Grounding the Debate

Click here to download a PDF version of this document

I came to Nicaragua to live in 1985 from San Francisco, California, where I had been involved in anti-AIDS work and where my address book already had too many names crossed out of friends who had died. So when I went to the wake of Marvin, a gay teenager who I think was the first person to "officially" die of AIDS in 1987, I thought, "oh no, here we go again". But so far it hasn't actually turned out that way.

Of all the countries represented here, Nicaragua is probably the one with the lowest incidence of HIV/AIDS. According to official data, between 1987 and June of this year, there have been a little over 700 HIV+ reported, with 328 cases of AIDS and 177 deaths.

Even taking into account possibly substantial underreporting, lack of detection and the like, Nicaragua is clearly in a different situation than the great majority of your countries. There are in fact some very interesting historical and epidemiological factors dating back to the '70s that hint at why Nicaragua is not in the same situation as, for example, our neighbor Honduras, which is just behind Brazil and Mexico in Latin America. Dr. Leonel Arguello can tell you the rather intriguing story tomorrow afternoon at the Nicaraguan panel: He was the Vice-Minister of Health in the '80s, in Epidemiology, and started the AIDS program in Nicaragua in 1986, the first Ministry-level AIDS program in Latin America. Leonel is now the director of an NGO, and one of the coordinators of the Civil Society Commission to Fight AIDS, which brings together over 80 organizations all over the country.

Back to grounding the debate. The strategies that we choose depend on the context. And the context for Nicaragua is that we still have the "epidemiological opportunity" to avoid a widespread epidemic here, but only if we come up with good -and better-prevention strategies. And SOON.

Because it would be naive and tragic to assume we've beaten the epidemic. In fact, a time bomb could go off here: In the current situation in Nicaragua, the risks of widespread transmission are extremely high at the same time that people's perception of risk is extremely low, one of the reasons being possibly precisely because the epidemic hasn't hit so hard yet.

The risk factors are the same as most places: poverty (we have the distinction of being the second poorest country in the hemisphere, after Haiti), an explosion in commercial and "transactional" sex by both men and women, many of whom start at a very young age, and where you get paid more for not using a condom--; a migration explosion. Last but certainly not least in a country where almost all HIV transmission is sexual is the problem of generalized high risk sexual behavior compounded by machismo.

I am pleased to hear Secretary Gómez commit the Nicaraguan government to do what it takes to confront the epidmeic, because while the Ministry of Health seems clear on the need to promote safe sex and condom use, in many respects, it has its hands tied by the Ministry of Education, which because of a rather fuzzy line between church and state and the enormous influence of the Catholic hierarchy, won't allow condom promotion in school curriculums or on school premises. With the ban on condoms, it's easier to get your hands on crack cocaine at your local school than on a condom.

To keep the time bomb from going off, the main challenge for us communicators in Nicaragua -in terms of prevention-- is to raise the perception of risk in order to promote safer sexual practices, thereby lowering actual risk.

If people don't perceive risk, it's possibly because so many other risks are so much closer to the surface: war, informal armed conflict, natural disasters like Hurricane Mitch, getting assaulted in the street, get in a car or bus accident, die from hemmoragic dengue or a botched abortion or diarrhea. In spite of such widespread poverty, the possibility of dying of hunger is a new clear and present danger. And at the moment, teen suicide is more of an epidemic than AIDS.

However, if we don't invest significantly in prevention now, all that might change, and AIDS could become a major epidemic here.

The difficulties created by a lack of coherency in governmental policies, as well as the sometimes doubtful separation of Church and State, mean we have continue to:

1. Encourage the government institutions to unify their policies and programs within the context of a truly lay State. Let the Church do its job, and let the State do its job, which is to protect the public's health, not impose moral imperatives. The 2 NGO representatives on the governmental AIDS commission, CONISIDA, are pushing this perspective. This is a challenge as well for donors and agencies who work with the government on this issue.
2. Coordinate strategies with those state institutions that, at a local or sectoral level, do in fact share the concerns and perspectives of most of the civil society organizations working on the issue.
3. In the absence of the support of formal education, strengthen all the forms of informal education at out disposal, which of course, includes the media and other communications initiatives.

So in terms of communications strategies:

1. While the celebrations of World AIDS Day and International Day of Solidarity with People living with HIV/AIDS have been crucial in Nicaragua for putting the issue into public debate and in the media, it's obviously not enough to carry out two short-lived campaigns a year. The effort needs to be continuous, sustained and omnipresent.
2. Given the low perception of risk, it's not particularly useful to treat HIV/AIDS as a single issue; it has to be grounded in the complex context of people's daily lives and realities. In fact, the NGOs that work on HIV/AIDS here do that already.
3. As NGOs working in the field, we can take advantage of the talents, specialties and reach of each one to develop strategies that combine the use of mass media and face-to-face peer education, support and mobilization.

To respond to the question of whether the solution is simply to upscale existing strategies or whether we have to re-think our approach, I'd venture to say we have to do both. In terms of rethinking:

• We have to rethink how to have a more permanent presence
• We have to rethink how to deal with the controversial and taboo subjects that are necessarily part of dealing with HIV/AIDS
• We have to rethink what kinds of changes we're really working for...which means
• We have to rethink how to focus the issue

In brief, I think one of the main things we need to do is to not limit our focus to information -which there has been a lot of- but rather to empowering people. And that means engaging them on a human, emotional level. From a communications point of view, I and the organization I represent, are firm believers in entertainment-education -"edutainment"-- as the best way to both engage people AND have a continual, sustained presence: TV programs, radio shows, radionovelas, street theatre, murals, music festivals... That, combined with an upscaling of the kinds of local popular health education and mobilization work already going on is a good overall strategy.

We all agree that to stem the tide of AIDS we have to talk frankly about sex and sexuality, gender relations, power relations, violence, subordination, and the like. We know that means risking confrontation, not only with the authorities, but also with the strongly held popular beliefs and values of many of the people we're trying to reach.

This is not new to anyone here. The challenge obviously is to figure out the right mix of confrontation and accomodation - meaning: not shy away from taking on taboo or controversial subjects even when you your position is likely to be totally unpopular... but to know how to do it with tact so that rather than getting the door shut in your face, you actually get invited in. The best way I know how to do that is to humanize the issues, turn them into human dramas that people can relate to.

In the weekly TV soap opera we produce, we took on issues that a lot of people thought we'd get kicked off the air for. Just to name two: having a gay main character, and having another of our characters have an abortion, which of course, is illegal (strictly speaking, being gay is also illegal in Nicaragua). We didn't get kicked off the air. Maybe because our adversaries thought we'd get more mileage out of getting censored and making a stink. The point is, it's possible to do. And we do blieve it's vital to have mass media initiatives in addition to local ones, to provide a kind of legitimation for the local initiatives. The more it gets done, the easier it will be for local organizations in small towns and villages to talk about the kinds of things you have to talk about when you talk about HIV and AIDS and not have the door shut in your face. Tomorrow afternoon, Yulio, an 18-year old member of a theatre group and communications network in the north of the country, can tell you about what happens when teenagers find their own voice and begin to talk about these issues make their demands known: they run up against parents, teachers, local authorities... If these kinds of conflicts create an impasse for the work, we're in trouble. But the solution is not to keep quiet, but rather to figure out how to legitimate the debate and build bridges.

In our experience, the best way to build a bridge is not to try to convince people that you're right and they're wrong. The only thing you need to convince people is that they can in fact think for themselves, open their minds to other possibilities, ways of living and solving their problems. In other words, they can take control of their own lives; they don't have to let other people or stereotypes or social norms dictate what's right for them.

Which brings us around to the issue of what kinds of changes we're really working for. Is our goal really to change people's behavior, or is it to help people -including ourselves, which we often forget-to take control of our lives in ways that are meaningful to each person? That's a much harder challenge. We all know that while consciousness and a sense of self-efficacy is not the only thing necessary to change behaviors and take control of your life, you certainly can't do it without it. However, we also know that "taking control of your life" is not a linear process, nor is it like nirvana, that once you reach it, you have it made. It's often two steps forward, one step back, and ironically often involves consciously self-destructive behaviors. Anyone who smokes, drinks and doesn't't always wear a seat belt can relate to that. We also know that information isn't enough: it's abundantly clear that knowledge of contraceptive methods -and even being able to negotiate their use-- is not the main key to reducing teen pregnancy, for example, when so many young women and unhappy in fact see getting pregnant as the solution to their problems: even if they don't get the guy, they'll at least get unconditional love from the baby - and who doesn't need unconditional love in this world?

In this regard, I'd like to throw into the mix that I think feminism and the women's movement - and especially the struggle against violence against women - have some important things to share with the anti-AIDS struggle. First of all, the issue of violence against women is so basic, and has been a magnet to get women involved and organized... and empowered - individually and collectively. It took a long time to raise the "perception of risk" among women. Even women who lived in violent situations often didn't perceive their own risk; that was just the way things were, or it was bad luck or whatever. To change that, you can't just propose a behavior change solution like leaving the relationship or standing up to their partner. To solve what might seem like a specific problem, you have to deal with the entire complexity of women's and men's lives, -not just violence-that make people so miserable and so stuck. You have to turn a personal problem into a social problem, change social and cultural norms, implement new laws and policies, provide services and support... You need consciousness change, behavior change, social change and advocacy, to put it into the categories used here.

As an aside, tomorrow afternoon you'll also hear about the Nicaraguan men's movement against violence against women, and about how what we know about the differences between men who aren't violent or are less violent with women, and those who are violent can be used to promote non-violence. That's obviously quite relevant to anti-HIV/AIDS work.

HIV/AIDS as an issue could be a magnet like violence has been, if we deal with it not as a single issue, but in context and in all its complexity. So contrary to conventional communication wisdom that says "one single message, repeated over and over", I'd venture to say that single message campaigns have limited lasting impact --even if the immediate impact of a message seems great-- while multi-issue and permanent communication that links issues together and helps make life and conflicts understandable and manageable is slower to demonstrate "impact indicators", but definitely facilitates more lasting and deep change, especially when accompanied by ongoing face-to-face peer education and support.

Support is a key issue. This year in our TV series, we dealt with HIV in only a couple of episodes, but we've gotten quite a large number of requests from young viewers who want us to deal with it much more. Why? Possibly because of a kind of nebulous perception of risk, of having heard about AIDS and knowing enough about it to know it's deadly but not enough to know if it could affect them... but my hunch is that it's a kind of code for saying: we want a "legitimate" way to talk about sex. Which is a code for saying: we want to talk about relationships and identity and self-esteem. Which is a code for saying: we want to TALK and feel connected, we need space to talk about our lives, all the things we experience and feel and want and fear that you're not supposed to talk about. The issue of HIV/AIDS can open up those spaces. If we don't, for young people -who are more than half the population of Nicaragua-- it could be a matter of life and death.