Old Shoshong

Susan and I had an eventful weekend.  Saturday afternoon, we investigated Old Shoshong.  In the late 1800s, Shoshong was an important trading post for southern Africa.  The Bangwato tribe initially set up in Shoshong.  Botswana's current president is Seretse Khama Ian Khama.  He is the son of Seretse Khama, the first president after independence from the British in 1966.  Their bloodline is part of the Bangwato tribe.  Old Shoshong is where their forefathers set up shop.  David Livingstone and other European missionaries also settled here.  The Bangwato later moved to Palapye after all of the resources in Old Shoshong were depleted.  There is a great opportunity for tourism in Shoshong--around this historical site and others.

Susan and I decided to take the scenic route to Old Shoshong.  You can get there by walking by the main kgotla (customary court).  Instead, we took the road less traveled by

Dried up river.  Susan and I figured that perhaps these were functional back in the 1800s when Shoshong was a trading center

Plaque outside of Chief Sekgoma I's Royal House

My friend Polao, who consented to be our tour for the day.  She is standing in the old cemetery.  Relatives of the initial inhabitants of Old Shoshong are still being buried here

The three of us walked over to the missionary side of the site.  They used this ironstone to summon their servants.  Pounding the rock that's in my hand creates a really loud sound.  Apparently part of this bell is being kept in the National Museum in Gaborone

Susan and I with the bell

Explanation of the missionary side

Some locals still use this site for religious purposes

These stone walls are the remnants of the missionary houses

Susan and Polao walking through the site.  It is set right up against the hill

We had a great time!  If you have some decent hiking shoes and don't mind trying to evade plants with spikes, this is a really interesting little day trip.  We also saw baboons sitting high up on the cliff.  Maybe we will get a closer view of them next time.

In Between the Trips, Sometimes We Work

On Friday, we had an event in my community.  I helped the youth officer, village development committees and other individuals in Shoshong organize it.  Every March is the Month of Youth Against HIV/AIDS.  The Botswana National Youth Council (based in Gaborone, the capital) made Safe Male Circumcision this year's theme.  We broadened it, deciding to include the promotion of yearly pap smears for women.  Better to have a message that targets everyone, right?  We thought so.

The event was a success.  It was exciting because it went relatively smoothly.  And in Botswana speak that means:

1.  It started over a half hour late;

2.  One person who was supposed to speak did not show up, but we found someone else;

3.  A drama group that wasn't invited to perform asked to be put on the schedule at the last minute.

It is important to organize any event in Botswana with this attitude: "Go tlaa siama."  That means, "it'll all be okay."  Nothing will be on time.  Accepting that before you start is essential.  Protocol is very important in Botswana.  Once people sit down, they expect to be served and want to be treated as guests (ie ten of us put up the tent while 75 people sat and watched).  Also, people have a tendency to tell you what they don't like right off the bat.  People complained to me that they had to share copies of the schedule, that there was no food, that we started putting up the tent too late....you name it, they complained about it.  I smiled, nodded, and kept going.  Sometimes that's all you can do.

The event in pictures:

All of us putting up the tent.  I would like to report that there were no tent-related injuries, but that would be wrong.  The wind was really strong that day.  At one point, I was standing on one side of the tent while people were securing the other side to the ground.  The wind kept blowing the tent up.  I was doing fine until one big gust of wind threw me completely off of the tent.  I fell on the ground in front of at least 50 people.  My whole left leg was scratched, my knee bleeding.  Fifteen minutes before the start of the event, I had to go to the clinic to wrap it up so I wouldn't be bleeding down my leg all day.  Instead of being upset, I stood up and burst out laughing.  It was hilarious.

Everyone waiting for the event to start

Pamphlets from the District Health Management Team in Mahalapye, Botswana National Youth Council in Gaborone, condoms, and information that Bright Mosimegi and I designed the night before.  Bright was the keynote speaker.  She is a nurse at the clinic and one of my favorite people to work with in Shoshong.  If I am asked to go speak at a school, she will always accompany me.  She is one of the main reasons the event was such a success.

Bright giving a condom demonstration as part of her speech.  Holding the microphone is Baetsi, one of the MCs.  Holding the penis model is Mma Kwasiwa, the woman at Mahalapye Hospital who actually does the circumcision surgeries.  To Bright's left is Mma Tshireletso, a health educator at Sheleketla Clinic in Shoshong.  She spoke about the connection between child labor and HIV/AIDS.  To her left is Rra Boetelo, one of the councilmen in Shoshong.  Farther left is the pastor who gave the opening prayer; Polao, who works for adult education in Shoshong; and Tshepo, a woman who works at the District Health Management Team in Mahalapye.

Two drama groups performed as people looked on, including my friend Susan, a Peace Corps Volunteer in a nearby village called Kalamare.  You can see her standing up in back.

To draw in more people, we ended the event with a football game between the Shoshong North and Shoshong South teams.  Shoshong North won (boo).

I made about 500 sheets of information about male circumcision and pap smears.  Bright and I wrote them the night before.  Susan and some of the nurses at the clinic helped me fold and cut ALL of them. I have few left, which means that at least 400 people were exposed to some sort of message about taking care of their reproductive health.  Most watched the drama and some speeches.  Maybe 30 only saw the football game.

And if none of those people change their behavior or take care of their health after our event, so be it.  But the community worked together.  That is beautiful in itself.

The Joys of Motherhood

One of my closest friends in Shoshong, Zola, recently had a baby. The little one's name is Rethabile. I am not sure about the exact translation, but it means something about happiness. All Setswana names have meanings.

I have visited Zola and Rethabile at home every week since I got back to Shoshong in mid-March. After giving birth, Zola is not allowed to leave the house for at least two months. At the two month mark, her grandmother must bring her out of the house. She cannot leave on her own accord. Although many mothers may choose not to leave the house for a bit in the United States, there is no cultural rule that specifies how long a baby must remain in the home. I wanted to know what other culturally-specific rules there were for conduct post-childbirth. The second time I visited Zola and Retha at home, I asked her more about this tradition.

The general reason the new mother is kept inside the house is because she is viewed as still sick and not ready for the outside world. This has many connotations. The first comes with food preparation. Zola is not allowed to prepare food in any way. Everyone else must cook for her. She has her own dishes and cannot share with others. Because she is actively breastfeeding, the rest of the family doesn't want her milk to somehow get into the food. Zola is not allowed to eat meat, sticking to simpler things like milk, porridge and tea. Zola must always eat laying on her stomach to help her stomach shrink back down to normal size.

Traditionally, the baby cannot leave the bedroom and anyone else who enters the house must stay in the sitting room. Yet, Retha came out with us in the sitting room all the time. So, like all cultural things, some families adhere strictly and others follow some guidelines and not others. Zola is also not supposed to shout or yell for anything. She should only speak with the people sitting closest to her.

Most interestingly I think are the cultural superstitions that follow things like childbirth and death. Most people aren't allowed in the room with the baby for 2-3 months because of the way the baby can be affected. For instance, if a woman who enters the house has had a past abortion or miscarriage, the new baby can get sick or even die. Or the baby may become mentally retarded, Zola said. And she also said that they believe that the baby can sense if its mother or father is having relations with someone else. And it will get sick. If the baby seems to be sick due to one of these things, the mother must put a bit of sand on the baby's tongue and he/she hopefully will be fine.

Oftentimes in Botswana you will see little baby girls with strings of beads around their hips, worn under their clothes. Rethabile is not wearing them yet, so I asked Zola about it. She said that she is waiting to get the beads from Rethabile's father's family. Apparently the girls wear beads in order to develop their hips. If they don't wear the beads, Zola explained, girls will develop into women without real curves.

In Botswana weddings, the man's family must pay the woman's family a bride price called "lobola." Lobola is determined by specific village custom, but can range from 4-18 cows. The groom's family must also buy clothing for the bride and many of her female relatives. Zola informed me that Rethabile's father's family must also give her things in recognition of the birth. If they don't pay in cows, they must pay child support every month in the form of food, money and clothing for the baby. Child support is technically regulated by the government, but every family situation is different, as the majority of women have children before they are married.

Circumcised: To Be or Not to Be

Conventional wisdom within Botswana is that the HIV prevalence rate is so high here due to one main factor: relationships with multiple concurrent partners combined with low rates of condom usage. There are deep cultural factors embedded within this, and I have tried to explain some of these in previous posts. Obviously this isn't the only reason, but it is the overall story.

When I first received my PC invitation to work on HIV/AIDS in Botswana, I was so excited. It was my dream placement. I was going to strengthen the community response to the virus. At that time, I knew nothing about the issues at stake in Botswana. But I don't think I ever imagined how much the government was doing to fight HIV--the decade of behavior change campaigns they have undertaken, the money they have poured into condom distribution and the amount of funding put into making antiretrovirals universally accessible to all who need them. These are amazing things and make the situation in Botswana different than most other developing countries. ARVs are not free for people in the states, even. It is unique. Very much so.

But, after a decade of this, there is not a large change in the prevalence rate of HIV within Botswana. I do believe that the youth are using condoms at a much higher rate than in the past. But the prevalence rate remains unchanged. The incidence rate is slightly lower, which pretty much means that HIV-positive individuals are dying at a slower rate, clearly the affect of universal ARVs. But the story is not over. HIV is still a problem in Botswana. Not the only problem, but a significant one, especially when one understands that ARVs will not be available like this forever. The government of Botswana feels like it needs something to slow the tide of HIV. And they think they have found the answer: circumcision.

Historically, male circumcision has been part of the culture in Botswana. Men would undergo the surgery (for lack of a better term) by traditional doctors out in the bush, as part of a manhood ritual. It wasn't very safe. So, in this new campaign, the Botswana government has termed it "safe male circumcision" (SMC), explaining that these operations are done by licensed doctors in clinics and hospitals--very different from the past.

The push for circumcision comes largely from a controlled study conducted in some southern african countries. Results from Kenya showed that men that were circumcised had a 60% more reduction of new HIV cases than the control group--men who were not circumcised. The results from Uganda were 55%.

The basic medical reasons for this relate to the anatomy of the penis and the foreskin. The foreskin contains a porous area similar to vaginal tissue, that can make uncircumcised men more prone to infections and diseases, including HIV. The foreskin also contains a large concentration of CD4 cells, the cells that HIV attacks.

With this information, the government of Botswana has invested handsomely in this campaign. In the absence of obvious behavior change successes, they are grasping at anything that will help--and the SMC campaign seems like the next best thing. But is it really? PCVs are here to support government efforts in preventing HIV and I will do my best to follow suite. That being said, I began to research other opinions on the study and male circumcision in general. Apparently there is a whole population out there that is against circumcision, for very specific reasons.

Although the SMC campaign alleges that circumcised men have less risk of infection, some doctors argue that the foreskin has important uses in terms of protection and reproduction. The basic philosophical argument is that it doesn't allow the penis to function as it was biologically intended to. They also talk about moral issues of having babies circumcised--changing their bodies without their consent. It's not something we think about often in the United States because so many babies are circumcised at birth. Those against circumcision frame it as a human rights issue, not far behind female genital mutilation.

I have not necessarily made any concrete decision on the subject, but I think it needs to be discussed. For me, the circumcision debate brings up larger issues related to western work in Africa and other places. What are we compromising in order to "solve" certain problems, especially health-related ones? It seems like we oftentimes look at the direct pros and cons of something--how many lives will be saved. I don't disagree that human lives are important. One would be crazy to say that. But I think we need to think more holistically, looking at cultural implications of our interventions.

Here are some links for you all to make your own determinations:

The Study and Other "Pro-Circumcision" Sites:

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60313-4/fulltext#article_upsell

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60312-2/fulltext#article_upsell

http://www.who.int/hiv/topics/malecircumcision/en/

http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm

Anti-circumcision information:

http://infocirc.blogspot.com/2012/01/36-cut-podcast-circumcision-and-hiv.html#more

http://www.noharmm.org/advantage.htm

http://www.circumcisionandhiv.com/

http://www.doctorsopposingcircumcision.org/info/HIVStatement.html