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Abstract
This article explores the possible relevance of African communalism to HIV/AIDS policies in Botswana and other parts of sub-Saharan Africa. We examine various interpretations of African communalism, which many consider to be the cardinal insight of African thought. We suggest several applications of this indigenous notion of personhood to HIV prevention in general and to routine HIV-testing policies in particular. This analysis demonstrates some of the ethical dilemmas and cultural complexities inherent in designing as well as implementing effective HIV-prevention programmes that strike a conscientious balance between protecting individual freedoms and securing public health. Recovering past traditions (such as African conceptions of personal identity) is valuable not only for the purpose of self-identification but also for helping us meet the challenges and problems of today in Africa. We also suggest that the human-rights-based approach to HIV prevention, which strives to protect individuals, is possibly incompatible with the socio-ethical ideals espoused by African communalism. We conclude that public health programmes in Botswana and other parts of sub-Saharan Africa would be more effective if those who designed and implemented them possessed a better understanding of indigenous conceptions of personhood or human agency as well as existing ethno-medical beliefs and cultural practices.
Notes
1 Botswana has one of the highest levels of HIV prevalence in the world: the 2008 Botswana AIDS Impact Survey (BIAS) estimated that 17.6% of the population aged 18 months and above was HIV-positive; the corresponding figure in the 2004 BIAS was 17.1% (UNAIDS, 2010). Botswana Sentinel Surveillance 2001–2009 suggests that HIV prevalence among pregnant women aged 15–49 has leveled off at 33% since 2005.
2 Perhaps it should be conceded from the outset that this stark antithesis between Western and non-Western conceptions of personal identity or agency commits the fallacy of—at least—the ‘straw person.’ The most popular caricatures of Western models of public health—namely, that they are non-holistic in orientation or that their behaviour-change models are exclusively individualistic—do a disservice to policies and practices of present-day international public health organisations. For example, the World Health Organization in the preamble to its constitution (see: <http://www.who.int/about/definition/en/print.html>) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” And while it may be true that some behavioural scientists stress individual agency as the most effective point of public-health or behaviour-change intervention programmes, most international public health organisations draw heavily on alternative models of behaviour change (such as the ‘behavioral ecological model,’ the ‘community coalition approach,’ and ‘community-based health-promotion interventions’) (see DiClemente, Crosby & Kegler, 2009).
3 Recent articles on public health ethics in the Bulletin of the World Health Organization have identified a ‘need to reconcile the claims of individual and mass approaches’ (e.g. Hyder, Merritt, Ali, Tran, Subramaniam & Akhtar, 2008; Krebs, 2008; Osrin, Azad, Fernandez, Manandhar, Mwansambo, Tripathy & Costello, 2009).
4 “This mentality,” writes Sono (1994, p. 7), “this psychology is stronger on belief than on reason; on sameness than on difference. Discursive rationality is overwhelmed by emotional identity, by the obsession to identify with and by the longing to conform to. To agree is more important than to disagree; conformity is cherished more than innovation. Tradition is venerated, ontinuity revered, change feared and difference shunned. Heresies [i.e. the innovative creations of intellectual African individuals, or refusal to participate in communalism] are not tolerated in such communities” (cf. Louw, 2001). Perhaps the psychosocial structural dynamics inherent in stigmatisation are not altogether unrelated to the potentially “overwhelming, totalistic, even totalitarian” strain of African communalism (Sono, 1994, p. 7).
5 For this historical corrective to revisionist or reconstuctivist accounts of African communalism, as well as for several other helpful comments, we wish to thank Professor Barry Hallen (Morehouse College).
6 See Taylor (1963) and Shutte (1993). Perhaps there are other senses of ‘inner’ to be explored: Hallen (2000, p. 44) stipulates that “Inú is a general or comprehensive term the Yoruba can use to refer to the psychological self, psychological in the sense of that inner, private, mental, enduring conscious element or dimension to the person” (see also Hallen & Sodipo, 1994, p. 5).
7 “It is important,” claims Maquet (1972, p. 76), “for a member of a small society to know his consanguineal relationships (that is, blood relationships by descent and collaterality) and his affinal relationships (that is, relationships based on allegiances and marriages), for they determine his various roles as son, father, paternal nephew, cross cousin, parallel cousin, uncle, son-in-law, etc. Each of these roles is defined by obligations and rights which establish very precisely how he must conduct himself towards his various kinsfolk, and what he may expect of them.”
8 Identities, by opposition, are not limited to this trajectory: there are also the identities by opposition between Muslims and Christians, liberals and conservatives, men and women, first-world and third-world, believers and non-believers, all of which animate struggle and conflict.
9 It is worth noting that, according to Gyekye (1997, p. 74), “morality requires us to look beyond the interests and needs of our own selves, and that, given the beliefs in our common humanity—with all [that] this concept implies for the fundamental needs, feelings, and interests of all human beings irrespective of their specific communities—our moral sensitivities should extend to people beyond our immediate communities.”
10 Allen & Heald (2004) explicitly compare Uganda to Botswana. There are various schools of thought on how to account for the HIV-prevention success in Uganda, as well as a more narrow debate around the argument for sexual abstinence versus condom use in the so-called ‘ABC’ strategy (see Cohen, 2004; Epstein, 2004 and 2005; Halperin, Steiner, Cassell, Green, Hearst, Kirby et al., 2004; Hearst & Chen, 2004; Stoneburner & Low-Beer, 2004; Green, Halperin, Nantulya & Hogle, 2006).
11 These estimates are provided in Botswana's 2010 UNGASS Country Progress Report (UNAIDS, 2010).
12 Though the question of what constitutes ‘adequately informed’ is appropriate not only in cases of opting-out but also in cases of affirmative consent (in which case the objection is not specific to opt-out routine HIV testing), the “the quality of informational and volitional elements of informed consent [in resource-poor nations] has been repeatedly questioned over the past decade” (Rennie & Behets, 2006, p. 53).
13 Presently, we can only speculate on the concrete or pragmatic implications of African communalism to the design of public health programmes; but, if considered relevant to designing more-effective HIV-prevention programmes, the question itself is empirical in character and thus amenable to social scientific research.