Untitled

African Journal of AIDS Research 2005, 4(2): 83–90 Printed in South Africa — All rights reserved Lover, mother or worker: women’s multiple roles and the HIV/AIDS and
reproductive health agenda in Tanzania*
Lisa Ann Richey
Department of International Development Studies, Roskilde University, Roskilde, Denmark International and national campaigns to prevent HIV/AIDS and efforts to promote reproductive health remain sepa-
rate in terms of conceptualisation and implementation. Local negotiations around reproductive health issues simi-
larly seem to lack explicit attention to HIV/AIDS. This paper argues that even in reproductive health clinics a gap
exists between the extent of knowledge of HIV/AIDS and AIDS talk. There also appears to be a mismatch between
collective knowledge of the behavioural and biomedical context of HIV/AIDS and the socio-economic context of
AIDS as a lived experience. Using an ethnographic account, I explore how one woman’s lived experience and her
knowledge of AIDS can teach us to take HIV/AIDS into account when theorising, promoting or providing services
for improving African women’s reproductive health. The background for this ethnography comes from data col-
lected during 25 months of fieldwork at 10 maternal and child health/family planning (MCH/FP) clinic sites in the
Morogoro, Ruvuma and Kilimanjaro regions of Tanzania. Rehema’s story shows that AIDS, like other diseases, is
significantly linked to host-susceptibility and economic vulnerability. Separate and competing vertical programmes
on AIDS and MCH/FP, as commonly encountered throughout Africa, cannot meet the needs of women in countries
like Tanzania. Yet, we still hear most often of abstinence, anti-retrovirals and condom use as the primary focus of
HIV/AIDS prevention and intervention in Africa.
Keywords: Africa, communication, ethnography, health care provision, family planning, national health care programmes,
women
Introduction
‘Maybe it was something caused by the changing weather demography, such discourses still drive encounters within or her own problems.’ In December 1999, 16 years after the the arena of ‘development’ and delimit acceptable knowl- first cases were reported in the Kagera region, Tanzania’s edge and means of knowing. Different roles are deployed President Mkapa declared AIDS a ‘national disaster’. By the by actors in varying ways with respect to HIV/AIDS, and time the National Policy on HIV/AIDS was released at the most women occupy multiple roles simultaneously.
end of 2001, an estimated 750 000 women of reproductive ‘Mothers’ and ‘workers’ are contracting HIV, while ‘lovers’ age were infected.1 As early as the 1990s, AIDS-related ill- are considered for AIDS-related interventions. nesses were the leading cause of death among reproduc- Throughout the course of my participant observation at tive-age women, accounting for over 30% of all deaths in maternal and child health/family planning clinics in Tanzania, Morogoro rural district between 1992 and 1995 (Adult I rarely heard about AIDS. I could, of course, visit any of the Morbidity and Mortality Project, 1997), in spite of the fact AIDS-related NGO projects — or in some cases, attend the that this district reports lower levels of HIV among pregnant separate STD-treatment clinic, or interview workers in the women than almost any other district (UNAIDS, 2002).
government AIDS Control Programme. But in the course of Meanwhile, international and national efforts for combating ‘normal’ interventions of women’s reproductive health, AIDS HIV/AIDS and efforts to promote reproductive health have was confined to the section of counselling for informed remained separate in conceptualization and implementation choice about contraceptive methods: condoms prevent sex- (see Richey, 2003). Local negotiations around reproductive ually transmitted diseases like AIDS, and other methods do health issues reflect a similar lack of explicit attention to not. Service providers were never shy about giving their HIV/AIDS. While experiences of HIV/AIDS ‘on the ground’ clients health care advice, both solicited and unsolicited, but continue to prove inaccessible through atomistic discourses AIDS was not a topic for these conversations. Women came of understanding such as those found in epidemiology or to family planning clinics because they were mothers, and * An early version of this article was presented at the University of the Western Cape, Cape Town, South Africa, at the conference ‘WritingAfrican Women – Poetics and Politics of African Gender Research’.
sexuality and sexually transmitted diseases were consid- 10.4% to 18.4% of married women using some form of con- ered to be a mother’s concern. Yet, as the case study in this traceptive method — and the percentage continued to climb paper exemplifies, HIV/AIDS remains the issue of reproduc- to 25.4% by the 1999 survey (Kapiga, Ruyobya & Boerma, tive health for many Tanzanian women. Furthermore, 1993; National Bureau of Statistics, 1997 and 2000). There HIV/AIDS cannot be disentangled from the socio-economic has been a continuous downward trend in the total fertility struggles of women, who are reproductive and productive rate from 6.5 in the 1988 census to 5.6 in the 1999 ‘workers’ in the newly liberalised Tanzanian economy.
Reproductive and Child Health Survey. However, the coun- Tanzania began HIV/AIDS control efforts in 1986 with the try has seen much less success in improving other aspects establishment of the National AIDS Control Programme, yet of reproductive health (see Richey, 2003 and 2004b).
HIV prevalence continues to rise in most parts of the coun- Notably, the proportion of births assisted by trained med- try (Tanzania Commission for HIV/AIDS, Office of the Prime ical personnel has declined steadily: Tanzanian women Minister, 2003). Tanzania’s policies have received criticism today are less likely to receive professional assistance in for relying on a thinly spread programme lacking effective delivery than they were in the 1970s. Clinics often lack top-level support or multi-sectored implementation, and for essential supplies, including basic drugs. Furthermore, the continuing to view AIDS primarily as a health issue (Baylies most recent national facility survey found that less than 1% & Bujra, 2000). Yet, I argue that even in reproductive health of government dispensaries had a working light source, clinics a gap exists between knowledge of the HIV/AIDS laboratory or refrigerator (National Bureau of Statistics, epidemic and the extent of HIV/AIDS talk, while there is 2000). The impact of HIV/AIDS and related illnesses on the also a disparity between the behavioural and biomedical already-declining public health sector can only be hypothe- context of AIDS, as we know it in the aggregate, and our sised. Yet, as Tibaijuka (1997, p. 964) reminds us, ‘the understanding of the socio-economic context of AIDS as deplorable state of public health facilities in the country will people’s lived experience. Underpinning social-scientific continue to contribute to the spread of disease, including knowledge is the assumption of contrasting roles for African women. ‘Lover’, ‘mother’ and ‘worker’ are envisioned asrequiring different sorts of development interventions, and Methodology: drawing on ethnographic knowledge
targets are set accordingly. However, understanding theoverlap and the gaps between women’s roles can help us Ironically, while HIV/AIDS eclipses all other development make sense of possible interventions and their limitations.
issues in some contemporary research on Africa, the condi- Using an ethnographic account, I explore how a better tion has had negligible effect in non-AIDS-specific analyses knowledge of people’s lived experience can teach us to (see Boone & Batsell, 2001; Barnett & Whiteside, 2002).
take HIV/AIDS into account when theorising, promoting or Epidemiological modelling provides useful data on the epi- providing services, especially for improving African demic and its transmission patterns. Economic, political, women’s reproductive health. A sub-theme of the paper is and demographic models document the relationship that more, but different, empirical accounts of developmen- between AIDS and poverty (Stillwaggon, 2002), political tur- tal interventions targeting African women are necessary if moil (De Waal, 2003), and mortality (Feeney, 2001). Yet, indeed we are to understand both the roles that they create, there is a need to understand more about AIDS than what we can know or predict from aggregate models. AsKleinman & Copp (1993) argue, the way problems are lived AIDS and the international reproductive health agenda
as experience is a valid type of information that is differentfrom statistics. Thus, I attempt to situate AIDS in the context Reproductive health and rights agendas have focused of studying reproductive health through a discussion of attention on important issues that had not yet been empha- what I learned from a Tanzanian woman I call Rehema.2 sized in population debates — such as, who controls fertil- Fredland (1998) argued that we are now in the ‘accept- ity, reproductive decision-making, the ethics of contracep- ance-response’ phase of the epidemic. However, in reality, tive methods, and the impact of gender relations in the acceptance is far from comprehensive and response is household, clinic and national policy environment. Still, piecemeal, and HIV/AIDS is not currently at the centre of reproductive health is focused more on reproduction than debates about the goals of reproductive health interven- on health. A population discourse dominated by concern for tions. The inability to deal with HIV/AIDS in reproductive controlling fertility, by women, couples, or governments, health discourses is not a result of an orchestrated AIDS- precludes adequate incorporation of the challenges that denial ideology, a top-down plan, or a conscious determina- HIV/AIDS brings to health-care policy and development tion to avoid the issue. ‘Discourse works by telling us in policies. National reproductive health programmes in devel- advance of any perception, what it is we can see and what oping countries are implemented through the structures of is or is not important’ (Cruikshank, 1999, p. 24). Still, there the old population control policies. Reproductive health in may be a gap between what we can see through our lenses many African communities might be best understood to of research and what is really there. Researchers may risk mean ‘remaining healthy enough to reproduce’. prematurely narrowing our vision through channels of iden- Tanzania has been successful in implementing the family- tity or social roles characterising women. Rehema’s life and planning component of its reproductive health strategy.
death suggest to me that, whether we focus on it or not, Between the 1992 and 1996 Demographic and Health HIV/AIDS is at the centre of reproductive health debates in Surveys (DHS), family-planning use nearly doubled — from Africa, and while we debate the appropriateness of various African Journal of AIDS Research 2005, 4(2): 83–90 components and their importance under the umbrella of repro- the house manager, Emmanueli, the gardener, and ductive health, AIDS may be trumping other objectives.
Rehema, the cleaner. Rehema was both loquacious and The background for this ethnographic study originates interested in me and in my health research in Tanzania.
from national survey data, together with data collected dur- Coming from a context of hope concerning notions of global ing 18 months of fieldwork at 10 clinic sites (equally distrib- feminism (see Booth, 1998), I tried to listen, understand, uted between urban and rural areas in the Morogoro, and provide support wherever possible for Rehema. As nei- Ruvuma and Kilimanjaro regions of Tanzania) during ther a subject of my structured research nor an official 1995/96, as well as six months in the Kilimanjaro region in respondent, and with no pool of similar interests or experi- 2000, and two brief trips there in 2002 and 2004.3 I con- ences from which to draw on to build a friendship, ducted interviews in Swahili with family-planning service Rehema’s relationship to me was as an acquaintance.
providers and engaged in participant observation at each However, Rehema insinuated herself significantly in my site. Regions were chosen to represent areas with high, learning about the field realities and priorities of reproduc- medium and low rates of contraceptive use, and clinic sites were chosen in consultation with the district and regional Demographically speaking, we had a few things in com- maternal and child health coordinators to reflect a variety of mon. We were both of reproductive age, currently employed, sexually active women. Yet, our differences on The point of using an individual narrative in a discourse key variables, of education, income, parity, and marital sta- commonly dominated by numbers is to suggest a different tus, constituted a challenge to communication, unavoidably type of understanding or epistemology — one that raises overlaid with configurations of race and class. A student on questions without giving us answers in the ways that we campus claimed that Rehema was a notorious gossip and can expect from predictions and models. Yet, at the same had a ‘loose’ reputation with men. The heterosexual nature time, it reminds us to question whether or not we are really of HIV transmission in Africa heightens an emphasis on getting answers or achieving certainty in our understanding sexual promiscuity, ‘both real and imagined,’ (Baylies & of reproductive health or ‘global AIDS’ (a term that might Bujra, 2000, p. 176). Thus, rumours about Rehema are imply that AIDS is everywhere and perhaps nowhere in par- likely to have stemmed as much from the small commu- ticular). Rehema’s story suggests that in cases when nity’s attempt to make sense of the epidemic around it as HIV/AIDS is at the centre of a woman’s life — even when it from any actual behaviour on her part. My conversations is unspoken — and available reproductive health services with her, usually at her initiation and always with her con- do not involve meaningful interventions for prevention or sent, speak to the multi-faceted struggle for reproductive treatment, AIDS threatens to render meaningless other health in Africa. The following interlude is accounted in my important accomplishments by the reproductive health field notes5 after one of our conversations: agenda. Thus, the following discussion describes how ‘Yesterday, I had a long talk with Rehema who told HIV/AIDS remained conspicuously absent in local negotia- me that “those people at UMATI [the Family Planning tions around reproductive health, research, and relation- Association of Tanzania] are telling lies — telling women to use injections which will spoil their eggs”. Itold Rehema what I knew about side effects, and we What I learned from Rehema
had a long conversation about family-planning meth-ods. She said that the nurses at the clinics don’t like The following case is important for three reasons. First, the to give pills anymore. “They just like to give injections particular data on HIV/AIDS came from informal, unstruc- and loops — because they are new.” She was frus- tured and unplanned interactions that took place on the trated with her attempts to get good family-planning margins of an intensive research project on reproductive services and had tried pills and injections, but both health. Why was AIDS conspicuously absent from interac- made her feel sick. She said that the pills made her tions in the maternal and child health/family planning vomit…. I told Rehema that I personally used pills, (MCH/FP) clinics? Second, the relationship of trust that but that the type of pill used was important, as they developed over time between Rehema and myself revealed have different doses and some are better for particu- the constraints of our gender, class, race and geopolitical lar people than others. It was strange to find myself positions within structures of power — it also epitomises in the position of counselling someone for method some of the struggles in implementing the Cairo agenda choice. Still, I understand her predicament, with a concerning how women from the North and South can work child she can barely support and an unreliable part- together towards improving reproductive health and rights ner. I told her to bring the old pill packet so I could in structures associated with the history of population con- see the hormonal combination to see if others might trol and limited by a debilitated health-care system. Third, be available in the clinics where I worked.’ Rehema’s economic insecurity, her preoccupations with her Rehema’s knowledge of my work in the family-planning own health, and her ability to afford health care reflect the clinics prompted her to tell me directly that she thought that intimate link between reproductive health, access to quality the family-planning workers were ‘telling women lies’ — health care, and economic livelihood.
placing me as a researcher, in an ethical dilemma. I had While conducting fieldwork in Tanzania, I lived for eight gone to Tanzania believing that it was important not to be months in one of the guest houses of one of Tanzania’s uni- misinterpreted by the women I worked with, as being one of versities. The house had three employed staff: Amadeus, the many white, Western women who come to push birth control. Still, I tried to negotiate between the expectations of probe further. I wondered to myself about what kinds of my informants and the recognition that I was given undue services or methods Rehema had hoped to get. On reflec- authority to speak the ‘truth’ because I was foreign, and tion, Rehema’s lack of interest in any of the constellation of knowing that my ‘helpful’ advice could undermine local services provided at the clinic, in light of her sufficient inter- capacity. Still, on the basis of many hours in the clinics and est to give up her morning and ‘see what kinds of things considerable reading on contraceptive methods, I felt it was they had’, points to a regrettable gap in reproductive health reasonable to clear up one woman’s perception that the service providers were ‘telling women lies.’6 Furthermore, I travelled around the region, and noticed that I was see- my knowledge that Rehema was struggling to care for a ing Rehema less frequently on my return trips to the house.
young son with no support from his father, and that she was When she was working, she was often feeling unwell and, not in any ongoing relationship with a man, no doubt in spite of her attractive appearance, she began to look shaped my response to her — I personally agreed that she drained. She would complain a bit about small aches and should be using some method of family planning.7 pains, and I would respond with the requisite Swahili Finally, my encouragement to Rehema to bring in the acknowledgement, ‘pole,’ and mention the option of going packet of pills so we could see them and talk about them to a clinic. She said that she had already been to a number was my own way of relocating the debate onto the material of doctors, clinics and healers — some familiar to me and plane. The pills, as I have argued elsewhere (Richey, others unfamiliar — and her health would appear to 2004a), are themselves identity artefacts that signify mean- improve at times. After months had passed, Rehema again ing in the Tanzanian context: pills are part of the cargo that initiated a discussion of her health in the context of eco- comes from outside as part of the package of development.
As elaborated by Long & Van Der Ploeg (1989, p. 231), the ‘I had not seen Rehema for quite some time — she ‘cargo’ involved in ‘development’ projects is not merely said that she was sick. Today she came and material inputs, but also a concoction of ideas and values explained that the staff are on their last day of work — a ‘trade in images…’. The pills were identity artefacts due to “redundancies”. She had come to talk to me associated with a kind of management strategy for one’s in the first place because she was trying to sell life, and they created an opportunity for intervention into sodas. The staff had a party for the retiring Dean, Rehema’s reproductive health struggles. However, by trying and they were told to take the extra sodas home to to negotiate the pills for Rehema, as opposed to intervening sell. I agreed to buy ten. Rehema began explaining on any of the other health issues she had discussed with that 200 people were going to lose their jobs at the me, I was also situating my stance on family planning as university today. Everyone was understandably the important point of reproductive health. I did not bring out upset. There was to be a meeting today, but my own method of family planning for discussion, nor did I Rehema was not going because she was afraid of present Rehema with condoms, which although that would chaos. She claims that the new Dean is a Haya and have been my recommended method for her, it perhaps they are known for only helping their own and for echoed the views of Tanzanian clinic workers who generally being harsh with others. She describes him as felt that expecting consistent condom use was desirable, “Mbenzi” [“the one who drives a Mercedes”]! Rehema was not very optimistic about the prospect When Rehema came with the packet of pills, I explained of retaining her job, but did hope for some settle- to her that they did have different kinds at the clinics in town ment cash that she said she would use to start where I worked. I recommended the best clinic I knew of another business. She hopes to buy crops such as where she could get advice, although I did not think that peanuts, millet, and flour from her home village and she would be likely to do so. Surprisingly, while I was work- sell them in Arusha town. I told her that I know a ing at Mjini clinic one morning, Rehema came. I found her young woman who does this and it is definitely a dif- sitting on a bench waiting to hear the health education lec- ficult job. She agreed, but added — “what else could ture and for ‘counselling for informed choice’. Together with I do?” Then, she digressed into a story of how a girl a handful of other women, Rehema was told about the who had gone with her to Zanzibar to import cloth advantages and disadvantages of the methods on the stan- had died recently. The girl had complained of pains dard menu of contraceptives provided. At Mjini, like in most (pointing to her upper stomach) and they had taken urban Tanzanian MCH/FP clinics, methods available at that her to the hospital. She was admitted to the hospital, time consisted of contraceptive pills, IUDs, Depo-Provera and the family went home to cook her food. When injections, contraceptive foam, and condoms. Clients could they returned, she was dead. I asked Rehema about be referred for Norplant or surgical sterilisation, and the cause of her death and she said they didn’t diaphragms were supposed to be part of the method-mix, know. “Maybe it was something caused by the but were never available. When it was time for each woman changing weather or her own problems.” “Was she a to select her method alone with the service provider, young woman?” I asked. Rehema replied, “Like me.” Rehema thanked the nurse and left. I asked her another I asked Rehema how her own health had been day at the guest house why she had come to the family- doing. She said that she was still having stomach planning clinic and then decided not to take a method. She problems, vaginal bleeding and problems with an responded vaguely that she had ‘just wanted to see what itching skin rash. She has taken antibiotics, flagyl kinds of things they had’. Not wanting to intervene, I did not and had a D&C — none of which helped the prob- African Journal of AIDS Research 2005, 4(2): 83–90 lem for long. She mused that maybe she will just live disease was transmitted or the safer-sex option of con- with her pain, but is going to try to see her specialist doms. It was also clear that she knew the options of her doctor one more time this week. He is a retired local health system very well, and could have gone for HIV gynaecologist from Muhimbili [Tanzania’s National testing if she wanted it. Perhaps she was one of the few University Hospital in Dar es Salaam] who has a pri- clients in Morogoro who paid up to 15 000 Tsh for an HIV vate practice in Morogoro. He charges 1 000 test at a private clinic. I do not know. What I do know is that shillings for each visit, well out of reach of all but the in 2000 when I returned to Tanzania, I received news from wealthiest women. At this point, Rehema’s friend Morogoro. Amadeus and Emmanueli ultimately had not who was helping to sell the sodas joined the conver- been deemed redundant and had retained their jobs at the sation. She affirmed the inaccessibility of health guest house. Rehema had died recently. Politely, no one care, explaining that when she had to take a child to discussed the circumstances of her death. Muhimbili in Dar es Salaam, the specialist charged 5 000 shillings for an office visit. Rehema said that to The health-care context of Rehema’s death
deliver by caesarean with her ‘expert’ cost 40 000shillings, and she had to go to the government hos- Tanzanian women’s reproductive health needs should be pital for a D&C because it cost 15 000 shillings at met within an integrated clinic structure designed for family the private doctor and she couldn’t afford it. The planning and maternal and child health services. This clinic conversation moved continuously between dis- could be situated within different types of health-care struc- cussing the day’s retrenchment of 200 university tures: (1) a dispensary, the smallest type of health facility workers, the health-care problems experienced by designed to serve a ward with a population of about 6 000; the two women and their children, and their attempts (2) a health centre, with 20–30 beds, that is supposed to to negotiate public and private health-care options.’ function as a small hospital; or (3) a hospital, which may be The realities of economic adjustment threatened to sever classified as district, regional or consulting (National Bureau Rehema’s low, but steady income. Instead of striking out at of Statistics, 1996). Private services are available for a fee the remote harsh inequalities in global capital, Rehema and from some church-based or NGO providers (such as Marie her colleagues interpreted the cuts in ‘local’ categories that Stopes or UMATI, the Tanzanian Family Planning made sense: the harsh ethnicity of the Mercedes-driving Association). Still, three-fourths of all family planners obtain Dean, and ‘bad luck’. Still, not to despair, and no doubt their contraceptives from government sources (National accustomed to a high level of insecurity, Rehema had alter- Bureau of Statistics, 1997), and more than 60% of all health native plans to start her own income-generating project — a services are provided by the government (National Bureau common survival strategy among Tanzanian women (see of Statistics, 2000), underscoring the importance of public Tripp, 1997). However, in our rather nuts-and-bolts discus- service provision for reproductive health access in Tanzania.
sion about small business, the topic shifted to her illness, The regional coordinator of the national AIDS project which I suspected at the time was AIDS. But we did not talk shared the statistics available on HIV in Morogoro at the time of Rehema’s death, but statistical diagnosis, like my I was surprised to find the lack of AIDS talk replicated presumption about Rehema, is still primarily based on clini- among the service providers, who might be expected to cal symptoms. The first 11 AIDS cases were recorded in deal with it most directly. One doctor working for an NGO Morogoro in 1986 and the number of reported cases clinic explained, ‘There is no functional STD clinic.’ The increased to 336 in 1991. But then the number of reported ‘STD specialist’ at Mjini clinic explained in an interview that cases appeared to begin a decline, with only 234 cases in most people in Morogoro buy medicine and treat them- 1992, 158 cases in 1993, and 168 cases in 1994 (regional selves for STDs. ‘They are ashamed and don’t come,’ she office of the Morogoro AIDSCAP programme, July 1996).
said. But if she suspected that a patient had AIDS, she The erroneous suggestion that AIDS was declining in both would refer them to the Regional Hospital. There they the regional and urban statistics was explained by the would claim to test for typhoid, but would actually do an HIV regional coordinator as a ‘problem with reporting’: in the test. If they received a positive result, they would not tell the past, the project had HIV test kits to use for testing patients, patient for fear that he or she would commit suicide. but now they are only being used for blood donors. The Anecdotally, expatriates in Dar es Salaam frequently Ministry of Health had cut funds, leading to fewer statistics linked any death or illness among Tanzanians to AIDS, a being collected. Therefore, it is difficult to tell whether num- suspicion that fitted neatly into perceptions of wild African bers are based on laboratory tests, symptomatic diagnoses, sexual behaviour (see Stillwaggon, 2003). Not wanting to estimation, or missing data. The coordinator also explained lend support to such a simplistic view, I sided with the that there were many sectors implementing AIDS preven- Tanzanians, and we did not talk about AIDS. So, I asked tion in Tanzania, especially the NGOs, but that there was a about health in general, and I heard about health care and problem with ‘transparency’ and ‘different messages coming costs and treatments. From interviews I conducted with 200 women who attended clinics in 1995/96, knowledge about The health education lecture that Rehema and I listened AIDS — that it is sexually transmitted, and that it has no to together included the message that condoms were the cure — was nearly universal. I also knew that Rehema was contraceptive that protects one from sexually transmitted informed enough to already know all of the typical AIDS- infections such as HIV, and in the words of a Tanzanian education messages that I could deliver about the ways the service provider, ‘you should use one if you are concerned about that sort of thing’. According to the district records, work in other areas of reproductive health, I asked: ‘Which there were 72 020 condoms dispensed to clients in STDs do you treat most often?’ Immediately, she answered: Morogoro Urban District during the year of my stay in ‘Syphilis,’ but then she stopped and added, ‘HIV of course Morogoro.8 Thus, with 5 453 women of reproductive age in is the highest, but it is just too much.’ On reflection, I had the area, the government clinics could have provided only asked a well-trained physician about her own practice in 13 condoms to each woman per year.9 In Tanzania, as else- Morogoro, and she had told me about the conditions that where, men often make the final decision on condom she could treat: syphilis and some gonorrhoea could be usage, and men were almost universally absent from treated, and she distributed condoms as well as other con- MCH/FP clinics. Rehema clearly knew about HIV, and con- traceptives to her patients, but HIV was ‘just too much’. The doms, and she knew about the health system and its serv- experience of this gynaecologist at the Morogoro Regional ices. Contrary to much of what we read in the AIDS preven- Government Hospital epitomizes the difficulties of placing tion literature, Rehema’s death did not result from HIV/AIDS within the reproductive health agenda. While in information scarcity. Indeed, as Farmer (1999) has aptly the past, over-population provided a crisis that some illustrated, the problem of AIDS is not a problem of igno- believed could be managed through family-planning inter- rance about the virus, and not a result of the cognitive ventions, AIDS does not conform so readily to the mould of deficit of individuals. ‘We know that risk of acquiring HIV does not depend on knowledge of how the virus is transmit-ted, but rather on the freedom to make decisions. Poverty is Concluding remarks
the great limiting factor of freedom’ (Farmer, 1999, p. xxv). My conversations with Rehema reminded me that the We are at a critical juncture when the ‘problem’ of HIV/AIDS realities of decline in the health sector and the costs of is being reformulated in a rapidly changing context of multi- health care are local priorities. While policies are often national pharmaceutical companies, plummeting life aimed at providing free services, the implementation of expectancy and promises of assistance from donor coun- these policies in the context of debilitated facilities is expen- tries. At this time, when the problems are being delineated, sive, especially for the poor. For example, at the Morogoro there may be an opening for critical, fieldwork-based contri- Regional Government Hospital, maternal and child health butions to become ‘policy relevant’. One example is services are officially free of charge. However, some serv- Baylies’ (2001) work demonstrating how AIDS has made ices involve a monetary cost as explained by an attending reproductive choice an illusion as women are not able to physician during an interview:10 tubal ligation is free imme- make meaningful decisions about their health and repro- diately post-partum for women who deliver in the hospital, duction. What is at stake here is whether or not we permit but it costs 1 500 shillings at other times; D&C is free, but enquiry to reduce HIV/AIDS to matters of ‘lifestyle’ and clients must bring gloves (450 shillings per pair) and bleach ‘behaviour’ — in the words of Farmer, ‘Is gender inequality (800 shillings); caesarean delivery is free, but clients must a lifestyle?’ (recounted in Hunt, 1997). After more than two bring sutures (1 500 shillings), intravenous drips (1 litre decades of devastation by the epidemic, the impact of 100–1 500 shillings), gauze (200 shillings per metre), and HIV/AIDS is just starting to be taken seriously in analyses of iodine (450 shillings); normal delivery is free, but clients African ‘development’. There is a need in contemporary bring sutures (1 500 shillings), syringes (100 shillings academic scholarship for theoretically grounded social- each), egometrin (300–900 shillings), and gloves (450 science research at the geographical interface of global dis- shillings per pair). While the fees for each service appear small, Tanzanians regularly complain about their cumulative What was Rehema looking for at the Mjini family planning expense and about the uncertainty of how much money clinic? Whatever it was, she did not find it. To meaningfully they might end up paying if they attend a clinic. These prob- situate HIV/AIDS within the critical agenda of reproductive lems have worsened throughout the 1990s, and the propor- health, we must develop new tools. These tools must aid in tion of births delivered in a health facility in Tanzania understanding both the complex configuration of needs, dropped from 53% in 1992 to 44% in 1999 according to such as those that brought Rehema to the clinic ‘to see DHS data. Rajani (2002) argues that the decline reflects the what kinds of things they had’, and the local and global con- undermined confidence in the health system. straints on providing reproductive health services to HIV- One of Morogoro’s premier obstetrician/gynaecologists positive women. What difference does a shift in interna- surprised me during an interview when I asked her: ‘What is tional discourse on reproductive health mean to someone the biggest gynaecological problem here in Morogoro?’ and like Rehema? AIDS problems are most often dealt with in she responded, ‘People are lacking in education about fam- policies and projects that are seen as competitors for repro- ily planning. They have seven or even eight children each.’ ductive health funding, not as contributors to rethinking Given the nearly universal knowledge of family planning in reproductive health policies and priorities. HIV/AIDS is a the country,11 and the drop in Tanzania’s total fertility rate of problem of ‘lovers’, while unwanted pregnancy is a problem nearly one child per woman during the 1990s,12 I was sur- of ‘mothers’. ‘Workers’ who struggle to negotiate productive prised that this was the biggest problem that she saw in her and reproductive labour must make difficult decisions over practice. When I asked for more information, she elabo- the means to acquire and allocate scarce resources. Both rated that things were improving compared to the past and state and NGO structures in Tanzania target ‘lovers’ for STI now those who have many children are mostly the ones liv- treatment, ‘mothers’ for family planning, and ‘workers’ for ing in remote areas. Wanting to understand more about her income-generating projects, with little communication, coor- African Journal of AIDS Research 2005, 4(2): 83–90 dination and meaningful intersections. Real women who providing good ‘quality of care’ (Bruce, 1990) as I elaborate in play all of these roles are left without coordinated options or For an argument in favour of recognising the force of our own The insight of the reproductive health agenda — particu- judgments in field work and for using them constructively, seeKleinman & Copp, 1993. larly the synergy between reproductive health, empower- From the National Family Planning Programme Report and ment and the right to health care — is not easily incorpo- Request for Contraceptives for Morogoro Urban District, rated into the existing behaviouralist models of HIV/AIDS Jan–March; April–June; July–Sept.; Oct–Dec, 1995. intervention. The clinic setting can provide an opportunity From ‘Taarifa ya utekelesaji wa huduma za mama na watoto ya for educating women about their reproductive rights and mwaka 1995 MCH-Hospital’, 15 March 1996. responsibilities — ideally in a provider-client relationship All pharmaceutical costs are the retail price in July 1996 at the that itself respects those rights. However, under-staffed Morogoro Pharmaceutical Supplies shop, a popular urban phar- facilities, training that focuses on medical skills while macy close to the hospital. The average monthly income in neglecting social ones, and performance targets that Morogoro region was between the estimated 30 000 Tsh per encourage quantity over quality of service are obstacles month for Morogoro rural residents (Ponte, 2002) and 94 600Tsh per month for residents in urban areas in the entire country that must be overcome. Continuing support for vertical pro- grammes, which may be more successful on their own but 11 In 93.5% of all couples, both partners knew a modern method of that neglect the needs of routine primary health care and contraception according to the 1999 Reproductive and Child discourage integration, does not address the multiple needs Health Survey (Bureau of Statistics, 2000). 12 The total fertility rate dropped from 6.3 in the 1991/92 Scholars over the past decade have pointed out the need Demographic and Health Survey to 5.6 in the 1999 Reproductive to consider women’s class position and men’s gender roles in and Child Health Survey (Bureau of Statistics, 2000).
analyses of international development which should gobeyond the Gender and Development (GAD) Plan. The Acknowledgments — The author would like to thank the anony- insight from Rehema’s story — that AIDS, like other dis- mous reviewers, and Steffen Jensen, Christian Lund, Hanne eases, is significantly linked to host-susceptibility and eco- Mogensen and Stefano Ponte for their comments.
nomic vulnerability, and that these issues are more relevantthan an exclusive focus on education-for-behaviour-change The author — Lisa Ann Richey trained in political science and pub- in dealing with the epidemic in Africa — is supported by lic health and is an associate professor in international develop- recent statistical analyses of the biomedical effects of eco- ment studies at Roskilde University in Denmark. She is a researchassociate with the AIDS and Society Research Unit at the nomic conditions (Stillwaggon, 2002 and 2000). That University of Cape Town, South Africa, and is currently working on Rehema’s susceptibility occurred in a context of multi-layers a project entitled ‘The politics of access to anti-retrovirals in the of gender inequality permeating the realms of ‘mother,’ ‘lover,’ treatment of African AIDS’, which examines identities, politics and and ‘worker’ is well-known yet merits restating. Yet, we still modalities of access to anti-retrovirals for treatment of AIDS in hear most often of abstinence, anti-retrovirals and condom Uganda and South Africa. Her recent publications have been on use as the primary focus of AIDS interventions in Africa.
the topic of the relationships between global population discourse,reproductive health and HIV/AIDS.
References
Estimates by UNAIDS include all people with HIV infection,whether or not they have developed symptoms of AIDS, who Adult Morbidity and Mortality Project (1997) Policy Implications of were alive at the end of 2001. Adult HIV prevalence was 7.8% at Adult Morbidity and Mortality. Dar es Salaam, Tanzania, AMMP.
All names of individual persons or clinics are pseudonyms. Barnett, T. & Whiteside, A. (2002) AIDS in the Twenty-first Century: I worked on three research projects over this period, all of which Disease and Globalization. London, Palgrave MacMillan.
were given formal research clearance and ethical evaluation by Baylies, C. & Bujra, J. eds. (2000) AIDS, Sexuality and Gender in the Tanzanian National Commission for Science and Technology Africa: Collective Strategies and Struggles in Tanzania and (COSTECH) and one of which also went through the Harvard Zambia. Social Aspects of AIDS. London and New York, University Institutional Review Board and the Tanzanian National Institute for Medical Research for clearance.
Baylies, C. (2001) Safe motherhood in the time of AIDS: the illusion A limitation of my methodology is that it could not be triangulated of reproductive ‘choice’. Gender and Development 9(2), July, pp.
with other methods, such as in-depth interviews with Rehema where she could speak directly to questions meant to investigate Boone, C. & Batsell, J. (2001) Politics and AIDS in Africa: research the knowledge I had gained from our other conversations. I agendas in political science and international relations. Africa regret that because of her unfortunate circumstances, I was unable to return to conduct follow-up interviews and to present Booth, K.M. (1998) National mother, global whore, and trans- my interpretation of her case to her for feedback. I think that she national femocrats: the politics of AIDS and the construction of would have given her perspective readily, allowing for the possi- women at the World Health Organization. Feminist Studies bility of alternative interpretations of the data.
All quoted passages are my own translations from Swahili con- Bruce, J. (1990) ‘Fundamental Elements of the Quality of Care: A Simple Framework.’ Studies in Family Planning 21(2): 61–91.
This does not mean that I agreed with all things told by the Cruikshank, B. (1999) The Will to Empower: Democratic Citizens providers to their clients, nor that I felt that they were necessarily and Other Subjects. Ithaca and London, Cornell University Press.
Farmer, P. (1999) Infections and Inequalities: The Modern Plagues.
Rajani, R. (2002) Situation Analysis of Children in Tanzania.
Berkeley, University of California Press.
Feeney, G. (2001) The impact of HIV/AIDS on adult mortality in Richey, L.A. (2003) HIV/AIDS in the shadows of reproductive Zimbabwe. Population and Development Review 27(4), pp.
health interventions. Reproductive Health Matters 11(22), pp.
Fredland, R.A. (1998) AIDS and development: an inverse correla- Richey, L.A. (2004a) Construction, control and family planning in tion? The Journal of Modern African Studies 36(4), pp. 547–568.
Tanzania: some bodies the same and some bodies different.
Hunt, N.R. (1997) Condoms, confessors, conferences: among Feminist Review 78, pp. 56–79.
AIDS derivatives in Africa. The Journal of the International Richey, L.A. (2004b) From the policies to the clinics: the reproduc- tive health paradox in post-adjustment health care. World Kapiga, S.H., Ruyobya, I. & Boerma, J.T. (1993) Tanzania Development 32(6), pp. 923–940.
Demographic and Health Survey 1991/1992. Dar es Salaam, Stillwaggon, E. (2002) HIV/AIDS in Africa: fertile terrain. The Tanzania, and Columbia, Maryland, Bureau of Statistics, Journal of Development Studies 38(6), pp. 1–22.
Planning Commission and Macro International.
Stillwaggon, E. (2003) Racial metaphors: interpreting sex and AIDS Kleinman, S. & Copp, M.A. (1993) Emotions and Fieldwork.
in Africa. Development and Change 34(5), December, pp.
Thousand Oaks, California, Sage Publishers.
Long, N. & Van Der Ploeg, J.D. (1989) Demythologizing planned The United Republic of Tanzania, Prime Minister’s Office (2001).
intervention: an actor perspective. Sociologia Ruralis 29(3/4), pp.
National Policy on HIV/AIDS. September 2001. Dar es Salaam.
Tibaijuka, A. (1997) AIDS and economic welfare in peasant agricul- National Bureau of Statistics Tanzania (1997) Tanzania Planning ture: case studies from Kagabiro village, Kagera region, Commission’s Demographic and Health Survey 1996. Calverton, Tanzania. World Development 25(6), pp. 963–975.
Tripp, A.M. (1997) Changing the Rules: The Politics of National Bureau of Statistics Tanzania (2000) Tanzania Liberalization and the Urban Informal Economy in Tanzania.
Reproductive and Child Health Facility Survey 1999. Dar es Berkeley and London, The University of California Press.
Salaam, Tanzania, MEASURE Evaluation, Technical Report UNAIDS (2002) Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections. Available at: Ponte, S. (2002) Farmers and Markets in Tanzania: how policy http://www.unaids.org/hivaidsinfo/statistics/fact_sheets/pdfs/Tanz reforms affect rural livelihoods in Africa. Oxford, James Currey.
Tanzania Office of the Prime Minister (2003) National Multi- World Bank (1993) Tanzania: A Poverty Profile. Washington, D.C., Sectoral Strategic Framework on HIV/AIDS 2003–2007. Dar es Population and Human Resources Division, Eastern Africa Salaam, Tanzania Commission for HIV/AIDS. January 2003.

Source: http://chdc.mak.ac.ug/working_group/Publications/Reproductive_health_agenda_in_Tz.pdf