Our Kind of People Page 5

  I found it difficult not to be overwhelmed by the physical presentation of some of our patients. The desire to recoil and protect oneself is not admirable, but it can be so strong that at first it can be hard to see beyond the manifestations of a disease, to see that before you lies a person with a disease—not a disease with a person. I would often marvel to myself while I stood outside a patient’s bedroom as I put on gloves and a protective gown, and after as I lathered my hands with sanitizer—standard hospital procedure to protect both patients and care providers—how thin this line is between professional responsibility and fear. If I and others with a background in health and knowledge of how HIV/AIDS works and is transmitted can be shocked by its physical signs, what to do then if you are a villager in a rural area without much information beyond the idea that HIV/AIDS is bad? What do you do if you witness a friend, as one man recalled to me, with “her whole body fill up with sores. Her skin color just change from yellow to black like that.”

  What makes HIV/AIDS even more disconcerting is the fact that a diagnosis is still often considered a death sentence. Idris explained to me that in Hausa-speaking northern Nigeria, the word for HIV/AIDS is kanjamau. This translates roughly as “skeleton.” In addition to suggesting the emaciated physical appearance of a person with HIV/AIDS, it also brings to mind the ultimate abomination of the human physical form, the stuff of horror films and nightmares, the living dead. If being negative is ordinary, then this HIV-positive person languishing in this liminal state, not quite alive, not yet dead, is clearly abnormal and as such suffers from discrimination that can lead to isolation and neglect.

  However, the nature of this disease is that it often does not show for years. This complicates its associated stigma. “You can’t see it because it doesn’t written for anybody’s face,” the old man in Idris’s village square said. He was expressing a common sentiment: you can’t see it, so be afraid. In other words, now more than ever we must use vigilance and segregate ourselves from these dangerous HIV-infected Others, even if, paradoxically, we cannot immediately recognize their difference.

  The disease is also seen as a commentary on a person’s moral standing. As one doctor I spoke with briefly about HIV put it, “Whenever people see you, they say, ‘Oh! Here is a sinner—somebody must have gone and done something really bad.’ People don’t want to be associated with that.” Thus HIV causes a remarkable metamorphosis, making the extrinsic and physical an intrinsic property of character. An HIV-positive person becomes at best a person with flawed judgment and at worst someone evil.

  “Dearly beloved, it has pleased God to afflict you with this disease, and the Lord is gracious for bringing punishment upon you for the evil that you have done in this world”—Michel Foucault quotes from a French ritual when discussing the treatment of lepers in medieval times. He might as well have described the present attitude toward those with HIV/AIDS, in Nigeria and perhaps elsewhere in the world. Despite the increasing availability of scientific information about the nature of HIV transmission, there are still many Nigerians who believe the disease is punishment for individual sins and aggregate societal ills. The anthropologist Daniel Jordan Smith has studied Nigerian attitudes toward HIV/AIDS and found that “the dominant religious discourse about AIDS is that it is a scourge visited by God on a society that has turned its back on religion and morality.” He recalls conversations with HIV-positive Nigerians who attributed their disease to the “sinful immoral lives they had led.”

  The impact of such thinking can be devastating. An HIV-positive woman I met briefly on a trip to Lagos explained to me the personal impact of this kind of moralizing on HIV infection.

  “Even in church, my church, then, they saw it as a big taboo,” she said. “The way the man would be preaching and be saying things: ‘We’re telling people don’t be a prostitute when you’re young. You should behave well. You should have good upbringing.’ I felt he was passing the wrong information because I, as far as I am concerned, I had a good upbringing. I wouldn’t justify that I was a saint, but I know that to a great extent I had a very good upbringing. I felt that man was passing the wrong information. That information was scary. He was putting the immediate society in a tight corner because among the people there, you wouldn’t tell me that I was the only one who was positive in that church. You can imagine the wrong information that he might be sending to that man or that woman who is HIV positive—that you are a prostitute! You are a bad person! He was being too judgmental, so you go home judging yourself to death: ‘Oh! I’m a bad person. I don’t even deserve to live in this world anymore. Oh! Nothing good can come out of me.’ Those were the messages that were always surrounding the pastor’s message, the message of death, judgment, guilt, failure.” She stressed the word prostitute each time, almost spat it out at me with vehemence as if trying to clear her mouth of something bad-tasting.

  The relationship between HIV and sexuality is complex and deserves special consideration. A major aspect of the moral component of HIV-related stigma derives from our anxieties about sex. Again, the work of Daniel Jordan Smith is instructive. His interviews with young Nigerians on the subject of sexual morality and HIV/AIDS yielded comments like “AIDS is God’s way of checking the immoral sexual behavior that is rampant in Nigeria now.” The intense focus on sexual impropriety as a cause for both the existence and the spread of HIV/AIDS leads to the conclusion that the moral failings of an individual can endanger society as a whole, making it all the more important to brand and exclude fallen individuals—to prevent additional lapses and mitigate the impact of those that have already occurred. Unfortunately, this practice can backfire, because it drives frank discussion about the nature of HIV to the margins and discourages honesty about diagnoses for fear of judgment and stigmatization. It creates a silence that facilitates the spread of the disease.

  Finally and perhaps most dramatically, the physical and moral forms of stigma associated with HIV/ AIDS attach not only to individuals but also to racial groups, countries, in fact a whole continent—Africa. The locus of the worst manifestations of the HIV/ AIDS epidemic in sub-Saharan Africa reinforces preexisting stigmatizing notions of Africans as inferior and Africa as a backward place. Ideas about Africans and Africa as unacceptably different are longstanding and complicated, and they have already been explored by many writers and thinkers. Africans have traditionally been considered emotionally and intellectually inferior, our savage bodies finding purpose only when subordinated to the white man’s will. During the colonial period, myths of savagery, ungodly ritual, human sacrifice and profligate sexuality became more common as an increasingly violent subjugation of the colonized necessitated ever more imaginative justifications. Some have argued that the branding of Africans as inferior emerged as exploitation of Africa’s natural resources, including African bodies as cheap labor, increased. In other words, in order to legitimize the abuse of another human, colonial masters had to diminish the humanity of their subjects and emphasize the otherness of the place from which they came.

  Anthropological and scientific writings of the colonial period are shot through with these sentiments. Among the more precise—and prescient—is Joseph Conrad’s fictional work about the Congo, Heart of Darkness. Conrad connected African inferiority and disease in a way that anticipated present-day racial and cultural stigmatization of those with HIV/AIDS in Africa:

  Black shapes crouched, lay, sat between the trees leaning against the trunks, clinging to the earth, half coming out, half effaced with the dim light, in all the attitudes of pain, abandonment and despair … they were nothing earthly now—nothing but black shadows of disease and starvation, lying confusedly in the greenish gloom.

  Conrad’s Africans begin as feeble creatures too weak to hold themselves up, too racked by the misfortunes that their blackness has bestowed upon them to stand tall and act with agency. They end as quasi-humans, of another world, their forms merged fully with disease and despair generated in the bowels of a continent composed of pr
imeval otherworldliness. It is a testament to Conrad’s descriptive genius and literary influence, and unfortunately also to the strength of the associations he so vividly captures, that present descriptions of HIV/AIDS in Africa stray very little from this script.

  “Soon Africa will be a continent of AIDS orphans,” begins CNN’s former chief international correspondent Christiane Amanpour in that television network’s 2006 documentary Where Have All the Parents Gone? A musical score of mournful reed flutes plays as a map of Africa appears on screen, emphasizing the exotic otherness of the continent. There follows an image of young “African” (in reality, Kenyan) children lolling in the dust as a baby cries and heavy breathing interspersed with despondent moaning is amplified over Amanpour’s voice.

  Next we are introduced to Mukhtar, who we are informed is “another African boy who wonders whether he too will become one of the million AIDS orphans in Kenya.” The camera zooms in on his face while he watches his cachectic HIV-positive father breathing laboriously in bed. As Amanpour narrates Africa’s struggle with AIDS, the screen fills with images of shabbily dressed people in shantytowns shrouded by red dust. Later we learn that Mukhtar’s father, who was rejected by his family once they discovered his HIV-positive status, had considered killing himself, his wife, and his son with rat poison because they are “a burden” and he does not “want them to suffer.” This snippet of a modern HIV/AIDS film echoes Conrad at his best, playing up that which sets Africa and Africans apart. Never mind that there is no monolithic African identity; Kenyans stand for all Africans. They live in otherworldly dwellings surrounded by filth. They even have a different, warped sense of morality. We are left wondering what kind of creature would consider killing not only himself but also his young wife and only son—of course, a person “infected with HIV.” This is all before anyone questions whether it is ethical to display a young Kenyan boy with HIV-positive parents for millions of people to see. One wonders whether a white European or American child would have received the same treatment.

  If this was but one representation, it might be excusable, but it falls into a panoply of images of HIV/ AIDS in Africa that play up stigmatizing identifiers. As recently as 2006, the New York Times displayed headlines screaming “Traditional Ways Spread AIDS in Africa, Experts Say,” deliberately evoking thoughts of strange ritual and exotic practices. We later find that one of these “traditional” ways is the universal practice of breastfeeding. Associations like this remind me of the poster I own from the AIDS charity Keep a Child Alive. Their public relations campaign unwittingly plays to ideas of African otherness while cementing the link between African-ness and HIV/ AIDS. In this image, the two are inextricably linked. Disease is African-ness and African-ness is a disease. So powerful is this association that a condition attributable to approximately 4 percent of the African continent’s population becomes the narrative for the other 96 percent. It results in the following conclusions relayed to me by a young Canadian woman working in Lagos, who described the reactions of her family members to her decision to move to Nigeria for a year: “My dad’s mom, when she found out I was going, she said, ‘You’re going to catch AIDS.’ I had an aunt who told me that I should bring a bag of my own blood with me … if I needed a blood transfusion.”

  A New Yorker article about the possible origins of a theoretical next big epidemic consolidates the associations of African-ness with strange or backward culture and disease. It follows a Stanford University virologist who is desperately trying to educate local villagers about the perils of consuming monkeys because they are receptacles for disease. “When I see a monkey like that, dragged through the street, bloody, on the way to market, it’s like looking at a loaded weapon,” he says after seeing a woman carrying a monkey on the back of a motorcycle. The piece features Cameroonians covered in buckets of monkey blood and stresses that in the present day, with easy travel linkages between Cameroon and California, it’s not hard for a virus to move between populations. This article is a striking example of what the medical anthropologist and AIDS activist Dr. Paul Farmer calls a “symbolic network that stresses exoticism and the endemicity of disease.” In other words, diseases like HIV/AIDS come from people with “weird” or “backward” cultural practices—Africans who eat monkeys.

  HIV/AIDS was not always associated primarily with Africa. Thirty years ago, the initial concerns about the virus were decidedly localized to the Western world. Homosexual men were initially vilified as the prime culprits for the propagation of the epidemic. At some point during the mid-1990s, when it became clear that there was an epidemic in Africa primarily spread by heterosexual sex, and when it became clear that public health programs along with readily available treatment in the West had led to a stabilization and decline in the number of new cases there, AIDS became African. That Africans in countries like Nigeria have not managed to control the spread of HIV/AIDS, as has been achieved in developed nations, supposedly reflects a host of vices for which Africans are constantly berated. We are disorganized and inefficient, so the virus spreads. We lack the intellectual capacity to create our own drugs and treatment protocols, so the virus spreads. We are untrustworthy and misappropriate funds for treatment programs, so the virus spreads. We lack compassion for the afflicted, so people die. In what might be the most unfortunate of ironies, we are stigmatized for stigmatizing: that is, according to the narrative, in developed nations people are cared for; they are not ostracized; they receive services and treatment. In Africa the infected, like Mukhtar’s father, are savagely expelled—as if fear of contagion is a uniquely African sentiment—cast out into the vast darkness of a physically and morally undeveloped continent. This is not to say fear and stigma do not exist, but they are not uniquely African phenomena.

  HIV/AIDS is an extraordinary illness, especially because it creates a social dynamic that in some ways mimics the biological process by which the HIV virus damages the human body. In the same way that the HIV virus causes a breakdown in communication among elements of our immune systems, leading to an inability to neutralize it and other diseases, so too does its associated stigma break down relationships among people, preventing many of those who have it from communicating their need for assistance and treatment. Indeed, a former senior World Health Organization (WHO) AIDS program official described stigma as a stage of the HIV/AIDS epidemic, “the stage of social impact … marked by stigma, grinding down its victims with shame and isolation, creating an environment of secrecy and denial which are both catalysts for HIV transmission.” If to be open about one’s status is to don a set of scarlet letters that says “not one of us,” not human, then it is understandable why so many would remain silent about or ignorant of their status. The more the virus spreads, the more people die, and the stronger the stigma grows.

  For me the impact of this stigma didn’t really hit home until after a discussion I had with a young woman I met at a bar on a military base about an hour away from the village where Doc worked and lived. We decided to make a trip to the Nigerian Army cantonment one afternoon for a drink. Because the area is predominantly Muslim and governed in part by Sharia law, the military barracks, with its multicultural, multireligious makeup of soldiers from all over the country, was the only place to get a drink, a cold beer, maybe even a rudimentary cocktail. The environment was perfect for the large army base, which was home to an infantry and artillery unit. There were acres of open field for firing ranges and target practice. A sleepy barracks with one- and two-story living quarters in strict rows occupied one corner of the base. The officers’ quarters were in another section nearby. Between them was an open-air space with multiple bars where young women served drinks and heaping plates of food to soldiers in fatigues. That’s where I met Elizabeth. She was a server at one of the bars.

  I can’t remember exactly how our conversation started, but it turned quickly—as many of my conversations then did—to the subject of HIV/AIDS. Elizabeth was eager to talk. We agreed to meet later at a hotel where I was to sta
y the night so that we could talk with greater privacy.

  Later that night, Elizabeth said, “I’ve gotten a sister,” meaning a close friend. “She stopped the drugs and she died. I never knew that she has been hiding.” We sat on the concrete veranda outside my guest chalet just before dusk. The hotel compound was full of similar chalets, simple concrete boxes surrounded by small grassy gardens fenced by small shrubs. A few stray chickens pecked at the gravel path for insects hiding between the pebbles. There were two WHO trucks parked beneath a red-blossomed flamboyant tree. I would find out the next morning that they belonged to two older British men managing a polio eradication campaign.

  The receding sunlight lingered on Elizabeth’s face. Her full cheeks had followed her from childhood into her twenties, and a rather delicate and un-imposing nose appeared almost as an afterthought between them. She wore dark eye shadow. Earlier, at the bar, I had watched her move gracefully from table to table serving drinks, seemingly flowing despite the long, tight purple skirt that forced her to take small steps.

  Her friend, Elizabeth told me, had been an excellent tailor. For that reason, Elizabeth had encouraged her to come up north to this town near the military barracks, where there was more work. Arrangements were made, and her friend soon journeyed from Cross River to Niger State to set up shop, start sewing, and hopefully earn some money. Her friend wasn’t to stay for very long. “Her mom died and she travel home,” Elizabeth said. “Later, I went home because I lost a cousin’s sister. When I saw my friend, she was down. I sympathized for her sickness and everything. Something swell her under the chest there,” Elizabeth said. She placed her palm flat against the right side of her stomach.