by Lance Nadeau
In my dissertation I am writing here in Rome, I am trying to offer a missiological evaluation of the health ministry (huduma ya afya), that has developed in the jumuiya (small Christian Communities) of Nairobi East. My interest in the health ministry is missiological. Why? Because lay ecclesial ministry, such as the health ministry, is a critical index of the local church's formation. And formation of the local church remains a basic goal of missionary activity. Furthermore, I see the huduma ya afya as an East African expression of a global phenomenon in the postconciliar church, namely, the rapid expansion and diversification of lay ministry. The worldwide growth in lay ecclesial ministries forms the most recent stage in the modern development of the laity's ecclesial identity and role.
One cannot discuss health ministry in contemporary East Africa without referring to what some experts call endemic HIV infection. Because the rate of HIV infection is so high in Nairobi East, a large percentage of the sick served by the wahudumu are HIV positive. It makes some sense, therefore, to speak of huduma ya afya as an "AIDS ministry." Nevertheless, I have reservations about the term "AIDS ministry." Although many people use it as a kind of shorthand, that description of ministry subtly focuses attention on a set of symptoms, not a person with HIV. In addition, "AIDS ministry" can make the last stages of HIV infection the center of one's ministerial efforts. A preferable designation might be, ministry to people living with HIV/AIDS. The foregoing expression also includes family and friends affected by HIV infection.
In 1999 while I was doing field research for my dissertation, afya lived with Ed Phillips at Kenyatta University. During that time, I accompanied the wahudumu wa afya of Nairobi East's jumuiya and the nurses of the Eastern Deanery Community-Based Health Care and AIDS Relief Program - the program in which Ed Phillips works as senior manager. afya also talked regularly with a number of Kenyatta University students about their sexual relationships and ukimwi. Many feared they had contracted HIV. Others had taken the HIV antibody test and knew they were HIV positive. At Mass, both Ed and I often devoted the homily to endemic HIV in Kenya. Kenyans seem reticent to talk about sexual behavior. Students often told me that they had never spoken with family or friends about their sexual experiences. Almost all who were HIV positive had not informed any family member or close friend about their diagnosis. The stigma attached to ukimwi made self-revelation dangerous.
Possible principles, attitudes, and goals that might inform a ministry to those living with HIV/AIDS.
1. Conversation. One principle would be the value of mere conversation. When I accompanied the wahudumu, it seemed to me that conversation was a major part of their service to the sick. Giving someone else attention and time might be all, even enough, for another.
2. Information. A goal would be to keep informed about HIV. Once a young woman came to talk with me about HIV. She was deeply distressed and told me of the many people she knew who had died with AIDS. At one point she said, "AIDS is going to kill all of us. Why is this happening to us?" I think that one element for ministry in East Africa is the ability to offer an informed opinion about the causes of pandemic or endemic HIV infection. Why is massive HIV infection happening? Is it inevitable that everyone will be infected? Admittedly, talking about causes and the future are complex questions for experts. Based on what I have read about this disease, I feel confident in saying that East Africa's HI V/AIDS epidemic, like any other epidemic, is a highly complicated syndrome, an intricate running together of biological, economic, political, and cultural factors. A minister who tries to keep up with the latest and best data on HIV can share that information with another. On occasion, information can give someone a sense that she or he has some power to deal with an alarming situation. Information may also shake up prejudice. At Kenyatta U, one woman refused to share in the Lord's Blood if another student drank from the chalice before her. She was afraid of contracting HIV. When she told me this, I gave her the information that I had about the chances of HIV infection through sharing food and drink. Even after our talk, she would not share in the one cup. At least, she had the information. Obviously, information alone does not produce behavior change. The implications of the foregoing truth are many.
3. Context. If I were to undertake any ministry in East Africa, one of my principles in that service would be to remember the following: Sex does not happen in a vacuum. To enter ministry in contemporary East Africa means dealing with the social and cultural conditions that expose people to HIV infection. Let me name a few of the social and cultural conditions I have in mind: poverty, political corruption, the status of women, the norms of male sexual behavior, and a fatalism about everything from traffic accidents to HIV infection. By the way, I have often remarked to Kenyans that I believe many of them have sex the way they drive.
4. Denial. If I were engaged in any ministry in East Africa, the following would be one of my goals: I would try to be aware of how I deal with denial. There is a story about Toots Shor. Shortly before his death from cancer, he said, "I don't want to know what I have." Was Shor an East African? For me, his avoidance - or is it his pretense - seems typically East African. If I were participating in ministry to East Africans living with HIV, how would I be with people who do not want to know? First, I hope I could acknowledge that I am not all that different from them. It takes courage to know. If I were a minister in East Africa, how might I bring avoidance to the surface? Would I introduce something like the following idea? We choose not to know something terrible because lack of knowledge allows us to believe that the terrible something will not happen. Unhappily, however, denial only pushes fear down to a deeper level within us. Or could I suggest a way out of denial by making the following observation? Denial seems profoundly at odds with the African value of community. If I must deny something terrible about myself, then I must avoid knowing whether my neighbor has that terrible something. Self-protective denial eventually makes us strangers.
5. An unmentionable: death. When I was in Kenya, I used to watch a popular Swahili soap opera on national TV. In one of the episodes, a character finds out that he is HIV positive. When he finally shares the news with his family, they are initially shocked. However, the whole tone of the episode quickly changes. After a few minutes of grief, the family engages in a long conversation about the fact that one can live with HIV for 20 years. In Kenya? If! were in ministry to East Africans, when and how would I talk about death? If you mention death to many East Africans, it is almost as if you were wishing that they would immediately drop dead. One of my goals would be to resist the temptation of moving quickly to narcotizing talk of miraculous healing and smooth resurrection. At times, talking about healing and resurrection can keep reality from being brought to public expression. On occasion, talking about healing and resurrection keeps experience from being experienced. In our scriptures and sacraments we have symbols, indeed a real presence, deep and strong enough to match the terror of reality. If I were in ministry, I hope I could be of service as someone committed to breaking through the routines of numbing reassurance, someone brave enough to believe that the God of our beginnings is also the Lord of our endings.
6. Another unmentionable: condoms. My contact with a committed Catholic medical student at Nairobi U led to one of my most enjoyable relationships in Kenya. This bright young man came to speak with me about condoms. He was questioning himself about what he should do if patients asked him for advice about condoms. His search led both of us to discover that condom use is more complicated than we had imagined. My friend the medical student is exceptional. Among Kenyan male intellectuals, representatives of male-dominated government institutions and NGOs, male medical professionals, and the open-minded Catholic clergy, I found the discussion of condom use shallow, male-centered, and a patriarchal rationalization of the power relations (yes, sex is about power) determining good old-fashioned East African heterosexuality. While at Kenyatta U, I did a survey of sexual attitudes among unmarried female students. After doing the survey, I embraced the feminist position that women and men have remarkably different goals in sexual relations. Women place more importance on affective relations in sex. Male animals do not. I recommend a piece of feminist literature: K. Giffin, "Beyond Empowerment: Heterosexualities and the Prevention of AIDS," Social Science and Medicine 46(1998): 15 1-56. Giffin argues that many, if not most, HI V/AIDS research and prevention programs do not incorporate women's values. The woman's desire for "fidelity, trust, and affective intimacy in sexuality is directly opposed by the symbolic meaning of the condom as a method of prevention of STDs: while unprotected sex signifies intimacy, condoms symbolize multiple partners, lack of trust, and lack of intimacy.... A direct conflict is thus created between survival and the construction of the female subject of desire: to the extent that women who hold these (unrecognized) values are persuaded to adopt condoms in their sexual relations, to that extent will they have been defeated as subjects of female sexuality and alienated from their own sexual desires." A final goal for ministry to East Africans: I would want Giffin's views to affect my efforts