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Development, Sexual Cultural Practices and HIV/AIDS in Africa

Samantha Page · 2019

74,551 words · about 5 h 13 min to read

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About this book

Author
Samantha Page
Language
English
Published
2019
Length
74,551 words · about 5 h 13 min
Sections
10 reader sections
Text
Digital text
Rights
CC BY 4.0 · repository export licence (OAPEN)

 

Contents (10)
  1. Front matter about 1 min
  2. Foreword about 3 min
  3. Index about 2 min
  4. CHAPTER 1 Introduction about 37 min
  5. Chapter 2 about 27 min
  6. Chapter 3 about 28 min
  7. Chapter 4 about 1 h 8 min
  8. Chapter 5 Religious Context In Malawi about 56 min
  9. CHAPTER 6 The Construction of Policy: Donors, AIDS and Cultural Practices about 1 h 9 min
  10. Chapter 7 about 22 min

Continue:

Front matter

Samantha Page

Development, Sexual Cultural Practices and

Development, Sexual Cultural Practices and HIV/AIDS in Africa

Foreword

Samantha contacted me back in 2008 when she was thinking of doing a Ph.D. about traditional cultural practices and HIV in Malawi. She’d read my research about traditional cultural practices and AIDS.

Initially, Samantha wanted to interview women and girls who had participated in sexual cultural practices. But I said to her perhaps it would be better to interview people who were worked on HIV prevention programmes in Malawi. As an outsider, trying to interview women about a sexual practice shrouded in secrecy is problematic.

Samantha went to Malawi to do her doctoral research in 2008. I met her for the first time there. I employed her to be my research assistant and collect data whilst she was conducting her interviews.

Since then we have been in regular contact and I have provided advice to her on her Ph.D. and her post-doctoral career.

This book is a welcome addition to the dearth of literature on sexual practices and AIDS in Malawi. It is an under researched topic but nevertheless an important one. Many assumptions are made about the link between AIDS and sexual practices so this book is an important contribution to knowledge as it highlights the reality in Malawi, based on 60 interviews with policymakers, programme managers, lawyers and MPs, Malawian and foreign, who work on HIV prevention issues.

What is interesting about her findings is how Malawians volunteer information about sexual cultural practices and AIDS as if they are making themselves appear modern and distancing themselves from the rural villager. Samantha uses the term ‘narratives of blame’—I think this is v vi FOREWORD very fitting—in other words how the stories told by Malawians blame the backward villager. In other words, the urban, educated Malawian elite is not responsible for the high HIV prevalence rates in Malawi, rather it is the uneducated, rural person.

Why is this book important? The significant amount of money international donors spend on trying to eradicate or modify sexual cultural practices is unjustified and wrong. So Samantha unravels the story using evidence from her interviews to highlight a flaw in donor thinking. That far too often donors don’t use evidence to support their work. They latch on to an idea thinking it is important, when really it isn’t.

California Center for Population Research,

University of California-Los Angeles,

Professor Emerita of Sociology,

ACKNOWLEDGEMENTS

I would like to thank all those I interviewed in Malawi. I would particularly like to thank the family I stayed with in Malawi who were so kind to provide me with accommodation and food and welcomed me to their home. I can’t thank you enough.

Thanks to all who supported me at Palgrave Macmillan: Karthika Purushothaman, Alina Yurova and Mary Fata in particular.

Thank you to Tony Chafer. If it wasn’t for you I would have dumped the idea of completing a Ph.D. many years ago but you encouraged me to persevere.

I have many mentors. Thank you to Susan Watkins who has provided me with endless support ever since I first became interested in the topic.

A huge thanks also to Louise Ackers. I really appreciate your advice and support.

Thanks to my colleagues in the Faculty of Social Sciences and the library at the University of Agder for providing financial support so that this book can be accessible online.

Also thanks to my colleagues in the Department of Global Development and Planning, especially Hanne Haaland, who gave me the time to write the book, Alf Gunvald Nilsen for pushing me to think about this book, write a proposal and for helping me with the process and reviewing chapters and Gibran Cruz Martinez for reviewing chapters.

viii ACKNOWLEDGEMENTS

Thank you to my wonderful friends Bella and Sandra. Thanks also to Mitty.

Lastly, I owe the deepest of thanks to my Mum and Dad, Martin and Jodie.

Introduction

The Development Aid Situation in Malawi ‘Harmful Cultural Practices’ and AIDS How the Church Frames AIDS

The Construction of Policy: Donors, AIDS and Cultural Practices

Glossary

Index

AIDS ATR CABS CBO CEDAW

CHAT DFID

EU

FBO GBV GFTAM GTZ HADG HCP HIV HMIS IAWP INGO M&E MANASO MANET+ MBCA MDHS MDICP MGDS

ABBREVIATIONS

African Traditional Religion

Common Approach to Budgetary Support Community Based Organisation

Convention on the Elimination of all forms of Discrimination Against Women

Country Harmonisation and Alignment Tool Department of International Development European Union

Faith-Based Organisation

Gender Based Violence

Global Fund to fight AIDS, Tuberculosis and Malaria German Technical Development Agency HIV/AIDS Development Group

Harmful Cultural Practice

Human Immunodeficiency Virus

Health Management Information System Integrated Annual Work Plan

International Non-Governmental Organisation Monitoring and Evaluation

Malawi Network of AIDS Service Organisations Malawi Network for People Living with HIV/AIDS Malawi Business Coalition on AIDS

Malawi Demographic and Health Survey

Malawi Diffusion and Ideational Change Project Malawi Growth and Development Strategy xii ABBREVIATIONS

MIAA MoE

Malawi Interfaith AIDS Association

Ministry of Education

Ministry of Health

Ministry of Women and Child Development

National AIDS Commission

National Action Framework

National Association for People Living with HIV in Malawi Non-Governmental Organisation

National Strategic Framework

National Statistical Office

Office of the President’s Cabinet

The U.S. President’s Emergency Plan for AIDS Relief Persons Living with HIV

Prevention of Mother To Child Transmission

Southern Africa HIV/AIDS Information Dissemination Service Sexually Transmitted Infections

Sector Wide Approach

Joint United Nations Programme on HIV/AIDS

United States Group

World Health Organisation

LIST OF FIGURES

Stop harmful cultural practices banner (Photo taken

on 10 July 2009. Malawi: Author)

Difference between global policies on gender-based violence, harmful cultural practices and AIDS and those at the national level (Source Author)

HIV prevalence by gender and marital status (% HIV-Positive)

among respondents aged 15-24, Malawi (Source Watkins

[2010] based on data from the Malawi Diffusion and Ideational

Change Project [MDICP 2004])

HIV incidence by gender and age, all ages above age 15, Rural and Urban Malawi, demographic and health survey data, 2005 (Source Cited in Watkins [2010] Prepared

by Patrick Gerland, United Nations Population Division, from DHS survey data)

HIV incidence by gender and age, all ages above age 15, Rural and Urban, Zambia, demographic and health survey data, 2001-2002 (Source Cited in Watkins [2010] Prepared by Patrick Gerland, United Nations Population Division, from DHS survey data)

HIV incidence by gender and age, all ages above age 15, Rural and Urban, Tanzania, demographic and health survey data, 2004-2005 (Source Cited in Watkins [2010] Prepared by Patrick Gerland, United Nations Population Division, from DHS survey data)

Table 4.1 Table 4.2 Table 4.3 Table 4.4 Table 4.5

LIST OF TABLES

Received information on the following topics at initiation New knowledge provided during initiation ceremony

List of items liked during initiation ceremonies

List of activities not liked during initiation ceremonies Negative experiences during the initiation ceremonies by age

XV

Box 6.1 Box 6.2 Box 6.3 Box 6.4 Box 6.5

Box 6.6

LIST OF BOXES

P15 Interview with a District Youth Officer

Response to UNAIDS question

Questions for students on cultural practice and HIV/AIDS PowerPoint presentation by the Seventh-day Adventist Church PowerPoint presentation by the Seventh-day Adventist

Church Cont

Data from UNAIDS consultancy

176 176 a Check for updates

CHAPTER 1 Introduction

In the mid-1980s, non-governmental organisations (NGOs) began to flow into poor countries to help them improve their lives and livelihoods. Malawi, a small country in south-central Africa, was an attractive location: it is one of the poorest countries in the world, it is peaceful and has little crime, English is the official language, it has reasonable roads such that NGO staff can move around relatively easily. In the period 1985- 1989 there were 16 registered NGOs; in 2001-2005 there were 196 NGOs, half of them focused on HIV prevention (Morfit 2011). In the first phase, NGOs typically focused on implementing programmes that would improve health (e.g. clean water) and agriculture. Increasingly, however, they were concerned with improving the situation of women and girls, who were considered to be particularly vulnerable to harms. A hierarchy of NGOs was established. At the top were international NGOs such as Save the Children, Catholic Relief Services and CARE, at the bottom were small organisations based in district capitals.

A major consequence of the establishment of NGOs was that it provided jobs in the formal economy for educated Malawians. Those with a PhD or an MA worked in offices in the Capital, Lilongwe, those with only a BA were stationed in district capitals, and those who had only a secondary education picked up jobs whenever they could, such as working on a short-term survey. The level of education determined not only one’s income but also their social status and whether they lived in one of the two large cities or in a district capital. Not surprisingly, those at the

© The Author(s) 2019 l S. Page, Development, Sexual Cultural Practices and HIV/AIDS in Africa, https://doi.org/10.1007/978-3-030-04119-9_1 top of the income and social status ladder looked down on those who had little or no education.

In 2008, I was working as a Programme Manager for a sexual and reproductive health NGO based in London. As part of my job, I went to Malawi to monitor a HIV prevention programme, funded by the Department for International Development (DfID). I was speaking to a Malawian woman in Blantyre (Malawi’s second largest city, located in the South of the country) who set up a Women and AIDS Community Based Organisation (CBO), which was indirectly funded by DfID. She was HIV positive. She spoke English and raised the topic about certain sexual practices said to be risky for the spread of HIV, often referred to in the literature, and by people in Malawi, as ‘harmful cultural practices’. One particular practice grabbed my attention. It is called fisi), which means ‘hyena’ in English. The story recounted to me was about a hyena. In this case the hyena is a man, who is hired to have sex with young women who participate in initiation ceremonies when they start menstruating. But the hyena practice has several other meanings, which I will come to later. A few years later, an NGO ran a banner in the daily newspapers—see Fig. 1.1: it was at the bottom of the first page, with a background of red and black, and said ‘STOP Harmful cultural practices’. The banner was produced by UNICEF.

I arrived in Lilongwe in 2008 to begin my research and was picked up by my friend who worked for an AIDS NGO. We travelled to Blantyre and she invited me to stay at her house with her family. I asked her if I could work from her office and was fortunate enough to be given desk space.

Fig. 1.1 Stop harmful cultural practices banner (Photo taken on 10 July 2009. Malawi: Author)

This was an invaluable opportunity as I shared an office with a policy officer and this enabled me to meet people passing by my desk. I was hoping that I would identify an organisation with which to carry out my research. It was not long after I was in my new surroundings that the Executive Director of a small CBO, based in the district of Mulanje, asked me what I was doing there. He then excitedly told me about the fisi practice. He said for him, fisi meant three things:

l. Surrogacy — if you see a stick on the door you should not go in as you know something is going on. 2. Kuchotsa/kutsatsa fumbi — sexual cleansing. During initiation ceremonies when a girl has reached puberty and is menstruating she is taught how to entertain her husband. The girl could be from 7,8 or 9-12 years old. She is told she must sleep with someone otherwise she will have problems. The person she will sleep with may be big or young. The impact of this a) early/unwanted pregnancy b) drop out at school c) early marriage d) contract HIV. 3. Kuchotsa milaza — concept whereby in Mulanje you may go out and you have left your husband and you sleep with other men. So you are forced to sleep with someone else who is the relative of the husband to be forgiven for sleeping with someone else. (Journal entry 26 August 2008)

He invited me to visit his village where he ran the CBO to find out more about the fisi. However after I visited his village, my friend, the Director of the AIDS NGO, told me that the practice was not particularly prevalent in that part of Malawi, and that he had exaggerated the story so that I would visit and perhaps help him access funding.

So I returned to my desk in Blantyre. Along came the Executive Director of a youth CBO. He told me ‘there are lots of cultural practices that go on in my village’ and therefore it would be a perfect site to conduct my research. He then described at length the practice of kusasa fumbi and then told me:

When initiation ceremony comes to an end, the village leaders or opinion leaders in the village, they plan for the men to have sex with girls. The men are from a different community. Also women are chosen to have sex with boys. They are also from a different village. Women get women and men get men. They are paid in food. No money. Condoms are not used. There is a need to exchange fluids so cannot use condoms. (Journal entry, 26 August 2008)

I was amazed that they volunteered to tell me about the fisi practice without having interviewed them. I then became aware of a widespread misconception in the NGO sector and beyond into the world of international donors that so-called ‘harmful cultural practices’ were the main driver of the AIDS epidemic in Malawi. It was the educated Malawian elites who described these practices at length, expounding on the risks they presented and efforts to stamp them out, while at the same time weaving into the discourse other fashionable interests of international agencies, such as the particular vulnerability of women, especially young women, to contracting HIV. It is important to highlight here that these stories about harmful cultural practices came from educated Malawians who speak English, not the villagers. But the link between these ‘harmful cultural practices’ and the epidemic was never supported by evidence. For example, while it is known that the prevalence of AIDS among widows is higher than among married women, there had been—and continues to be—no evidence that this was due to widow inheritance (when a woman’s husband dies, she lives with her husband’s brother) rather than to years of marriage to a man who had died of AIDS. From a biomedical perspective the latter is more likely.

Biomedical evidence shows that ‘harmful cultural practices’ are not the main contributors to the AIDS epidemic. So what is interesting is why so many educated Malawians working in the AIDS sector told me about the practices, not the villagers, and blamed them for the spread of AIDS.

In this book I analyse the responses these practices evoke: these include lawyers, researchers, policymakers, government ministers, NGO and INGO staff, staff working for bilateral and multilateral agencies, national and district officials and health workers.

This book explores policy surrounding HIV prevention. It draws attention to the ways that the elites in Malawi—people who stand out because they are educated and thus speak and read English, the official language, in contrast to the majority of Malawians who live in villages and have, at best, completed primary school. Those who have a university degree dominate the policy arena: they are staff in the civil service and they implement the programmes of NGOs and bilateral or multilateral agencies programmes (Watkins and Swidler 2009; Myroniuk 2011). They are middle-class people in government positions or working in International NGOs.

The educated elites I met almost invariably disparage those who have less education. I found that upon meeting an educated Malawian, they often began the conversation by telling me about what came to be called the ‘harmful cultural practices’ of the uneducated villagers. They thus make it clear to expatriates who buy into the distorted accounts of the elites.

I show that the epistemic community in Malawi (epistemic community includes international donors working on HIV and AIDS as well as the Malawian elite) are reframing both sexual cultural practices and women’s rights concepts in the context of what is widely considered an emergency, the AIDS epidemic. This epistemic community comprises those working in the field of AIDS, who frame narratives about AIDS to achieve other goals, both ideal and pragmatic, for example for the purposes of self-preservation and self-interest. Haas’ (1992) notion of the ‘epistemic community’ is particularly useful for conceptualising the HIV prevention community in Malawi. Haas describes an epistemic community as ‘a network of professionals with recognised expertise and competence in a particular domain or issue-area’ (Haas 1992, p. 3). He says that epistemic communities are groups of professionals, from a variety of different disciplines, which produce policy-relevant knowledge about complex technical issues (Haas 1992, p. 16). This book makes the case that the Malawian elite is influencing the policy agenda on AIDS and harmful cultural practices. This book also examines how others—e.g. international staff working for International NGOs, bi- and multilateral donors—adopted the views provided by the Malawian elite without questioning the evidence. But why would they? First, donors and NGOs have little interest in establishing an evidentiary base for any of their programmes! and second, UNAIDS did not want to disseminate the evidence about low probabilities.

I also explore how evidence is produced in the context of AIDS and how certain sexual cultural practices have been co-opted by the NGO discourse in order to explain why HIV prevalence is so high in Malawi as well as other African countries.? My analysis is oriented around how different narratives on AIDS are framed, and what and how evidence is used to support them. As I show, these narratives are not based on face-to-face encounters with women involved in these practices. What is under consideration is the way the Malawian elites present rural people as backward by deploying the phrase ‘harmful cultural practices’: the elites then blame the AIDS epidemic on these practices. What my theoretical framework shows is how this constructed and epidemiologically inaccurate narrative has been taken up and endorsed by international donors.

Initially, this research intended to examine the contribution of sexual cultural practices such as widow inheritance and initiation rites (Munthali and Zulu 2007) to the transmission of HIV (Coombes 2001; Chizimba et al. 2004). However, after I read about the exotic cultural practices that are considered harmful (Malawi Human Rights Commission 2006), and the research of epidemiologists (e.g., Gray et al. 2001; Boily et al. 2009) it was apparent that many, perhaps most, of the cultural practices are unlikely to contribute significantly to the epidemic. Far more important are everyday practices, such as unprotected sex with multiple sexual partners both before and after marriage (Smith and Watkins 2005; Chimbiri 2007; Dimbuene et al. 2014).

These everyday practices are also part of the traditional culture: in particular, when a man asks a woman or girl to have sex, the man must offer her resources in exchange. Wealthy men drive the sexual exchange, and have significantly higher levels of HIV, yet there are few, if any, NGO programmes that target men for behaviour change.

In my conversations with Malawians, the practice of fist is invariably introduced. Yet as well as the absence of the epidemiological evidence to show that the fisi practice is of low risk, there is also a lack of evidence to suggest the fisi practice is widespread to the extent that it would significantly increase HIV prevalence rates in Malawi. When those in the NGO community who are concerned with fist talk about it, they invariably refer to two of the 28 districts, Nsanje and Mangochi as examples. For example, a fisi (a male adult who has sexual intercourse with newly initiated girls) is uniquely practiced in societies such as among the Chewa and among the Yao in which their form of initiation for girls (called chinamwali and chindakula respectively) encourages sexual intercourse for initiates (Malawi Human Rights Commission 2006, p. 8). But we see also the role of fisi in widow cleansing, fisi for Procreation, Birth Cleansing (kulimbitsa mwana), Death Cleansing and for Cleansing Infidelity (Malawi Human Rights Commission 2006, p. 8). In my conversations with Malawians it was also assumed by them that the fisi was infected.

Although the fisii are involved in a variety of rituals, the NGOs focus on young girls, probably because so many of them are engaged in helping women and girls. I did not hear much about fisi and sexual cleansing for someone who died. It is also important to mention that the fisii are paid.

Further, there is a lack of anthropological evidence to argue that this practice contributes significantly to high HIV rates. Studies in Malawi (see, e.g., Skinner et al. 2013; Munthali et al. 2006; Munthali and Zulu 2007; Kamlongera 2007; Banda and Kunkeyani 2015) and several donor and government-funded studies on sexual cultural practices and AIDS in Malawi (Kornfield and Namate 1997; Matinga and McConville 2003; Malawi Human Rights Commission 2006; Kalipeni and Garrard 2004; College of Medicine 2005; Kadzandira and Zisiyana 2006; Chimombo 2006; Conroy et al. 2006) have been used to explain how sexual cultural practices are spreading HIV in Malawi, yet these results have been amplified outside these studies’ findings.

Why is there then so much focus on something that in numerical terms at best has a minor effect on the increase of AIDS at a national level? The fisi practice does not contribute significantly to the spread of HIV for four reasons. First, epidemiological evidence reveals that the probability of infection during one heterosexual act is startlingly low.’ Second, there is a lack of evidence to demonstrate how prevalent the practice is in Malawi. Third, although studies have been carried out on sexual cultural practices in Malawi, there is little empirical evidence to demonstrate that the fisi practice is contributing to the spread of HIV at a national scale. Fourth, although the emphasis on fisi in HIV discourse has been on poor young women (15-24) as drivers of the epidemic, HIV prevalence rates are higher in urban areas among women aged 30-34 who are in the highest wealth quintile in Malawi (Mishra et al. 2007). This category of women is significantly different from girls and young women living in rural areas aged 15 and below who may be participating in the fisi practice. This category of women is also different from widows where the term fisi is used for widow cleansing rites.

Narratives linking sexual cultural practices and HIV have been constructed which blame the fisi practice for the spread of AIDS. The fisi practice is being used as a scapegoat for three main reasons. First, the elites working in NGOs need constant donor funding. Thus, maintaining the fist narrative to attract donor funding contributes to the stability of the policies and programmes directed to reduce transmission and thereby ensuring their jobs remain intact. Second, to project the issue of AIDS as a disease being spread by rural people, which detracts attention from the educated elite’s sexual behaviour. Third, it supports a Christian narrative that sees those practising African Traditional Religion as backwards. This narrative has been amplified because it reflects the modernising agenda of key elites in Malawi, as opposed to reflecting a proportionate threat to the spread of AIDS. This deflects attention from high-risk sexual practices such as multiple sexual partners particularly among urban and affluent Malawians. AIDS policies should be designed to address contemporary patriarchal constructions of gender and power than a one-off highly un-evidenced traditional sexual practice. What I argue is there is evidence of a lack of evidence to support the policy to eradicate the practice of fist because of the link with HIV.

THE ARGUMENT

In this book, I argue that a complex interplay of interests has led to the construction of the narrative that the sexual cultural practice of fist contributes significantly to the spread of AIDS. I argue this complexity can be best understood through three sets of arguments.

The first and main argument is that a narrative of blame is maintained by national elites in Malawi, to ensure that HIV is kept on the development policy agenda within the institutions in which they work, thus attracting donor funding and retaining the elites’ professional status and salaries. Although the elites are concerned about getting the virus, this blame narrative ensures that the target group for intervention is rural communities rather than the elites themselves. This argument complements the theoretical work of Mosse (2011) who has pioneered the use of what he terms the ethnography of aid, using this methodology to unravel the complex layers and actors that combine in the production of development policy and practice. Mosse (2011) highlights the importance of actor relationships in constructing policy, as well as emphasising the importance of policy in mediating social and professional relationships (2011, p. 10). Mosse builds on the work of Harper (1998) and Wood (1998) and describes actor relationships as ‘complex relationships including negotiations over status, access, disciplinary points of view, team leadership struggles, conflict management or compliance with client frameworks defining what counts as knowledge’ (2011, p. 10). In terms of policy, Mosse argues that ‘policy ideas gain currency because they are socially appropriate....they can submerge ideological differences, allowing compromise, room for manoeuvre or multiple criteria of success, thus winning supporters by mediating different understandings of development’ (2011, p. 11). Like Mosse, my study emphasises policy construction as a process mediated by those involved in the policy process as well as highlighting the importance of the policy itself. In my research, those mediating the process were the people I interviewed working on HIV prevention. The policy that these actors are mediating is that traditional sexual cultural practices should be eradicated because they argue these practices are the main driver of the HIV pandemic in Malawi. Additionally, Mosse asserts that:

The interests of national elites and the electoral concerns of those in power affect the state’s policy choices, sector priorities, and programs, with important consequences for the poor. Equally, well-intentioned sector reform programs can run aground where they challenge vested interests, and democratic reforms often have limited or unpredictable effect on power relations. (Mosse 2004, p. 51)

This is relevant as I argue that one reason national elites are able to influence the HIV policy agenda is related to the desire of donors— and the NGOs that they support-to be given a simple and rational explanation for high transmission that they can easily focus implementation around. Mosse (2011) also makes reference to international professionals who have to secure their positions within institutional and social contexts, which he says are hugely complex. Although Mosse in this context mainly refers to international professionals, I show that the same is true for national professionals working in development in Malawi, which means that groups of specialists and professionals need to sustain certain agendas to maintain their own status and positions. This argument is also linked to the work of Gibson et al. (2005) who argue that the structure of foreign aid can produce perverse outcomes that impede effectiveness and that the aid system is based on a set of power relations between actors ultimately driven by money.

These points are relevant to my argument: as I show in chapter four that organisations and agencies working on AIDS are major employers in Malawi. Although these development organisations are unlikely to disappear, they are also unstable as they rely on external funding. Successive themes come and go (e.g. HIV/AIDS, governance, gender, climate change) and with them jobs appear and disappear. Maintaining the narrative that the sexual cultural practice of fisi is spreading HIV can ensure policy and programmes directed to reduce HIV transmission continue. Today we see that interest in AIDS is declining so those working in NGOs are anxious: what would be the next ‘big issue’ that would support them?* This would most certainly be the case in many countries in sub-Saharan Africa that heavily depend on donors.

My second argument is that AIDS is presented by national, educated elites as a disease being spread by those living in rural areas, most of whom have little education beyond the first years of primary school and are often referred to by the elites as ‘ignorant’. The narrative of sexual cultural practices thus absolves the educated elite from contributing to the epidemic as well as detracting attention from higher HIV prevalence rates in urban areas. This argument is situated within and supported by the literature on what is called ‘the underdeveloped other’ (Gramsci and Hoare 1971; Escobar 1988; Hobart 1993; Quarles van Ufford and Saleminck 2006). As I highlight in this book, this ‘othering’ is a result of those elites working in HIV prevention providing explanations to ‘problems’ that satisfy donors and therefore ensure continued funding. As a result, the educated elites who are perceived as civilised, distance themselves from rural people who they perceive as uncivilised. As Escobar (1995) asserts ‘rather than being eliminated by development, many “traditional cultures” survive through their transformative engagement with modernity’ (1995, p. 219). Elites in Malawi maintain their positions through their engagement with western discourses on modernity and distance themselves from Malawians living in rural areas who they perceive as backwards. The Malawian elites are making themselves look like the modern, unproblematic group that donors should work with.

The third argument is that the Malawian elites see those practising African Traditional Religion as backwards. Those who have converted to Christianity perceive themselves as modern and progressive. This argument has been guided by postcolonial theorists including Bassey (1999), Kitching (1982), Ngugi wa Thiong’o (1986), and Lloyd (1967). They describe the elite in sub-Saharan Africa as the postcolonial elite as they have converted to Christianity. Postcolonial theory is thus relevant to my study as it follows on from the imperialist idea of westernising the backward. What it demonstrates is that the elites in Malawi are perpetuating an imperialist narrative by blaming people who practise African Traditional Religion as backwards, thereby establishing their modernity. Further,

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