Epilogue: Homegrown in PNG – Rural Responses to HIV and AIDS
By Hammar, Lawrence
A three-years-long, multi-sited, multi-method study conducted throughout Papua New Guinea by the Institute of Medical Research revealed a staggering prevalence of sexually transmitted disease (STD) that threatens an already fragile political-economy and health services delivery system. Logistics, methodological complexities, and political and especially religious sensitivities hampered conduct of such research. Extremely little HIV social research has been allowed to inform interventions or serosurveillance protocols. Well-intended but ill-conceived international initiatives have promoted a normative AIDS paradigm that misconstrues HIV transmission risk, incites greater fear, increases stigma, and promotes anti-condom rhetoric. This collection ‘HIV/AIDS in Rural Papua New Guinea’ presents a sustained series of ethnographically based accounts of rural responses. In this epilogue I situate the importance of those responses in a discussion of the great divide between the lived realities of HIV infection and AIDS related suffering on the one hand, and the discursive practices and policies of media, public health, international donors and NGOs on the other.
Key words: public health, sexuality, gender, disease, HIV, AIDS, Papua New Guinea.
‘As for me, I can give out the condoms to the men, but we don’t give them out to women. The nursing sisters say ‘no, you must follow God’s law’, that “it will only encourage the women to have sex again anyway’”
(STD clinic employee, Enga Province, April 4, 2006).
This very special issue of Oceania is composed of provocative ethnographic data that have been collected, analysed and assembled by seasoned field-workers. Each contributor has shown sociological insight and pointed to exciting new directions for research on HIV, AIDS, sexually transmitted diseases (STDs), sexual behaviour, and health services delivery systems in Papua New Guinea (PNG). Collectively and individually, the essays are linked to other research areas, ask pregnant theoretical questions, and make me think harder about the future of PNG. If I say that it seems currently to be hanging in the balance, it’s because for three years (2003-2006) I worked alongside colleagues at the Papua New Guinea Institute of Medical Research. The research we conducted on HIV, AIDS, STDs, and sexual health and behaviour brought us to 11 mainland field-sites, split roughly between ‘urban’ and ‘rural’ settings. We worked in villages that hugged the shoreline toward PNG’s border with Indonesia near Wutung, in settlements that straddled mine-site boundaries (and villages flung far from them), and in quasi-hamlets strung out along oil pipelines. The data we collected suggest that PNG’s HIV epidemics will continue to expand and have increasingly devastating effects. That politicians and public health officials continue to draw comparisons to ‘African- style epidemics’ to understand something that is home-grown, however, is a terrible contradiction, another example of the process of externalisation that continues to hamper a ‘national response to AIDS’ that is in fact largely driven by foreign donors. This issue of Oceania is especially valuable for putting rural settings and responses front and centre where they belong.
Katherine Lepani’s wonderfully reflexive discussion of sovasova in the Trobriand islands recalls what medical anthropologists used to call ‘culture-bound illnesses’ and is linked with early works of Paul Farmer in that the residents of the Haitian village in which Farmer worked (Do Kay – a pseudonym) attempted to Tit’ this new thing – SIDA – into preexisting ethnomedical schema. Do Kay villagers quibbled surprisingly little over the pathogenic agent of SIDA, eventually accepting rather easily the presence of a microscopically small virus and worrying over a vaguely expressed ‘foreign homosexuality’, slowly arriving at a consensus as to its putative transmission route – the ‘sending of sickness’ via sorcery, something that is happening daily across PNG.” This raises the problem of how, as Verena Keck makes clear in her interesting contribution here, ‘biomedical information about HIV/AIDS is perceived and adopted into local contexts’. In even starker contrast, Trobriand islanders had no such schema within which to fit gonorrhea and Donovanosis, much less a particularly virulent and disfiguring form of syphilis, when they arrived in the late 19th and early 20l” centuries. Some sufferers of syphilis were buried alive by frightened villagers, so horrified were they by the stigmata that initially resembled a fulminating presentation of yaws, the treponemal cousin of syphilis. Accounts have appeared of the stigmatization of those known or thought to be suffering from AIDS (Haley n.d.a., n.d.b.; Hammar n.d.b.; Layton 2004), including strangulation, torture, burning, drowning, and being thrown into rivers, latrines and chicken and pig enclosures. The Post-Courier and The National, PNG’s two English-language daily newspapers, have reported the piling up of the bodies of AIDS victims in under- resourced morgues and their burial in unmarked graves. The airing in August of 2006 of the ABC documentary, ‘Sick No Good,’ was followed by public condemnation of the callous treatment it uncovered – and equally of its airing to foreigners.
At some point in the past several decades, members of Lepani’s (then) host/(now) home village began to suspect improper sexual mixing: sovasova is said to be an internally stagnating form of sexual congress occurring between people thought too closely related. It causes changes in skin tone and pallor, chronic pains, swollen abdomens and other symptoms. As she makes clear in rich ethnographic detail, some villagers have begun to accept a bacterial cause for what might (or might not) be pelvic inflammatory disease – or worse. Indeed, their acceptance has been just as uneven and highly contested as have been worries about the efficacy of newly used ‘traditional’ cures. There was also great contestation in Haiti in the early years of its AIDS epidemic in terms of the efficacy of Christian prayer, village-based ritual, natural medicines, medical doctors, and Vodoun priests. Some Trobrianders appear to ‘see’ sovasova in what might be cases of AIDS … or maybe they’re just cases of sovasova. Whereas one acquires HIV from others in intimacy, and insofar as AIDS was in Haiti and is now in PNG thought to be ‘sent’ or ‘done’ by others, sovasova seems instead to occur and to do so literally between people.
Verena Keek’s work among the Yupno of the Finisterre Range bordering Madang and Morobe provinces follows well upon the compelling writings of her countrymen Hansjorg Dilger (2003) and Wolfgang Kempf (2002) on the perils for (especially male) youth of modernity in this age of AIDS. Keck focuses here partly upon the remoteness with which the Yupno must contend in economic terms and the degree to which their relative geographic isolation hinders the communication of potentially life-saving knowledge about HIV transmission risk and technologies, including condoms, especially to unmarried youth. The literal road is two-way, letting STDs in along with economic opportunities, but metaphorically one-way in that villagers do not perceive themselves as posing transmissive risks to others or ‘the village’ as a high risk setting. This is something that I suspect would resonate among Trobriand islanders and Gogodala. Not that some knowledge of viruses and bacteria isn’t present among their host community members, but by discussing disease etiology (or in the case of Alison Dundon’s contribution here, temporary mental illness ) in terms of disturbed social relations, Keck and Lepani place themselves in a lengthy intellectual genealogy of anthropologists (see Hammar n.d.c.). Insofar as AIDS is truly for Yupno, and apparently Gogodala and Trobrianders, a disease syndrome for which no cure exists, one can ask how they’ll take on the ‘miracle’ cures and mushroom potions available just down the road in Lae and which Yupno will market them. These potions were for the Gogodala until recently available on nearby Daru island, but the most prominent seller thereof now peddles them from Mendi General Hospital in remote Southern Highlands Province with help from a Goroka-based medical doctor.
Our editors Alison Dundon and Charles Wilde have divided and pooled their labor sensibly; the short titles of their two very fine Ph.D. dissertations – Dundon’s Sitting in Canoes (1998) and Wilde’s Men at Work (2003) – suggest something of the content therein and in the several interesting essays they have already published about religion, work, and cultural and social change among the Gogodala of Western Province (see especially Dundon 2004; Wilde 2004, and other references to their work in this collection). Dundon’s contribution here and data she presents elsewhere (e.g., 2004: 79) suggest that in the context of AIDS and its accusation, expressions of Christian femininity are becoming increasingly punitive and condemnatory. Their stinging rebukes of female sexuality, delivered with icy stares at what seem to be post-coital shenanigans or in near- delirious channelings of the Holy Spirit, probably haven’t made sex – even within the ideal confines ofa happy, Christian, monogamous marriage – an easier topic about which to speak with friend and family or behaviour to experience positively.
Insofar as there are few such happy, Christian, monogamous marriages, as Wilde (2005) found while researching Gogodala male attitudes toward condoms, no wonder that lust and longlong (‘craziness’, in Tok Pisin) go hand-in-hand. Gogodala women seem also to be active in what Richard Eves (2003: 256) has called in his important essay, ‘AIDS and Apocalypticism’, ‘the general Salvationist project’, and as such seek to ‘contain sexuality within the confines of monogamous marriage’. Sexual desire, however, won’t stay put in the ways preachers, politicians and public health officials want it to. It remains the irresistible force against the immovable object of many centuries’ worth of religious and moral stigmatization of it and its alleged wages – venereal disease – which has been dubbed the ‘dirtiest subject of them all’ (Rosebury 1973: xvi). Wilde explores the terrible paradox facing young unmarried men in PNG: responding smartly to ad campaigns promoting the efficacy of condom usage (by using them) means to behave in ways thought immoral and antiChristian. Another facet of such paradox is revealed also by Dundon, who shows that AIDS has become not so much the Great Imitator, as syphilis was dubbed centuries ago, but rather, the Great Deceiver. Its visual spectre is thought grotesque, but it comes nevertheless silently into communities, dressed in the guise equally of beloved spouses, feared criminal gang members, admired rugby players and demonised sex workers, spawning fear and cognitive mayhem in about equal amount. In similar settings but across the border in Manokwari in Indonesian Papua, Sarah Richards (2004) shows that Western horror film codes inform the fear and stigmatization of AIDS sufferers, and worse, excuse demonisation of those same sex workers. ‘It was as if stories about people suffering AIDS drew symbolic material from the scripts of horror films’ (Richards 2004: 82).
In similar fashion, some men in remote villages of Lake Kopiago District in Southern Highlands Province (and many more in Eastern Highlands and Simbu provinces) have sought to contain the cause of death within the confines of traditional ideas of gender relations and sorcery. They have taken advantage of the retreat of government services in the area to reassert recently waning masculine power over women. In one particularly grim case reported by Nicole Haley (Haley n.d.a., n.d.b.), the suspicious recent deaths of men (probably from AIDS) were blamed on vulnerable women dubbed witches, who were then horribly tortured and mutilated and in several cases murdered. The contributions here and those of Wardlow (2006), Eves (2003), Haley (n.d.a., n.d.b.), Wood (1998), Levy (2005) and others (Hammar 2004a, 2004c) suggest a vibrant and growing corpus of ethnographic work about ‘AIDS’ ‘in’ ‘rural’ ‘Papua New Guinea’, each trope of which could sustain additional entire issues of Oceania. Common is the accusation of Outsiders’ for bringing AIDS into homes and villages and of those ‘insiders’ thought responsible, of being sorcerers, however feeble and marginalized socially they may be empirically. Lelet believe that ‘HIV/AIDS is a disease of white people, introduced into PNG by them . . . ‘ (Eves 2003: 253).
This collection is situated within a broader field of HIV social research because it takes anti-condom discourse seriously. Frank fabrications of manufacturing flaws in condoms and beliefs about their alleged inducement of sexual promiscuity, even stories of their ability to ‘carry’ HIV in their tip thus becoming the agent of transmission, have increased in recent years and come equally from the pulpit as from the pages of newspapers. In the main they go unchallenged by public health officials and donor organizations, owing to the imperative not to offend Christian churches and sensibilities. One example was the decision made early on in high- level deliberations to replace the term ‘MSM’ with ‘male sexuality’ (Lepani 2004: 8), but which was overturned in the face of monies offered by organisations who trade heavily in such acronyms, such that now 1MSM’ is practically required speech of workshop and conference attendees. Dr. Thomas Vinit is just one of many prominent physicians opposed to condoms, and he has been made head of the Lifestyle Diseases division of the National Department of Health. Because condoms were not ’100% safe’ (left undefined), he argued, the government was ‘improper’ in distributing them at all, and he dubbed this a ‘medical scandal’. In explanation, he offered that ‘the HIV/AIDS cells compared to the sperm cells were much smaller’ (Peter 2006: 3). That he has been joined by highplaced politicians and religious leaders to condemn what they believe in earnest to be bad faith and poor policy is something about which I’ll have more to say immediately below.
In order to extract as much as possible from such discourses and these kinds of ethnographic data I will discuss the concept of ‘moral demographies’ introduced by Philip Setel (1999) in A Plague of Paradoxes. Setel’s fascinating ethnography is filled with accounts given by professionals and villagers, men and women, old and young, verbally and otherwise, of the kinds of social, nutritional, ecological and cosmological decline occurring on the slopes of Mt. Kilimanjaro. These are expressed nowadays by Papua New Guineans, too: lived accounts and embodied experiences inform readers of the historical processes of demographic, social, cultural and even sexual changes that have occurred in ways that bench scientific accounts of the properties of viruses simply can’t. The singular moral demography that Papua New Guineans are now narrating to one another is of the stable, house- and garden-bound ‘housewife’ at the mercy of the mobile husband. He becomes infected at the site of employment by in-migrating predatory sex workers against whose wiles he is apparently defenseless, and then carries it home to his innocent wife (or wives) who then infect doubly innocent children. Setel’s humanistic stance toward fieldwork, his findings, and his perceptive mode of analysis are relevant to PNG – and indeed for a brief time he worked there. I show this partly by reference to ethnographic data I helped to collect in our study of HIV, AIDS, STDs and sexual health. I will then discuss why this is an important collection and why questions of language have never been needed more in PNG public health and public policy debates, I don’t know how widely open yet is the ‘window of opportunity’, but if there is one, the language of HIV and AIDS (beginning with terms such as ‘HIV/ AIDS’) must change.
THE IMPOSSIBILITY OF CONDOMS
‘Advising people to use condoms means to put them, at risk of getting AIDS, and just spreads AIDS’
(Bishop Bonivento, Do Condoms Stop or Spread AIDS? 2001: 35).
As do those in other countries, Papua New Guineans do and think and say, including engage in sexual activities, cognize the risks thereof, and communicate those to others, in terms of other people. Yet, this has little informed the national response to AIDS, which still fetishises quantitative approaches to monitoring infections and sexual behaviour. Normative assumptions in public health and public policy posit the individual as standing against or outside of society; divorce sexual acts from their purposes, pleasures, or meanings; continue to count as opposed to attempt to understand sexual behaviours; do not question the truth of what is allegedly being counted and reported quarterly; and persist in ignoring the various contexts, especially cultural, of sexual activity. Sexual desire is analysed and discussed in epidemiology as little as it is in the village, yet notions of sexual identity are bandied about in ignorance of qualitative research conducted about them. Ethnographic data on gender relations and sexual networking in PNG have gone largely unused by policy-makers, physicians, politicians and public health officials.
This is clearly evident with regards to the tangled relationships between condoms and the nation’s many thousands of health workers. They are often hard-working, dedicated, and under-appreciated, but over the past 15 years have come under a lot of friendly and notso- friendly fire for their conservative attitudes regarding AIDS and STDs broadly and regarding sexual and reproductive health matters more specifically. In addition to being often unclear about STD signs and symptoms6 and HIV transmission routes and risks, they are also often believers in, promulgators of, and working in settings rife with falsehoods about condoms and their usage. Having randomly chosen amongst 11 Summary Reports (out of a total of 20) written by the NHASP-sponsored social mapping team about fieldsites at which I had worked, this is what they concluded from their work in Southern Highlands Province:
Churches in the districts were strongly opposed to the distribution of condoms to young people, and many respondents, especially in Koroba/Kopiago, were totally against it on the grounds that it goes against church rules and the word of God. Young people in Orel (Imbongu) argued that if there were no condoms young people would be scared and stay faithful to one partner. They argued that the government should therefore ban factories producing condoms. Several health centres included in the mapping are run by missions and even though they had stocks of condoms, they would not distribute any because doing so is seen to be contradictory to church rules. In one case, at Ma[r]garima Health Centre, this had led to young people breaking into the centre to steal condoms [as we found in Tari and Inu]. Three of four health clinics included in the mapping of Koroba (Topani, Hanyanoma and Honianda) did not distribute condoms because they are perceived to be \contrary to church rules and not one hundred percent safe. Health workers at Inu Health Sub Centre (Nipa/Kutubu) were aware that it is hard for young people to control their sexual desires and that condoms would provide some protection, but are prevented from distributing condoms by village leaders and the church (ECPNG) (NHASP 2005a: 51).
Health workers in both religious and (ostensibly) secular settings struggle with the moral aspects of work related to AIDS and with some of the conflicting doctrines and policies, practices and assumptions of their churches, religious leaders, health care settings, and colleagues that they simply refuse to distribute condoms. The STD clinician from Wabag who is quoted at the outset of my contribution, doesn’t agree with double standards operating in his health facility. Nevertheless, he willingly enough contravenes health policy in bending to the wishes of nursing sisters for whom Christian tenets trump health policies. 1 have seen interactions with married female patients during which advice about simply abstaining from sex is provided – not condoms – even in case of out- migrating miners who return to their wives cashed and liquored up: ‘don’t let him’ rings perniciously empty in many tens of thousands of marriages, ‘monogamous’ or not. Many people and programs are so riven with conflicts about condoms – personal as well as institutional, logistic in addition to philosophical – that they don’t or won’t distribute them at all. Following completion of my contract with the IMR, I interviewed a prominent member of the Catholic Diocesan Health Services who explained in some detail some of the stresses he feels and strains under which he works, given its well-documented opposition to contraception and condoms. As to the first, he confessed that were a member of a Catholic congregation or women’s group to attend an antenatal clinic or an HIV-related presentation and he were to discuss condoms he’d be reported to the Bishop and perhaps lose his job. He isn’t even allowed to touch condoms or to suggest their usage even in case of infected spouses. His colleagues have simply given up: ‘for us’, he concluded, ‘condoms are just impossible’ (author’s fieldnotes, emphasis added).’
Taking their place in many health settings are faux medicines and religious exhortations. Despite one of the foundational messages in recent years being that ‘there is no medicine for AIDS’, in many settlements and public squares placards and sign-boards hawk alleged cures for AIDS in the form of mushroom potions, Noni juice preparations, and myriad other forms of netsa marasin (‘nature medicine’, in Tok Pisin). Many are now available in branches of God’s Farmacy. However understandable they may be in terms of principles of Melanesian ethnomedicine, people’s understandable wish for privacy, and the high price of medical care, they surely blunt the effectiveness of new initiatives that would roll out anti- retroviral therapies (ARVs) in clinical settings under conditions of clinical supervision, of post-test and follow-up counseling, and confidentiality. A placard posted in the tuberculosis ward of a hospital says: ‘It is true that there is no cure for HIV/AIDS in the world. However, 42 HIV/AIDS patients in PNG have fully recovered and are living normal lives again’. Medical personnel I queried hadn’t taken notice, though their tuberculosis patients test HIVab+ at a rate of 30%-40% (author’s fieldnotes, April, 2006). Patients are taken off tuberculosis treatment (or never go on it in the first place) in favor of these other ‘treatments’, sometimes even at the behest of medical workers themselves. That some of them are scams but that others are well-intended, prayed over, believed in and perhaps in some ways efficacious in boosting immune system function only underscores the necessity of taking just about everything seriously – and none of it. Another advertisement, located in the foyer of that same hospital, claims to have found ‘HIV/AIDS medicine in the Lord, Jesus Christ, when we implemented what the bible directs in Acts 2:38, John 3:3-5, and Mark 16: 17′.* I asked medical personnel what they knew or thought about the advertisement, but the answers were luke-warm in content: ‘didn’t know about it’, ‘maybe it works’, ‘AIDS is a curse that only God can remove’, and so on. The continued living of the HIVab is sufficient proof for many physicians and medical researchers of divine intervention and virus removal.
AIDS IN A SOCIAL FIELD
PNG’s AIDS paradigm is still unfolding, but its epidemiological assumptions, models of risk and its avoidance, funding sources, and cognitive and behavioural outcomes are well-known (Hammar 2004a, b, c, n.d.a., n.d.b., n.d.c.). It remains as little anxious to shine the light where the bulk of infections occur – in marriage – as to highlight factors of socialstructure and political-economy that express male sexual prerogative and reproduce it anew. Its assumptions about what ‘high-risk’ versus ‘low-risk’ means are debatable. It remains conflicted about condoms not just in terms of whether they are morally right or objectionable, but also as to with whom one should and with whom one does not use them. The AIDS paradigm in PNG is little bothered by empirical facts and remains ambivalent regarding transmission routes and prevention measures. It remains quiet about the ubiquity of sexual violence and dishonest about its misconstrual of the risks of transmission. The prevention of HIV transmission per se has never truly been a top priority, but rather the erection of an organizational edifice that monitored and allegedly surveilled upon it; only recently has there begun to be an evidence-based approach. Instead, there has been a grudging acceptance of a threat that has been allowed to grow. ” Little is done to debate or subvert sex-negative church doctrines and challenge the legality of discrimination against gays and lesbians or the misogynistic language used against women and girls in prostitution. Male (hetero)sexual privilege is acknowledged obliquely but not in terms of the gender imbalance of the House of Parliament and in Christian doctrine per se. While the identities of high-ranking politicians have been guarded in the newspapers, breaches of confidentiality are routine in many health facilities, and girls and women formerly in prostitution are shown and named in stories that trumpet new success in cooking and sewing skills learned in courses run by Christian charities. Facts and policies about HIV and AIDS are like two magnets turned the wrong way – the more the former get in the way of the latter, the more they are resisted.’4
PNG is certainly not the first country in which the empirical facts of transmission routes and risks bear little relationship to the policies formed about them, and there are many reasons why this is so. The incredible linguistic, cultural, and behavioural diversity of the country has fascinated virtually everyone who has visited PNG, but yet it complicates the production, dissemination, and reception of messages about HIV and AIDS. Take the trope of ‘sex’; it would appear in Lepani’s writing to be a good thing in and of itself in the Trobriand islands, which is probably linked to their positive attitude towards the use of condoms. Nevertheless, throughout much of the remainder of the country sex is productive of socially valued goods, persons, and relations (in the form of children, bride-wealth, names, and social structural linkages) but still bad per se. Strathern and Stewart (2000), for example, write perceptively of Mae Enga and Medlpa dream imagery and speech contests involving sexual intercourse and its potential products. ‘The dream’, they write, ‘could thus also represent the conversion of hostility into alliance as happens when a sexual encounter is further transformed into an alliance. Sexuality and desire represent a potential, then, for both hostility and friendship, depending on how they are taken and developed over time’ (Strathern and Stewart 2000: 79-80). Sex certainly is useful: on Daru island, Western Province, sex is a quite trifling thing, neither good nor bad per se so much as something one could purchase if one wanted to, or sell, trade, or barter to get something else. In yet further contrast, HuIi men nowadays in the Tan Basin of Southern Highlands Province who are alleged to have had sex extra-maritally for reasons of pleasure are accused of ‘removing sex from its proper reproductive purpose’ (Wardlow 2006: 98). Nursing sisters remonstrate others for ‘misusing’ sex – even refusing to provide STD treatment altogether – as if sex is a material item of finite amount and that comes in only one size. Among the Yupno, according to Keck, sexual activity can lead to new forms of stigmatization and further strained social relations, especially when its signs are borne corporeally. As she shows in interesting detail, sex-related social disturbances are as likely to implicate health workers and village leaders as parents and church representatives. Sullivan et al. (2003), Levy (2005), and others have shown the same thing. This is so because the sex lives of health workers, church leaders, expatriates and political leaders – that is, those who formulate and implement policy – isn’t yet on the table.
Sex is also seen and played as ‘a dangerous game’, as in Wilde’s contribution here to continuing theorization of emerging masculinities for Gogodala. Sex becomes a debilitating activity linked to mental disturbance, as Dundon suggests in terms that come close once again to recalling ‘culture-bound illnesses’. In some fiery street-preaching that occurs in the highlands, sex and condoms are understood as evil, condoms being dubbed ‘Satan’s tools’ in newspapers and by street-preachers. Sex for pleasure’s sake is frequently claimed to index the downfall of Tradition and to be the antithesis of proper Christian \modes of behaviour. As the Wabag- based STD clinician told me that nursing sisters had told him that they feared, ‘it’ll only make women want to have sex again’ – and we certainly can’t have that. The fact that condoms cannot do this – whereas their husbands do, and do often make their wives have sex – is yet more evidence of the externalisation of risk and exaggeration of agency.
This is certainly not to say that sex is everywhere, all the time and by everyone spoken and thought of negatively (see especially Lepani’s contribution here). Nevertheless, sexpositive Christian preachings or public health messages are extremely rare – I’ve never encountered either – and the same sex-negativity underwrites the One- size-fits-air tendency of mainstream prevention programs. The officially sanctioned ‘ABC’ campaign and its proxy phrase, Lukautim Yu Yet Long AIDS, are two examples of dubious usefulness. I can’t imagine a more collectively social country than PNG, which is why ‘Prevent AIDS’ rings so falsely. Each contributor here shows how ill- suited are such programs and slogans in behavioural settings common to PNG and that feature sexual cultures as dissimilar as Dobuan is to Duna, Gogodala is to Gumine or Kiwaian is to Kawelkan. The problem is compounded by the fact of the close identification of many Papua New Guinean individuals and communities with particular Christian denominations and sects some of whose AIDS-related doctrines and policies differ sharply. Given the rich ethnographic details our contributors have brought to the table, it is hardly surprising that the first tenet of ostensibly ‘safer sex’ guidelines is not to have it at all. This is a problem more broadly associated with Christian doctrine-inflected intervention programs and hardly unique to PNG. Miliakere Kaitani found in her study of 700 Fijian males that as educational status went up, associations of ‘safe sex’ with ‘abstinence’ also increased (Kaitani 2000: 12-13). This would be ‘interesting’ if it weren’t both an illogical association (abstinence isn’t sex, and cognitively, it leads later to greater amounts of unsafe sex) and a dangerous one. Enjoining others to abstain from sex in the sense conveyed in English of delaying onset of sexual activity and waiting before taking up with a new partner, however, is not the same as admonishing others not to have sex at all, which is what ‘Noken Koap’ means in Tok Pisin (the ‘ in ‘ABC’). Were Papua New Guineans to abstain in that second sense, the country would simply grind to a halt and many, many thousands of girls and young women would starve. ‘ABC’ isn’t ‘wrong’ just on evidentiary grounds, as Keck, for example, shows so convincingly, but also because it sets up Papua New Guineans to fail. It strikes me as wrong to expect abstinence from those who are expected simultaneously to be submissive, although not all Papua New Guinean wives are the latter as Lepani shows in her essay. Lukautim Yu Yet long AIDS strikes a similarly false note in that it individualizes what is clearly a social, collective problem and fails to provide any conceptual or behavioural tools with which, again, on the individual level, to prevent AIDS.
Further obstacles are posed by roads, communication (in terms of extreme heteroglossia) and communications (in the sense of downed telephone lines and busted computers). These and other obstacles hinder the distribution of condoms, affect the attendance rate of health personnel, and slow the speed with which HIVab test results can be returned.” As well, the on-going climate of political instability, economic downturns, and lack of financial accountability in high (and low) places makes external donor countries skittish. The fact that religious organizations and communities do so much fine work in education and health – in effect, subsidizing roughly 50% of what in other countries is the government’s work -means too often that chances for critical scrutiny of the content of HIV- and AIDS-specific programs are mooted. The Catholic Church’s ‘HIV/AIDS Policy’ document, for example, doesn’t even mention the word ‘condom’, and neither does the ‘Faith Community Leaders Covenant on HIV/AIDS’ (included in full in AusAID 2005: Appendix 8.2), despite each many times stumping for ‘prevention’. Other high-level documents side-step male sexual and political prerogative altogether and fail to critique the social ground of AIDS intervention programs, for example, by failing to mention the characteristically large age differences at marriage for male and female or the compulsory nature of heterosexuality. Some ‘careand-counseling’ initiatives appear little if at all concerned with prevention in the first place, mostly because the issue of preventing infections between serodiscordant couples would require 100% condom usage, not just with Outside’ partners, as many religious and public health leaders have it. There has yet to be a poster or message that specifically targets husbands as constituting a ‘high-risk’ group.
After five years’ worth of ‘awareness’ campaigns many say that ‘awareness’ is still ‘low’, and that hoped-for changes in ‘risky’ sexual behaviour have not happened (see Hammar 2004a; Levy 2005). Of course, this is a criticism neither of the effort expended, the amount of money spent, nor the passion held by those who have organized and run such campaigns. Nevertheless, the particular content of the messages and campaigns and the ways in which various media deliver them were mooted a long time ago. Certain portions of the NHASP-sponsored Social Mapping Project reports for individual provinces, for example, read almost identically in terms of the strains and tensions evident in the attempt at representation. The Summary Report for Western Province concluded with regards to the knowledge/understanding of ‘HIV/AIDS’ nexus:
Most respondents said it is a very dangerous and deadly disease, a killer disease, and that there is no medicine and no cure. Only in two cases the respondents said they were not clear or did not know about HIV/AIDS. Even though it was obvious that people know about HIV/AIDS, when asked what they knew not one respondent mentioned the main route for transmission i.e. through unprotected sex or infected blood, and most merely said it is a killer disease and that there is no cure (NHASP 2005b: 13, emphasis mine).
Finally, too many programs, interventions, and initiatives have been conceived, implemented, and received in an either/or fashion. They tend to take decidedly secular or religious stances, for example, to sexuality and condom usage (and usually the latter). They highlight the preeminent need for prevention or care and treatment. They promote a sense of alarm, danger and threat to either the ‘general population’ or (more often) to the usual suspects – the putative ‘high-risk’ members of alleged sub-groups on whom blame is cast but now, sometimes, prestige and money showered.’
The striking irony of seeing AIDS as a global epidemic is that while it is undoubtedly the case, in practice the response is largely at a rhetorical level… (Dennis Altman, ‘Globalization and the “AIDS Industry’”, 1998 p. 244).
I hope to have shown by now that the ‘national response to AIDS’ has in PNG been a largely deductive exercise. It has tried to hew closely to the tenor if not always the precise tenets of international ‘best-practice’ manuals wherever possible and to adopt all the right acronyms and slogans – no matter how ill the fit. The Australian Agency for International Development deserves credit for facilitating and funding the national response, especially over the past five years, on which it spent AUD60,000,000. Major roles have been played by the United Nations Development Program, UNICEF, the European Union and other international players and by private companies such as oil Search Limited and Ok Tedi Mining Limited, many of whose thoughtful personnel and innovative programs are quite ahead of the curve. In hindsight, and given the obvious challenges posed by geography, politics, and infrastructural deficits, an unrealistic kind and degree of structure was expected to guide reporting systems, to tighten up condom distribution networks and to oversee the proper functioning of provincial AIDS committees (PACs). For example, of the only two NACS web-site web-pages that are still active (the remainder of the site having for years been moribund), one of them is years out of date, including even the names of already deceased PAC chairpersons: yet PAC chairpersons and others were to keep in contact by email with supervisors and others. The point is not so much to point out the numerous problems, such as theft, lack of financial accountability and personnel turnover, that collectively sank good intentions, but to question some of the ruling myths. Quite the buzz stirred in 2003-2004 in PNG when word of the UNAIDS- and WHO-sponsored The Three Ones’ hit town: one monitoring and surveillance system, one national coordinating body and one strategic plan. Faith in such has cooled, of course, even by major promulgators such as the World Bank. External donors have begun to realize that such singular approaches can add new layers of government, creating all manner of new problems (see also Godwin et al. 2006), but without demonstrably preventing HIV transmission.
The external nature of the funding streams determines that the shape and contour and speed of our various HIV and STD epidemics will be similarly externalized. Frequent hand-wringing reference is yet made to ‘African-style’ epidemics that threaten ‘the general population’ through the acts of ‘prostitutes’ and disaffected youth. Petty (2005: 76, emphasis mine) argued the same thing but from her vantage point in Nova Scotia:
We had … heard news about a frightening epidemic among gay men and others in the United States, but when the epidemic came to Nova Scotia, the categories w\e inherited from the American epidemiologic enterprise seemed ill suited to the reality we were witnessing. In fact, our categories were not yet distinct and it was very difficult to understand local realities against a global backdrop. It was a complex moment in which we did not yet have the tools to challenge meso- and meta-level policies that rang false when applied in a specific setting like ours’.
In like fashion, it has proven yet too difficult to say publicly that we’ve ‘got a PNG epidemic, a largely home-grown disaster on our hands’. There are many reasons for this some being psychological, others being more about economics and the politics of nationalism – but they demonstrate the fact that the expanding HIV and AIDS epidemics has not been particularly well theorized.’” Dennis Altman’s (1998) programmatic and yet particularly thoughtful piece, ‘Globalization and the “AIDS Industry’” well captures the PNG context. The ‘globalization’ of his title refers to AIDS-related funding sources as much as to creeping capitalism or the spread of evangelical Christianity. All three compel people and cultures into ever tighter space/time compression, for example, including how fast HIV epidemics can be proclaimed, HIVab test results returned, and prevalence reported. Sociologically, the institutional arrangements involving pharmaceutical companies (for example, the Indian, Chinese, Indonesian, and Malaysian companies that make the condoms that many, and antiretroviral drugs that some Papua New Guineans use), the fact that nation-states vary greatly with regards to the degree of strength they show domestically (such as the claim often made about PNG, that it is ‘a weak state’), and the paradox that PNG’s ‘national fight against AIDS’ is largely external donor country-funded (said to be 97% so), make for many ambiguities in the conceptualization and implementation of initiatives. ‘ How does one justify this or that assumption about what ‘high-risk’ or ‘high- risk setting’ means in the nearvirtual absence at the level of policy formation of empirical evidence or application of sociological insight? Does proclamation of a ‘heterosexual epidemic’ mean very much in a country in which many of its cultures traditionally mandated male-male sexuality as a developmental pathway and in which serial intercourse and obvious male homoeroticism was common? It is therefore curious how quickly such acronyms as ‘CSW (commercial sex workers) and ‘MSM’ (men who have sex with men) were adopted, since both prostitution and being gay remain illegal.
Altman’s model of an ‘AIDS industry’ also underscores the importance of critically and reflexively approaching its discursive frameworks. In PNG those too often mean bodyfearful, sex-shameful, anti-condom, and frankly misogynous messages. These slogans (discussed here in one way or another by each contributor and elsewhere by Hammar [2004a, c, n.d.a., n.d.b.]) can easily be shown to have enabled a systematic misconstrual of risk and to have produced the very thing – more unsafe sex – that the slogans were ostensibly designed to prevent. Because both external donors and domestic authorities hold the reins of power with regard to funding streams and internal use of resources (guaranteeing Port Moresbybased, capital-intensive, personnel-heavy expenditures that have obvious public visibility) the truth content of the ‘awareness’ materials is seldom assessed, much less what awareness means in an oral culture or how effectively written messages will actually ‘trickle-down’ in ‘culturally appropriate ways’. Educational materials shy away from scrutinizing social structures most implicated, none saying, in effect, look out for male relatives, complain about royalties that go only to male landowner groups,20 beware of expatriates, and let’s admit that unprotected sex is our enemy.
In contemporary PNG such truths as are communicated in albeit slowly improving posters (showing, for example, how one can and cannot ‘get’ HIV) are intended less to prevent transmission than to ‘correct’ widely held notions of the HIV-transmissive potential of sorcery, food, clothing, casual contact, and mimicking behaviours. Keck mentions a Yupno youth who believed that following in the footsteps of a person who is HIVab+ is sufficient (see also Wardlow 2006: 98; Hammar 2004c), and Wilde, Dundon, and Lepani have also provided similar examples here. In the public press and at professional gatherings the ‘knowledge bases’ of ordinary Papua New Guineans, particularly those who live in rural areas, are often denigrated, as are those who are or aren’t Christians and who do or allegedly don’t control their sexual urges. The simple lack of education is often pointed to as the cause, but perhaps there are limits to what one can learn from posters and bumper-stickers. A student from Lae’s Unitech wrote a letter to the editor of the Post- Courier claiming that ‘HIV/AIDS’ was a ‘disease of knowledge where the wise will understand and keep away from it, while the fools will take no notice of it and die on their own foolishness even if consequences are seen’ (Sulupin 2006: 10). He went on to say that those who have sex extra-maritally go on to commit Other crimes’, and argued against the PNG government spending any more money on prevention: ‘Therefore, let the AIDS virus select the wise and eliminate the fools as a step to minimise corruption’ (2006: 10). This and hundreds more examples that could be cited suggest that the grasp and communication of factual information by leaders is in PNG not markedly better than that of their followers.
THE GREAT DIVIDE
To summarize my argument is to say that there is an enormous gap in PNG not so much between the experiences of urban versus rural dwellers in terms of HIV infection and AIDS-related suffering (although that’s possibly also true), as between the lived realities in both kinds of environs, on the one hand, and the discursive practices and policies of media and public health, international donors and NGOs, on the other. One example is the growing prominence of ‘Positive Living’-style discourse whose tenets are virtually impossible to keep up. It fits well, of course, within Christian evangelizing discourses, and I’m not suggesting that it is wrong to live positively so much as that the phrase signifies a broader movement that has effectively muzzled and handcuffed what little outrage is expressed about cause, what few outbursts are publicly allowed regarding prevention. As my colleague Steve Layton is fond of saying, ‘there’s nothing positive about living with HIV (see Layton 2004); his point is that it’s beside the point to talk about good health and nutritious food when clean water is too distant for one’s care-takers regularly to fetch, when one doesn’t have two toea to rub together, when local health workers have already outed one’s HIVab status, when the local preacher has already blamed AIDS on sin and profligacy, and when six urban clinics in Port Moresby have closed in the space of a single year. ‘ These, too, are the contemporary realities, but one wouldn’t know it from attendance at ‘leadership workshops’, ‘HIV/AIDS trainings’, and donor presentations about the new and improved High-Risk Settings Strategy.
Any number of examples could be cited regarding the sources and forms of this gap and about its implications for the future of HIV and AIDS-related initiatives and interventions, but each underscores Layton’s critical point above. Radio and television announcements mention sites in Port Moresby at which people can seek voluntary counseling and HIVab testing services. One prominent television advertisement, however, confuses potential clients by showing a Papua New Guinean woman receiving through the mail, in the same letter her pregnancy test results and HIVab test results, both positive. Where is the post-test counseling? What if the husband or mother-in-law or boyfriend had opened the letter? The reality, although great strides have been taken in this regard, is of broken confidentiality. How well clinically supervised will likely be the ARVs on which she might be put and how stable is the supply and low the price will be of such therapies? What can she do now, sexually – just say ‘no’?
MORAL DEMOGRAPHIES IN TOWN AND COUNTRY
But it is true that today, Chagga culture has crumbled and is dead. The youth today are all tied up in the profligacy of the disco, bearing children out of marriage, and so on. Women are doing petty business, and men are all along the highways leaving home. The home is crumbling. Before, you never saw married women wandering around Arusha, or going to the border, or in the markets selling beer. Now it’s totally different. There are even girls wandering all over the place. They go all the way to cities down south and their parents don’t even know. AIDS comes from all of this. At Christmas the men come from outside, come home, and bring the gift of AIDS. They drink and make love, and try to get their women pregnant . . . They come home and what do you do to stop this infection at Christmas? We will end up having a funeral every day. We will be tired.
(Philip Setel, A Plague of Paradoxes, 1999: 59-60).
One hears this kind of harangue nowadays also in Port Moresby settlements, Papuan Gulf villages, and highlands markets. A psychiatrist who was training would-be HIVab test counselors in 1991 recounted bitterly and succinctly many other ethnographic and historical data that Setel presents in fine detail of the sexual, demographic, and economic changes that have been experienced by the Chagga people dwelling on the slopes of Tanzania’s Mt. Kilimanjaro. Over the past 150 years the kihamba – an all-encompassing regime of production and reproduction for the Chagga, has been transformed. That kihamba is broadly both a model of and a model for culture underscores that such crises as Chagga have experienced have not been wrought s\olely on the cellular level – say, in compromising the immunological function of individual bodies – but are also crises of the moral and collectively social. In the wake of HIV and AIDS epidemics that are now devastating PNG, and given similarities of colonial rule, evangelical Christianity, and health crises, the relevance to Papua New Guineans of Setel’s compelling ethnography is acute.
Of particular relevance is his nuanced analysis of the effects at the level of sexual praxis of the declining amount and quality of land available to Chagga for the purpose of social reproduction. For a Chagga man’s extended family to stay, he had to go elsewhere to seek employment in mines or other resource extraction centres. The urban settlements of PNG now have markedly fewer gardens than previously and are supported little anymore by marine resource collection: much of the marketing of garden vegetables and most of the work related to transportation, entertainment and security is done by in-migrating highlanders. (Social) reproduction by way of exchange of sexual services has had to pick up the slack of declining agricultural and marine production. In one particularly good case study of Port Moresby’s 8-Mile settlement, it was concluded that while residents did their best to model (Kihamba- equivalent) relations that might still obtain in home villages, structural factors prevented them from doing so very well. When production- and village-based identity began to break down, as one researcher noted, the scope and intensity of kinship relations began to shrink in size and in efficacy. ‘In order to survive’, Chao (1989:98) noted, ‘each household carefully guards the interests of its members and its kindred. Towards those outside this relatively small group, one tends to be suspicious or apathetic . . . This situation makes organizing large groups very difficult, and developing a sense of community almost impossible’. Based on significant first-hand experience in neighboring 9-Mile settlement I can say that Huli-speaking immigrants there experience a great deal of cultural dislocation. They fight constantly with Kerema and West Papuans living nearby and en masse with Enga and others in repeated ‘payback’ killing, and sexual and domestic violence are rife. These and other factors preclude the fostering and maintenance of the kind and sense of community needed to make intervention programs work really well. ‘Community mobilization’ around HIV and AIDS has been slow to come to Port Moresby” because it was misconceived to begin with. International ‘best-practices’ manuals and funding requirements frequently stump for ‘multi-sectoral responses’ that would bring together police, health, government, education and business sectors. Those aren’t, however, the lines on which PNG social-structures are drawn, which is to say Christian denomination, tribe and gender.
AIDS has tracked, in a sense, as some social theorists have put it, the ‘fault-lines’ of those countries and cultures, including poverty, gender inequities, racial injustice, heterosexism, and ethnic bigotry. At the same time, just as do rules about who can or can’t wield weapons, ride a bicycle, own land, or enter the House of Parliament, AIDS has deepened and widened those fault-lines because HIV transmission has been so heavily structured socially and because the burden of individual bodily suffering and collective social caring has been borne unequally. AIDS appears on and immiserates individual human bodies, but often in gender- and ethnographically- specific ways. AIDS indexes the many social ills that exist between those bodies – as, for instance, when the bodies of its victims lie unclaimed in hospital morgues, or when compensation claims are made by the relatives of deceased parties against bewildered and still grieving widows, and when letters to the editor are written and calls from the pulpit are made to stigmatize ‘the guilty’ on behalf of ‘the innocent’. Ever since AIDS began showing its face in PNG, debilitating oral thrush, chronic diarrhea, and all-too-obvious weight and hair loss have been among the more prominent bodily signs, but stigma, isolation of the HIV-infected, misogyny and routinely compromised confidentiality have too often characterized the illness of the social body. Educational deficits suffered by females, male-dominated systems of land tenure, and evangelical Christian doctrines filled with gendered double-standards around sexuality, fertility and marriage have blunted reproductive health initiatives, fueled condom ‘misinformation’ campaigns, reinvigorated homophobia, and crimped media attempts to foment safer sexual practice, even by just being able frankly to utter the K-word; koap – that is, sexually to penetrate.
THE IMPORTANCE OF THIS COLLECTION
My remarks above are intended to convey a sense of just how complicated things are nowadays, how careful we must be in assessing the degrees to which this or that message or program ‘is working’, and how imperative it is to consider the historical forces that have forged contemporary PNG culture around AIDS. These authors show just how high the stakes are: each contribution takes up these (and other important) issues. I will note something that the editors could not: this is an extremely important collection of essays for a number of reasons.
First, and for mostly predictable reasons, since the first HIVab+ blood test result was reported in 1987, there has been a remarkable urban ‘bias’ (in the bad sense) to normative reportage about HIV and AIDS, in public policy discussions, and to the implementation of programs and initiatives designed ostensibly to thwart HIV transmission. The nation’s capital, Port Moresby, is the hub of the ‘national response to AIDS’ being home to the National Department of Health, the House of Parliament, media organisations, and the National AIDS Council and National HIV and AIDS Support Project. Also and perhaps more importantly, it is home to or houses branches and offices of many local and significant NGOs (such as Anglicare’s Stop AIDS and the Friends Foundation); to AusAID and its commonwealth country counterparts, NZAID and the British High Commission; to major lending organizations such as the Asian Development Bank; and to major international NGOs such as Save the Children, World Vision, Caritas, UNICEF, and Hope Worldwide. The fact, however, that all of this is based in a capital that is unreachable by road by probably 95% of the rest of the country, means that this bias carries an extra-heavy cost. Sadly, the fine work that NGOs elsewhere do, for example, Help Resources (based in Wewak), Tokaut AIDS (based in Madang), ADRA (in Lae), and ATProjects (in Goroka), to name just four, gets overlooked. Tellingly, these are NGOs whose focus is greatly if not wholly rural in scope and tenor. The AusAID-funded ‘social mapping’ project managed by the National HIV and AIDS Support Project (and carried out using local research assistants) also managed to work in all 19 provinces, and did remarkably well in terms of geographic inclusion. Nevertheless, one commonly reads of assessments of levels of knowledge about and attitudes toward HIV and AIDS in the rural hinterlands of PNG that make it appear terra incognita. Worse, the solution is assumed simply to be the more frequent and effective delivery of the same materials. Even if the information contained in pamphlets and posters were pitched at the level of what, of viruses and derma and contact there between, were correct – and it frequently isn’t – the information will reach ears pitched at the level of who. Both viruses and sorcery bundles are invisible, but at least the social- causation-of-disease model makes sense.
That’s what makes these contributions here so valuable. Without wishing to get caught up in nominal debates about the remaining usefulness of tropes such as ‘rural’ and ‘local’, there are only three ‘cities’ in PNG – Port Moresby, Lae, and Mt. Hagen – and neither the Yupno, Gogodala, nor Trobriand islanders live anywhere near one. Most Papua New Guineans migrate and travel for manifold reasons – in pursuit of marriage, money, employment, fun, compensation, or refuge. Still, the bulk of the country’s 5.5 million residents were born and live in, still think in terms of, may have businesses in, and when they finish traveling, return home to this or that rural environ, whether to fishing grounds and canoes, sago stands and coconut trees, or sweet-potato and coffee gardens. That movement, dislocation and relocation are in PNG constant has not really been factored into intervention equations, mostly because ‘bad’ places and alleged kinds of ‘bad’ people have been dubbed high-risk, not unprotected intercourse per se.
However much people may travel between them, when arrayed at opposite ends of the spectrum – for example, in terms of availability of electrical power – ‘rural’ and ‘urban’ places and spaces and life-ways really are different. I have yet to see in rural villages, for example, any girls or young women using cell phones given to them by businessman boyfriends so as to arrange sexual trysts, as I did at Koki Market in Port Moresby and in provincial capital-located motels and hotels. In a single day, a Mt. Hagen or Lae or Port Moresby dweller might see or hear an AIDS- related message of some sort in a church service or theatre group, at a tradestore or on a billboard, a newspaper or television, and perhaps on the street. Such media and messages do not often reach the Yupno, however, and too few reach the Gogodala and Trobriand islanders.21 The data and analyses offered here, in other words, should be seen as not just additions to the ethnographic corpus about HIV and AIDS in PNG but as important correctives to the presumptions of urban messages. In terms made clear by several contributors, just imagine living where there are no condoms, HIVab testing, or functioninghealth centres. In an oral-focused, visual- based culture, imagine not knowing what AIDS ‘looks like’, as one informant said to Lepani, but dying to know anyway – maybe dying eventually from a lack of that knowledge. The essays of Wilde and Keck can help medical workers prioritize their work, those of Keck and Lepani will help policy makers question sacred assumptions, and Dundon’s brings to the table more clearly some of the darker side of public health messages – or at least the social fields into which such messages get insinuated. This special issue collectively ought to enable politicians to reconfigure their speech and agenda in a non-threatening way.
Second, this is the first collection of wholly ethnographic pieces devoted to these topics in PNG,’ although an impressive ethnographic corpus has amassed in bits and pieces over the years. These data were collected in process, in situ. As such, they read differently and are qualitatively different from the kinds of air- tight, bloodless reports, and government documents as tend to be produced by members of the ‘AIDS industry’. These kinds of data are needed at the level of policy-formation, grant monies-seeking, and public discussion in workshops.
Third, this issue brings recurring debates over method into sharp focus. In terms of the normative AIDS paradigm in PNG, what little that passes for ‘qualitative’ research on HIV and AIDS (see the ‘comprehensive bibliography’ published in 2006 by the National Research Institute) has been typified by the use of KAP/B (Knowledge, Attitudes, and Practices/Behaviour) and focus group- style approaches. Those are largely deductive exercises, however, and they deploy methods better for getting at what ‘community’ members think NGOs and funders would like to hear are ‘community’ norms than investigating behaviour in situ. Until recently, the evidentiary base in PNG has tended toward the safe and inwardlooking. In-vitro, clinic-based reportage about mostly blood donors, military recruits and antenatal females has predominated over ethnographic-style, in-vivo approaches, and at the same time been quite sharply driven by external funding streams whose headwaters are located in another country. That which is more authentically Papua New Guinean – behavioural multiplicity, homoeroticism, high mobility, multi-stranded misogyny, and increasing belief in sorcery as the cause of deaths probably due to AIDS – has been lamented in public but effectively erased at the level of policy because of the centrality of models of culture- asconsensus. Accordingly, ‘risk group’-style thinking consolidated early on at the level of policy and implementation, and nave empiricism substituted for critical scrutiny of badly needed epidemiological data. The study of those public health policies and those who in one way or another implement them – from political leaders to the sex lives of health workers – has been verboten. There is therefore no substitute for the kinds of data that our contributors here collected, just as there is no method quite like long-term, intensive immersion in language, contradiction, strife, love, fertility, nutrition, and political intrigue as the contributors have all pursued.
Indeed, this collection looks more like a movie than a collection of snapshots because of the skills of the contributors at fieldwork and the long-term nature of their involvement. Like Dundon and Wilde, I had the privilege (if also suffered the difficulties) of conducting intensive ethnographic research in PNG’s Western Province, although at a fieldsite that was, by comparison, almost antithetical to their Balimo. As with Verena Keck, I have since returned several times to my field-site after a long absence – to find great changes having occurred in people’s knowledge of and attitudes toward AIDS, STDs, and HIV transmission routes and risks. Daru island, I can confirm, is experiencing yet again a public health crisis; letters and news that reach me are most depressing to read. It’s bad enough that many of my best informants and dearest friends have already died – what’s worse is that so many of these deaths have gone unnoticed. It bears commenting that a European- style venereal disease lock hospital was erected on Daru in 1915 and nearby in Kikori in 1917, so STDs and attitudes toward and policies about them are hardly new to the area. This time, however, I fear, AIDS will prove to be not just transiently debilitating (as are malaria and typhoid outbreaks), but rather, permanently fatal, unbearable politically, and crippling socially.
Fourth, this collection augments well the completion of several larger-scale research initiatives and the beginning of new ones. We eagerly await wider publication of the results of the nationwide social-mapping study that the anthropologist Bent Gustafsson directed; I cannot quite capture the enormity of her exercise and the importance of their findings.2′ One such is the difficulty of reading from ‘knowledge’ levels to those of internalized understandings and changing behaviour. The Summary Report, for instance, concludes that ‘while people’s knowledge about the virus is generally good, the level of understanding is still low. People seem to have difficulties in understanding HIV, what it does to the body and how something that does not have any signs or symptoms can kill people. People in all regions generally are scared of HIV/ AIDS’ (NHASP 2005c: 4). The European Union has sponsored a near- nationwide initiative aimed at HIV and AIDS-related peer education strategies. The Asian Development Bank will be launching a $US25,000,000 project that would establish many hundreds of condom distribution points and many STD treatment and HIVab testing sites. Such bold initiatives face may difficulties in the field, and would do well to listen hard to what these research projects have found. As Dundon shows here in interesting detail, condoms were in Balimo quite literally ‘taken off the street’ by nursing sisters, and Wilde and Keck provide helpful hints as to the obstacles that condom distribution efforts yet face, as well as some of the bright spots thereof as Lepani in particular r