Re: [xmca] Papers for discussion: HIV,interventions and activitytheory

From: Mary van der Riet <vanderriet who-is-at>
Date: Tue Nov 11 2008 - 03:10:19 PST

Hi Steve, Andy

In an earlier email, Andy suggested that, “following CS Peirce, you have
to coordinate the attack on three registers: the symbolic (AIDS is
caused by a sexually transmitted virus), the indexical (a social
movement of people motivated to stop the unsafe sex) and the iconic
(making unsafe sex look like what it is, not sexy but unsafe).”

1. yes knowledge is key (but not the sole key) – people need to know
what causes HIV and how it is transmitted, prevented etc

2. indexical: yes, social movements play a role – key issue is how do
they emerge (can they be initiated?), and how are they sustained?
My sense is that those already infected are often part of movements
(partly as a means of support – they join support groups, they join the
Treatment Action Campaign to argue for better treatment options etc) –
but those who are a high risk or do not know their status, are not part
of any social movement until they need it

3. Yes, the iconic. Ultimately, those engaging in sex have to do so
differently, they have to do so with ‘safety’ in mind. As Andy said in
one of his emails, they have to associate the act with a problem, and
act accordingly. [Andy’s points: successful campaigns which “aim to make
certain dangerous behaviours just look stupid. Bascially, you need to
change the image of a sexually attractive man or woman. It is often the
case that rational understanding of the lethal consquences has little
effect if people *feel* powerful and good when doing the unsafe
practice]. So, the key issue is how does one get the ‘individual’ to not
feel powerful and good in doing unsafe sex? I would love to see some
examples of campaigns which portray “unsafe sex being stupid”. I’m going
to get my students working on that one!

I would add a two other ‘registers’ or suggest adjustments to these
registers in addressing the HIV/AIDS problem in SA (and possibly

4. localized or ‘contextualised’ approaches seem to work best (rather
that one strategy fitting all). Different contexts have different
dynamics and respond to interventions in different ways. (this is not
antithetical to a CHAT perspective – things are inherently related to
their context). Start small..

5. There is a need for processes/change to occur on many ‘levels – as in
the case of Uganda discussed below – horizontal and vertical processes
are needed.

This next bit is a bit rambling.
I agree that ‘social movements’ play a role. I think it’s a bit unclear
how this would happen (except with a sort of generalised effect – eg
apartheid became very unpopular not because everyone took a stand
against it – the US as a powerful government didn’t, and neither did the
UK - but because enough people over a long enough time - and yes some
with deliberate strategies about how to change the response to apartheid
– objected to it. It then became not ‘normal’, no ‘accepted’, and in the
ATheory terms – the contradictions became so immense that the system was
in crisis.

How to do this with the ‘activity’ of sex? I agree that if women/young
girls did something differently in their interaction with male partners,
this would shift the dynamics and change the act.

I have a few questions about how and whether this has happened as a
response to the feminist movement? Could we argue that women in contexts
where male and female are considered equal, and/or where a battle has
been fought over many years to entrench that equality, have greater say
and control within the activity of sex? One of my questions is whether
this happens all of/most of the time in those contexts, and another
question is whether it was ‘feminism’ that afforded this?

Steve, when you raised the issue I thought of Denmark. I don’t know its
social history, but I think one key issue which supports the position of
women in society in Denmark is that the state provides so many services
for women (day care etc). This allows for a different wI think what I have been heading towards is the idea that its yes, it
might be a social movement (how does one start a struggle then becomes a
key thing), but I think it also has a lot to do with the conditions in
which one lives. The number of people who smoke in SA has dropped since
the state legislation about where smoking was allowed ie people changed
‘individual’ behaviour because it is no longer as ‘possible’ to
enact. The ‘norms and conditions’ about the practice changed.

Would it be possible for young women in sexual interactions to create
different norms? I don’t think so, not on their own. If the society
generally supported a different way of acting, and this was the ‘norm’,
then yes, they could, in the activity with a male partner, have greater
strength and the possibility to do something different. But in the
situation they are in at the moment, I don’t think so.

An interesting study conducted by colleagues of mine in a research
organisation called CADRE found that a dominant practice amongst South
African youth is that of ‘concurrency’ – not just many partners, but
many partners concurrently (see Parker et al, 2007). This served as a
form of ‘security’ both on an emotional level, and also financial
security. I don’t know if this is a consequence of the long term impact
of apartheid (fragmented and disrupted families, many absent fathers,
precarious economic situation). Some of these dynamics exist in other
places in the world. But the important thing is that this security was
more important than ‘safe sex’. It was also the view of the female youth
in the video in my presentation at ISCAR, whose mother was HIV positive
and ill, and whose father had recently died of AIDS. The argument goes
something like this: “no we don’t used condoms because if we do the boys
will leave us”. Now, maybe if you are in a dire situation at home, with
parents and other adults who should be caring for you, ill, dying, or
absent, then one needs security at all costs. So, how does one deal with
this? In a country with such fragmentation, family life is not secure.
And HIV threatens this even more.

The other issue is that there are extremely high levels of gender
violence in the SA context (see Jewkes; Wood & Jewkes; Wood et al). Some
extreme examples: recently a woman was verbally and physically abused at
a taxi rank in KZN because she was wearing a mini skirt – her skirt was
torn off her and she was paraded in the street. Multiple partners for
men are considered very normal – as a women in this kind of relationship
your power is not very great. This means that they don’t necessarily
have, Steve, what you refer to as the “ultimate power and motivation to
significantly change how sexuality is done in SA”. They might have the
motivation, but the conditions don’t really enable them to have much
power. Patriarchy is very strong in SA. Polygamy is common. In some
rural contexts women don’t traditionally have the right to own property
and are kicked out of their houses by other family members if their
husbands die. There are the trends of older men finding younger women as
sexual partners because they believe they are less of a risk, or that
they as virgins will ‘cure’ HIV; there are the instances of young women
taking older men as partners to obtain money for cell phones, or

Steve asks “What incipient forms have feminism, womens rights movements,
etc. already taken? What could be done to help?”. I am not sure There
is a sense that women do have power in that in most cases they run
households (covertly managing budgets/funds); there tend to be higher
levels of employment for women than for men (SA unemployment figure is
about 27%, and in some rural areas such as that in the research as much
as 60%); and there are many church structures which are run by women
(Women’s Manyano’s). But there are also what I would refer to as
counter-feminist movements. Within the HIV field, there are proponents
of virginity testing - a group of Zulu women who are arguing that a
return to culture is the way to combat the spread of HIV. They focus
exclusively on young girls and publicly ‘test’ for virginity,
stigmatising those whom they perceive to be sexually active. Many young
girls want to belong to this movement of virgins. The social dynamics of
forced sex and unequal power in relationships is not addressed. Culture
‘silences’ those who speak out against the practice.

There have been attempts to impact on the gender relations by discussing
the role of fathers (see HSRC Fatherhood Project), and building these as
better role models (they have some wonderful images of fathers and sons,
Mandela and children; see also Morrell, 1998, 2001); and also addressing
the notion of ‘masculinity’, and how it creates the conditions for
violence in relationships, and how it contributes to the spread of HIV.
One critique of this is that many are already privileged and a focus on
their ‘condition’ takes resources away from the possibility of
empowering women.

There are also many interventions which focus on the development of
youth, providing them with a motivation to live beyond the disease
(LoveLife, SoulBuddyz etc). Their rationale is that youth who are
motivated towards a significantly different future will not take the
risks that those who do not have any hope (about life, employment, a
better future etc) seem to be taking
All of these approaches have some effect, but do not significantly
change the dynamics of the spread of HIV.

Why do I keep returning to the local? Maybe because it seems easier to
manage and to conceive of something happening. My sense is that over a
few years of a research process, the people in this one context really
did want to do something differently, and they were open to suggests
about what. They are not unaware of the problem of HIV, they were
extremely concerned about it. Admittedly, those most concerned were
adults (parents who keep seeing youth die). But they wanted to act
differently, they don’t want their lives to be so precarious. Male youth
don’t seem to see this as much. They seem to feel invincible, and the
priorities in their lives ito a particular identity and status are

Uganda is interesting. The analysis of why HIV/AIDS incidence has
dropped points to a range of processes which run simultaneously (see
Low-Beer, & Stoneburner 2003 & 2004). Firstly there were ‘horizontal’
levels of action which seem to not have occurred in other contexts. What
this meant is that people themselves engaged about HIV and death/dying
and risk through social networks/community level processes, without
there being large scale media interventions. Building on this, there was
a particular approach taken on a ‘vertical’ level. There was public and
loud acknowledgement by the state that HIV was a problem, there were
media campaigns which reinforced messages such as ‘zero grazing’, and
there were state policies which made it ‘easy’ to live with HIV – it was
a notifiable disease, voluntary counselling and testing (VCT) were
widely available, medication (ARVs) were widely available. So, it seems
that a combination of a vertical process – top down, policy/legal
framework which create the conditions in which people live with HIV; and
a horizontal process (which seemed to be more or less ‘spontaneous’,
create the appropriate conditions for individuals to do something
differently. [There is not much mention of ‘gender’ in this scenario].
Of significance is that many of these dynamics do not exist in SA.
Discrimination and stigma create terrible conditions for making HIV a
notifiable disease (which would then lead to the possibility of
marshalling public health resources). The stigma and discrimination have
lead to a legal framework which protects the rights of the individual to
privacy in relation to their HIV status. The government’s stance on HIV
has been hugely problematic (Mbeki’s era and denthe main role, but there are arguments that it did not start there, that
Mandela’s government did little to address HIV – see Nattrass). Besides
the denialism, having a powerful figure like Jacob Zuma publicly
acknowledge that he had unprotected sex with an HIV positive person
without a condom, and then had a shower to protect himself from HIV,
does nothing for the promotion of protective health practices. There are
also resource and management issues: in the last 18 months, there have
been cases of defective condoms entering the health system. This has
lead to warnings about NOT using condoms with certain serial numbers,
but all it seems to have done is add fuel to the argument against condom
use. In the video, one young woman argues that the government says we
mustn’t use condoms, because they are not safe. The resource and
management issue is confounded by the serious lack of capacity at a
local government level – post apartheid problems. The pediatric ward at
my local hospital has just been closed because it is so unsafe – lack of
staff. These are problems which exist through the public sector –
health, education, public safety.

However, as seems to happen only in SA, things change very quickly! We
now have a new president and a new health minister (who doesn’t promote
garlic and beetroot and traditional remedies for HIV) (we also have a
new potentially significant opposition to the ANC, but that’s another
story). This new minister (Barbara Hogan) has publicly acknowledged HIV
has priority health issue. So maybe things will change ito the
management and treatment of HIV (which affects incidence etc). This
might set the conditions for a public response which is different.

But I keep returning to the local possibilities, because it seemed, from
my experience in this one particular research context, that people
wanted to know what was ‘wrong’ and what the dynamics were, and they
wanted to be engaged in making it change. I don’t think that I (or
anyone else) could go into any setting and just try to change things. I
think something about the ongoing engagement with a group of people
(through a research process), over time, in a way similar to
participatory research (with people as participants and not research
subjects), stimulates an interest, investment in, and potential
ownership of the process. Something in the Change Lab process seems to
be similar to this – a group of people collectively (and willingly)
engaging in a reflection on the nature of their reality (very Paulo
Freirian). For me, this is where the potential for change seems to
reside – in the collective reflection and ‘re-imagining’ of local
conditions. This is not a social movement in the sense that there is
advocacy etc (very successful with the Treatment Action Campaign – TAC,
which got the government to role out ARV and mother-to-child treatment).
Maybe it seems more possible because for me as a researcher, it is more
manageable than imagining a social movement!


 Some references

Jewkes R et al., (2001) Relationship dynamics and teenage pregnancy in
South Africa, Social Science G Medicine, 52(5):733-744,

Wood K, & Jewkes R. (1997) Violence, rape and sexual coercion: everyday
love in a South African township. Gender and Development 1997; 5(2):

Wood K, Maforah F, & Jewkes R. (1998) "He forced me to love him":
putting violence on adolescents' sexual health agenda. Soc Sci Med;
47(2): 233-42.

Wood, K., & Jewkes, R. (2001). Dangerous Love: Reactions on Violence
among Xhosa Township Youth. In Morrell, R. (2001) Changing Men in
Southern Africa. Pietermaritzburg: University of Natal Press.

Low-Beer, D. & Stoneburner, R. (2003). Behaviour and communication
change in reducing HIV: Is Uganda unique? African Journal of AIDS
Research, 2 (1). 9-12

Low-Beer, D. & Stoneburner R. (2004). AIDS communications through social
networks: Catalyst for behaviour changes in Uganda. African Journal of
AIDS Research, 3(1). 1-13.

Morrell, R. 199African
Studies”. Journal of Southern African Studies 24 (4): 605–630.

Nattrass, N. (2007) Moral combat: Aids denialism and the struggle for
antiretrovirals in South Africa. Pietermaritzburg, South Africa:
University of KwaZulu-Natal Press

Parker, W. ; Makhubele, B; Ntlabati, P. & Connolly, C. (2007)
Concurrent sexual partnerships amongst young adults in South Africa:
Challenges for HIV prevention communication. Johannesburg, RSA: CADRE

Mary van der Riet; School of Psychology; University of KwaZulu-Natal
Private Bag X01, Scottsville, 3209

tel: 033 260 6163; fax: 033 2605809

>>> Steve Gabosch <> 11/09/08 09:11 AM >>>
Mary, Andy, I got distracted and didn't ask a question that occurred
to me during your discussion of possible social bases for an effective
movement to reverse the AIDS crisis in SA.

It is an obvious question, and is addressed to some extent in the
video that was shown at ISCAR: what about young women? It seems to
me that they more than anyone have the ultimate power and motivation
to significantly change how sexuality is done in SA. Of all the
places in the world that could use a thriving feminist movement - and
there are plenty of those - the life and death situation in SA and
Africa would certainly qualify it as one of the most needed places.
You can't just wish movements like that into existence, but sooner or
later, women are bound to form one. Once such a thing begins to roll,
all the other social layers mentioned - grandmothers, orphans, etc. -
will feel empowered and will also become more politicized. Many of us
on xmca are old enough to have witnessed that in the US women's
movement, sometimes called the third wave of feminism. What are the
prospects of building a women's movement in SA that is willing to take
the issues of AIDS head on (not to mention other issues)? What
incipient forms have feminism, womens rights movements, etc. already
taken? What could be done to help?

Well, just some thoughts. What do you think?
- Steve

On Oct 21, 2008, at 2:10 AM, Mary van der Riet wrote:

> Dear Andy
> I think that there might be a social base for a 'social movement' in
> this context, in the sense that parents (the older generation) is
> extremely worried about the rate of infection and the increase in the
> number of deaths. However, parents/older people have relatively little
> 'sway' in this context (as do parents all over the world in relation
> to
> youth).
> Although there are orphans, they are often not in orphanages (SA
> doesnt
> have many and the problem of orphans is huge), but with extended
> family
> members, or grandmothers who remain the sole adults in the family who
> have not succumbed to HIV. The idea of mobilising orphans is an
> interesting one. My sense is that they are usually so overwhelmed by
> the
> struggle to survive without adults that being advocates for changing
> broader social conditions would be hard. They are also often very
> young
> when they are orphaned (under 10), and so disempowered age-wise too.
> Changing the attractiveness of being sexually active (for example as
> you suggest, making taking risks into 'stupid' acts) sounds very much
> like changing 'norms/conditions' in the context. There are many
> interventions with youth which try to create other activities for them
> (so that the focus is not on sex and risks), and encourage a focus on
> the future. There are examples of campaigns which focus on creating an
> 'HIV-free generation', but I dont think they have re-imaged the idea
> of
> being sexually attractive - and these campaigns have not had much of
> an
> effect.
> Another possibility of a social base is the people who were involved
> in
> the research in the first place (youth in the research context). My
> assumption is that reflecting on the findings (of risky practices,
> rate
> of infection, prevalence of HIV etc)> might create the conditions for future contradictions.
> Do you have a particular reference for Peirce and the three
> 'registers'
> - seems like something useful there
> Mary
> Mary van der Riet; School of Psychology; University of KwaZulu-Natal
> Private Bag X01, Scottsville, 3209
> email:
> tel: 033 260 6163; fax: 033 2605809
>>>> Andy Blunden <> 2008/10/14 03:37 PM >>>
> Mary,
> Your work is really exciting. The problem seems almost
> insurmountable - how to change the sexual mores of an entire
> population??
> Just thinking randomly about a few things ...
> Social movements need a social base. Is it possible to
> identify some social group who is motivated to dedicate
> themselves to this task? For example, efforts to stamp out
> alcohol abuse in Indigenous Australian communities have
> turned to the older women to recruit their shock troops
> because these women suffer from the drunkenness of their
> men. Maybe even the orphans in orphanages could be
> mobilised? ...
> The Transport Accident Commission here has had a great deal
> of success in lowering the rate of people getting killed in
> car accidents by advertising campaigns which aim to make
> certain dangerous behaviours just look stupid. Bascially,
> you need to change the image of a sexually attractive man or
> woman. It is often the case that rational understanding of
> the lethal consquences has little effect if people *feel*
> powerful and good when doing the unsafe practice.
> In general my theory is that, following CS Peirce, you have
> to coordiante the attack on three registers: the symbolic
> (AIDS is caused by a sexually transmitted virus), the
> indexical (a social movement of people motivated to stop the
> unsafe sex) and the iconic (making unsafe sex look like what
> it is, not sexy but unsafe).
> Does that strike ant bells?
> Andy
> Mary van der Riet wrote:
>> Hi all
>> I would like to raise the question asked in both of my papers
> presented
>> at ISCAR (and referred to by Mike below), about the possibilities of
>> intervention in social problems - such as an epidemic. This is also
>> partly in response to Steve Gabosch's post (My Iscar), and an
> off-list
>> discussion I have been having.
>> CHAT (and the ATriangle) really has helped me to understand some of
> the
>> dynamics around individual responses to HIV. They have, as Steve
> says,
>> ‘methodological power’.
>> The most common response to me research topic is ‘What do you say
>> about interventions?’ I don’t think there is an easy answer to
>> this. There is perhaps not even ‘an’ answer to this question.
> My
>> second paper reflected on the implementation of a ‘social
>> mobilisation’ process in the same community referred to in the
> first
>> paper. I perhaps need to provide some background on the idea of
>> ‘social mobilisation’ as we used it. Some of my colleagues (in
>> an organisation called CADRE) had funding from Save the Children
> to
>> pilot a ‘social mobilisation’ process. The idea was conceived
> by
>> Save the Children and was in response to the dominant
>> ‘individualistic’ orientation of most HIV and AIDS
> interventions.
>> The phrase was not theorised deeply by us and because of time
> pressure
>> we did not look at literature on other ‘social mobilisation’
>> processes - which perhaps we should have (and I think that social
>> mobilisation in the Marxist sense that Steve refers to is perhaps
> what
>> the Treatment Action Campaign has been doing ito advocating and
>> mobilizing for better policies on HIV treatment and access to
>> medication - perhaps a question is what is ‘political’ action
> in
>> trying to achieve behaviour change as opposed to policy change?, and
> how
>> does this relate to 'individual' level change?)
>> After being given the brief by Save the Children, we operationalised
>> it in our own terms (the report is available on -
> Making
>> HIV/AIDS >> South Africa, 2002). The initial premise was that this was a context
>> with a high rate of risky sexual practices, and it was a context in
>> which HIV was stigmatized, silenced and ‘othered’. The aim
> became:
>> how can we, firstly, understand and, secondly, influence the
>> community’s ‘response’ to HIV and AIDS to that the broader
>> context of their ‘individual activity’ could change. The
> assumption
>> was that this would set the conditions for individual change.
> However,
>> it wasn’t really an intervention and implementing the process was
> not
>> based on a CHAT analysis, so my reflection in the paper is really
>> applying CHAT after the fact. It also had slightly different goals
> to
>> what might have been addressed if the research data had been
> followed
>> through. The social mobilisation process focused on the group’s
>> ‘response’ to HIV in
>> a very broad sense (in part to address stigmatisation), and this
>> broadness, I think, meant that very limited ‘changes’ resulted
> from
>> the process.
>> I think that the degree of interest on the part of residents of this
>> particular area in the research process and in the social
> mobilisation
>> process suggests that it might be possible to set up a process of
>> critical reflection through a ‘Change Laboratory’ process in an
>> ‘open’ setting (ie not an organizational setting). This is
> what
>> I would like
>> to do once my phd process is finished and this might be able to
>> generate some ‘solutions’ to the very huge problem of HIV/AIDS.
> One
>> of the useful things about the research context is that there is
> some
>> degree of ‘coherence’ amongst the village residents and between
> the
>> villages themselves. However, the research process took place a few
>> years ago
>> and there have been changes since then. And I am still learning
> about
>> the ‘change lab’ process and would need to raise a team of people
> to
>> engage in something like this, but its something I am thinking
> about.
>> so, how does one and how can one make 'changes' in society happen to
>> the degree that one needs in the HIV/AIDS pandemic (which the UNAIDS
>> Report 2008 says is on the rise in Britain, Russia, China, Germany,
>> Ukraine and Indonesia)?
>> Mary
>> Mary van der Riet; School of Psychology; University of KwaZulu-Natal
>> Private Bag X01, Scottsville, 3209
>> email:
>> tel: 033 260 6163; fax: 033 2605809
>>>>> "Mike Cole" <> 2008/10/07 08:44 PM >>>
>> We have contacted Taylor and Francis to get the new "arrticle for
>> discussion" available as a pdf file on their
>> MCA page. Meantime, we have these papers for discussion that one or
>> another
>> of you has asked to discuss.
>> Discuss away!!
>> mike
>> --------------
>> *Race and Language as Capital in School: A Sociological Template for
>> Language Education Reform
>> * <>
> Allan
>> Luke
> DRAFT*<>
>> Yrjö Engeström, University of Helsinki
>> *CHAT and HIV/AIDS: An activity system analysis of a lack of
> behaviour

> >
>> Mary van der Riet
>> *Activity Theory and reconceptualising HIV/AIDS

> >
>> Mary van der Riet
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