In the summer of 2007 I spent a day at the Kazungula medical clinic in Zambia. On the day of my visit, the scheduled patients were pregnant women who were coming for their initial prenatal appointment. That visit included an HIV test. On that July day, 9 of 21 women (42%) had positive initial and confirmatory HIV tests. None seemed shocked. When I met with the medical staff from that same area this summer, I found out the numbers were still the same. The clinic nurse I was shadowing that day attributed the high number, at least in part, to truck drivers sitting in their cabs in the gravel lot down the road waiting to clear customs. If we extrapolate that number out to the village as a whole and assume that over one-third of the women in this small town in rural Zambia are HIV-positive, the enormity of the HIV pandemic in sub-Saharan Africa becomes clearer. What intricate, invisible social networks expose the women in Kazangula to HIV disease?
And what role do the truck drivers waiting in a days-long queue play in those networks? Where will they drive to when they leave Kazangula en route to a half dozen other countries in southern Africa? How many towns like Kazangula exist across sub-Saharan Africa? What is the infection rate of the women in those towns? What is the infection rate of the truckers? What is the infection rate of the wives of those truck drivers back in the villages around this region? How do we address it?
The town of Kazungula would make an ideal location for a long-term sociological study…or a movie. Kazungula is a small village on the banks of the Zambezi River, about thirty miles upstream from Victoria Falls. This geographical location sets the village apart from countless others that dot the rural Zambian countryside: it is situated at the confluence of the Zambezi and the Chobe Rivers, on the border of Zambia, Zimbabwe, Botswana, and Namibia. This makes Kazangula an important transportation node for the long-haul tractor-trailers that serve as the primary distribution network across sub-Saharan Africa. It is, in other words, an international crossroads. That phrase is dangerously misleading when applied to Kazangula. One thinks of Istanbul, for example, as the international crossroads of the East and West, of the Christian and Muslim worlds, and can immediately conjure up images of exotic shops, cultures, cuisines, and communities; exotic would not be a term regularly applied to Kazangula.
The distance across the Zambezi from the soil of Zambia to the soil of Botswana is 1,400 feet. There is no bridge, so a small diesel engine ferryboat shuttles those tractor-trailers—along with a ragtag assortment of safari tourist caravans, SUVs, and cars—across this international border. Kazangula lies about two miles off of the Livingstone-Sesheke highway down a narrow hardtop road riddled with potholes. That road is crowded with this odd parade of vehicles pulled off onto the shoulder awaiting their turn on the ferry. The line begins more than a mile outside the town. The truckers, tour operators, tourists, and regular citizens who are occupying them are gathered in a tangled crowd outside the Zambian customs office trying to complete the process for international travel. For tourists, tour operators, and citizens, the process for clearing customs and getting onto the ferry can take up to four hours. For the long-haul truckers driving those tractor-trailers, the process can take up to three days as they wait for vehicle and cargo inspections.
Kazangula has no economic infrastructure—no industry, no skilled workers, no retail base. Poverty is the universal norm for the citizens of Kazangula. From April to August, after the rainy season has ended and the crops have been harvested, food can be plentiful. But what happens from then until the following April? What happens when the corn cribs on the farms dotting the landscape outside the village are empty and the harvest is still months away?
What happens, then, in a village that has no economic infrastructure (but plenty of desperation) when a steady stream of truck drivers with a regular paycheck are parked in a gravel lot waiting for days to resume their route? An informal economy springs up. In Kazungula it yields makeshift stands offering any kind of goods its citizens can imagine selling: “top off” cards to add minutes to cellphone accounts; dried, salted fish fanned out on tables; informal restaurants selling plates of kapenta or nshima to be washed down with homemade beer (called Chibuku or “Shake Shake”); a tub of water for bathing; bolts of cloth for the wife back home to make a new chitenge, or long skirt. These goods or services can be had for the right price. So can sex. In fact, it seems to be a bestseller in the market. In this informal economy, how far would a woman with no prospects of a job go to feed herself, her children, her family? What would she do as food becomes scarce and her children get hungrier and hungrier? What would you do?
The predominant HIV prevention strategy exported to Africa from the United States has three messages: abstain from sex, be faithful to your partner in monogamous marriage, or use condoms every time you have sex. Abstain, Be faithful, Condoms: ABC. This exportation comes through the funding the Bush Administration has committed to HIV prevention and treatment through the President’s Emergency Plan for AIDS Relief (PEPFAR). The ABC approach is the only model that guides HIV prevention programs under PEPFAR. The first and third messages—abstinence and condom use—are defined in opposition to each other. “Abstinence” is a noun that invokes a certain kind of behavior—a behavior of refusal—and connects that behavior to identity. We know what kinds of persons abstain. “Condom” is a noun that invokes a certain kind behavior—a behavior of activity—and connects that behavior to identity. We know what kinds of persons use condoms. The terms themselves are exclusive by definition—one who abstains does not use a condom—but they are also exclusive in terms of the values they inscribe on the person who behaves in the ways they underwrite. Each one reinforces mutually exclusive identities that are perceived as threats to the other.
Christianity plays a central role in constructing and maintaining this dichotomy, both in Zambia and in the United States; over 90% of Zambians identify as Christian and the preamble to the country’s constitution states that Zambia is a Christian nation. In the United States, Christianity provides a number of mechanisms to underwrite abstinence and to support people who abstain in their identity as abstainers—theological texts, biblical interpretations, True Love Waits youth rallies, weighty traditions, and ethical arguments. These mechanisms do not merely reinforce this identity in the United States. They are part of the prevention messages exported by the United States to other countries under PEPFAR. For example, True Love Waits, the abstinence support model developed by American evangelicals, has become the predominant governmental HIV prevention strategy for young people in Uganda. This strategy is funded through PEPFAR and the initiative is spreading to other African countries as President Bush acknowledged in his address to the annual meeting of the Southern Baptist Convention in 2007: “I thank the Southern Baptists who are working to promote a culture of life abroad by helping lead the fight against… HIV/AIDS. In Uganda, Southern Baptists sponsor… True Love Waits…. And now we’re building on the success by expanding this important programs to six more countries in Africa.”
If Christianity has a number of mechanisms to support abstinence and the identity of the one who abstains, it does not employ similar mechanisms to underwrite condom use or to support any identity that values condom use; those mechanisms, with very rare exceptions, are constructed and maintained outside of Christian communities. Most often, when Christians develop an argument of limited approval of condom use, those arguments generally advocate accommodation: “We Christians will agree that condoms should be used so that the spread of HIV might be slowed.” In these arguments, the rhetoric does not imply that condoms are things that Christians ourselves might use but are things that Christians could permit others to use to lessen the spread of HIV. The problem with limiting Christian speech to this claim is at least two-fold: 1) it assumes that Christians ourselves do not use condoms to limit the spread of HIV, and 2) it reinforces the assumption that people who do use condoms are the kind of people who are specifically not Christian.
The second behavior in the ABC triumvirate is ‘Be faithful.” The model is almost always invoked in social contexts as monogamy, the formal ideal of modern heterosexual marriage, professed both by the state and by the church. “Be faithful” is a natural partner to “Abstinence” for the predominant sexual ethical narratives of Christianity. Invoking abstinence and fidelity, those narratives articulate common claims of upright morality as well as socially approved identities: people who are abstinent until marriage become faithful partners in marriage, according to the rhetoric. This mutual support may make for a coherent ethical and moral code and it may help reinforce long-held norms of the way one should live one’s life. There is reason to wonder, however, if it might actually hurt the women and men of Kazangula.
If “Abstinence” and “Condoms” are mutually exclusive while “Abstinence” and “Be faithful” present an interconnected coherent picture to which one should aspire, then “ABC” prevention messages may, in fact, be detrimental to the people in relationships in which one person is HIV-positive and the other is HIV-negative (serodiscordant relationships). Because “Abstinence” and “Be faithful” are so powerfully linked to a certain kind of identity imbued with moral authority, there is no space to imagine a kind of moral identity that consists of both fidelity and condom use. This is, however, precisely the kind of identity that could make a difference in Kazangula. If we were to assume that 1/3 of the men and 1/3 of the women in Kazangula were HIV-positive (according to data from the nurse at the health clinic in 2007, that number is higher but the point is clear even if we limit our prevalence to 1/3), that means the likelihood of a couple in which at least one of the partners is positive would be just over 55%.
Kristin Dunkle, a behavioral scientist at The Rollins School of Public Health at Emory University, collaborated with colleagues from Emory and San Francisco to explore this very question in Zambia. Their findings were published in July 2008 in Lancet. Dunkle and her colleagues analyzed data from demographic and health surveys conducted on 2,279 residents of Lusaka, Zambia and found that the vast majority (between 55% and 92%) of new infections in Lusaka occur in long-term serodiscordant relationships. The researchers estimate that voluntary HIV testing for long-term married or cohabitating serodiscordant couples accompanied by counseling on risk reduction and condom use would reduce the annual incidence rate of new infections from 20% to 7%. This simple intervention would prevent between 35% and 60% of all new HIV infections in Lusaka. Kristin Dunkle and her colleagues have demonstrated the limits of “ABC” prevention and offer a simple, realistic model that could drastically impact HIV transmission rates in Zambia. The challenge—a challenge embedded in religious language and practice—consists of finding ways to articulate a new kind of identity: the moral, condom-wearing Christian. If American Christianity were to develop the mechanisms to help articulate this identity, they could serve not so much as a new commodity to be exported to sub-Saharan African countries through PEPFAR but as moral, ethical, and theological perspectives that could complicate prevalent norms among Christians here in the United States regarding abstinence, fidelity, and condom use. We have already seen how those norms serve as the necessary precursor to programs such as True Love Waits and how those concrete programs are then spread to developing countries through PEPFAR.
That challenge is daunting because there are inordinate barriers to the actual practice of risk reduction and condom use as methods of HIV prevention. Both women and men know the rules of engagement in the complex negotiations of sex and those rules do not encourage a frank discussion about using a condom. For the women in Kazangula who walk down to that gravel parking lot and for the truck drivers who invite those women into their cabs, finding a way to change those rules is key. When those women go back to their homes a mile away from that parking lot and the men finish their month-long haul and go back to their homes a thousand miles away, they also need some freedom to play by a new set of rules with their husbands and wives. The church could wield tremendous influence in changing the dynamics that perpetuate the implicit but well-known rules that the men and women are constrained to follow because the church is a primary source of the creation and maintenance of broader cultural conversations about gender, sex, morality, and power. The value-laden meanings of “Abstinence” are so tied to the value-laden meanings of “Be faithful” that they crowd out any other meanings of value in regard to the complexities of sexuality and sexual behavior. Those of us who care about Christian languages and practices—languages of theology, ethics, or Biblical interpretation and practices of formation, compassion, or social justice—have some capacity to begin to create those other meanings of value; forging connections between the value-laden meanings of “Be faithful” and the value-laden meanings of “Condoms” would be a good place to start.