The human sperm

Chiure is the District with the highest population in Cabo Delgado Province, with about 260’000 inhabitants of mainly Macua origin living in 140 villages and on 4210 km. There are, on average, 26’000 inhabitants per health centre, one doctor and 51 nurses for the entire district. As in many other African countries, AIDS is a highly prevalent chronic disease in Mozambique, with an estimated 16% of the population (15-49 years) carrying the virus and 10% infected in the Northern part of the country. Chiure District HIV testing centres report a prevalence of 23% (Chiure District Health Data 2008); a minimum of 25’000 persons in the District are infected with HIV. Furthermore, less than half of the population has access to health centres and death registration rate is below 25%.

In such conditions, empowerment of the rural population to prevent and/or manage health issues appears a necessary but long term intervention. Given that – despite a constant increase – a relatively low HIV prevalence still prevails in the Northern region, prevention activities are essential to keep this level down.

Community Empowerment for Health

Wiwanana is a Macua word and means “mutual understanding and collaboration”. The so-called programme stands at the interface between the state health service providers and the communities, where it acts as mediator, moderator and educator. Such interface is necessary where wide spread and deeply rooted distrust against the state health services exists, as it is the case in this working area (“I did not go to counselling in the VCT for fear that they would give me pills with AIDS”, home based care volunteer, 2008). Local partners support the programme as they recognize the existing communication gap and the importance to approximate the poles. Wiwanana is mainly active in the rural communities, where trained field workers use participatory approaches to initiate learning processes on four health topics: Hygiene and Sanitation, Malaria, Mother and Child Health and HIV/AIDS. At their first community meeting, key community players are identified to later facilitate the organisation of health groups within their community. Such groups then perform house to house visits and speak during community assemblies.

During the many community meetings and discussions on safe sex, HIV/AIDS and family planning held since the start of the programme, the importance of human sperm remains paramount and unshakable, and its consequences for HIV/AIDS prevention are worrying.

The human sperm – traditional beliefs

In Macua culture, men and women are equally convinced that human sperm bears the following qualities and characteristics:

- Energetic value to the woman who receives it during sexual intercourse
- Nutrition for the foetus during pregnancy
- Food to the pregnant woman
- Having polluted colostrum (“first milk”)
- Capable of polluting normal breast milk

Whereas the population sees the first three aspects as beneficial, the presence of sperm in the colostrum (sometimes also defined as “sperm which exits in the mother’s breast”) and breast milk is a negative aspect.

The human sperm – consequences

Following these traditional concepts, single women tend to actively seek casual relationships with men, as they consider sperm as a necessary and nutritious element. The same is true during pregnancy: Frequent sex with the husband or with another man (if there is no husband) is considered beneficial. Married couples may have unprotected sex regularly. However, if the husband is far away, a pregnant woman may actively seek a sexual relationship with another man, to guarantee the best conditions for herself, and for the foetus. This is not always to the pleasure of the family. Sexual escapades often result in conflicts, as it is believed that each man who had a sexual relationship with a pregnant woman shares the development and making of the coming child. If a woman had sexual relationships with more than one man during pregnancy, one speaks of “gravida juntada” (Portuguese for “joint pregnancy”).

Whereas sperm is generally considered beneficial to the foetus, it also is commonly accepted that complications during labour indicate extra-marital sex during pregnancy. In this case, the family will investigate who else has “contributed” to the “making” of the child to make him pay child allowances. This potential economic benefit can be torturous to the woman in labour. A pregnant woman with complications during labour will be left to suffer and refrain from seeking help until she admits and tells the name of a second man. Only then will she be sent to the health centre for help. As a consequence, a woman is likely to admit extra marital sex on the basis of saving her and her baby’s life. This delay in care-seeking can be of disastrous consequences both for the women and for the child.

In 2008 a head of a clan reported, “the first-born of my grand child was delivered by Caesarean section, done in Nampula hospital, and we thought it was because she did not tell us the names (of the men with whom she had had sexual relations ). When she was pregnant for the second time, our family insisted that she must give birth at home in the village, in presence of the traditional midwife and the family members, not to repeat the same mistake. But then the Safe motherhood group of Wiwanana and the traditional midwife convinced us that she should give birth in the hospital, otherwise she would die.”

Once the newborn has arrived, it is deprived from drinking the highly nutritious colostrum (first milk) of the mother. Colostrum is perceived as dirty breast milk, already polluted by sperm from sexual encounters during pregnancy (“we think that the first milk coming from the breast is full of sperm, and therefore we do not recommend to feed it to the newborn as it is dirty milk”, group discussion of various leaders and members of the community, May 09). Instead, the newborn will receive breast milk from another mother until his/her own mother has started to produce breast milk – a dangerous behaviour in areas of high HIV prevalence. Whereas colostrum is considered to be spoiled by sperm from encounters during pregnancy, normal breast milk has the potential to be polluted by sperm from sexual encounters during the lactation period. For this reason, breast-feeding mothers are not allowed to have sex at all for about 2 years. Also, the penis of the man may “frighten” the child, which will consequently fall ill. Many men take this period of abstinence during lactation as an excuse to have sex with other women. Furthermore, it can also have negative consequences for the baby: A breast feeding woman may not take a sick child to the health centre for fear of being accused of extra marital sex - since her husband is supposed to strictly observe the same rule.

In Northern Moçambique, initiation rites are widely held both for young men and women. During these festivities, mostly elderly “initiation rite counsellors” tell the young how to behave in sexual matters. The above named concepts are transmitted and enforced during these rites, which have a very strong sexual component (e.g. girls dancing naked imitating sex with men using a wood phallus etc.). Sometimes, at the end of the initiation rites, girls are encouraged to have sex with many different men, “to try out which fits best” (“from now on you are grown up; you are ready to sleep with any man”, female rite counsellor). Due to their length, price, intensity and strong social dynamic, initiation rites are a key moment in the definition of sexual behaviour for young people in Cabo Delgado. Messages related to the prevention of AIDS and other Sexually Transmitted Diseases are normally not given during these rites.

Cultural norms and the compliance with traditional concepts are a means of social coherence. Today, the same rules increase the spread of HIV, an epidemic likely to affect 20-30% of the population, and already killing thousands.

Some findings on condoms distribution and use

Wiwanana applies a condom distribution concept which it calls “intelligent distribution”: Local shop keepers are contracted and supplied with somewhat stylish and commercially advertised condoms for sale; religious and political leaders as well as traditional health service providers are supplied with “no-brand” - condoms for free distribution. Shop keepers are also supplied with balloons for sale to children, to prevent them from playing with condoms.

Despite the cultural barriers indicated above, the general demand for condoms appears to be on the rise. In 2008, the programme was not able to meet the demand due to a complete condom stock rupture at District level during several months.

Complementing national efforts, Wiwanana provides about 1-2 condom per man per year in the District. The sales of condoms in local community shops are stagnant and sellers are not interested to sell them anymore due to low demand (up to 6 condoms sold per month). Women appear to be especially reluctant to buy condoms at open shops. A woman publicly seeking and receiving condoms may be accused to be a prostitute by members of the community.

In addition – but probably more for curiosity than eagerness to use it – female condoms are frequently asked for in community meetings. The Ministry of Health has now launched the introduction of these on a pilot basis. Wiwanana will support the District Health Directorate in its efforts and closely monitor the reactions of the communities.
Traditionally, condom use is out of question for a pregnant woman seeking to “feed the child and herself”, as the objective of such behaviour is based on more profound reasons than pure pleasure. The man, on the other hand, may not use condoms for other reasons (”it needs to be flesh and bone, that is what I pay for“, man, community reunion, 2009).

During a recent group discussion with young men (n=23) and women (n=12), reasons for young men to not use condoms were:

• want “flesh-to-flesh” contact
• irrigate the woman
• want value for money

Reasons for young women not to use condoms were:

• suspect HIV/AIDS to be in the condom
• need of vitamins (sperm)
• need to have children
• fear that the condom stays in the womb

These reflections may indicate a certain gender imbalance regarding awareness and knowledge on the subject. They also confirm the deep roots of cultural concepts around human sperm, especially its nutritive value to the receiver. Whereas the concept of “human sperm” is an important influencing factor, sexual decisions and condom use are affected by other aspects also: “My husband told me to use condoms such as I could finish my studies, but I refused. I got pregnant, had the child, my husband left, the child is not registered as it needs the father to be there”, young woman, focus group discussion 2009. “When I asked a young woman for sex, she wanted to use a condom, but I refused and told her I will ejaculate outside. I convinced her as she wanted the money and I got some sexually transmitted illness from this relationship”, young man, focus group discussion 2009.

The intervention

Wiwanana has a broad, participatory, community-near approach covering many, but not all, influential factors, such as promotion, formal and informal information, education and communication. Most important, the project gained trust among the population – an essential base for introducing change (“in the beginning I did not want to participate in Wiwanana meetings; I thought they were spreading cholera and AIDS”, male farmer, 2008). Methodologies and topics changed and were added during the last ten years; they were constantly adapted to experiences.

HIV prevention efforts were included in the programme since 2003, with the following strategic objectives: Consistent use of condoms, reduction of concurrent relationships, delayed onset of sexual activity, prompt care seeking in case of illness (STI, HIV), use of sterilized instruments during traditional treatment (needles, blades), improved referral between traditional healers and formal healthcare providers, increase of male circumcision, better use of mother-and-child services (PMTCT).

Main target groups are young people (especially young girls), high risk individuals such as casual sex workers or truck drivers (which play a paramount role especially in evolving epidemics), but also “normal” women and men.

To attain the objectives and to increase its impacts, Wiwanana works with relevant peer leaders, such as initiation rite counsellors, traditional healers, elders, religious leaders, informal community drug injectors, village health workers or shebeen (bar)-girls. An enabling and consistent framework is provided by strong local Government stewardship.

In 2008, Wiwanana has been working with 248 village health groups, organized 222 meetings with traditional healers and initiation rite counsellors; 69 encounters with young people, 22 at local schools and 83 meetings in bars, discos and other public high risk places. It has realized 42 radio emissions on AIDS, 24 film and 15 theatre presentations. A spot to promote Voluntary Counselling and Testing (VCT) was broadcasted 560 times. About 100’000 believers have been reached through Christian and Islamic church leaders. Wiwanana also works with 17 female sex workers, 23 advisors in 10 shebeens (local bars), as well as youth groups in 9 schools.

Strongly committed to HIV prevention, Wiwanana closely works together with another SolidarMed programme called SMART. SMART supports state HIV services such as voluntary counselling and testing, antiretroviral treatment, the prevention of opportunistic infections, the prevention of mother to child transmission, home based care and STI clinics. With an additional “technical assistance to the health sector” component at District level, the base for integrated health system strengthening is also provided.

Discussion

Individual health-related behaviour is influenced by many factors, including political, socio-cultural, economical, educational, personal and environmental. Each factor depends on various underlying variables, of which some weigh more and some weigh less. The collusion of all these variables will, at the end, result in a certain behaviour of a specific individual at a specific time point.

Understanding these variables, weighing their relevance for specific health related problems and assessing their interdependency with other variables is necessary for the design of successful interventions aiming at behaviour change. With its programme, Wiwanana intends to influence some of the key factors of health related behaviour.

Having sought to understand the key cultural barriers to HIV prevention, Wiwanana has subsequently made various efforts to address these obstacles. Its peer education concept and its strong collaboration with initiation rite counsellors, traditional healers and village elders are examples for strategies to overcome them.

However, isolated NGO efforts to act on traditional health related concepts are not sufficient to provoke change. Messages and stimuli must come from multiple sources, be consistent in content, ongoing in time, adapted to local culture and embedded in an enabling framework. Changing traditional concepts is a long term effort (probably over generations) involving various inputs through different channels and at different levels. Wiwanana’s experience, confirmed by community members, is that messages are adopted more easily when reaching the individual from different sources, such as radio, peers, leaders, pamphlets, theatre, traditional healers, affected relatives, initiation rite counsellors etc.

A female farmer in 2009: “…before, I was a prostitute…I once assisted a Wiwanana meeting talking about AIDS and its prevention, but I did not believe it…then, one day I assisted a theatre play about AIDS, and I started wondering whether it was true or not…finally when I saw a man dying of AIDS here in the village, then I started thinking and changed my behaviour.”

New behaviour appears to be easier adopted than a complete change of habits and concepts. For instance, the acceptance of – not harmful – traditional medicines as a complementary treatment is the basis to motivate people to search help at health centres in high risk situations.

Working closely with the communities in rural areas, Wiwanana has generated a rich bouquet of experiences with the local culture and traditional health beliefs. In this example, the deeply rooted concept of the importance of sperm for women and foetuses has been identified as an important cause for sexual high risk behaviour. Taking it into account for the design of its interventions, Wiwanana is able to contribute to awareness building in young men and women, who think, debate and act on the AIDS pandemic and prevention measures in the District. A few years ago it would have been shocking and seriously offending to publicly talk about sex. This time however, is now over (“some values of our tradition are braking away for the sake of our health”, female farmer, 28y).
This felt progress is comforting. Yet, whereas behaviour change is possible, the process may be slow – a mixed acknowledgment given the high human toll and emergency of the situation. For the moment, constant presence will be necessary to keep up the momentum and to avoid fall backs into previous structures.

The Wiwanana programme is now in the phase to become a National organisation with a strong knowledge management component. As such, it hopes to secure a more permanent position, act long term, disseminate its experience and counsel other local organisations and institutions on cultural and community empowerment aspects in health and health promotion.

HIV is a complex disease, resonating far beyond health dimensions. For this reason, SolidarMed has chosen a comprehensive approach and interventions now cover all main areas from prevention over treatment to care. One of the most important variables, however, remains the individual and its beliefs buried in a network of external inputs.

*M.A. Hobbins is the Country Coordinator of SolidarMed in Chiure, Mozambique; F. Haupt works as Project Coordinator of Wiwanana, Chiure, Mozambique; J.C. Samuel is in charge of Strategic Development Wiwanana, Chiure, Mozambique, and J. Ehmer is the Health Programme Officer of SolidarMed in Lucerne, Switzerland. Contact: Dr. Michael Hobbins, MSc, PHD; SolidarMed, P.O. Box 357, Pemba, Mozambique; tel/fax: +258 272 44048, cel: +258 82 34 36 180, Email: m.hobbins@solidarmed.ch

Acknowledgement: We would like to thank all local stakeholders, but especially the Wiwanana team for all their efforts and contributions in the programme during the last 10 years. Without them, this article would not exist.