Prof Moira Chimombo

Introduction

If we want to bring an end to the AIDS epidemic in Africa, we must adopt a family approach to prevent the further spread of HIV. The foundation of this family approach is three-fold: virginity/abstinence before marriage, faithfulness/abstinence within marriage, and Christ-like character, embracing self-control, commitment, and compassion, which lead to companion-ship in the family. To achieve the necessary impact of the family approach, we have to address HIV prevention from the cradle to the grave. This we do through early childhood education, the education and empowerment of caregivers and guardians of orphans and vulnerable children, the training of teachers to implement moral values-based life skills education throughout primary and secondary education, pre-marital counseling, and parenting education.

Already in 1969, John Mbiti, well-known Kenyan philosopher, wrote on the stresses on the traditional African family:

The size of the family is shrinking from the traditional extended family concept … The authority and respect which parents enjoyed under traditional morality and customs are being challenged … The education of children is increasingly being passed on from parents and the community to teachers and schools … whereas under the traditional set up both boys and girls receive[d] preparatory education concerning marriage, sex and family life, especially after and during their initiation rites. … [W]e are heading for tragic social, moral and family chaos whose harvest is not far away. (Mbiti 1969)

We are now witnessing the “harvest” of the AIDS pandemic:

[T]he estimated number of maternal, paternal, and double orphans due to AIDS in Malawi, South Africa and the United Republic of Tanzania rose from 1.2 million in 2001 to 2.9 million in 2007. However, … all but a small minority of orphaned children are being absorbed into kinship, community, and other support networks. (UNAIDS 2008:47)

The family set-up in Africa was, and still is, recognized as extended rather than nuclear. Grandparents, aunts and uncles, nephews and nieces, as well as mother, father, and children, are all considered to be members of one family. In the past, parents expected to be looked after by children when they got old; there was, and still is, no welfare state. Now, in many cases, it is the vulnerable grandparents, or aunts and uncles, looking after their equally vulnerable orphaned grandchildren, nephews and nieces.

In a society where the primary purpose of marriage is procreation, rather than, or even without, companionship, children are essential to the concept of family. Yet these are the very ones being orphaned, because the “middle” generation is dying in such large numbers. Some grandparents are looking after as many as 12 orphans, although the average is only 2-3 in the villages where we work. The worst-case scenario is that of child-headed households, which is what happens after the only living relatives themselves succumb to the stress of old age without the expected extended family support provided in previous generations:

Arguably the epidemic’s cruelest legacy … is the orphans it is leaving behind. … Orphaning rates above 5% worry UNICEF because they exceed the capacity of local communities to care for parentless children. (The Economist 29 November 2003, emphasis added)

“In Africa, AIDS is a family disease” (Bartholet 1991). Ever since the beginning of the AIDS pandemic, transmission of HIV in Africa has been largely heterosexual (UNAIDS 2008:43). Not only that, but even more importantly, it has frequently occurred within marriage, because of the phenomenon of multiple concurrent partnerships (see, e.g., Helleringer & Kohler 2007, Halperin & Epstein 2007). This has serious implications for mother-to-child transmission of HIV, with almost 90% of the world’s 2 million HIV-positive children living in Sub-Saharan Africa (UNAIDS 2008:33).

As such, AIDS is “an attack on family integrity” (cf. Hekman, 1992:132), for four main reasons. First, HIV often infects one spouse, followed by the other. Secondly, initially one spouse has to care almost full-time for the other until his/her death; then later, one of the children, usually the eldest daughter, has to care for the second spouse until his/her death. Thirdly, even if HIV doesn’t lead to mother-to-child-transmission, the children will sooner or later be orphaned. Fourthly, once the children are orphaned, it becomes the responsibility of the extended family, usually the grandparents, to care for the orphans. The following testimonies illustrate the significance of these factors.

Testimonies:

(1) Child-headed household—Flossy Lemani

(2) Gogo Frank at Kondanani

(3) Irene Chaluluka—SAFE’s National WHY WAIT? Field Coordinator

To highlight these factors, here are a few statistics for Malawi:

What is of particular concern for the prospects for marriages is that 47% of new infections are occurring in people who are in a single stable relationship (Shumba 2009). Furthermore, current programs and models primarily address individual behavior modification rather than couple-based protection strategies. Focusing on individuals’ behaviors to reduce the spread of HIV may prove inadequate in sub-Saharan African countries, such as Malawi, where infection within marriage is becoming increasingly common. (Anglewicz et al. Forthcoming, p. 9)

These are the reasons why it is so important to adopt a family approach to preventing the transmission of HIV.

All SAFE’s programs consider the family as a whole: husband, wife, children, and the extended family, particularly grandparents. In other words, we work with people at all stages of life, from the cradle to the grave, in the context of the family, in the communities where we work. At the same time, we give a variety of kinds of support.

For the youngest children in a community, we provide training for caregivers to give holistic early childhood development, care, and education, to cater for not only the children’s immediate physical needs, but also their long-term intellectual, psycho-social, emotional, and spiritual development. Part of the training includes attention to nutrition, to ensure sound brain development which will permit the children to reach their full potential. Already, after only one year of such early children education, children from our first preschool were doing significantly better than their counterparts from other preschools or no preschool, by Grade 3.

If the young children are not educated properly at the preschool level, they will never break out of the cycle of poverty which, for many urban-based children, is resulting from their being orphaned by AIDS and their subsequent return to the village to be cared for by their grandparents or other relatives. A major contributing factor to dropout in later years is absence of appropriate preschool facilities.

An important aspect of the training which we have recently added is that of grieving counseling, in which we have trained grandparents to handle not only their own grieving, but also that of the orphans in their care. This is significant for psycho-social and emotional development, which will allow the children to overcome their grief and move on.

As the children grow, we have set up a network of support for them to be assisted through primary and secondary education. Even though primary education is free, most schools require children to wear school uniforms, which we provide for the poorest families. Later, we help those young people who are selected to attend secondary school, by paying school fees, and supporting them in other ways. For example, Flossy (the orphan mentioned earlier) asked for a kerosene lamp and kerosene to enable her to study in the evenings, after dark, so that she can do better in secondary school.

While the students are in primary and secondary school, we try to ensure that they are taught our character development and life skills curriculum, WHY WAIT?, so that they master the skills they need to make moral choices, after critically and/or creatively reasoning about a particular problem. Our main focus is on helping them develop the necessary self-control to act on their moral decisions, but the foundation is a healthy awareness and knowledge of moral values which underpin a healthy self-esteem. In schools which have adopted the WHY WAIT? curriculum wholeheartedly, dramatic changes have been observed. Just one example will suffice. At Ndirande Primary School in a high-density area of Blantyre, the main commercial center of the country, with an enrolment of over 7,000 students, the dropout rate fell from 7.5% to 0.0001% within three years. Even more notable was the drop in teen pregnancies: in 1998, just before the program was introduced, there were over 130 pregnancies; in 1999, there were only 20+ pregnancies; from 2000, there have not been more than 2 pregnancies in any one year.

Because the vast majority of the students are vulnerable as a result of being infected or affected by HIV&AIDS, we also devote some time to teaching them parenting skills. We are fully aware that many of them will not have seen modeled either the life skills or the parenting skills they will need to lead a stable life once they have identified the right marriage partner. If they do not acquire the necessary life skills and parenting skills, they are in grave danger of repeating the mistakes of their parents that led to themselves being orphaned. If that happens, the poverty cycle will never be broken.

Apart from the support we give the grandparents for their grandchildren, we also provide agricultural inputs, including maize seed and fertilizer. These have resulted in the grandparents bringing back to their local preschools food for their grandchildren’s feeding program, from their good harvests. We are currently planning to give training in both Farming God’s Way and natural medicine (through anamed—Action for Natural Medicine). Our aim is to increase the chances of food security and long-term sustainability, and reduce dependence on artificial fertilizer. In addition, at the monthly “Gogo Grandmother” meetings, we provide instruction in nutrition, to ensure that the orphans are being appropriately nourished.

SAFE’s mission is to encourage both youth and families to implement the “A, B, C” of HIV/AIDS prevention, so that:

Abstinence—Affirms both the dignity and responsibility of human sexuality.

Be faithful—Builds strong supportive families which will encourage both A and B.

In order to do this,

C becomes Christ-like Character, demonstrating Control, Commitment, and Compassion, thus, being able to enjoy true Companionship.

For families to be stable and stay safe, we help young people develop Christ-like character so that they can exercise the self-control to maintain their virginity by abstaining from sexual intercourse before marriage. This self-control is essential for them to be faithful to their future spouse before marriage, and subsequently to be faithful within marriage. However, exercising self-control is not easy when one’s basic human needs are not met. It is particularly important, for example, to help orphaned teenage girls to stay away from prostitution, or teenage boys from drugs leading to crime, which are merely short-term solutions to poverty, often leading to even greater poverty—if for example the girl gets pregnant and/or is infected with HIV, and has to abandon school. Thus we seek ways of fulfilling the basic needs of all the people in the communities where we work.

In this way, the communities begin to recognize their own and each other’s human dignity. Many people are totally unaware of their personal dignity and worth as human beings created in God’s image, both male and female, and it is wonderful to see their eyes lighting up once they realize that they are special. Arising from this new-found awareness of their dignity is an improvement in their interpersonal relationships. One cannot respect other people if one does not respect oneself.

As a result, the family comes to reflect the image of God—Father, Son, and Holy Spirit. The parents demonstrate their love for their children by providing them with the necessary food, shelter, clothing, etc., and protecting them from dangers, in the same way as God has loved us. Over time, the parents teach their children, most effectively by simple example, that human dignity calls for responsibility. The children learn what it means to have a work ethic, and also how to protect God’s creation by conserving the environment and other resources.

As they grow up, the children learn moral values by observing their parents modeling them. Moreover, they learn that love is a choice, as they see their parents choosing to continue to love each other on a daily basis, throughout the ups and downs of family life. At all times, the parents hopefully demonstrate servant leadership, rather than an autocratic parenting style, so that when the children make a mistake, they punish them appropriately, but particularly they help them to recognize the mistake, and change their behavior, accepting their parents’ and God’s forgiveness.

This recognition that, as Christians, we can start again when we have sinned, repented, and sought forgiveness helps young people develop a healthy conscience, which distinguishes between right and wrong behaviors, with the former improving self-esteem and the latter leading to feelings of guilt. It also helps break the silence resulting from shame and the fear of stigma surrounding the HIV epidemic. When we recognize that “all have sinned and fall short of the glory of God” (Romans 3:23), so that we are not alone in having made mistakes, we are more willing to acknowledge these sins, not only in ourselves (which might otherwise make us ashamed) but also in others (which might otherwise lead us to stigmatize them).

The young people also learn that their mind matters. They can CHOOSE between good and bad behaviors, and even engaging in sexual intercourse before marriage is a choice, except in the case of rape. They even learn about their own sexuality through their mind. Although different cultures express themselves in slightly different ways, for example, with different kinds of initiation ceremonies, ultimately the core human values which we derived from God are universal.

Finally, the people we work with develop an understanding of how to respond to the problems that confront them. Instead of reactively sitting back and waiting for others to help them, they proactively seek answers, not just at the family level but even at the community level. For example, the pastor in one community where we work has mobilized the community as a whole to work in community vegetable gardens so that all the families are helped. He has even taken orphans into his own home to bring them up with Christian values.

Most prevention approaches tend to address only technical problems, as Campell and Williams (1990:21) point out:

The practice of having multiple sexual partners is the main causal factor in the transmission of HIV in Africa. Promoting the use of condoms does not address this issue. It advocates a technical solution to a problem which can be addressed only through fundamental changes in social attitudes, values and behavior.

Rushing (1995:235) goes further:

In the final analysis, whether the HIV/AIDS epidemic in Africa slows down will depend on millions of people changing their behavior. And since behavior is anchored in cultural norms, social institutions, and the structure of social rewards, change will be hard for health care professionals to bring about. … African programs must be adapted to the traditional social practices and culture of Africa.

Even the current promotion of male circumcision is a technical solution. Although there is mounting evidence that male circumcision before HIV infection reduces quite substantially the danger of becoming infected, and if infected, reduces quite substantially the danger of transmission (Halperin & Bailey 1999), like the promotion of condoms, it does not entail behavior change:

In particular, behavior will have to change among men, who have a vital role to play in overcoming the traditional attitudes and practices that have contributed so much to the spread of AIDS in Africa. (UNICEF 2002:7)

Nonetheless, almost 30 years later most approaches continue to treat HIV&AIDS as almost exclusively a medical problem, as Jungar and Oinas (2004:109) point out: “The tragic [sic] of the medical construction of ‘African AIDS’ is that it hampers the implementations of effective prevention programs.” This is because most approaches fail to seriously consider the implications of the fact that AIDS is a behaviorally transmitted disease. They ignore the broader social, psychological, economic, and especially spiritual impact, not just on the individual person living with HIV but on every member of his/her nuclear AND extended family.

Even most life skills programs maintain too narrow an understanding of how to achieve behavior change. By contrast, in our approach, we maintain a balance between the knowledge, desire, and skills, for each component, and at each stage of learning, from early childhood through primary and secondary education to mentoring the grandparents looking after orphans, thus promoting a healthy and stable family life. Below is the framework (taken from Focus on the Family 1999):

Young people who learn life skills in this integrated way, rather than as a large number of separate skills, each perceived to be equally important but unrelated to others, will be more likely to make right choices of marriage partner, and also subsequently bring up their children with similar moral values, within stable families.

Ultimately, we will not be able to stem the spread of HIV unless and until we adopt a family approach, which takes account of all the strains and stresses on families infected and affected by AIDS. This is how SAFE has been slowly developing its programs, since 1993, and is continuing to develop ways of improving the quality of life of communities absorbing the huge number of orphans. SAFE works with the grandparents looking after very young orphans; it trains caregivers to give Biblically holistic early childhood education at Community-Based Child Care Centers; it provides Christian values-based life skills education in primary and secondary schools; it provides training in parenting skills and nutrition. All these activities SAFE engages in from a Biblical worldview perspective.

Although Anglewicz et al. (forthcoming, p. 9) come close to the solution, when they state:

Overall, our findings highlight … the necessity of considering HIV risk from the couple, rather than the individual, perspective when planning HIV interventions and policies in sub-Saharan African countries with generalized epidemics.

They and other researchers, as well as governments, NGOs, etc., all need to recognize that the answer in sub-Saharan Africa is not just a couple-based approach but a whole family approach.

Anglewicz, Philip, Simona Bignami-Van Assche, Shelley Clark, & James Mkandawire. HIV risks among currently married couples in rural Malawi: What do spouses know about each other. Forthcoming in AIDS and Behavior

Bartholet, Jeffrey. 1991. AIDS: Africa’s family disease. Newsweek 16 September:42-43.

Campbell, Ian D & Glen Williams. 1990. AIDS management: An integrated approach London: ActionAid.

Focus on the Family. 1999. No apologies: The truth about life, love, and sex.

Halperin, DT & RC Bailey. 1999. Male circumcision and HIV infection: 10 years and counting. Lancet 354:1813-1815.

Halperin, DT & H Epstein. 2007. Why is HIV prevalence so severe in Southern Africa? The role of multiple concurrent partnerships and lack of male circumcision. Southern African Journal of HIV Medicine, March:19-25.

Hekman, Randall J. 1992. The attack on the family: A response. In William Bentley Ball, ed., In search of a national morality: A manifesto for evangelicals and catholics. Grand Rapids, MI: Baker Book House and San Francisco, CA: Ignatius Press, pp. 131-143.

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