declaration of Human Rights (1948). This Declaration forms part of what is known as the International Bill of Rights. What is significant about the Universal Declaration is that it represents the basic international pronouncement of these rights, carries considerable moral weight, and is widely considered to form part of customary international law [122]. This is comprised of three further UN texts: The International Covenant of Economic, Social and Cultural Rights, The International Covenant on Civil and Political Rights, and its Optional Protocol. Other important international and regional treaties have been formulated and adopted using the framework of the Universal Declaration. These include the African Charter on Human and Peoples Rights, adopted by the OAU and which came into force in October 1986. There are important differences between the western and other traditions in terms of individual as opposed to group rights (though this need not cloud our view of the basic universality of human rights). Because of these differences, many westerners show a lack of understanding of group rights, although these are not necessarily in opposition. A salient example is the right to self-determination. This can be articulated in terms of a people, or nation. Some of the rights set out in the African Charter on Human and Peoples Rights, particularly Articles 19-24 relating to colonialism, are articulated in the language of group, rather than individual rights [123-1291. And the United Nations recognise both community rights and the rights of groups. It is clear that human rights are fomulated in the context of peoples experiences. However, as Jallow and others have pointed out, other articles in the African (Banjul) Charter remain somewhat vague, emphasising duties; and these could be manipulated by elites [123]. On the Continent, many Africans would wish to emphasise the religious factor in the fomulation of human rights [ 130, 1311, although there are problems with particular fundamentalist theologies which discourage social responsibility. How human rights should be implemented and respected is a question of beliefs, values, solidarity, organisational strategieswhat Mamdani calls the creativity of popular activity [132+spurred on by activist ethics.

A fundamental principle of human rights is the principle of non-discrimination in the enjoyment of rights and liberties. It is perhaps useful here to pinpoint the international human rights instruments and show how they inform public health policy on HIV/AIDS, indicating some of the important, critical literature and key reports. The necessary inter-relatedness of human right and development, which of course pre-dates the AIDS pandemic, has been highlighted in the development discourse on AIDS, as exemplified by President Museveni of Uganda. The hegemonic North-South relations, as well as pre and postcolonial history, necessarily underwrite these considerations. In particular, the human rights conditionality now generally attached to economic aid packages by the industrialised countries, including the European Community [108-l lo], raises fraught and complex questions. How should the South respond to this conditionality when the British Government, for example, one of the countries emphasising this condi-

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6.2. Humon legislation

rights co~erzants ir@ming

public health

The scope of the International Bill of Rights and the relationship between Human Rights Law and public health Icgislation has been set out with great clarity by Hsusermann and Danziger in their important background document probided for the Global Expert Meeting on AIDS: A Question of Rights and Humanity. which met m The Hague, Netherlands, in May 1991 [IX]. The second major document is a Commonwealth Secretariat report, Ethical and Social Aspects of AiDS in Africa (1990). It is the culmination trf ucjrkshops in Nigeria (Lagos) and Zambia (Siavotipa) 1: ILIIX 1990 attended hy representatlves from 4 numbc~ ()I African states. Neither of these major reports is indexed in the major computerised AIDS data bases. or has been circulated by WHO GPA. Many statcv hdvc developed public health legislation relating to the control of contagious and infectious diseases It ii cl-ucial to point out that public health eapcrts worldwide have continued to emphasise that HIV cannot be transmitted casually, or through the respiration route. like TB. Myths about alleged transmission through mosquitos or other biting insects. through touching, sharing utensils or bedding. need 1~ be dispelled. A number of African journalists hate contributed to this important informational campaign through their regular health columns [ 134. 1351.Their voices need to be joined by other trusted, influential individuals and groups in the region and in the continent wherever people are meeting together. It follows that there can be no public health rationale for the isolation or quarantine of a person on the grounds that they may be infected with HIV, or have AIDS. Any restriction on the grounds of HIV status is. therefore. unjustified and amounts to an infringement of human rights. Evidence would clearly suggest that discrimination hampers public health efforts to implement effective prevention and care programmes j136. 1371. Where there is prejudice and blame, people do not come forward for information, counselling or treatment. Respect for human rights and dignity- 01 persons with HIV or AIDS is an essential condition for effective AIDS intervention. Pro-active stand5 have been adopted by the 42nd World Health Assembly since its resolution of 13 May 1988 to help protect the rights of persons infected with HI.\ 6.3. Inrernationrrl resistance to restrictive gration law U.S. immi-

protest against the current restrictive U.S. legislation refusing entry to people on the grounds of their seropositive status (and subsequently relocated to Amsterdam, Netherlands), is a victory for the advocates of human rights. The U.S. example also illustrates how North American immigration law and an unenlightened public health practice may combine to launch a further assault on human rights and dignity in a country whose founding myth, and declaration of independence, are based on equality. Resistance in the form of international human rights awareness and activism shows how discriminatory practices may be challenged and changed.

7. ETHICAL. DISCOLHSE

The particular social and cultural construction of ethical agendas places members of certain communities at particular risk [ 138, 1391. Ethical agendas refers to situations in which a decision balancing one good against another must be made. Ethical decisions require an act of judgment [140]. Ethical discourse, therefore, may seek to sustain particular beliefs, values, attitudes and behaviours that may be consonant with the medico-moral discourse; or, alternatively, it may challenge and subvert these beliefs and values. It is a very hotly contested area. Conventionally, ethical discourse encompasses talk and argument about right conduct. In basic terms, ethical principles in relation to public policy will set out to determine the greatest good to the greatest number (beneficence), to promote equity and distributive justice, and the respect for autonomy, dignity and human rights. They tend to be discussed in two categories: --Measures intended to protect society (the greatest number or the common good).(These range from the most coercive measures, like quarantine, to the more liberal measures, like the need for information and education.) -Measures intended to protect individuals. (These include the rights of the patient to confidentiality and treatment. Many of these rights, if not inscribed in codes of medical ethics, are already contained in the Declaration of Human Rights and in the common law of most countries.) This literature, hitherto largely from the North, has been summarised in a number of related articles by Manuel et al. [141, 1421. The Northern literature is now extremely abundant. Southern sources are rarely indexed. Also, day-to-day pressures, rapidly deteriorating socio-economic conditions, and inadequate funding hamper even informal circulation of recommendations and decisions taken by African professionals and pressure groups. Where the concept of beneficence is consonant with an informed public health policy and rationale, this tends to promote the wellbeing of citizens. However,

The World Health Assemblys example has been followed by other international and national agencies, including the UN and the European Community, influenced by organised, activist lobbies. The boycott of the international conference on AIDS originally to be held in Boston, U.S., in 1992, in

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183

some discourses of control will seek to conflate the greatest number with a dubious, exclusive notion of the public good in which those living with HIV or AIDS and other marginalised, stigmatised groups are deemed to lie outside that community [143]. There are rumours of possible restrictive measures in some African states under military rule. In countries with poor communication infrastructures, such measures could be applied without common knowledge, so that professional and other influential citizens and pressure groups might not intervene, or only at a late stage. There are further implications here for the necessary intersections of human rights, development, and gendered discourses. In some countries, it has been suggested that journalists are not censored in their reporting of AIDS, but rather that the reporting is shaped by factors largely internal to the media professions. This would appear to be the case in Nigeria [144]. However, in Nigeria or elsewhere, police and military could function as agencies of forced migration, as has been the case with removals of persons, particularly of women, in many parts of the developing world. Forced eviction is now considered a gross violation of international law (according to the UN subcommission on the Prevention of Discrimination and Protection of Minorities at its 43rd annual session which met in Geneva in August 1991). But enforcing this law in military regimes is another matter. Even before the AIDS pandemic, there has been a periodical cleaning up of cities and forced removal of free women. There are further examples from a host of African countries dating back to the colonial period [30]. Earlier public health policy in relation to infectious diseases, such as the earlier isolation of leprosy patients, can be instructive; and perspectives from African historians are lacking. In crisis situations with no popular representation, ideologies may change rapidly and repressive measures may follow, with the usual scapegoating-in the South, as we have seen, the scapegoats are prostitutes and free women. The implications and agenda are obvious in patriarchal societies. Renewed attempts to control women may be strategised in terms of public health needs. Increasingly, the ethics of caring is discussed in relation to costs. This is the case both in the industrialised North, and in the South. The problems, however, are not of the same order. Significantly, an increasing number of sponsored studies are concerned primarily with health costs. These need to include the cost of training new health personnel to replace those who have died of AIDS, and to assist those coping with burn-out [145-1491. However, the interests of some assessors, their financial backers, and readership, may conflict with those of the affected communities; and the gender dimension is variously addressed. The most recent are concerned with South and Southern Africa [15&155].

To some, the principle of benejicence may seem a just, if minimalist position. For many involved in the frontline, this is simply not enough. It is also a question of who decides, who has access to resources, and of the competing budget priorities in developing contexts. There are competing models of the community [156, 1571. It is difficult to underestimate the impact of the New Right, of Reaganism in the U.S., and its imitators in the U.K., its moral and economic agendas (the enterprise culture and increased privatisation of services, with particular implications for women), both in the Southern and Northern hemispheres. For a purely individualist concept of society or association, concern with self interest and mutual non-harm, a minimalist benejicence, may well seem appropriate. We need to ask ourselves what form of society, what form of civil association we want. A different model of community and society, one predicated on a presumption of inalienable rights, social justice and community responsibility-and one which would fully enfranchise women, not merely extend property and bourgeois rights for men (as in the French revolution) would demand more than just a no harm principle. Members of the West and Central African AIDS Research Network, professionals meeting in Lagos in November 1991, have argued that, by and large, rural and semi-rural communities have retained a sense of solidarity and mutual responsibility. This is the case despite civil strife, the obvious fragmentation and break-up of the extended family, exacerbated by economic distress and structural adjustment programmes, and the fostering of consumerist appetites among the elites. In increasingly participatory societies, solidarity or community are a great source of strength [158]. The importance of community-based care systems extending existing structures has been constantly stresed, and effectively demonstrated, by frontline health workers [159-1621.

8. ACTIVIST

DISCOURSE: A NEW PARADIGM

In the South, there is a demand for the latest drugs, and for properly conducted drug trials involving both local and western medicines. Other ethical and rights principles are involved here: those of human and North-South solidarity [ 1631which impinge on medical ethics. The question of access to drugs and participation in drug trials inflames passions. In some seriously affected activist circles, there has been a startling paradigm change. The Universal Declaration of Human Rights, which informed modem principles of ethics in public policy making, was formulated at the end of the second world war in a period of anti-fascist consensus. The horrors of the Nazi mass extermination of the Jewish people had become public knowledge. The world had also learned of the enforced experimentation on

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SEIDEL

categories of camp inmates. In this postwar context, the ethics of informed consent was of paramount concern [ 164, 1651. No tests could be conducted on a minority group or individual. The ethics of human subject research was shaped by these atrocities and the need to protect vulnerable people. In view of various unethical research interventions, particularly those involving blood testing, it may be argued that these ethical codes are still very much needed, particularly in the South. However, what is remarkable is that the rights discourse of some activists, of those living with HIV or AIDS, both in the North and South, is demanding a complete reversal and immediate departure from the agreed postwar principles. It is a case of activist ethics [166]. And it translates a particular mode of resistance. 8.1. Rights discourse of organised groups living with HIV or AIDS and of African pressure groups: setting out the rights agenda

It is the demands of AIDS activists and political community activists that are influencing and changing the parameters of the ethical agenda. In so doing, they are positively influencing policies, the perception of AIDS and of people with AIDS. In the North, ACT-UP together with Body Positive groups, and an array of AIDS coalitions have forced the pace. ACT-UP and Body Positive in particular are concerned with both activism and ownership of knowledge. They have transformed the AIDS discourse from a medical and medico-moral paradigm to a rights and ethics agenda. Different paradigms are involved. Some are more overtly political, engaging with issues of resources and gender-based power and rights, with different time scales and urgencies for those living with the infection [167]. In Africa, the two supranational professional bodies. The Society on AIDS in Africa (SAA), and the Society for Women and AIDS in Africa (SWAA), have also set out important demands and priorities. SAA, meeting in Casablanca, Morocco in April 1991, set out an impressive list of recommendations [168]. SWAA has held workshops in Harare, Zimbabwe (1989) in Lagos. Nigeria (1990) [169], and in Yaounde in Cameroon (1991) and in Arusha. Tanzania (September 1992) and clearly set out its concerns. SWAA represents both the Women in Development and. increasingly, gender and development concerns. SWAAs interests in the region include workshops with the African media, particularly with print journalists, to encourage them to be informed of HIV related issues and rights, and to report in a responsible fashion. Other national research groups and networks, like the Women and AIDS Support Network in Zimbabwe [170], and in Nigeria, WHERNIN [ 1711, and Women in Nigeria, concerned with womens health and empowerment, are playing an advocacy role. In Tanzania, WAMATA organised a workshop on HIV and the law in October 1990. The womens

networks are also combating certain traditional practices which adversely affect womens health like genital mutilation (female circumcision) [172, 1731. The human rights dimension of this form of womanabuse [174] has been recognised by the UN and by an increasing number of organisations in Africa, as a human rights violation [175]. It is reported that it was first put on the agenda of the UN Centre for Human Rights in 1981 when Efua Dorkenoo (Foundation for Womens Health and Development) was allowed to address the Working Group on Slavery [ 176179]. The severe health implications for girls and women, in the long and short term, are widely acknowledged by health professionals, yet there appears to be no research mto the possible correlation between the more radical varieties of this altogether heterogeneous practice, the tearing of delicate vaginal tissues during painful intercourse provoking bleeding and susceptibility to HIV (particularly if the women have histories of untreated STDs) [180]. Other practices adopted in various regions to increase male pleasure may also have HIV implications. These include the insertion of certain herbs in the vagina to make it dry or tight [91.p.43; 181, 1821. This could also result in tearing of the tissues, and in condom breakage. These practices are being addressed by SWAA and are on the national agendas of professional womens health groups on the continent. However, they tend to be articulated in terms of womens needs [181], rather than rights. The knowledge of human rights legislation and of ethical codes of practice will vary considerably from one country to another, and within each state. The United Nations Association (UNA), of which the regional branch is located in Accra, Ghana, endeavours to play a role in educating people about the UN charters and peoples rights. Elsewhere, as in The Gambia, human rights centres are emerging. In two African countries where political participation and grass roots democracy are high on the agenda, in Uganda and, in a very different context, within the mass democratic movement in South Africa, political activists are challenging the current state, and that of post-apartheid South Africa, to formulate a more appropriate agenda. 8.1. I. South Africa: the Maputa Statement (1990), the Township AIDS Prqjert (Soweto) and the Alexandra AIDS Action. The Maputo Statement on HIV and AIDS (April 1990) [183] with particular reference to South Africa is an example of the politicisation of AIDS--not in the usual sense of denial, or blaming the other [78], or an argument based on spurious nationalism, or elite career advancement [184, l&5]---but in a mass democratic perspective. The Maputo Statement was attended by delegates from the PIfrican National Congress (ANC), progressive political, community, health and welfare organisations in South Africa, members of the Frontline States, with participants from other countries. The documents declared the urgency of

The competing

discourses of HIV/AIDS in sub-Saharan Africa

185

dealing with HIV in Southern Africa, and committed progressive organisations, including the ANC, to take this up in community-based organisations. An AIDS Task Force was proposed to challenge the state and formulate an appropriate agenda for the control of HIV and AIDS in South Africa [186]. The responses and involvement of community groups in South Africa, summarised by Zwi and Bachmayer [186], are in protest against inadequate government action and the medico-moral response of a number of health professionals. Among the range of progressive organisations, concerned both with trade union members and health care workers, the gay community has also sought to develop a nonracial and non-sexist approach to HIV education and care. It is significant, also, that among the black community groups, the Soweto Township AIDS Project was started by a black woman activist, Refiloe Serote, whose experience was in campaigning, not in community health. Mainstream health professionals lacking political consciousness and political experience, both in the North and South, would find this hard to comprehend. It challenges professional barriers and gatekeepers. The Township Project has played an important part in developing appropriate community-based educational and counselling initiatives. In Soweto, as in many communities, sex is not discussed openly; and for women to initiate discussions about sex is particularly difficult, often leading to social ostracism. This is by no means peculiar to Soweto or the Horn of Africa. In the Soweto Township project, and now in the Alexandra AIDS Action, led by Serote, face to face discussions on sexual health and condom use are possible because a basis for political trust, sharing, solidarity and concern had already been established. The community is now taking on the HIV agenda in a politically charged environment. This is deeply impressive; and with the adequate support of service structures would surely seem to be the way forward for participatory and democratic community care. ANC statements have helped to stimulate and legitimate the involvement of community groups in addressing problems caused by HIV infection, recognising the part played by the apartheid policies [187, 1881. Health and health education are seen as resources to be owned and managed by the mass democratic movements. 8.1.2. TASO, Uganda. In Uganda, members of The AIDS Support Organisation (TASO) have demanded a more care-based agenda. Their voices have become stronger because of growing international support, recognition, and respect, both for their founder, Noerine Kaleeba, and, more generally, for this first indigenous African AIDS NGO. As distinct from the Soweto Township AIDS Project, TASO is not building on a political model of community activism and solidarity, yet it operates within a broader political context of grass roots mobilisation (the Resistance Committees) and now

mirrors its basic structure in the villages. TASO is not an overtly combative organisation: its spokespersons appeared to value consensual decisions within the National AIDS Coordinating Body-despite a potential conflict of interests in as much as the overriding concern of the National AIDS Programme was prevention, not care. Any lobbying was done quietly, behind the scenes, maximising personal and professional networks. TASO proceeded rather by example than through any sustained lobbying. It is a different political style. It was difficult for an invited WHO expert in Kampala addressing a TASO counselling training session in July 1988 to dismiss the potential efficacy of local medicines in treating, or, at least, alleviating certain opportunistic diseases when core members of the TASO group were ostentatiously consuming herbal preparations and claiming that they brought relief. He admitted that their quiet demonstration had constrained his comments in response to questions about research on traditional medicines and cooperation with herbalists, and the possibility of a local, affordable cure. Hitherto, the medical establishment at Makerere University, while expressing interest in cooperation and evaluation of particular herbs and recipes, has continued to postpone both meetings and trials. The issue has not gone away-and is very much alive elsewhere [ 189, 1901. But TASOs voice has been drowned by the dominant paradigm. Their empowerment, and possibility of owning scientific knowledge, has been frustrated by the unequal power relationship and the non-answerability of the medical establishment. But there are some inspiring exceptions. Many TASO clients are still consuming costly mixtures of rare herbs. They are knowingly carrying out their own trials as both experimenter and subject. Theirs is not a blind belief in ethnomedicine-but an active hope, together with a realistic assessment that whatever vaccine may be developed in the North is likely to remain outside the health budget of Uganda and its many NGOs. It is a case of Southern activist ethics. TASOs Kampala clients, particularly the men, eagerly discuss the latest drug trials, as do their Northern counterparts. They are equally aware that knowledge is power and may prolong life. Health professionals returning from international AIDS conferences are endlessly quizzed. Some of TASOs male clients knowledge of developments is even more remarkable, given the very limited availability of relevant journals and their astronomic cost. A number, largely more educated men, express the desire to have access to AZT. This costs about U.S.$7000 per person for each year of therapy [191]. I would like to have this drug. I have read about it. A person can live for a long time with this drug. But Uganda is a poor country-so we cannot have it [192]. In any case, there would seem to be general agreement among professional health workers that AZT

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GILL SEIUEL

administration calls for a hi-tech care environment, not available in Uganda. This double deprivation of rights is very hard to take. 8.1.3. African ,41D.S Research hctwork (West and Central Zones). .A key workshop organised by the West and Central African .4IDS Research Network (Lagos, Nigeria. 5-7 November 1991) debated the issue of ethics and rights in research, including drug and vaccine trials. This has resulted in a series of recommendations and ethical guidelines for the international research community [193]. The Lagos Workshop recommendations are unambiguous. It will now no longer hc possible for Northern scientists. drug companies. or funding agencies, to assert that their African professional counterparts have failed to articulate clear-cut policy recommendations. In other words, .4fricans and African professionals may no longer be considered as a muted group [22, 231. In terms of ethical drugs and vaccine trials and the WHO-favoured surveillance methods (sentinel groups which involve categorisations of risk groups; and anonymous non-linked surveillance), the workshop spoke with one voice. articulating a predominantly anti-colonialist and human rights discourse informed by African conditions. -Drugs and vaccines originating outside Africa must not be tested on African AIDS patients without substantia! evidence of previous trials and known outcomes of such agents on AIDS patients in the country of origin. -For monitoring and compliance purposes. the African AIDS Research Network should immediately set up a committee that would serve as members (watchdogs) in all African countries, thus monitoring compliance within their localities and reporting violation to its general assembly. Discussion the practice violations in ian rule. A agreed: ensued about the modalities of ensuring of human rights, and how to report countries under military and authoritarpragmatic and practical formula was

Ethical and profeessivnal guidclinrs for collaborative research with Northern partners were clearly enunciated by Luo [ISal. She cmphasised the need to recognise African researchers expertise and the importance of qualitative research Other contributions formal and informai. focu~d on il,mmunity versus individual rights [19SJ. OII !~uman rights [I961 and HIV related issues including the promotion of shared confidentiality among ~+losefamily or the care-group, media responsibilities [i&l]. isweb of appropriate Litid c~~unbelling. Finally, in an AIDS education. extended and heated p!~n;t~ v. religious organisations and their spokcsper:,cail,: ?I<IL :irged to adopt more :!l-~rigmutising attitudes positive. supportive .I1 I 11, h towards the cotrinrurii~, :i\~ng KII!I HIV and AIDS; and to develop a merry I.~,I1lIIltltlit4-based theology. The recommendations anti guidelines will be developed and extended hy discussion with other African a Pan African regions. with a view ii: Iroducing position [197]. The Networks I,agos guidelines are a watershed. The document ha3 been unofficially welcomed by the Ethics Cotnnr~ttec recently set up by the Ugandan AIDS Commission (July .4ugust 1992) to consider Northern request.. ior vaccine trials. It is now even more tirncll th:tt the major ethical issues involved enter into l~ubhr. &bn:c (as recently advocated by Schoepf) [19X JO!]

African scientists should form pressure groups to take a stand against violations and other ethically-related issues. Reports of any violation should be channelled to international human rights organisations (e.g. Amnesty International) for decisive action to be taken. Mass education should be instituted to inform citizens of their rights in relation to drug and vaccine trials of unproven
efficacy and safety.

The need for womens empowerment was the subject of Akinsetes important and wide-ranging address [ 18 11. It was clearly a major and shared concern of other SWAA members, embracing both the Women in Development and gender and development positions. The priority to be given to babies and children was also stressed, in view of the alarming number of AIDS orphans and of street children (particularly in the central and eastern regions).

Of the different. alar! II! WIII~ cases. overlapping discourses that seek \j* ~n!lu~~rcc llublic policy on AIDS, there arc those \<hich br;ind out clearly as discourses qf right3 am/ ~I~J~~I~I~~~I?~~~II. as contrasted [X2]. While with discotuxs 01 wrltrr~i v /\ c~/~~.ciorz each has different possih!h~res ot meaning, the first set open up meaning to Lhc .:,iiaruics of participation and self-determma tion. II! the ,+:cond, meaning is closed and immobiliscd. I he! also have very different political and sexual agcntki \ and psrticipation across the divide. An 1rn1~~~1 tar,r , cq:iiremcnt for participation is access to an ;I~JV oprialc information base: we need to broaden pnrticipatr~ry equity [203], at both regional and communri~ !~:~:cl The entrenched medical dominance and fr>t</!f ,ir,f !,rr,st. together with <is the more judgmental uwc/ioJ -t)~or,d discourse and their particular gender represenitrions inhibit the process of empowerment. par~~c~p~uon and solidarity. There has been p~agrcih since (he Fifth Intersince national Confer~,uc.~ *Jii :1I/)S in Africa. Kinshasa (1990)) when human r1ght.s did not figure even once as a key term ]204]. People with HIV or AIDS need to be legally empowered through the enabling discourse.r of the luternational Bill of Rights, the appropriate regronal ( ovenants or Charters-in the case of Africa, the .4frican (Banjul) Charter, together with the no less important related Conventions: the Convention on the Elimination of All Forms of Racial Discrunination the Convention of All Forms of Discrimimition s,gainst Women. and

The competing discourses of HIV/AIDS in sub-Saharan Africa the recent Convention on the Rights of the Child [205,206]. In other words, they need to involve each of the four main human rights treaty bodies (The Human Rights Committee, Committee on Economic, Social and Cultural Rights, Committee on the Elimination of Racial Discrimination, and Committee on the Elimination of Discrimination against Women) [207]. Human rights concerns in turn need to inform enlightened public health policy and policy options [208-2121. Similarly, professional codes of ethics based on a minimalist beneficence fall short: they need, instead, to be shaped by the informed discourses on patients rights, and the discourses on human rights and freedom. But this is still not enough. Interventions and research protocols need to be drawn up with the participation of people with HIV and AIDS, empowered as advocate groups, assisted by professionals in multi-sectorial ventures. Women as the least empowered are the most at risk. They need to be involved in the planning process and implementations [2 131 as autonomous individuals at risk. They need information, appropriate services, including free and confidential STD treatment, and support using a peer model. Women need specific targeting, not just a trickle down effect, and should not be seen primarily as vectors or carers. They need to be empowered to take informed decisions about their sexual and reproductive lives and reproductive choices [214-2161. HIV/AIDS in sub-Saharan Africa is about: -Human rights --Gender -Public health -Ethics, including a global ethic [217,218] -Development and North-South relations and inter-regional African cooperation in a postcolonial context -Discrimination against illness. Despite the existence of international and regional legal instruments, the quality of life for people living with HIV and AIDS, as, indeed, for African populations in general, depends no less importantly on other linked considerations and conditions. These include: -An open, caring, non-militaristic society based on popular sovereignty with the rights of free and autonomous association, a free press and non-discrimination. -The empowerment of women as subjects [219-2251. -The mobilisation of community resources in health education and community care settings [226]. -The absence of war and destabilisation [227, 2281. -A new economic order, or North-South rearrangement, cancelling Third World debts, and alternatives to structural adjustment pro-

187

grammes which have adversely affected women and children [223,229,230]. The new paradigm must be solidarity and cooperation, as opposed to coercion and discrimination, a solidarity and cooperation based on the universality of human rights. Are we-is the world now mature enough, now wise enough-to accept that the deepest meaning of solidarity requires that we consider ourselves as if we, too, were infected with HIV--on a human level? This would seem to be the only way to proceed in both research and care settings. In his inspiring address to the Fifth International Conference on AIDS in Montreal in June 1989, Jonathan Mann talked of the AIDS revolution, underlining the inextricable link between human rights and AIDS, and, more broadly, between human rights and health [23 11;and reiterated in Amsterdam (July 1992). To that, we would add the inextricable link between human rights and development [232]. The right to health, the right to development are overlapping discourses of rights. The latter must include an explicit recognition of gender oppression, both in development theory and practice. This necessarily implies a critique of the dominant model of sex, equated with gender, as an essential and irreductible difference, founded in nature; and a critique of naturalist ideology [55, 56, 233-2361 in general, which has both racist and gender implications. This predominantly rights discourse, in its various dimensions and its empowering anger, are being taken further in the discourse of organised community AIDS activists-Victors, not victims; Rights, not charity. To settle for less is an assault on our integrity as human beings: it is an assault on our shared humanity. Acknowledgements-A shorter version of this paper was present in Lagos in November 1991 at the International Workshop organised by the African AIDS Research Network (West and Central African zones) on HIV, ethics and human rights. In Nigeria, I should like to thank members of the Network, particularly the President, Professor Femi Soyinka, for their kind invitation, and the Faculty of Health Sciences, Obafemi Awolowo University, Be-Ife, for their hospitality. In Uganda, may I express my thanks and al&ion io TASdmembers who were such & inspiration; and to the University of Bradford (U.K.), Research Commit~ tee for initial funding. This paper draws on two periods of fieldwork respectively in both Uganda and Southern Nigeria, and on secondary sources.
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5. For a helpful introduction in English to Foucaults considerable work, see, for example: Rabinow P. (Ed.) The Foucault Reader. Penguin, London, 1991. 6. See Bloch M. (Ed.) Political Language and Oratory in Traditional Society. Academic Press, L.ondon, 1975. I. OBarr W. M. and OBarr J. F. (Eds) Language and Politics, Contributions to the Sociology qf Language, 10. Mouton, The Hague, 1976. 8. Grill0 R. (Ed.) Social Anthropology and the Politics of Language, Sociological Review Monograph 36. Routledge, London. 1989. 9. Seidel G. Political discourse analvsis. In Handbook ot Discourse Analysis, Vol. 4 (Edited by van Dijk T. A.?, pp. 43-60. Academic Press, London. 1985. 10. Wodak R. (Ed.) Lanpuaae. Power and Ideolopp:. Ben_. jamins, Amsterdam, 79818. N. Language and Power. Longman, Il. Fairclough London, 1989. D. Visions partielles, visions partiales: 12. Juteau-Lee visions (des) minoritaires en sociologic. Sociologic et SociPtPs 13, 3348, 1982. C. and Ribtry C. Sexisme et Sci13. Michard-Marchal ences Humaines. Pratique Linguistiyue du Rapport de Sexage. Presses Universitaires de Lille, Lille, 1982. 14. Michard C. and Ribtry C. Enunciation and ideological effects: Women and Men as subjects of discourse in ethnology. Feminist issues 6, (2) 1986. (French edition 1985.) characteristics of 15. Michard C. Some socio-enunciative scientific texts concerning the sexes. In The Nature of the Right-A Feminist Analysis of Order Patterns (Edited bv Seidel G.) PP. 27-60. Beniamins, AmsterGam, 1988. __ 16. Seidel G. Le discours dexclusion: les mises i distance, le non-droit. MOTS 8, 5-16. 1984. 17. See for example, Wipper A. Riot and rebellion among African women: Three examples of Womens Political Clout. In Perspectives on Power (Edited by OBarr J.). Durham, N. Carolina, 1982. 18. Cohen R. Resistance and hidden forms of consciousness among African workers. In Third World Lives of Struggle (Edited by Johnson H. and Bernstein H.), pp. 244258. Heinemann, London, 1982. 19. Ardener S. G. Sexual insult and female militancy. Man 8, 422440, 1973. L. Sexual Visions, Images of Gender in 20. Jordanova Science and Medicine between the Eighteenth and Twentieth Centuries. Harvester Wheatsheaf. Hemel Hempstead, 1989. 21. van Dijk T. A. Discourse analysis with a cause, Editorial. The Semiotic Review of Books, Vol. 2.1, pp. l-2. Toronto Semiotic Circle,-1991. Women.Dent.London. 1975. 22. ArdenerS.(Ed.)Perceiuina 23. Ardener E.-Belief and the problem of women. Perceiving Women (Edited by Ardener S.), pp. l--27. Dent, London, 1975. 24. Fortin A. J. AIDS, development and the limitations of the African State. In Action on AIDS. National Policies in Comparative Perspective (Edited by Miztal B. and Moss D.), Chap. 10. Greenwood Press, New York, 1990. reports from 25. In some sensitive prevention programme Africa, high risk groups continues to be lexicalised, but may be taken up in the discourse in a less-stigmatising way, emphasising the importance of peer education among sex workers (prostitutes). See for example, Williams E. et al. Correspondence. AIDS 6, 229-242, 1992, reporting from Cross River State, Nigeria. 26. Treichler P. AIDS and HIV infection in the Third World: a First World chronicle. In Remaking History. Dia Art Foundation, Discussions in Contemporary Cul-

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pp. 8-9, 1991. See also former Zambian President Kaundas intervention at the 6th International AIDS Conference in Montreal, Canada, June 1989 as a further example of development discourse on AIDS. See, for example, Mahmoud F. B. et al. African Women-Transformation and Development. Institute for African Alternatives, London, 1991. Mbilinvi M. Women and develonment ideoloav. At?. __ Rev. 2; 1433, 1984. Chafe& J. S. Gender equality: towards a theory of change. In Feminism and Sociological Theory (Edited by Wallace R. A.), pp. 135-160. Sage, Newbury Park, CA, 1989. Stichter S. B. and Parpart J. L. (Eds) Patriarchy and class. African Women- in the Home and Workplace. Westview Press, Boulder. CA, 1988. Lewis B. The .impact of development policies on women. In African Women South of the Sahara (Edited by Hay M. J. and Stichter S.), pp. 170-187. Longman, London, 1989. Blumberg R. L. Towards a feminist theory of development. In Feminism and Sociological Theory (Edited by Wallace R. A.), pp. 161-199. Sage, Newbury Park, CA, 1989. See also Wallace T. and March C. (Eds) Changing Perceptions. Writings on Gender and Development. Oxfam, Oxford, 1991. Brett A. Why gender is a development issue. In Changing Perceptions. Writings on Gender and Development (Edited by Wallace J. and March C.). Oxfam, Oxford, 1991. For the theoretical framework, see the first issues of Questions feministes: Guillaumin C. Practice of power and belief in nature. Part 1: The appropriation of women. Feminist Issues 1, (2), 1981; Part 2: The naturalist discourse. Feminist Issues 1, (3), 1981. (French edition 1978.) Guillaumin C. The question of difference. Feminist Issues 2, (I), 1982. (French edition 1979.) To attempt to summarise these cogent arguments: Naturalist ideology, a historically defined structure of belief, suggests that womens lives are defined, and strictly limited, from birth by their biology, by their biological, female sex and reproductive capacities. According to this belief, females are naturally destined to follow different (feminists would argue dominated) lives from their male counterparts. This truth is seen to derive from nature, and to represent a fixed and immutable system. (There are obvious analogies with apartheid in which the differences between races and their different destinies have been seen to be a cultural and male supremacist system which constructs and seeks to perpetuate womens oppression.) In this perspective, the dominant construction of gender, and its deconstruction in both theory and practice, is shown to be a sexual and politico-cultural issue, central to womens emancipatory agenda, and achievement of full human status, irrespective of biological sex or sexual orientation. It necessarily implies a critique of heterosexuality and its institutions. [See also Refs 233-236.1 See also MacCormack C. P. and Strathern M. (Eds) Nature, Culture and Gender. Cambridge University Press, Cambridge, 1980. Jones K. B. and Jonasdottir A. G. (Eds) The Political Interests of Gender, Developing Theory and Research with a Feminist Face, Modem Politics Series, Vol. 20. Sage, London, 1985. Greene G. and Kahn C. Feminist scholarship and the social construction of women. In Making a Difference (Edited by Greene G. and Kahn C.), pp. l-36. Methuen, London, 1985.

60. Ankrah M. E. AIDS and the social side of health. Sot. Sci. Med. 32, 976980, 1991. Struggle for Econ61. Obbo C. African Women-Their omic Independence. Zed Press, London, 1980. Obbo carried out the fieldwork for AIDS in Africa (Edited by Bamett T. and Blaikie P.), Belhaven Press, London. 1992, which draws largely on Ugandian data. of women in Uganda: real 62. Boyd R. E. Empowerment or svnthetic. Rev. Afr. Political Econ. 45/46, 106117. . 1989. P. and Seidel G. Human rights in 63. Nkamuhayo Uganda. Rev. Afr. Political Econ. 45146, 174179, 1989. 64. Standing H. and Kisekka M. N. Sexual Behaviour in Sub -Saharan Africa. Overseas Development Administration, London, 1989. issues in research65. See also Standing S. Methodological ing sexual behaviour in sub-Saharan Africa. Paper presented for the Overseas Development Administration Conference: AIDS in Developing Countries: Appropriate Social Research Methods. Brunel University, London, l&11 May 1990. 66. Seidel G. Thank God I said NO to AIDS: on the changing discourse of AIDS in Uganda. Discourse Sot. 1, 61-84, 1989. 67. Marshall R. Power in the name of Jesus. Rev. Afr. Political Econ. 52, 21-37, 1991. 68. Banda M. Faith, hope and chastity. AIDS Action 45, March 1991. grassroots response, World 69. Tamali N. Ugandas AIDS No. 18, 9-10, November 1991. 70. Musoke D. Uganda: condom backlash. World AIDS 19, 4, 1991. 71. This report [69] lends itself to different readings, intertextual and paradigmatic. TASO was originally started up by a woman, and was non-denominational. Here, only men are cited, and principally a reverend who is making health policy decisions (see also Ref. [36]). 72. Geertz C. The Interpretation of Cultures. Harper and Row, New York, 1973. 73. Bond G. C. and Vincent J. Living on the edge: structural adjustment in the context of AIDS. In Uganda: Structural Adjustment and Chaos (Edited bv Hansen H. B. and Twaddle M.). James Currey, London, 1991. 74. For a critique of the eurocentric frames of reference from a Dominican perspective, but with only passing references to gender, see Oyeshola D. A. The church and development in black Africa-a critical assessment of the praxis of the Roman Catholic Church. Ph.D. thesis, Universitv of Bradford. 1989. in Uganda as a gender issue. 75. Kisekka M. N.-Aids Womens Mental Hlth Afr. Women Therapy 10,35-54, 1990. 76. Tabet P. Im the meat, Im the knife-sexual service, migration and repression in some African societies. In A Vindication of the Rights of Whores (Edited by Pheterson G.), pp. 204226. Seal Press, Seattle, 1989. 77. Longwe S. R. and Clarke R. Proposed methodology for combating womens subordination as a means towards improved AIDS prevention and control. Expert Group Meeting on Women and HIV/AIDS, and the Role of National Machinery for the Advancement of Women, Vienna, 2428 September, 1990 (EGM/ AIDS/1990/WP.5). 78. Sabatier R. (Ed.) Blaming Others: Prejudice, Race and Worldwide AIDS. Panos, London, 1988. 79. Frankenberg R. The other who is also the same: the relevance of epidemics in space and time for prevention of HIV infection. In?. J. Hith Services 22. 73-88, 1992.

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GILL SEIDEL 100. See, for example, Emeagwali G. and Turok M. (Eds) Structural Adjustment and Women in Africa, papers presented at a symposium organised by the Institute for African Alternatives, London (in preparation). 101 Ahlberg B. M. African culture and development: the changing sexuality in sub-Saharan Africa, and its impact on womens reproductive health. Extract from Group Meeting on Women and HIV/AIDS and the Role of National Machinery for the Advancement of Women, 2428 September (EGM/AIDS/1990/WP.7), Vienna, 1990. why woman must pay? 102 Bujra J. Taking Development: Gender and the development debate in Tanzania. ,4fi. Rev. Political Econ. 41, 4463, 1990. and 103 Bledsoe C. The politics of AIDS, condoms heterosexual relations in Africa: recent evidence from local point media. In Births and Power, Social Change and the Politics of Reproduction (Edited by Handwerker W. P.). pp. 197-222. Westview Press, Boulder, 1990. these are by no means limited to the Con104 Historically, tinent, or to the South. See, for example, DavenportHines R. Sex, death and punishment. Attitudes to Sex and Sexuality in Britain since the Renaissance. Fontana Press, London, 1990. 105 This affirmation became the core of the Statement of Belief drafted at an informal consultation at the 7th International Conference on AIDS in Dakar, Senegal, in December 1991, organised by the UNDP working in an informal partnership with the Salvation Army, Save the Children Fund U.K. the U.K. NGO AIDS Consortium, with financial backing from UNDP and AIDSTECH. programmes are to be effective, 106. If AIDS education they need to address interpretive resources. The history of sexually transmitted diseases illustrates that neither information nor fear bring about behaviour change. Hence the need for qualtitative, experiential studies and a departure from the WHO-favoured KAP studies. See, for example, Ssali A. et al. Exploring sexual terminology in a vernacular in rural Uganda. 8th Int. Co@ on AIDS, Amsterdam, July 1992 (Poster POD 5513). however, in gender terms, to 107. It remains problematic, whom these prevention messages should be addressed, as far too much onus has been put hitherto on women as controllers of mens sexuality and those carrying the burden of care. AN sociological research needs to look at the intersections of gender, race and class. See Schneider B. E. AIDS and class, gender and race relations. In The Social Context of AIDS (Edited by Huber J. and Schneider B. E.), pp. 1943. Sage, London, 1992. 108. Lome Briefing. Human Rights tapping softly at the door, No. 13. December 1989. in 109. Bullock S. Structural adjustment and conditionality European Community aid to sub-Saharan Africa: the record of Lome III and the prospects for Lome IV. MA thesis, School of Development Studies, University of East Anglia, 1989. for a New 110. Parfitt J. and Bullock S. The prospects LomC convention. Rev. Afi. Political Econ. 47, 104116, 1990. M. The human rights 111. Cobbah J. and Hamalengwa literature on Africa: a bibliography. Hum. Rights Q. 8, 115-125, 1986. Introduction. Hum. Rights Int. Reporter 112. Anonymous. 12, 5-8, 198881989. 113. Shivji I. G. The democracy debate in Africa: Tanzania. Rev. Afr. Political Econ. 50, 79-91, 1991. 114. Copans J. No shortcuts to democracy: the long march towards modernitv. Rev. Afr. Political Econ. 50, 922101, 1991. -

80. Kisekka M. N. and Otesanya B. N. Sexually transmitted diseases as a gender issue: examples from Nigeria and Uganda. Unpublished revised version of a paper presented to the Association of African Women for Research and Development (AAWRD), Dakar, Senegal, 8814, August 1990. 81. Friedman G. Puppets against AIDS: breaking through racial and cultural barriers. WHO AIDS Health Promotion Exchange, No. 3, 3-7, 1991 (AREPP, African Research and -Educational Puppetry Programme, AREPP. is based in Johannesburg and has toured many rural and urban regions of South and Southern Africa). 82. See also Gordon G. and Lynch E. Theatre as a tool: how to develop a performance AIDS Health Promotion ExchangeNo. 3, 12-15, 1991. See also Unmasking AIDS, video, International Planned Parenthood Federation, London, 1991. 83. See the critique by Auvert B., Moore M., Bertrand W. E. et al. Dynamics of HIV infection and AIDS in Central African Cities. ht. J. Epidemiol. 19, 417428, 1990. P. Prostitution en Afiique. IExemple de 84. Songue Yaounde. IHarmattan, Paris, 1986. 85. Tabet P. Etude sur les rapports sexuels contre compensation. Report presented to the Division of Human Rights and Peace, UNESCO, May 1988. and alternative strategies: career 86. Pittin R. Marriage patterns of Hausa women in Katsina City. PhD Dissertation, School of Oriental and African Studies, University of London, 1984. principle and 87. Pittin R. The control of reproduction practice in Nigeria, Rev. A). Political Econ. 35, 1986. B. Prostitution viewed cross-culturally: 88. Zalduondo Towards recontextualizing sex work in AIDS research. J. Sex Res., 1991. 89. Nelson N. Selling her Kiosk: Kikuyu notions of sexuality and sex for sale in Mathare Valley, Kenya. In The Cultural Construction of Sexuality (Edited by Caplan P.), pp. 217-239. Tavistock, London, 1987. 90. White L. Domestic labour in a colonial city: prostitution in Nairobi 1900-1952. In Patriarchy and Ciass. African Women in the Home and Workplace (Edited by Stichter S. B. and Parpart J. L.), pp. 131~160. Westview, Boulder, 1988. 91. Paguezy H. SIDA et Modification des Comportement Sexuels: le Cas de Reclusions de Longue Duree Chez les Mango du Sud de ZaLre, p. 42. Aix en Provence, ANRS, CNRS and Paris, 1991. 92. See Ref. [30]. This does not prevent them from being sought after and courted as potential brides. 93. Pittin, cited in Ref. [76]. I. 0. and Caldwell P. 94. Caldwell J. C., Orubuloye Changes in the nature and levels of sexual networks in an African Society: the destabilization of the traditional Yoruba system. Health Transition Working Paper, No. 4, Australian National University, 1990. 95. See also Caldwell J. C., Caldwell P. and Quiggin P. The social context of AIDS in sub-Saharan Africa. Pop. Dev. Rev. 15, 1855234, 1989. B. E. Women and AIDS: an 96. See also Schneider international perspective. Futures 21, 72-90, 1989. has been theorised 97. This oppressive social relationship by Guillaumin as sexage, an analogy with servage (serfdom) and esclavage (slavery), Refs [55, 561. 98. Schoepf B. G., Engundu W., Nkera R. W., Ntsomo P. and Schoepf C. Gender, power and risk of AIDS in Zaire. In Gender and Health in Africa, pp. 187-204. Africa World Press, IUC, Trenton, NJ, 1991. B. Women, AIDS and economic 99. Grundfest-Schoepf crisis in Central Africa. Can. J. Afr. Stud. 23, 625644, 1990.

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136. Mann J. Opening Statement in the World Summit of Health Ministers, 26 January. Reported in the Guardian (U.K.), 27 January, p. 2, 1988. 137. This has been echoed by the current WHO GPA Director, Merson, at the 6th International Conference on AIDS in Africa. Dakar, Senegal, December 1991. 138. Lang N. G. Difficult decisions: Ethics and AIDS. J. Sex Res. 28, 2499262, 199 1. 139. See also Ekeid S-V. Ethical issues relating to healthcare for people with HIV infection and AIDS. Paper presented to the Global Expert Meeting, AIDS: A Question of Rights and Humanity, 21-24 May, The Hague, Netherlands, 199 1. overview. Gen. Hosp. 140. Kellv K. AIDS and ethics-an Psyihiat. 9, 331-340, 1987. 141. Manuel C., Enel P., Charrel J., Reviron R., Larher M. P., Thirion X. and Sanmarco J. L. The ethical approach to AIDS: a bibliographical review. J. Med. Ethics 16, 1427, 1991. 142. See also a special issue which groups their major recent articles: Sante Publique. Etudes et Recherche, Ethique et SIDA, 2e an&e, No 3, 1990. M. Bugs, drugs and placebos. In Taking 143. Horton Liberties (Edited by Carter E. and Watney S.), pp. 161~181. Serpents Tail and ICA, London, 1989. 144 Esiet N. The right to know and the right to be informed-the role of the mass media. International Workshop on AIDS, Ethics and Human Rights organised by the African AIDS Research Network (West and Central Zones), Lagos, Nigeria, November 1991. 145 Foster S. D. et al. Costs of treatment for HIV disease at the District Hospital in Zambia. 8th fnrernafional Conference on AIDS, Amsterdam, July 1992 (Poster POD 5769). clinical care for 146. See also: Foster S. D. Affordable HIV-related illness in developing countries. Trop. Dis. Bull. 87, RI-9, 1990. 147. Finger W. R. Pediatric AIDS: children dramatize the far-reaching costs of the pandemic. Network, Family Hlth Int. 11, 3-7, 1990. aspects of HIV 148. Foster S. and Lucas S. Socio-economic and AIDS in developing countries. A review and annotated bibliography. PHP Department Publication No 3, London School of Hygiene and Tropical Medicine, 1991. D. and McConnell C. The impact of AIDS 149. Nabarro on socio-economic development. AIDS 3, Suppl. 1, S265-S272, 1989. 150. Whiteside A. HIV infection: the nature of the economic impact-an overview. The Economic Impact of AIDS in South Africa Workshop, 22-23 July, Durban, South Africa, 1991. 151. Whiteside A. The impact of AIDS on industry: Zimbabwe, a case study. The Economic Impact of AIDS in South Africa Workshop, 22-23 July, Durban, South Africa, 1991. 152. Barnett T. and Blaikie P. Simple methods for monitoring the socio-economic impact of AIDS: lessons from sub-Saharan Africa. The Economic Impact of AIDS in South Africa Workshop, 22-23 July, Durban, South Africa, 199 1. 153. Hore R. AIDS: its potential impact on health care costs in Zimbabwe. The Economic Impact of AIDS in South Africa Workshop, 22223 July, Durban, South Africa, 1991. 154. Broomber R., Steinberg M. and Masobe P. The economic impact of the AIDS Epidemic in South Africa. The Economic Impact of AIDS in South Africa Workshop, 22-23 July, Durban, South Africa, 1991. 155. Davachi F. et al. The economic and social implications of AIDS in and African setting. Fifrh International Conference on AIDS, Montreal, 1989.

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156. See Loewy E. H. AIDS and the human community. Sot. Sci. Med. 21, 2977303, 198. 157. Friedland L. R. and Karstaedt A. S. HIV-related ethics-who should decide? S. Afr. Med. J. 79, 5277528, 1991. by NGOs; and also by 158. They may also be manipulated elites for political advancement, Community is a hotly debated concept in development sociology. 159. See, for example, Charbit Y. and Loenzien M. de Attitudes et Comportements de la Population Rurale Senegalaise Face au SIDA. Institut National dEtudes Demographiques, Paris. 1991 160. Kalibala S. and Kaleeba N. AIDS and communitybased care in Uganda. AIDS Care 1. 173-175. 1989. A. D. Caring for people with 161. Campbell I. and-Rader AIDS: it can be done! Afr. Hlfh 4674, 1990. 162. Campbell I. D. and Williams G. AIDS Management, an Integrated Approach. Action Aid and World in Need/AMREF, London, 1990. Internationale des Droits de 1Homme. 163. Federation Droits de Ihomme et relations Nord-Sud. LHarmattan (Preface de D. Mitterrand). Paris. 1985. (Edited collection of papers presented at the Congres de la Federation Internationale des Droits de IHomme, UNESCO, Paris, 17-18 November 1984.). I. L. A History of In164. Faden R. R and Beauchamp formed Consenr. Oxford University Press. Oxford, 1986. Code and Helsinki principles 165. The postwar Nuremberg were updated in the U.S. in the Belmont Report: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report: Ethical Princip1e.s and Guidelines .for the Protection of Human Subjects of Research. Depdrtment of Health, Education and Welfare, Washington, DC, 1978. 166. Levine C. Has AIDS changed the ethics of human subjects research? Lair. Med. Hlth Care 16, 167-l 73, 1988. 1986. 167. See the Ottawa Charter for Health Promotion, Declaration of the Society on AIDS in 168. Casablancas Africa, 27 April 1991, listing 16 recommendations. 169. Society for Women and AIDS in Africa (SWAA). Second International Workshop on Women and AIDS in Africa, Lagos, May 2883 1. Communique and Recommendations. Womens Global Network .for Reproductive Rights Newslett. 32, 14.-15. 1990. issue 170. Women and AIDS Support Network. AIDS-an for every woman. Edited Report on the Proceedings of a Woman and AIDS Support Network Conference held in Harare, Zimbabwe, 23324 November 1989. Willmore B. and Ray S. Women and AIDS Support Network and AIDS Counselling Trust, Harare, 1990. 171. Kisekka M. N. Womens health research network in Nigeria. Critical Publ. Hlth 2, 29-32, 1990. held in Nigeria, 172. For a report on a 1989 workshop organised by the Inter Africa Committee on.Traditional Practices Affecting the Health of Women and Children, see Kanu M. T;aditional abuse of women and children. Guardian (Nigeria), 4 July 1989. harmful traditional prac173. Franjou M. H. Eradicating tices. People (IPPF) 18, (2). 1991: reporting on a conference held in Paris under the auspices of the Economic Commission for Africa (ECA), following the 2nd Conference of the Inter African Committee on Traditional Practices A,fferting the Health of Women and Children, held in Addis Ababa, November 1990 which recommended the promulgation of specific laws to forbid the practice of female genital mutilation. In the Gambia, health workers involved with family planning and HIV prevention also seek to discourage female genital mutilation. 174. Hosken was one of the early and most committed activist-scholars. Hosken F P. The Hosken Report on

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Genital and Sexual Mutilation of Females (2nd enlarged edn). Womens International Network News, Lexington, 1979. Koso-Thomas 0. The Circumcision of Women, A Strafegy for Eradication. Zed Press, London, 1987. Armstrong S. Female circumcision: fighting a cruel tradition. New Sci. 4246, 2 February 1991. UN International Year of the Child Report, No 9. Female Circumcision is a Health Hazard. New York, 1979. Lightfoot-Klein H. Prisoner of Ritual: An Odyssey into Female Genital Circumcision in Africa. New York, 1989. Dorkenoo E. and Elworthy S. Female Genital Mutilation: Proposals for Change. Minority Rights Group, London, 1992. It is as if the dominant paradigm of male circumcision foreclosed the issue. Male circumcision is by no means comparable (other than, perhaps, in the removal of the clitoris hood-but it is the more radical infibulation and excision which is far more widely practised). In an altogether monocausal medical explanation, male circumcision is deemed to be the primary inhibitor of HIV transmission, accounting for the epidemic levels in central and Eastern Africa, both severely affected regions, where male circumcision is rare. This is contrasted with West Africa, where male circumcision is widely practised (among the Yoruba, for example, it is the norm), and where far fewer AIDS cases have been reported but where the situation has been described as subepidemic. Although it is true that HIV prevalence remains low in areas where this practice is carried out. this is very reductionist. It is also a poignant and heavily symbolic example of the general silencing of women-centred hypotheses. A Panos report, Triple Jeopardy, Women and AIDS, London, Paris, Washington, Panos Institute, 1990 was quick to dismiss any link between female circumcision and HIV infection (pp. 15-16). The report simply notes that any sex which involves bleeding increases the risk of HIV infection (p. 16). Akinsete R. Women and AIDS: special needs of women. Paper presented at the International Workshop on HIV, Ethics and Human Rights. Lagos, November 1991. Runganga A. 0. The vaginal use of herbs and other substances in sexual intercourse by a sample by Zimbabwean women. 8th International Conference of AIDS, Amsterdam, July 1992 (Poster POD 5511). Maputo Statement on HIV and AIDS in Southern Africa. Hlth Policy Planning 5, 386388, 1990. Fortin A. J. AIDS and the Third World: The Politics of International Discourse. Paper presented at the 14th World Congress of the International Political Science Association, 28 August-1 September 1988, Washington, DC, 1988. Fortin A. J. The Politics of AIDS in Kenya. Third World Q. 9, July, 1987. Zwi A. and Bachmayer D. HIV and AIDS in South Africa-what is an appropriate health response? Hlth Policy Planning 5, 316326, 1990. See, for example, Zwi A. Piecing together health in the homelands. Second Carnegie Inquiry into Poverty and Development in Southern Africa. University of Cape Town, Cape Town, 1982. Price M. Health care as an instrument of apartheid policy in South Africa. Hlth Policy Planning 1, 1588170, 186. Commonwealth Secretariat, Report of an Expert Meeting on Evaluation of Traditional Medical Practices in Africa, 30 June-4 July, Harare, Zimbabwe. Commonwealth Secretariat, London, 1986.

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and public health. 208. Mann J. AIDS--discrimination Paper presented at the IV International Conference on AIDS, Stockholm, Sweden, 1988. United 209. AIDS and Human Rights, Final Document, Nations Centre for Human Rights, Geneva, 1989. (HR/AIDS/1989/3.) 210. Tauer C. A. AIDS, human rights and public health. Med. Anthropol. 10, 177-192, 1987. Report of an International Consul211. United Nations. tation on AIDS and Human Rights, Geneva, 2628 July 1989, pp. 33,34,38-39. UN (HR/PUB/90/2), New York, 1991. 212. Bayer R. AIDS and the ethics of public health challenges posed by a maturing epidemic. AIDS 2, Suppl. 1, S217-S221, 1988. 213. Mitchell J. L. Women, AIDS and public policy. AIDS Publ. Policy J. 3, 5&52, 1988. sensitive article on reproductive 214. For a particularly choices, see Levine C. and Dubler N. N. HIV and childbearing-uncertain risks and bitter realities: The reproductive choices of HIV infected women. Milbank Q: 68, 321-351, 1990. D. Research on AIDS: interventions in 215. Schotmer developing countries: state of the art. Sot. Sci. Med. 30, 126551272, 1990. 216. Williams E. et al. Nigeria: empowering commercial sex workers for HIV prevention. 7th International Conference on AIDS, Florence, Italy (Poster W. D. 4041) 1991. the measure of an Ethic for 217. Roy D. J. Humanity, AIDS. J. Acquired Immune Deficiency Syndrome 3, 449459, 1990. 218. Ankrah M. speaking at a plenary session of the 7th International Conference on AIDS, Florence, Italy, June 1991. between the Status 219. United Nations. Interrelationships of Women and HIV Epidemic: A Review of Published Literature, Expert Group Meeting on Women and HIV/AIDS and the Role of National Machinerv for the Advancement of Women, Vienna 2428 September. Division for the Advancement of Women (EGM/AIDS/l990/BP.2), United Nations Office, Vienna, 1990. J. and Danziger R. The position of 220. Hausermann women and the implications for vulnerability to HIV infection. Paper presented to the 7th International Conference on AIDS. Florence. Italv. June 1991. Women in Africa in the 1990s. 221 Abuja Declaration. Womens Int. Network News, 16, 54, 1990. Centre for Research on Women (ICRW) 222. International Strengthening Women: Health Research Priorities for Women in Developing Countries. ICRW, Washington, DC, 1989. V. M. Gender, Development and Policy: 223. Moghadam Towards Equity and Empowerment. WIDER Research for Action, World Institute for Development Economics Research of the United Nations University, Helsinki, 1991. Sub224. Howard R. Womens rights in English-speaking Saharan Africa. In Human Rights and Development in Africa (Edited by Welsh J. and Melzer R. I.), pp. 46740. Albany State University of New York Press, Albany, 1984. 225. Rosser S. V. AIDS and women. AIDS Educ. Prevention 3, 230-240, 1991. organisations 226. Some inspiring examples of community in Uganda, Zimbabwe, Zambia and Ghana as summarised in the UN Report, Division for the Advancement of Women [219] (and cf. Refs [16C-1621). 227. Dodge C. P. Health implications of war in Uganda and Sudan. Sot. Sci. Med. 31, 691698, 1990. 228. Ogba L. 0. Violence and health in Nigeria. Hlth Policy Planning 4, 82-84, 1989.

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