From the first day I entered Botswana as a Peace Corps Volunteer, the words "behavior change" have become ingrained in almost everything I do. Changing behavior is at the forefront of finding the best ways to deal with the scourge that has plagued the country with the second highest prevalence rate of HIV/AIDS in the world.
But behavior change isn't easy in anywhere.
My friends back home have a lot of questions when we talk about HIV/AIDS. If so many people have it, then why aren't people wearing condoms? People in Botswana watched thousands of their friends and family members die in the late 90's and early 2000's, so how can anyone have unprotected sex? Do people understand how serious this is?
I try to put behavior change in a context most Americans can understand. A lot of people in America want to change their diet and lose weight. They know what foods are bad, are aware of the health risks, understand what leads to weight gain, are inundated with options for exercise routines and regularly see campaigns targeting healthy eating. Yet a surprising majority of people don't make smart decisions.
The challenges to losing weight or staying healthy vary for each individual. Michael Pollan and other food experts commonly point out that fat, salt and sugar light up the pleasure centers of our brains in a way that elicits a deep craving. It can often be that urge that can lead to a somewhat powerless feeling that spirals a person down the road of weight gain, away from diets or makes it harder to continue positive behavior change. As someone with a major sweet tooth, the all too familiar desire of sugar is something I fight daily.
Obviously HIV/AIDS can meet with more instant health problems than weight gain, but when it comes to behavior change there are overlaps. Almost everyone in Botswana knows the types of transmission, statistics, and risks of HIV/AIDS. The educational campaigns have effectively spread the messages and are still hoping to see that major change, much like healthy eating campaigns in America. It would be a slight understatement to say sex hits the pleasure centers of the brain the same way salt, fat and sugar do.
A majority of people I talk to feel choice is a huge part of behavior change. In America it's common to hear people say others should just choose to eat healthy, stop an addiction or make the right decision. When I hear people talk about Africa, I often feel that similar theme spilling over. People should just choose to have safe sex, know their partners and prevent HIV/AIDS.
Choice is a huge part of behavior change, but even choice can come with its own labyrinth of a tumultuous pre-determined and unknown future. Our bodies possess a genealogy that can establish body size, metabolism and health risks we inherited from our ancestors. You can choose to be a marathon runner, get in the best shape of your life and still drop dead from an unimaginable heart attack. A casualty to the somewhat pre-destined aspect of life.
The major difference between choices about a healthy diet in America and choices about HIV/AIDS in Africa is power. While most Americans have the power to choose what and how much they eat, where they exercise and how they could change. A lot of people most at risk for HIV/AIDS in Africa don't have power to make life-altering decisions. To be clear, young women between the ages of 20-35 in Botswana have a much higher percentage of HIV/AIDS than men in the same age cohort.
Women are often trapped in positions where asking a husband or other man to wear a condom can be met with suspicion, beatings, or worse. They are more likely to contract HIV due to abuse, and more likely to be abused when their status is disclosed. Younger women who are raped, engage in transactional and/or inter-generational sex, don't have a say in those acts being safe. Women and men having more than one sexual partner are regularly in a cyclical tragedy of Russian roulette just one infected person away from contracting the virus and immobilized with fear hoping their partner is clean. People with disabilities are frequently taken advantage of sexually, resulting in major numbers of unidentified victims of abuse.
Behavior change is impossible without the cultural, economic and gender role assistance to put people most at risk on equal footing.
Amongst all of the concern for changing behavior there are signs of hope. At some weddings for younger people in Botswana you can hear the bride and groom talk about being best friends, altering gender roles and giving a glimpse of a different future. Safe male circumcision campaigns are beginning and while there is still a long way to go to reach the goals the work has begun. Local people are taking on the messages, fighting multiple concurrent partnerships, while empowering and supporting people most at risk to make responsible decisions.
There won't be a simple answer to changing sexual behavior in any part of the world. That frustration can sometimes lead to dismissal and over-generalizations that Africans will never change. I feel those kinds of comments come from a place of ultimate terror that lives are being lost and we can't work to make an immediate difference. On this World AIDS Day, let's remember the obstacles to changing any behavior and continue the fight, "Getting to Zero."
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