“A Place of Trouble”: The Political Ecology of HIV/AIDS in Chipinge, Zimbabwe

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Notes

¹ Research for this paper was undertaken through grants from the National Institute of Mental Health (1R03MH62250-01) and the Social Science Research Council. The University of Pennsylvania, the Zimbabwe National Traditional Healers Association, and the Zimbabwean Medical Research Council provided institutional support for this research. Currently, Dr Taylor is supported by a training grant from the National Institute of Mental Health to the HIV Center for Clinical and Behavioral Studies at NY State Psychiatric Institute and Columbia University (P30-MH43520; Principal Investigator Anke A. Ehrhardt, Ph.D.).

² Bassett & Mhloyi, “Women and AIDS in Zimbabwe.”

³ Goodman & Leatherman, Building a New Biocultural Synthesis; Brown et al., 1998.

⁴ Goodman & Leatherman, Building a New Biocultural Synthesis, 10.

⁵ Ibid.

⁶ Glick-Schiller challenges the culturally biased representations of AIDS and the hegemonic processes through which risk groups have been constructed in the past. She argues that the boundaries used by epidemiologists to create high-risk groups “do not grow immediately and automatically out of epidemiological research;” instead, they are produced within specific social and cultural contexts, which are then extended to other contexts based on the assumption that epidemiological categories are universal. The tendency to stereotype cultural behavior within risk groups has, according to Glick-Schiller “reified the concept of culture, over generalizing the behavior of internally diverse categories of persons within a defined sub-category” (“What's Wrong with this Picture,” 250).

⁷ Watts & Bohle, “The Space of Vulnerability,” 45; see also Leatherman, “A Space for Vulnerability in Poverty and Health,” 51.

⁸ Ibid., 48.

⁹ Ibid., 51.

¹⁰ Watts & Bohle, “The Space of Vulnerability.”

¹¹ Leatherman, “A Space for Vulnerability in Poverty and Health,” p. 47–48.

¹² The district is divided into two regions: Chipinge North and South, which were formerly called Chipinga (now Chipinge) and Melsetter (now Chimanimani) during the colonial era (Rennie, “Christianity, Colonialism,” 35). Chipinge town is linked by road to Birchenough Bridge (62 km northwest), Chimanimani (64 km northeast), and Mutae (170 km north); 30 km to the south lies Mount Selinda (Ibid., 37).

¹³ Chipinge is one of seven districts in Manicaland province that extends between the Sabi River and the Mozambique border, with the Chimanimani district to the north, and Bikita and Chiredzi districts to the west (RRU [Zimbabwe Relief and Recovery] population statistics, Zimbabwe office of the UN Humanitarian Coordinator, http://www.zimrelief.info/index.php?sectid=12&articleid=756 [accessed April 1, 2005]).

¹⁴ Chipinge town was first a trading post established by Thomas Moodie in 1892 (Tabex, Encyclopaedia Zimbabwe, 71). The village was moved in 1895 and renamed Melsetter after Thomas Moodie's homeland in Scotland (ibid., 71). The village was later renamed Chipinga in 1907 after a local chief, and finally changed to Chipinge in 1982 (ibid). In 1903, a police camp was established; in 1909, the first school was built; dairy farming was established at the turn of the century; in 1931, two cheese factories were built near Chipinge; and in 1946, a Town Management Board was elected (ibid). Affluence produced by the commercial tea and coffee plantations resulted in the development of a brewery, a bakery, farm depots, two banks and a credit union, and an airfield in Chipinge town (McCrea & Pinchuck, The Rough Guide, 304).

¹⁵ World Gazetteer, “Zimbabwe 2004: Cities and Places,” http://www.world-gazetteer.com/wg.php?x=&men=gpro&lng=en&dat=32&geo=-247&srt=pnan&col=dq (accessed October 4, 2004).

¹⁶ The majority of life's daily activities in Chipinge take place in kumusha, which comprises a cluster of huts and their surrounding fields, usually inhabited by one or more elder men and their extended families (Bourdillon, The Shona Peoples, 57). Traditionally, the Ndau live in dispersed settlements and their villages are composed of scattered hamlets (ibid).

¹⁷ “Hard MaShona living” describes the harsh realities of rural life, where all household chores are done manually (e.g. plowing, cooking and washing clothes) and there are few modern amenities such as telephones, electricity, or running water.

¹⁸ The Shona, as a distinct ethnicity, is a modern invention of postcolonial nationalism based on a common language, chiShona: a Bantu subdivision first used by South African linguist Clement Doke in 1931 to consolidate and unify the diverse collection of dialects spoken within the then Rhodesia (Kambudzi, “The Zimbabwe–Mozambican Border,” 28).

¹⁹ Others supplement their income by selling pottery or hand-woven baskets, or brewing traditional beer, while some men also work as blacksmiths or carpenters.

²⁰ Tabex, Encyclopaedia Zimbabwe, 2.

²¹ Farmer, “An Anthropology of Structural Violence,” 309.

²² Lebert, Tom, “Backgrounder-land and Agrarian Reform in Zimbabwe.” Land Research Action Network, 21 January 2003, http://www.landaction.org/display.php?article=61 (accessed 4 October 2004).

²³  Chimurenga is the chiShona word for resistance or rebellion, which is often used in reference to revolts (Rasmussen & Rubert, Historical Dictionary, 60). The first Chimurenga (1896–97) was led and fuelled by grievances over the loss of land tenure. The second Chimurenga was the war of liberation led by ZANU and ZAPU, and was directly related to the people's disenfranchisement from the land (Lebert, “Backgrounder-land and Agrarian Reform in Zimbabwe,” 6; Bucher, Spirits and Power, 31).

²⁴ In the first decade after Independence, the Zimbabwean government acquired 40% of the targeted 8 million hectares and resettled more than 50,000 families on 3 million hectares of this land (COHRE [Center for Housing Rights and Evictions], Land, Housing and Property Rights in Zimbabwe, 2001, http://www.cohre.org/get_attachment.php?attachment_id=1563 [accessed 27 December 2003], 16). However, by 1999, 11 million hectares of the richest agricultural land in Zimbabwe were still owned by commercial farmers, who were for the most part white (Human Rights Watch, 7), http://www/hrw.org/reports/2002/zimbabwe/(accessed 1 April 2005).

²⁵ Unfortunately, several hundred thousand farm workers have been largely excluded from the land resettlement program. Moreover, many lost their jobs because of farm closures, while others were driven away because of violence (COHRE, 16).

²⁶ An estimate of 300,000 Mozambican refugees were dispersed throughout the southern African region, which included primarily Malawi, Swaziland, Lesotho, South Africa, and Zimbabwe, which was believed to hold about one third of all the Mozambican refugees (Kambudzi, “The Zimbabwe–Mozambican Border,” 38).

²⁷ Patel, “A National Disaster.”

²⁸ Current data suggest a decline in HIV prevalence, which is currently estimated at 20.1%, down from 22.1% in 2003 (See UNAIDS Fact Sheet: Sub-Saharan Africa. UNAIDS 2006 Global Report, http://data.unaids.org/pub/GlobalReport/2006/200605-FS_SubSaharanAfrica_en.pdf [accessed 1 November 2006]). According to the Global Report, “This decline is twofold; studies have shown both a substantial increase in condom use since the early 1990s and that more young people have been delaying their sexual début and reducing the number of casual sexual partners; however, a significant factor in the decline is attributed to high-mortality rates.”

²⁹ WHO December 2005 Health Action in Crisis: Zimbabwe, http://www.who.int/hac/crises/zwe/en/ (accessed May 2005, The HIV and AIDS Epidemic in Zimbabwe).

³⁰ NAC/MoHCW.

³¹ Ibid., 20.

³² Ibid., 30.

³³ Jackson, AIDS: Action Now, 18.

³⁴ Previous UNAIDS reports (UNAIDS/UNICEF, Children on the Brink 2002: A Joint Report on Orphan Estimates and Program Strategies, 2002, http://www.unicef.org/publications/index_4378.html [accessed 4 October 2004], 2) have focused on two generic populations—urban and nonurban—that are not necessarily rural sites. In Zimbabwe, the median estimates for HIV infection among pregnant women in nonurban areas was 33.15% (the maximum percentage was 70.7%), while the median rate for the urban areas was 31.1%. The estimates for HIV infection for STI or TB patients (both male and female) for these two populations are, however, very striking. In 1996, 53% of STI patients in the major urban areas were HIV-positive, while the HIV infection rate for STI patients living outside major urban areas was 71.8%. In 1997, 74% of urban patients with TB were HIV-positive, and in 1995 there was 84.3% seropositivity among nonurban TB patients.

³⁵ UNAIDS, AIDS in Africa Fact Sheet 1998, http://gbgm-umc.org/programs/wad98/saepap98.html (accessed 4 October 2004), 12.

³⁶ In 1995, national HIV surveillance found that the northern part of the Manicaland province (which includes Mutare and Rusape) had 69.3% HIV infection rate in the cohort surveyed, while the southern part of the province (which includes Chipinge district) had 87.7% infection rate (UNAIDS/WHO, Report on the Global HIV/AIDS Epidemic, June 2000, 13). These estimates are ridiculously high, and are most likely inaccurate.

³⁷ Barnet & Whiteside, AIDS in the Twenty-First Century.

³⁸ World Bank, Meeting the Healthcare Challenge.

³⁹ In the1980s, Zimbabwe made significant developmental gains, which included a rise in life expectancy for both women (55.6 to 60.1 years) and men (52.0 to 56.5 years) and a decline in infant mortality from 86 to 66 per 1000 births (see United Nations, Child Mortality Since the 1960s; Denberg, “Migration and Health,” 14). In the late 1990s, the economic indicators for growth started to wane—the GDP, exports and foreign-exchange reserves had declined, while inflation, consumer prices, and unemployment rose (ibid., 15).

⁴⁰ The United Nations Population Division (2003) projects that Zimbabwe's population in 2015 will be 35% smaller and in 2050 it will be 61% smaller. Zimbabwe is also projected to have the second lowest life expectancy in the world, with an average of 33.1 years between 2000 and 2005 as compared to 67.6 years without AIDS, resulting in a loss of 34 years (UNPOP 2003). Between 2000 and 2015 there will be 4.2 million deaths, creating a 311% increase in mortality since the beginning of the epidemic (Lisa Garbus and Gertrude Khumalo-Sakutukwa, Country AIDS Policy Analysis Project, AIDS Policy Research Center, University of California San Francisco, October 2003, http://hivinsite.ucsf.edu/InSite?page=crari [accessed 1 April 2005], 59). Robinson and Marindo (“Current estimates,” 194) estimated that 66% to 73% of all deaths in Zimbabwe will be HIV-related and that 81% to 86% of those deaths will occur in individuals between the ages of 20 to 39 (USAID, Zimbabwe: Health and Family Planning Briefing Sheet, July 2002, http://www.reliefweb.int/rw/rwb.nsf/AllDocsByUNID/5c54184bc493045085256c320058391d (accessed 4 October 2004).

⁴¹ Ibid.

⁴² Ibid.

⁴³ Parker et al., 1991, 79; see also Abramson and Herdt, ”Assessment of Sexual Practices;” Herdt et al., “Introduction;” Schopper et al., 1993; Geshekter, “AIDS in Africa.”

⁴⁴ Bassett & Mhloyi, “Women and AIDS.”

⁴⁵ Jackson, AIDS: Action Now, 61.

⁴⁶ However, rural and urban Zimbabwean women have also engaged in sex outside of marriage.

⁴⁷ For the Ndau, there is a cultural imperative for a new bride to have a child quickly to prove her fertility and finalize the marriage (Bourdillon, The Shona Peoples, 50). There are also economic rewards to having more children, because more children raise the level of production of the household and generate more wealth and status (ibid.). See also Mutambirwa, “Health Problems in Rural Communities”; Jackson, AIDS: Action Now, 106; Bourdillon, The Shona Peoples, 47.

⁴⁸ Due to “deep-seated fears about the spiritual consequences of childlessness,” many women with HIV or AIDS continue a pregnancy, fearing that an abortion will result in retribution from the ancestors or the loss of social support (Jackson, AIDS, 106). If a person dies before attaining this spiritual maturity, they suffer “kufiririra,” which literally means “obliteration” and is the most dreaded of all deaths (Mutambirwa, “Health Problems,” 9). Childbearing is thought to be a sign of spiritual and moral maturity because of the self-sacrificing behavior that accompanies the physical, mental, and emotional preparation for a new child; thus, having children is considered the first step toward spiritual growth and development, with the first pregnancy symbolically cleansing the body of the physiological impurities associated with immaturity (ibid.). Fears of being perceived as infertile or sterile motivate Ndau women and men to have children at any cost, and childlessness is an unacceptable situation for most (Mutambira, “Health Problems,” 8; Bourdillon, The Shona Peoples, 47).

⁴⁹ Other variables include: fears that a woman will be perceived as being “loose” if her partner does not force intercourse; the practice of women cleaning their men and themselves with the same cloth after coitus; the belief that sex with a new person or for the first time cannot result in pregnancy; the belief that men need to have sex in order to stay “fit;” as well as the beliefs that a married woman cannot refuse sex from her husband, that condoms suggest a “lack of trust,” that sex within marriage is for procreation, while sex for enjoyment requires other women, that only men are supposed to enjoy sex, that husbands and wives do not discuss sex, that condoms suggest an “accusation of infidelity,” and that faithful wives cannot get an STD (Jackson, AIDS, 63–4).

⁵⁰ Masasire, “Kinship and Marriage,” 42.

⁵¹ Herbs used for dry sex in Zimbabwe are generically called wankie, although there is a popular form called mutundo wegudo, which is made from soil where baboons have urinated (Sayagues, “Zimbabwe's Last Taboo,” 1). Wankie comes in two forms. One is powder taken daily in porridge or tea, and the other is inserted into the vagina before sex (Mercedes Sayagues, “In Zimbabwe, love is a hot, dry season.” Weekly Mail and Guardian, October 1998, http://www.mg.co.za/ [accessed 1 April 2005], 1). See also Civic & Wilson, “Dry Sex in Zimbabwe;” Ray et al., “Local Voices;” Jackson, AIDS, 63; Brown et al., “Dry and Tight;” Runganga & Kasule, “The Vaginal Use of Herbs;” and van de Wijgert et al., “Intravaginal Practices.”

⁵² Zimbabwean men in a study reported that “wet sex is not desirable because it reduces friction, prevents the vagina from heating up, causes an annoying sound and the fluids smell bad” (Sayagues, “Zimbabwe's Last Taboo,” Sayagues, “In Zimbabwe,” 2). The late Peter Mutandi Sibanda, the former cultural secretary of Zimbabwe National Association of Traditional Healers (ZINATHA), stated that “[m]en find a wet woman disgusting … [and that] … Men want a tight vagina: no fluids, no lubrication and no foreplay” (quoted in Sayagues, “In Zimbabwe,” 2).

⁵³ Jackson, AIDS, 65; Civic & Wilson, “Dry Sex.”

⁵⁴ A Shona wife, however can also decide not to be inherited, or opt to be inherited by her oldest son (Bourdillon, The Shona Peoples, 51). Conversely, if the wife dies her family may be obligated to provide the husband with another wife.

⁵⁵ The virgin cleansing myth, however is not unique to Southern Africa: there is evidence that it is indeed a cross-cultural phenomenon, with examples from India to nineteenth-century Victorian England for the treatment of syphilis or gonorrhea (Mike Earl-Taylor, “HIV/AIDS, the stats, the virgin cure and infant rape,” April 2002, http://www.scienceinafrica.co.za/2002/april/virgin.htm [accessed 1 April 2005], 2; see also IRIN, “Focus on the Virgin Myth and HIV/AIDS,” 25 April 2002, http://www.aegis.com/news/irin/2002/IR020406.html (accessed 1 April 2005).

⁵⁶ According to this report, since 1994 there was a 40% annual increase in child rape cases reported (Jan Raath, “Study Finds Three out of Ten Zim Children Sexually Abused,” 20 March 1997, http://pangaea.org/street_children/africa/zimba3.htm [accessed 1 April 2005], 1–2). At Chipinge District Hospital, doctors and nurses reported countless cases of young girls (four years and younger) being admitted for problematic STIs. One public-health worker estimated that about 60% of all rape victims in Zimbabwe are younger than twelve years old, and the average age for infant rape is three years old.

⁵⁷ Watts & Ndlovu, Violence Against Women in Zimbabwe, 3; see also Raath, “Study Finds”; Njovana & Watts, “Gender Violence”; AFROL, “Gender Profiles: Zimbabwe,” http://www.afrol.com/Categories/Women/profiles/zimbabwe_women.htm (accessed 1 April 2005); and “Zimbabwe: Sexual abuse rises as humanitarian crisis worsens,” Africa Online, HARARE, 24 April 2003 http://www.irinnews.org/report.aspx?reportid=43217.

⁵⁸ Furthermore, seldom is there a harsh punishment for offenders because the police are not trained to deal with acts of violence towards women, creating numerous obstacles for women to report an assault. AFROL states that “According to Women in Law and Development in Africa (WILDAF), domestic violence accounted for more than 60% of murder cases tried in the Harare High Court in 1998” (AFROL, “Gender Profiles: Zimbabwe,” 4). Also, they found that “over half of Zimbabwean women believe that wife beating is justified” in one out of five cases (Lisa Garbus and Gertrude Khumalo-Sakutukwa, Country AIDS Policy Analysis Project, AIDS Policy Research Center, University of California San Francisco, October 2003, http://hivinsite.ucsf.edu/InSite?page=crari [accessed 1 April 2005], 27). Ndau women feel not only that their husbands are entitled to beat them from time to time, but that this helps maintain the marriage.

⁵⁹ This text is a literal translation that is at times hard to read. I adhere to her text because it more accurately captures her sentiments, adding parenthetical comments only where necessary for clarity.

⁶⁰ NAC/MoHCW 2004.

⁶¹ Wasserheit, “Epidemiological Synergy,” 61.

⁶² Moss & Kreiss, “The Interrelationship Between Human Immunodeficiency Virus Infection and Other Sexually Transmitted Diseases,” 1654–5; Augenbraun & McCormick, “Sexually Transmitted Diseases in HIV-infected Persons,” 440–3; Wasserheit, “Epidemiological Synergy”; Laga et al., “Non-ulcerative Sexually Transmitted Diseases”; Plummer et al., “Sexual Transmission of HIV.”

⁶³ Jackson, AIDS: Action Now, 18; Meursing, A World of Silence, 39.

⁶⁴ Some men in Zimbabwe believe that respectable women, such as wives, cannot get shameful STIs because of their inherent virtuous nature and therefore do not try to protect themselves with extramarital sex (Jackson, AIDS: Action Now, 65; see also Green, “Anthropology of STD” and Indigenous Theories).

⁶⁵ Ulcerative STIs, such as chancroid, genital herpes, or warts increase HIV susceptibility both by damaging epithelial barriers in the genital tract which fight off infection and by increasing the levels of lymphocytes and macrophages (CD4 cells) that are the targets for HIV infection (Kreiss et al., “Isolation of Human Immunodeficiency Virus”; Piot & Tezzo, “The Epidemiology of HIV”; Moss & Kreiss “The Interrelationship Between Human Immunodeficiency Virus Infection and Other Sexually Transmitted Diseases,” 1651; McNamara, “Female Genital Health,” 116). There is also an increased risk of HIV infection with nonulcerative STIs such as Chlamydia, gonorrhea, or trichmonas (Moss & Kreiss “The Interrelationship Between Human Immunodeficiency Virus Infection and Other Sexually Transmitted Diseases,”1654–5; Augenbraun & McCormick “Sexually Transmitted Diseases in HIV-infected Persons,” 440–3; Wasserheit, “Epidemiological Synergy”; Laga et al., “Non-ulcerative Sexually Transmitted Diseases;” Plummer et al., “Sexual Transmission of HIV”).

⁶⁶ Le Bacq et al., 1993.

⁶⁷ Goodman, “Tuberculosis and AIDS”; Drobniewski et al., “Tuberculosis and AIDS.”

⁶⁸ Today, one third of the world's population is infected with TB bacilli, and a single infected individual, if left untreated, can infect 10–15 people a year (WHO, “Country Profile: Zimbabwe,” 1996, http://www.who.int/GlobalAtlas/predefinedReports/TB/PDF_Files/zwe.pdf; WHO, World Tuberculosis Day, 13).

⁶⁹ Drobniewski et al., “Tuberculosis and AIDS,” 86.

⁷⁰ WHO, World Health Report, 1.

⁷¹ WHO, World Tuberculosis Day, 14.

⁷² Most cases of TB among HIV-infected individuals are thought to be a reactivation or (re)infection of a latent TB infection rather than a new infection caused by recent exposure (Drobniewski et al., “Tuberculosis and AIDS,” 87; Goodman, “Tuberculosis and AIDS,” 708; Rose, “The Relationship Between TB and HIV Infection,” 577–8). Diagnosis of TB in HIV-infected patients is also difficult because many of the clinical symptoms, such as weight loss, fever, night sweats, chills, cough, and sputum production are also common in a number of other AIDS-related illnesses (Goodman, “Tuberculosis and AIDS,” 708; Rose, “The Relationship Between TB and HIV Infection,” 580). According to Rose (“The Relationship Between TB and HIV Infection”) and Goodman (“Tuberculosis and AIDS,” 709) TB diagnosis in HIV-positive patients requires “a high degree of clinical suspicion” because of the false negatives of the TB skin, sputum test, and “atypical” pulmonary infections that are difficult to detect through radiology.

⁷³ Nunn & Felton, “Surveillance of Resistance,” 164.

⁷⁴ DOTS (Directly Observed Treatment, Short-course) are a recommended strategy by WHO and the World Bank to eradicate TB. The DOTS strategy is based on five main elements: (1) Identify infectious cases for treatment and cure; (2) Observed compliance of treatment regimen; (3) Must be provided with a treatment that ensures a cure; (4) Adherence to correct dosages of medication; and (5) Government support to make TB a high political priority (World Tuberculosis Day, 1997).

⁷⁵ Rose, “The Relationship Between TB and HIV Infection,” 575.

⁷⁶ See Mosley, “Does HIV or Poverty Cause AIDS?” and Fenton, “Preventing HIV/AIDS.”

⁷⁷ The first two programs were the Growth with Equity Plan (1981), which established Zimbabwe as a socialist society, and the Transitional National Development Plan (1986) to transition from a war to normal economy (Africa Governance Forum, “Local Governance for Poverty Reduction,” 23).

⁷⁸ Africa Governance Forum, “Local Governance for Poverty Reduction,” 23; World Bank Group, “Meeting the Health Care Challenges,” 2; WHO, World Health Report. The economic liberalization implemented under the 1991 ESAP failed to control the government's budget deficit and created economic stagnation and reduced job creation, which was later exacerbated by the drought of 1991–92, rising cost of food and services, and declining wages (World Bank Group, “Meeting the Health Care Challenges,” 2). The most damaging ESAP guideline for Zimbabwe in regard to its response to HIV/AIDS was the mandatory elimination of state-funded welfare programs that provided free national health care and education (Sanders & Sambo, “AIDS in Africa”).

⁷⁹ Poverty in Zimbabwe has been defined as “the inability by an individual, household or community to satisfy their most basic needs,” which include: “food, clothing, shelter, clean water, sanitation facilities, health facilities, education facilities, clean air, employment, transport, productive land, etc” (Africa Governance Forum, “Local Governance for Poverty Reduction,” 3, 2).

⁸⁰ WHO, World Health Report.

⁸¹ In 1996, average real earnings were lower than they were prior to independence (Bollinger, J. and L. Stover, “The Economic Impact of AIDS in Zimbabwe,” Futures Group International in collaboration with Research Triangle Institute (RTI) and The Center for Development and Population Activities: The Policy Project, 1999, www.policyproject.com/pubs/SEImpact/SEImpact_Africa.pdf [accessed 4 October 2004], 3). According to Bollinger and Stover (ibid.), 20% of the population receives 60% of the national income. Sixty percent of the population live below the poverty line and spend 33–55% of their total expenditures on food and health care (ibid., 3–4; Denberg, “Migration and Health,” 17).

⁸² These “growth points” are usually positioned along major roads near heavily populated areas, and consist of small stores and beer halls where local artisans or merchants come and sell their wares.

⁸³ Haacker, Marcus. “The Economic Consequences of HIV/AIDS in Southern Africa.” IMF Working Paper 02/38, 2002, http://www.imf.org/external/pubs/ft/wp/2002/wp0238.pdf (accessed 1 April 2005); Loewenson & Kerkhoeven, Socio-economic Impact of AIDS; Whiteside, HIV Infection and AIDS; Bollinger & Stover, “Economic Impact of AIDS.”

⁸⁴ One in seven caretakers also gave up their job to care for a sick family member, 42% of healthcare costs were paid for by the sick person and their spouse, and another 41% of medical costs were covered by contributions from other household members (Mushati et al., 2003).

⁸⁵ Medical expenses often deplete family savings; children (especially girls) are withdrawn from school; the nutritional status of the family declines; more households are headed by women, the elderly and children; and after death, there is the additional cost of the funeral (Bollinger & Stover, “Economic Impact of AIDS in Zimbabwe”).

⁸⁶ Zimbabwe Farmer's Union in 1997 found that the agricultural output of AIDS-affected households in the communal areas declined by nearly 50%, and maize production by both commercial and smallholder farmers declined by 61% due to AIDS-related death and illness (Kwaramba, Socio-economic Impact of AIDS; Topouzis, “Addressing the Impact,” section 2).

⁸⁷ Loewenson & Whiteside, Social and Economic Issues, 31.

⁸⁸ Barnett & Blaikie, AIDS in Africa; FAO, “HIV/AIDS.”

⁸⁹ Ibid.

⁹⁰ FAO (ibid.) estimated that Zimbabwe from 1985 to 2020 would have a 23% loss in agricultural labor due to AIDS. In 1997, a report found that maize production by both small and commercial farmers declined by 61% (Kwaramba, Socio-economic Impact of AIDS). Impact studies in Zimbabwe reveal a decline in cultivation acreage for the 1997–98 season due to reasons related to HIV/AIDS: shortage of labor, lack of essential inputs, draught power, and farm implements. AIDS-affected households showed poor crop management and harvest, experiencing losses in marketed output of more than 50% of maize, cotton, and sunflowers (Bollinger & Stover, “Economic Impact of AIDS,” 6).

⁹¹ WHO, World Health Report, 1.

⁹² Ibid.

⁹³ UNAIDS, AIDS in Africa; WHO, World Health Report, 1.

⁹⁴ Vuylsteke, Sunkutu, & Laga, “Epidemiology of HIV and Sexually Transmitted Infections in Women.”

⁹⁵ For statistics, consult http://www.who.int/hiv/pub/epidemiology/hiv_aids_2001.

⁹⁶ Lisa Garbus and Gertrude Khumalo-Sakutukwa, Country AIDS Policy Analysis Project, AIDS Policy Research Center, University of California San Francisco, October 2003, http://hivinsite.ucsf.edu/InSite?page=crari (accessed 1 April 2005), 1.

⁹⁷ Older men, called “sugar daddies,” pursue sexual relationships with young girls, especially those who are virgins (Jackson, AIDS: Action Now, 66). Secondary-school girls also develop sexual relationships with “sugar daddies” to pay for their school fees (ibid.). According to Jackson (ibid., 66), in the rural area of Masvingo, the term “jelly mamma” (similar to sugar daddy) is used to refer to a married woman who pays young boys for sex.

⁹⁸ UNAIDS, AIDS in Africa.

⁹⁹ Twenty percent of babies born with HIV are infected during pregnancy, and 30% during breastfeeding (Ish Mafundikwa, “Fear of Social Backlash Hampers Zimbabwe's Fight Against AIDS Baby Deaths,” 4 October 2002, in The Prevention News Update, Centers for Disease Control and Prevention, http://www.thebody.com/cdc/news_updates_archive/oct4_02/zimbabwe_babies_aids.html [accessed 4 October 2004]). Only 40 hospitals in Zimbabwe offer HIV-positive women nevirapine to reduce transmission of the virus; however, this drug is only administered to women who can confirm their HIV-positive status (ibid.).

¹⁰⁰ Current prevention strategies ignore the reality that African women are socially, culturally and economically disadvantaged and therefore unable to negotiate the use of condoms needed to protect themselves (Ulin, “African Women and AIDS”). Discussion about condoms in the context of marriage can be very disruptive because it raises issues of infidelity and distrust (Jackson, AIDS: Action Now, 64). For Ndau men, just the mention of condom use either signals a woman's desire to be unfaithful, or is considered an affront to their masculinity.

¹⁰¹ First, this strategy assumes that there is both an open dialogue about sex and that women are equal partners in sexual negotiations. However, the greatest deterrent to the use of condoms is their contraceptive effect. To prevent a pregnancy is unnatural because the purpose for having sex is procreation and to extend the lineage. Current prevention strategies ignore the reality that Shona-Ndau women are socially, culturally and economically disadvantaged and therefore unable to negotiate the behavior changes needed to protect themselves and their children. Critics such as Gupta & Weiss (“Women's Lives and Sex,” 399) argue that there is an “urgent” need for an approach to prevention that is “grounded in the realities of women's lives and sexual experiences.”

¹⁰² These women in rural Zimbabwe are referred to as “spares.”

¹⁰³ Heise & Ellias, “Transforming AIDS Prevention.”

¹⁰⁴ World Bank, “Education and HIV/AIDS,” 7.

¹⁰⁵ HIV/AIDS in Education Assessment Team (HIV/AIDS-EAT). “Impacts of HIV/AIDS on Education in Zimbabwe,” draft submitted for discussion with senior MoESC management, 2001, http://hivaidsclearinghouse.unesco.org/ev (accessed 4 October 2004).

¹⁰⁶ After independence, the Zimbabwean government restructured the national public health services to expand access in rural areas, making services free for those who earned less than Z$ 150 a month (Meursing, A World of Silence, 29). However, with the implementation of the ESAP in 1991, access to health care sharply declined due to the imposition of new fees (Whiteside, HIV Infection and AIDS). A decade later, Zimbabwe's crumbling healthcare system is severely underfunded, resulting in overcrowded hospitals and mortuaries full to capacity (Michael Wines, “With Health System in Tatters, Zimbabwe Stands Defenseless,” New York Times, 5 February 2004, http://query.nytimes.com/gst/fullpage.html?sec=health&res=9E0DEFDA133BF936A35751C0A9629C8B63 [accessed 1 April 2005]; Integrated Regional Information Network (IRIN), “Zimbabwe: Health sector suffers from shortages,” Relief Web, Johannesburg, 22 September 2003, http://www.irinnews.org/report.aspx?reportid=46277 (accessed 1 April 2005); WHO, World Health Reports, 2; MDC Press, “MDC's Health Policy: Putting People First,” 2001, http://www.mdczimbabwe.org/ [accessed 27 December 2003]).

¹⁰⁷ IRIN 2003c: 2; Lisa Garbus and Gertrude Khumalo-Sakutukwa, Country AIDS Policy Analysis Project, AIDS Policy Research Center, University of California San Francisco, October 2003, http://hivinsite.ucsf.edu/InSite?page=crari (accessed 1 April 2005), 42.

¹⁰⁸ USAID 2002; Haacker, “The Economic Consequences,” 12.

¹⁰⁹ Bollinger & Stover, “Economic Impact of AIDS,” 9.

¹¹⁰ BBC News, “Zimbabwean Migrant ‘Flood’ Neighbor,” 30 January 2003, http://news.bbc.co.uk/2/hi/europe/2709829.stm (accessed 1 April 2005).

¹¹¹ In 2003, this resulted in drug suppliers and pharmacies raising prices over 1,000% to cover increases in import costs (IRIN, “Zimbabwe: Rising Costs of Medical Drugs Impacts on Poor,” 7 October 2003, http://www.irinnews.org/report.aspx?reportid=46575 [accessed 1 April 2005]).

¹¹² Agence France-Presse “Zimbabwe-drugs: Zimbabwe hospitals refuse non-emergency ops: report.” 28 September 2003, http://www.aegis.com/news/afp/2003/AF0309E8.html (accessed 4 October 2004).

¹¹³ From an epidemiological point of view, the spread of diseases has always been associated with the movement of people, which brings large numbers of people into close contact and creates an optimal environment for disease transmission (see Russell, Jacobsen, & Stanley, International Migration; Lyons, Male Migrants as a High-risk Group; Jochelson et al., “HIV and Migrant Labor;” Duckett, “Migrants and HIV/AIDS;” Romero-Daza, “Multiple Sex Partners”). Initially, AIDS researchers thought that the migration of HIV-infected persons provided an efficient vehicle to transport disease to places where they were previously unknown; however, migration also affects the health and well-being of migrants and those left behind (Denberg, “Migration and Health,” 13; UNAIDS, “Population Mobility and AIDS,” 2001, http://data.unaids.org/Publications/IRC-pub02/JC513-PopMob-TU_en.pdf). Thus, population mobility is more than just a transporter of HIV; it is a politicoeconomic process that breeds broader social and behavioral changes, which make migrant populations in particular vulnerable to HIV infections (ibid.). Being a migrant, however, itself is not a risk factor; it is the activities undertaken during the migration process that place individuals at risk of HIV infection. The link between migration and HIV/AIDS is related to the conditions and structure of the migration process, poverty, exploitation, separation from families and partners, and separation from the sociocultural norms that guide behaviors in stable communities. First, migrant laborers are exposed to poor working and living conditions that contribute to their general low health status (Denberg, “Migration and Health,” 13). They often live together in crowded rented apartments, or in temporary housing on commercial farms. Second, most migrants are isolated from the societies in which they work (ibid.). Moreover, international migrants do not have the same political rights as nationals, and subsequently have limited access to legal or health resources. Finally, separation from one's family socially frees many migrants from the cultural norms that regulate sexual behavior and many turn to prostitution and drugs as a way to escape their loneliness, frustration, and social isolation (ibid., 13; Romero-Daza, “Multiple Sex Partners,” 200).

¹¹⁴ Jackson, AIDS: Action Now, 60.

¹¹⁵ In Chipinge, long-distance truck drivers look for overnight accommodations with local prostitutes at the beer halls along the main road to save money on hotels. Five kilometers outside of Chipinge town is a military base that contributed to the development of a commercial sex industry in town.

¹¹⁶ Machipisa, L. “Zimbabwe-AIDS: Army Battles Random Testing,” 26 March 1996, InterPress News Service, http://www.aegis.com/news/ips/1996/IP960306.html (accessed 1 April 2005), 1; Jackson, AIDS: Action Now, 90.

¹¹⁷ Commercial farmers in Chipinge argue that Mozambican migrants are essential to large-scale agriculture production because they fill in the gap of local workers that has declined by 30% (Denberg, “Migration and Health,” 18).

¹¹⁸ The Tongogara refugee camp, which is close to Chipinge, houses hundreds of people from Mozambique and several East African countries, including the Democratic Republic of Congo (DRC).

¹¹⁹ Although migrating to cities was a viable option for Ndau men, many single Ndau women seldom pursue this path for fear that they will be perceived as loose and immoral women who engage in prostitution while away from home. Denberg (“Migration and Health,” 16–17) reported that in 1980 “life-time out-migration” of men aged 25–44 years was between 50% and 75%, while only 26% of the population was urban, which later doubled in the mid-1990s.

¹²⁰ Botswana officials report that 125,000 Zimbabweans unlawfully enter Botswana every week (BBC News, 30 January 2003, http://news.co.uk/2/hi/europe/2709829.stm [accessed 1 April 2005]). Unable to cope with the massive flow of illegal immigrants from Zimbabwe, Botswana has been repatriating truckloads of illegal immigrants every day (ibid.).

¹²¹ Agadzi, AIDS: The African Perspective of the Killer Disease, 140.

¹²² Goodman & Leatherman, Building a New Biocultural Synthesis, 5.

¹²³ UNAIDS Fact Sheet: Sub-Saharan Africa. UNAIDS 2006 Global Report, http://data.unaids.org/pub/GlobalReport/2006/200605-FS_SubSaharanAfrica_en.pdf (accessed 1 November 2006); WHO/UNAIDS 2003 UN report, Impact of AIDS, http://www.un.org/esa/population/publications/AIDSimpact/AIDSWebAnnounce.htm (accessed 1 April 2005).

¹²⁴ UNAIDS Fact Sheet: Sub-Saharan Africa. UNAIDS 2006 Global Report, http://data.unaids.org/pub/GlobalReport/2006/200605-FS_SubSaharanAfrica_en.pdf (accessed 1 November 2006).

¹²⁵ Ibid.

¹²⁶ Ibid.

¹²⁷ UNAIDS 2006 Global Report (New York edition): errata sheet, http://www.unaids.org/en/Publications/Corrigenda/20060530-GR06.asp (accessed 1 November 2006).

¹²⁸ Goodman & Leatherman, “Building a New Biocultural Synthesis,” 5.