Better Health For All

by Tara Zolnikov

PhD Candidate, Developmental Science, North Dakota State University; Environmental Health, Harvard School of Public Health

Western Kenya is significantly affected by HIV/AIDs, with rates up to 15%. Many variables, including the environment and transient populations, contribute to the high percentage of HIV in the region.  The sister cities, Busia, Kenya and Busia, Uganda, are the busiest border crossings between Kenya and Uganda. Heavy commercial traffic travels from Kenyan ports to landlocked countries in Sub-Saharan Africa.

The mid-way location offers drivers a night’s stay and a profitable market for transactional sex.  Other contributing factors of the spread of HIV in Western Kenya are attributed to culture.   Cultural factors may include the unspoken acceptance of polygamy, disco matangas, and wife or sister inheritance.

While working with the Kenya Red Cross, I experienced a ‘disco matanga’, also known as a disco funeral.  Because of the low socioeconomic conditions of the province, this event takes place to help raise money for a deceased individual’s funeral.  This event also includes wife or sister inheritance, or the transfer of a widow to the former husband’s brother or family member.  The disco matanga has a select group of people who are invited, generally of the same tribal affiliation (e.g. Luo, Luhya).

The party, with music and dancing, starts around 10 to 11 pm and can last for days, but typically goes throughout the night until the morning hours.  Men are generally drink a “home brew” and smoke marijuana or chew miraa. An MC makes attendees pay if they want to remain sitting or go out and dance to avoid paying.

Men also pay for girls who they want for their dance partners.  This dance is also used to decide on later transactional sex; if unwilling, girls are frequently raped as a consequence.  To date, a solution regarding this cultural practice does not exist.  There are many reasons why risky sexual behaviour has not been addressed at disco matangas:

•    The high mortality rates resulting from AIDS contributes to a larger percentage of orphans in the province.  Orphanhood is also associated with risky sexual behaviour.  At disco matangas, orphans are also largely unsupervised.  This situation contributes to an increased risk of sex and resulting adverse health effects (HIV transmission, sexually transmitted infections, and pregnancies).

•    The environmental context of disco matangas contributes to risky sexual behaviours.  The location is frequently undisclosed until the last minute and located deep in the woods which would make any intervention within the event difficult to target.

•    There is not a lot of available entertainment in this region.  Adolescents look forward to attending disco matangas for entertainment.  How would any teenager feel if their parents told them they could not attend a school dance or prom? To eliminate this need for entertainment, an additional setting needs to be provided for adolescents.  A youth center is one viable option; however, it also needs to be free of charge and available at all hours.

•    Because communities are rural, it is difficult to disseminate information to every person that may be affected. How does one disseminate knowledge, education, or an intervention to a population inclusive of many ages, occupations, and located sparsely throughout the region?

•    The consumption of alcohol, miraa, marijuana, and “home brew” contribute to risky behaviours. Unfortunately, the female population is at an increased risk because men are more likely to consume these substances and display sexually aggressive behaviour without the consent of the female.

•    Because this province has the highest rates of HIV in Kenya, there is a surplus of public health messages being disseminated.  Personally, I think there has been a message shift from “don’t have sex” to “let’s put everyone on ARVs.”   I believe the shift of information is difficult for people to understand and digest.  ‘If we are all taking ARVs, doesn’t that mean we can’t contract HIV?’  We need to collaborate, combine, and coordinate our HIV education efforts in the region.

Public health interventions should consider cultural influences.  There are many times that we, as scientist, humanitarians, and public health advocates, forget that other individuals do not have the same knowledge base that we do.  Therefore, my initial instinct would be to design a phenomenological qualitative study to understand current knowledge and perceptions.

I would approach the population and ask if they are aware of the consequences of risky sexual behaviour and that disco matangas presents a scenario that may put them at risk for HIV transmission or pregnancies? If they are aware of this information, why do they continue to go?  The majority of the population has mobile phones, so is there a number that they would want to call if they were in danger?  I would further probe and ask for their solutions to the problem.

Researchers from the Western world come from such a different, individualistic perspective, but Western Kenya is a collectivist society and we should integrate these societal perspectives into our interventions.  Is there someone that could disseminate the message better than us – as researchers or as an outside influence?

My initial instincts are to design an intervention for disco matangas to introduce education on risky sexual behaviour to adolescents and their parents. Unfortunately, this may not be effective.  The better approach for involvement would be to include grandparents, because grandparents often live with and spend more time with the children who are attending these events.

The stories that I have listened to about the rapes that occur at disco matangas are gut-wrenching and as an advocate for gender rights, it is very worrisome.

Proposed solutions have been to include community health workers be on watch and attend the events, but because of the location and small exclusive invitees, this is difficult.  We have also thought about emergency phone numbers for adolescent girls to call, but again, who will be able to help them when they are one hour away from the nearest town?

Do we send a community health worker out in the middle of the woods at night to help a girl and risk the chance of getting raped herself?  Should we focus on eliminating the alcohol, the setting, or the night time setting?  Could we promote positive youth development and provide a social setting in a community centre?  Would adolescents located in remote villages have access to this?

There are many angles that we could consider from a public health programme implementation perspective, but what would be the most effective?  My instinct is to focus on girls and eliminate them from the disco matanga scenario.  If girls are attending disco matangas solely to interact with boys, peers, and friends, one possible solution would be to provide other sources of entertainment and ways for adolescents to socially interact in a safe setting.  Additional perspectives need to be garnered for further insight, resource feasibility, and sustainabilityto further explore this option.