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HIV/AIDS education in the Arabian Gulf state of Bahrain
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HIV/AIDS education in the Arabian Gulf state of Bahrain
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INFORMATION TO USERS This manuscript has been reproduced from the microfilm master. UMI films the text directly from the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter face, while others may be from any type of computer printer. The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleedthrough, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left-hand comer and continuing from left to right in equal sections with small overlaps. Each original is also photographed in one exposure and is included in reduced form at the back of the book. Photographs included in the original manuscript have been reproduced xerographically in this copy. Higher quality 6” x 9” black and white photographic prints are available for any photographs or illustrations appearing in this copy for an additional charge. Contact UMI directly to order. UMI A Bell & Howell Information Company 300 North Zeeb Road, Ann Arbor MI 48106-1346 USA 313/761-4700 800/521-0600 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. HIV/AIDS Education in the Arabian Gulf State of Bahrain by Shannon Kathryn O’Grady A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (Education) May 1996 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UMI Number: 9636361 C o p y rig h t 1996 by 0 1G rady, Shannon K ath ry n All rights reserved. UMI Microform 9636361 Copyright 1996, by UMI Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. UMI 300 North Zeeb Road Ann Arbor, MI 48103 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UNIVERSITY OF SOUTHERN CALIFORNIA THE GRADUATE SCHOOL UNIVERSITY PARK LOS ANGELES. CALIFORNIA 90007 This dissertation, written by Shannon. K athjj.n.O JG rady........................... under the direction of hSL Dissertation Committee, and approved by all its members, has been presented to and accepted by The Graduate School in partial fulfillment of re quirements for the degree of DOCTOR OF PHILOSOPHY Dean of Graduate Studies D ate....... DISSERTATION COMMITTEE Chairperson Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ABSTRACT HTV/AIDS Education in the Arabian Gulf State of Bahrain This study examines the role of culture in the development, content, and implementation of Bahrain’s HIV/AIDS educational programs. It presents some of the conflicts inherent in developing and implementing HTV/AIDS education programs for a traditional Islamic country. Physicians from the island’s Ministry of Health were interviewed regarding how they first developed their HTV/AIDS programs, some of the obstacles they encountered, the role of their religious leaders, and how they have sought to create a campaign suitable for the local culture. The study also explores Bahraini students’ knowledge and attitudes towards the virus to determine if their perspective is similar to that of the government’s and to see in which areas they have been affected by Bahrain’s HTV/AIDS campaign. Finally, the study looks at the knowledge and prevention practices of intravenous drug users on the island, to assess whether Bahrain’s HTV/AIDS campaign has been effective in reaching this high risk population. The study concludes with recommendations for a more effective means of targeting populations that are potentially at risk for HIV transmission in Bahrain. ii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. * D e c U c 4 t i o K * 7 o - m t f ft anot t A , *?0i tAeOi O w e , eM coteiaqeMtfMt , cut d endl eee f t a&et t ce. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ACKNOWLEDGMENTS This study could not have been completed without the help of the many Bahrainis who gave their time, their sincere comments, and who risked their own personal security in helping me to conduct my fieldwork in Bahrain. I would like to thank the doctors from Bahrain’s Ministry of Health who took a genuine interest in this project. For reasons of confidentiality, I cannot mention any names, but they know who they are. I would also like to thank the seven Bahraini young men who shared their insights about drug use and HIV in Bahrain. It is my sincere hope that they will find a way out of their addiction one day. And for those who were HTV positive, I hope their current state of good health will continue. I am also grateful to my dear friends, Miriam Amie, Vivian Binder, Claire Cameron, James Johnston, and my wonderful Bahraini friend, whose name I cannot mention, for their generous assistance and support of this work. And to my parents, whose tireless encouragement has been a great inspiration. Finally, I would like to thank Professor Nelly Stromquist for her substantive and insightful comments which contributed greatly to this study. S & 4 M M 6 * 0 ' f aul t y Glendale, California January 14,1996 iv Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table of Contents ABSTRACT...................................................................................... ii DEDICATION.................................................................................. iii ACKNOWLEDGMENTS.................................................................iv I. INTRODUCTION...................................................................... 1 Background of Topic...................................................................2 Purpose of Study......................................................................... 12 Research Questions.................................................................... 16 Importance of Study.................................................................... 17 Tentative Hypotheses..................................................................19 Methodology............................................................................... 20 Methodological Assumptions..................................................... 24 Limitations.................................................................................. 26 Delimitations............................................................................... 29 Definition of Terms.....................................................................30 Organization of Study................................................... 32 H. REVIEW OF THE LITERATURE............................................. 33 AIDS Metaphors.......................................................................... 33 Plague Metaphor.......................................................................... 35 AIDS as Homosexual and Heterosexual Promiscuity..................39 AIDS as Self-Inflicted Illness...................................................... 43 AIDS as Punishment for Sin........................................................ 44 Religion and the AIDS Virus....................................................... 47 AIDS and Religious Doctrine...................................................... 48 Religion and Morality...................................................................51 AIDS and Morality in the US...................................................... 52 AIDS and the Catholic Church.................................................... 54 AIDS Prevention in the Developing World..................................56 HIV/AIDS Prevention in Asia..................................................... 58 HTV/AIDS Prevention in Africa................................................... 72 HIV/AIDS Prevention in Caribbean and Latin America..............79 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. HTV/AIDS Prevention in the Middle East....................................84 Chapter Summary.........................................................................95 m. METHODOLOGY......................................................................99 Introduction................................................................................. 99 Selection of the Problem............................................................. 99 Research Design........................................................................ 103 Selection of Respondents...........................................................104 Method of Data Gathering.........................................................110 Setting........................................................................................114 Access........................................................................................115 Data Analysis and Interpretation............................................... 121 Chapter Summary...................................................................... 124 IV. ANALYSIS AND INTERPRETATION OF DATA.................126 Health Education in Bahrain...................................................... 126 Emergence of an HTV/AIDS Campaign.....................................129 HIV/AIDS Campaign Objectives............................................... 140 Target Audience and Media Used.............................................. 142 Campaign Content...................................................................... 148 Campaign Analysis/Influence of Religious Leaders....................153 Disease of Shame....................................................................... 158 Religious Approach.................................................................... 161 Analysis of Campaign Literature................................................ 164 The War Metaphor..................................................................... 165 AIDS as Foreignness..................................................................167 AIDS as Punishment from God.................................................. 168 Fidelity........................................................................................170 Campaign Effectiveness..............................................................171 Effect of Culture on Students’ Attitudes.....................................182 Knowledge of HTV/AIDS............................................................184 Association of Sickness with Sin and Foreigners........................186 Heightened Fears of Contagion.................................................. 190 Compassion and Repentance..................................................... 195 Adherence to Islamic Beliefs..................................................... 199 Intravenous Drug Users and HIV Transmission........................ 205 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Introduction .........................................................................205 Sami........................................................................................... 207 Yousif........................................................................................ 216 Hasan......................................................................................... 220 Nader......................................................................................... 224 Amir........................................................................................... 227 Fadel.......................................................................................... 229 Tariq.......................................................................................... 230 Peers as Primary Source of Information.................................... 233 Insufficient Information............................................................. 234 High Risk Practices................................................................... 234 Peer Support..............................................................................235 Social and Political Discontent ...........................................236 Chapter Summary..................................................................... 237 V. SUMMARY AND RECOMMENDATIONS.......................... 243 Summary of Research.............................................................. 244 Recommendations.....................................................................254 Concluding Comments............................................................. 260 APPENDIX.................................................................................... 266 A - Kuwait’s First International Conference on AIDS..............266 B - English Version of Questionnaire........................................270 C - Arabic Version of Questionnaire.........................................272 D - English Translation of HIV/AIDS Pamphlets.....................274 E - Arabic HTV/AIDS Pamphlets..............................................281 BIBLIOGRAPHY............................................................................293 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter I Introduction In December 1992, the Arabian Gulf State of Bahrain launched its first HIV/AIDS prevention campaign. This educational campaign coincided with the December 1st World AIDS day, an official date set by the World Health Organization to publicize new information and preventative education about the Human Immunodeficiency Virus. Bahrain’s campaign was directed by the country’s ministry of health, and its content was developed by the ministry’s health education office. Assistance was also provided by the World Health Organization’s Eastern Mediterranean regional bureau in Alexandria, Egypt. This study takes an in-depth look at how Bahrain, a traditional Islamic country, has implemented its HIV/AIDS prevention campaign, paying particular attention to the how the island’s conservative religious culture has affected the campaign’s content, the people’s attitudes towards the virus and its carriers, and how one high risk population, intravenous drug users, view the disease. 1 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Background of Topic Acquired immune deficiency syndrome (AIDS) is a blood borne disease with no cure at this time. It is classified by the World Health Organization (WHO) as a major pandemic in the world today. AIDS was first recognized as a disease caused by the presence of HIV (human immunodeficiency virus) in the early 1980’s. Since then, the numbers of HIV carriers and AIDS patients have increased worldwide. HIV infection is transmitted by an exchange of bodily fluids. The most common modes of transmission are by unprotected sexual intercourse, both vaginal and anal, and by the sharing of drug injection equipment containing infected blood from unsterilized needles and syringes. Additional modes of transmission include blood transfusions, injection, pregnancy, and in some cases childbirth. Some HIV infected people have remained asymptomatic for as long as ten to twelve years without any AIDS related illnesses or full blown AIDS (Berer, 1993). Since HIV can lie dormant in the blood for so long, health officials fear that there may be far more people who carry the AIDS virus (HTV infection) than current numbers indicate (Sills, 1994). AIDS, in its advanced stages, causes the immune system to cease functioning, which renders the patient vulnerable to a variety of serious illnesses. AIDS 2 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. patients often die from pneumonia, Kaposi’s sarcoma, tuberculosis, or other infectious diseases. In January 1994, the World Health Organization (WHO) estimated that there were 14 million adults and one million children infected with HIV and approximately one-fifth of them would eventually develop AIDS. According to WHO, the world population is being infected with HTV at a rate of 5,000 per day and it is possible that 30 to 40 million people will carry HIV by the end of the century (WHO, 1994). WHO also predicted that 90% of these infections will be found in the developing world. Since HIV is sexually transmitted, the majority of those it affects are young and middle aged adults, the most productive members of society. In North America and Europe, most of the initial HTV infections were found among homosexual and bisexual men, and intravenous drug users. However, current reports of HIV transmission in North America show that the infection is rapidly growing among the heterosexual population (Sills, 1994). HIV infections and AIDS cases have been reported in Africa, Europe, the Middle East, Latin America , the United States, the Caribbean, the Pacific Islands and on every continent in the world, with the majority of cases being reported from Africa and the USA(Sills, 1994). In the 1980’s two-thirds of 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. all HIV infections were found in sub-Saharan Africa. Today, Africa has the highest number of AIDS cases worldwide. In America, there are an estimated one million HTV carriers. Brazil has the majority of the estimated two million HTV infections in the Latin America region (Sills, 1994). Every European country has reported AIDS cases and South Africa has now moved to the epidemic phase. The Harvard AIDS Institute predicts that by the year 2000, the largest number of AIDS cases and HIV infections will be found in Asia (Sills, 1994). WHO estimates that Thailand has nearly 300,000 infected with HTV and by 1997 between 125,000 and 150,000 Thais will have died of AIDS. In India, more than one million people are infected with HIV. The economic cost both in health care and in production will amount to billions for countries with high incidence of HTV infection. The burden it will put on already strained economic systems in developing countries will be tremendous. There are also social costs; the large numbers of AIDS orphans found in areas with high numbers of ADDS and HIV, particularly on the African continent has affected social welfare systems as well as put pressure on families for financial assistance. The Arabian Gulf countries of Kuwait, Bahrain, Qatar, the United Arab Emirates, Oman, and Saudi Arabia have reported AIDS cases and HIV 4 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. infection among their indigenous populations. While the numbers of reported AIDS cases in the region is smaller than other regions at this time, the actual number of AIDS cases is probably more than reported due to underreporting by some countries and underdiagnosis. As of 1993, the six Arabian Gulf States had reported a total of 149 AIDS cases to the WHO, eleven of which were from the island of Bahrain, the smallest of the Arabian Gulf States. The numbers of reported HIV infections were unavailable to the researcher. There are also some difficulties in ascertaining an accurate estimate of HIV infections because most testing is concentrated on specific groups considered to be high-risk for HIV transmission. According to Sills, (1994:2), No country has an accurate count of the number of people infected by the Human Immunodeficiency Virus. Much of the testing to date comprises small samples of high-risk groups, such as prostitutes and drug addicts, and is therefore unrepresentative of entire populations. It is also difficult to count the number of AIDS cases since health care systems in many countries lack diagnostic ability. Governments do suppress information about AIDS and that once actual numbers are known, a crisis of even greater magnitude than is portrayed will be revealed (Sills, 1994). To increase accurate reporting, the World Health Organization has promised 5 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. confidentiality regarding HIV infections and AIDS cases in circumstances where governments have surpressed this information. Because AIDS is viewed as a disease that affects those engaging in “deviant” behavior, or behavior that is not in accordance with religious doctrine, the Islamic countries of the Middle East still regard the admission of AIDS cases in their countries as shameful. While AIDS patients are viewed with compassion and pity, they are also the target of widescale social prejudice and condemnation because most of the association of the virus with IV drug use, prostitution, and homosexuality. Historically disease and particularly sexually transmitted diseases have been viewed in theological terms (Fernando, 1993). Prejudices and stigmas combined with compassion are not unusual attitudes towards those carrying infectious diseases. It is not uncommon for sickness to be seen as punishment to groups or individuals within a society for sin. AIDS is an example of this because of its early classification as a disease which attacks only drug users, homosexuals, and prostitutes, i.e., sub-cultures associated with crime, violence, sexual deviance and undermining family values. Yet, the religious culture strongly advocates caring the sick, despite how the illness was contracted. This stigma towards HIV carriers and AIDS patients not only 6 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. contributes to underreporting of the virus but to prejudice towards HIV carriers and AIDS patients. When these perceptions are held by governments, the quality of medical treatment may also be affected. There are certain features unique to the spread of HIV infection in the Middle East and the Arab Gulf countries. The initial AIDS cases in the region were due to imported blood or from people who had sexual contact with persons in areas where HIV was prevalent, and by sharing needle injection equipment with HTV positive drug users. It is now being spread indigenously, most commonly by heterosexual contact with an infected person or by sharing unsterilized needles. Homosexuality is one mode of transmission of the virus. Not enough is known about the behavior patterns of homosexuality in the area, and because of the strong taboos, public health education campaigns do not address the issue. Additionally, what may be considered homosexual behavior according to one culture, may not be the agreed upon definition by another culture. Therefore, should the term homosexual be used in an AIDS education program, it may not be clear what constitutes homosexual behavior, and if the term is used it may alienate those in need of such education because of the strong social taboos against homosexuality. 7 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Prostitution, another high risk category for contracting HIV infection, although illegal in the Arab Middle East, exists in nearly all the countries of the region (WHO, 1994). The role of prostitution in the spread of HIV infection within these traditional societies needs to be further explored in order to effectively develop and target HIV prevention programs. According to Bahrain’s Ministry of Health, prostitution on the island has contributed to the spread of HIV. Prostitutes may resist protecting themselves or their clients as they may fear such precautions could threaten their livelihood. It is difficult to target programs to this high risk group because, similar to homosexuals, there are strong taboos, even stronger in Islamic society, towards women who engage in sex outside of marriage. In Saudi Arabia, or parts of the United Arab Emirates, a woman could be severely punished and under some jurisdictions even killed for engaging in prostitution. The negative public perception and strong taboos towards prostitution make prostitutes a difficult to reach within a traditional, religious society. Unlike Thailand or Hong Kong where commercial sex workers can easily be located, the harsh laws in the Islamic countries prevent public discussion and open acknowledgment of these activities, which results in commercial sex workers, 8 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. a high risk group and their client population, being overlooked because of the conservative culture. Intravenous drug use accounts for a large percentage of HIV infections in the Arabian Gulf countries(WHO, 1994; Al-Haddad, 1993). Drug users are often isolated from the mainstream society with little access to public health information. Many do not receive accurate information about HIV prevention until it is either too late or unless they enter drug rehabilitation programs where they will be informed about how they can protect themselves from HIV. The explicit language needed to explain to IV drug users how to take precautions against HTV transmission is not something that can be publicly discussed, therefore, drug users only receive this information inside of drug rehabilitation clinics or hospitals. Outside of this environment, their educators are their peers, some of who have already contracted HIV. Eventually they do get some prevention information, but not nearly to the degree that is needed (see chapter IV for a more detailed discussion). Homosexuals, commercial sex workers, and drug users initially constituted the highest risk groups for HIV transmission both inside and outside of the Middle East. Currently, however, an increasing number of heterosexuals have also contracted the virus. Traditional societies face specific challenges in 9 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. targeting high risk groups, because the acknowledgment of the existence of such groups can be difficult in cultures which are rooted in religious tradition and eager to maintain an untarnished image both inside and outside of their borders. There is the additional task of finding a culturally suitable method of delivering the content to those who are at risk. Furthermore, in the Gulf States, a number of foreign workers come from countries outside of the Gulf states, so AIDS education must also be available in their language, and not targeted specifically to the Islamic culture, since large numbers of those at risk come from Christian, Hindu and Buddhist backgrounds. To confront the issue of AIDS and HTV infection within Arabian society, individuals, health officials and government leaders first have to face their own prejudice towards high risk groups in order to effectively educate, counsel and treat them for HTV infection. Stigmas towards prostitutes, drug users, and homosexuals are very strong in the Middle East. These traditional stigmas will have to be put aside to facilitate development of HIV/AIDS programs. Open discussion of social problems is needed without concern of appearing less devout than their Islamic neighbors. In April of 1994, the Bahrain Ministry of Health and WHO sponsored a conference to deal specifically with the counseling of HIV infected 10 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. individuals. A large part of the week was spent looking at the social issues, including prejudices that health professionals have to confront when dealing with HIV infected individuals. Bahraini health officials candidly discussed the prejudices and stigmas that exist within their own society towards the behavior of high risk groups. Doctors from the State of Bahrain’s health ministry also spoke openly about the problem of HIV transmission among IV drug users, through prostitutes, and through sexual relationships outside of marriage. Since 1992 Bahrain has conducted a national HTV/AIDS education prevention campaign to help reduce the numbers of HIV infected people on the island. Lectures have been given by doctors to companies, schools, and the religious sector of the society. Because of the conservative attitudes among the local population, health officials have had to pay particular attention to the appropriateness of the campaign in order to effectively communicate preventative methods without appearing to be condoning sexual relationships outside of marriage. They have worked with the religious leaders to help spread their information and have had to openly publicize some of the island’s social, problems in order to address the issue of the spread of HTV among high risk groups. Though they have encountered some 11 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. obstacles such as internal disagreements regarding the content of the campaign, they have worked together to utilize cultural and traditional resources in both the content and implementation of their HIV/AIDS education campaign. They still face some difficulties in targeting high risk groups and affecting people’s attitudes towards HIV carriers and AIDS patients. Religion and morality play a large part of individuals’ perceptions of HTV carriers/AIDS patients. This is even the case in the so-called secular West, so one can imagine the kinds of issues that populations of traditional religious societies are forced to confront during this major pandemic. In this scientific age, we are reluctant to admit the intermingling of the traditional and the modem, because it is precisely our scientific culture that distinguishes our modernity from our ancestral beginnings and millennia of human history. However, I hope to demonstrate that AIDS is an excellent example showing that the emperor (science) is still naked and that we are not far removed from traditional mentality (Fernando, 1993:8). Purpose of Study One objective of this study is to explore the influence culture, particularly religious norms, has had on Bahrain’s HTV/AIDS education programs and to present the conflicts inherent in developing and implementing such programs for a traditional Islamic society. When culture is discussed in the context of a 12 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. predominantly Islamic country, the religion is the culture. Unlike in the West where church and state are largely separate institutions, in nearly all of the Islamic countries of the Middle East, the religious leaders are either directly involved with the governing of the country, or they have a significant influence over the government and the people. The people of the Arabian Gulf peninsula and the Gulf countries share the Islamic culture which is evident in their everyday life. The traditional values are the people’s religious values that have not been attenuated by the influence of modernization. Bahrain’s government is a secular one, and there is a less restrictive and more tolerant atmosphere than the other countries of the Arabian Gulf region. However, it is still a largely conservative Islamic country which means the people’s values are based on the principles of the Koran. The majority of the Bahrain’s natives are devout Shi’a Muslims who pray daily and closely follow the messages from their religious leaders. The negative social stigma attached to high risk behavior (prostitution, IV drug use, homosexuality, and sexual relationships outside of marriage, particularly for women) is very strong in Bahrain as it is in all Islamic countries. These behaviors are condemned by the religion and bring shame to those practicing them in the society. In most Islamic countries, prostitution still brings the most severe 1 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. condemnation by the society. Women who are labeled as prostitutes bring the most shame to their families and to the society. Islam is the core of their belief system, therefore, all of their perceptions are influenced by their religious values, particularly regarding social problems or social issues. To understand exactly what kinds of social prejudices and stigmas exist among Bahrainis, the second part of this study examined the attitudes of a group of Bahraini college students towards HIV/AIDS. This group was also chosen because most HIV infections worldwide occur in sexually active young adults (WHO, 1994). Even in the sexually conservative environment of the Arabian Gulf countries, young people may engage in sexual relationships. More often it is young men who travel outside the Gulf for sexual experiences that are prohibited within their own society. Young adults, particularly those who are unemployed, are those most vulnerable to drug abuse, another high risk behavior for transmitting HIV infection (Al-Haddad, 1994). The final area of the study explored the knowledge and behavior patterns of IV drug users on the island to help further understand the areas in which education would most benefit this high risk group. Drug use remains a serious problem in Bahrain, and in order to curtail the sharing of contaminated needles, HTV/AIDS education along with other measures are 1 4 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. needed to prevent the spread of HIV among this particular group. In Bahrain, HTV seroprevalence was initially found among IV drug users, but the virus has increasingly been spread by heterosexual contact (Physician C, interview 1993). In the early stages of this study, it was the researcher’s objective to examine solely the government’s HIV/AIDS education programs; however, as the study progressed, it was apparent that to fully understand the implication of the government’s HTV/AIDS education prevention programs, it was necessary to look at other segments of the society in order to gather a comprehensive understanding of Bahrain’s programs and to assist in the triangulation of the data gathered. Therefore, the decision was made to include in the study the attitudes towards the virus and its carriers of Bahrain’s young adults and, in addition, include the knowledge and attitudes of IV drug users to see exactly in which areas HIV/AIDS education could be further improved. These issues were investigated through: (1) interviews with Bahrain’s Ministry of Health officials; (2) interviews and brief questionnaires with higher education students regarding their knowledge and attitudes of HIV transmission; (3) an examination of the content of AIDS information 1 5 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. campaigns; (4) comprehensive interviews with IV drug users regarding their knowledge of how HTV is transmitted and their behavior patterns when injecting drugs; (5) a description of the religious and political environment of the country and how it influences the behavior and attitudes of the above groups. Research Questions Three research questions will guide this study: 1. To what extent has Bahrain’s traditional Islamic culture affected the development, content and implementation of Bahrain’s ADDS education programs? 2. How has culture, particularly religion, affected student attitudes towards HIV transmission and HTV carriers/AIDS patients? 3 . How have high risk groups, specifically IV drug users, been influenced by Bahrain’s HTV educational campaign? What do IV drug users know and believe about the disease? What kinds of precautions, if any, are drug users taking towards preventing the transmission of HIV when injecting drugs? What kinds of behavior are putting them at risk for HIV infection? 16 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Importance of Study Since the start of the AIDS epidemic in the 1980s, a number of articles, journals and books have addressed HIV/AIDS in terms of its history, high- risk groups, social stigmas, prevention programs, government policy and funding and other related areas. Thousands of publications have addressed the urgency of this pandemic disease, but none to date have looked in-depth at HIV/AIDS education programs in the Arab Gulf countries, particularly at the role of their culture in the development and implementation of HIV/AIDS education programs. Some descriptive studies have appeared at conferences (Kuwait, 1994) or as guidelines for the development of HIV education programs in religious societies (WHO, 1994). Additionally, Bahraini researchers have conducted local quantitative studies on HTV seroprevalence among IV drug users (Al-Haddad, 1994), studies on students’ attitudes and knowledge of HTV transmission (Salah, 1993) but no published research shows that any qualitative studies have been done on HIV prevention programs in the Arab Gulf countries, nor do any studies attempt to look in depth at the attitudes, practices, and beliefs of intravenous drug users in the Gulf countries. Bahrain is a small country with a population of less than half a million Bahrainis. Families tend to know each other, and as in other 1 7 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. traditional societies, protecting the family name is critical to their reputation. Therefore, openly admitting that one is an IV drug user is usually only done by those seeking help to stop using or to those in the same peer group. But many are fearful their families may find out, so it is not easy for researchers to gain access and trust within this sub-culture. Another difficulty researchers face when attempting to engage in qualitative research is the issue of secrecy. In a non-democratic, traditional society, power and authority are in the hands of a few. What is publicly revealed about the society is subject to approval by ministry officials. Traditional concepts of honor and shame impede open discussion of social problems in Arab society, therefore no qualitative studies to date have been published surrounding the issue of H TV and high risk group behavior. Even public acknowledgment by some government officials would be interpreted as shameful behavior. There are many questions that remain unanswered regarding high risk groups’ behavior patterns and there is a tremendous need for research to be done in the region, not only on the issue of HTV and AIDS but on drug use and the behavior patterns and trends of drug users (Al-Haddad, 1994). This study was conducted to offer insights into the complexities of developing HIV/AIDS prevention programs in a traditional society. It will 18 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. look at the role of culture, particularly religion, and how it has influenced prevention education, and its affect on local attitudes. It will also attempt to understand the knowledge and behavior of IV drug users so that health officials will better be able to understand the areas that most urgently need to be addressed. While this study was conducted in Bahrain, the findings may be of use to other traditional societies, particularly those in the Islamic Middle East. Tentative Hypotheses 1. The development of specific HIV/AIDS educational content, particularly to high risk groups, has been inhibited by cultural factors such as taboos towards the explicit discussion of safe sexual practices and reluctance to publicly address the specific behaviors that put individuals at risk for HIV infection. 2. Health officials are able to use some traditional aspects of their culture to facilitate the development of the content and the implementation of AIDS educational programs such as utilizing the religion as a core message in AIDS prevention, and utilizing the religious clergy to help educate the population. 19 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 3. Internal prejudices and cultural constraints affected the initial implementation o f HIV/AIDS prevention education in Bahrain. The delay in the development of AIDS education programs may have affected the knowledge transmitted to IV drug users. This delay may have contributed to spread of HTV by the continual use of contaminated needles among drug users. 4. The students’ perceptions of the disease is shaped by their traditional religious values and is also similar to the way populations have viewed plagues and fatal disease throughout history. 5. Peers have become a primary source of information about HIV infection to intravenous drug users. 6. Intravenous drug users do not have enough information about how HIV is transmitted to effectively protect themselves from contracting the virus. Methodology This section offers an overview the methodology used for this study. A more detailed account is presented in chapter three of the study. This is a 20 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. descriptive qualitative study that was conducted to explore the role of culture in Bahrain’s HIV/AIDS educational prevention programs. One objective of the study was to accurately depict the ideas and attitudes of the groups/individuals being studied. To do this, it was necessary to conduct open-ended interviews with the subjects. Interviews were recorded when possible, but due to the sensitive nature of the subject, many individuals refused to be recorded. When the recorded was turned on, it inhibited open, candid discussion. The reluctance to be recorded was more apparent among IV drug users than government officials. The four doctors who were selected for the interviews were from Bahrain’s Ministry of Health and were directly involved with AIDS education or AIDS policy making on the island. Decisions involving HIV policy, counseling, and other aspects of the disease are concentrated among very few individuals at the Ministry of Health. The researcher only interviewed those doctors who had an important role in AIDS education or AIDS policy making on the island. One was the health education officer in charge of AIDS educational campaigns; another was a psychiatrist who is chief of medical staff at the government hospital and the head of Bahrain’s AIDS committee, a committee formed by the health ministry, which recently includes members 21 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. from other ministries, to make decisions about AIDS policy on the island; another was in charge of HIV counseling programs and a leading psychiatrist at the government mental hospital; the fourth doctor had participated in AIDS research on the island and given lectures on HTV transmission. The doctors were each formally interviewed at least twice, and informal discussions were held with them throughout the researcher’s stay in Bahrain. The researcher also analyzed the content of four AIDS pamphlets that were produced by Bahrain’s Ministry of Health and the Eastern Regional Office of the World Health Organization. These pamphlets were translated by a professional Arabic translator who works as a translator for United Press International in Kuwait. The information was translated from Arabic to English to offer the researcher more insights into the content of Bahrain’s HIV/AIDS campaign. To gather information on the students’ attitudes towards HIV carriers, thirty college students were given a short list o f open-ended questions in Arabic regarding their attitudes towards AIDS patients and HIV transmission. The questions were presented in Arabic and the students were asked to write their answers on the same piece of paper in class. The question sheets were then collected and a general discussion of AIDS was held with the students. 22 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The students’ questionnaires were translated by the Bahraini secretary of the English Language Center at Bahrain University. One important area for research of this study was to gather information about IV drug users on the island. This was done by interviewing in depth seven IV drug users (two were HTV positive). Details regarding how these interviews were obtained will be discussed in chapter three and four of this study. Several informal discussions also took place with these individuals throughout the researcher’s stay in Bahrain. The interviews were held in both Arabic and English depending on the respondents’ fluency in English. If Arabic was used, the key informant translated what the researcher did not understand. The key informant spoke English well, and because he knew the other users, they trusted him. He also understood the language of their sub culture. Qualitative analysis was selected for this study with the objective being a final product that offers a rich presentation of the ideas and behaviors of the groups being examined. Various authors have cited qualitative studies as yielding in-depth and holistic insights into phenomenon that could not be captured in a purely quantitative study(Lofland, 1984; Marshall and Rossman, 1989; Patton, 1987; Strauss and Corbin, 1990; Yin, 1989). The samples are 2 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. small because of the tremendous time it took to cultivate relationships within each of the groups being studied. It was the researcher’s preference to study in-depth, a small group, particularly among the IV drug users, in order to establish a rapport with the users to better understand them. Each individual had to be met several times in order to gather the necessary information and to validate it. All of the interviews were transcribed, if recorded, and coded according to methods obtained from qualitative research literature (Strauss and Corbin, 1990; Patton; 1987). All of the research was conducted in the Arab Gulf State of Bahrain from August 1993 to July 1994. Methodological Assumptions 1. The health officials interviewed are able to provide an accurate account of the government’s perception of the AIDS situation in Bahrain. Interviews with them will yield enough information to determine how culture has affected the development and implementation of AIDS prevention programs in Bahrain. 24 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2. Interviews and questionnaires given to thirty college students provide some understanding of how culture affects the attitudes of college students towards HIV and its carriers. 3. The seven IV drug users interviewed for the study are at risk of HIV transmission because of their drug injection practices. Two of the seven had already contracted HIV. The study focused on their high-risk behavior which is related to the research question and set them apart from other groups in the society. The interviews with these individuals will provide some understanding of the behavior patterns of IV drug users in Bahrain. Seven in-depth interviews constituted a sample that provided sufficient data to base some conclusions. More subjects would have been desirable, however, due to the sensitivity of the subject matter, much more time would have been needed to cultivate relationships with more IV drug users. The researcher focused on issues in the study that related to the experiences of all the subjects interviewed. 4. All subjects interviewed in the study answered the questions with enough openness and honesty to allow valid conclusions to be derived from the data. 2 5 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The researcher spent time with each of the subjects to allow relationships of trust to be developed which created a comfortable atmosphere for discussing the sensitive issues of this study. Limitations The three areas of focus of this study are to explore the role of culture in the development and implementation of AIDS education in Bahrain; to understand how the culture has affected the attitudes of young adults (college students) towards the HTV carriers and AIDS patients, and to look closely at the knowledge and behavior patterns of one high risk group in Bahrain, IV drug users, in order to determine how effective the AIDS campaign has been in reaching this high risk group. The study was conducted in Bahrain from July 1993 to July 1994. Most of the interviews were conducted in English. The use of a second-language for some subjects may have limited the depth of their responses. Information regarding HTV numbers, AIDS cases, demographics, and statistics related to drug use were not provided to the researcher by the government officials because these issues are considered to be sensitive and not for publication outside of the few members of the health ministry who are directly involved with these areas. The numbers o f AIDS cases in the region 26 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. were obtained from the World Health Organization. The researcher’s status as a non-Bahraini, and an independent researcher may have prevented her from having access to such information. The researcher, however, believed the interviews with IV drug users were more candid because of the researcher being a non-Bahraini. Since Bahrain is a small island, it would be more risky for a drug user to confide in a Bahraini researcher whom they did not know because they may fear the researcher may know their family or they may feel it is shameful to admit their problem and discuss it openly with anyone outside of their close circle of friends. Furthermore, since drugs are highly illegal in the country, they may fear being turned in by another local, or they may doubt their motives. Therefore, the advantage to the researcher being non-Bahraini, was that the users believed what they said would not go to other Bahrainis or to the police. They also felt that because the researcher was western, she may understand their problem more because to them the west is a place rooted in social problems and westerners are quite familiar with such problems. But because of the difficulty in accessing IV drug users, often the interviews were conducted in extremely informal settings where the interviewer had to do the interview spontaneously with only a notebook and pencil available, but often 27 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. without tape recorder or prepared interview questions. The reliance on a translator for some of the interviews may have diminished the researcher’s ability to understand any nuances in the language of the interviewee. One final area that may have limited the scope of information made available to the researcher was that she was a female interviewing males. While the men were always helpful, and candid in their responses, they may have revealed information about sexual behavior that could put them at risk for contracting HIV if the researcher had been male. The discussions of the transmission of HIV with drug users was limited to their drug injecting practices. Their sexual behavior was not included as a part of this study. The study was limited to a period of one year in Bahrain. If the study had been longer, changes in the approach to HIV/AIDS education may have been observed since the government is continuing its work in this area. The sample size of IV drug users, while studied in-depth, may not be enough to make generalizations to all IV drug users in Bahrain. The composition o f college students used for the study may limit the generalizability of the study to other students. Finally, the majority of those interviewed for the study were male, because most IV drug users in Bahrain are male, most government officials are male, and the technical college where 28 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the student attitudes were examined is primarily a male institute. Interviews with women were gathered when possible, and will be shown in the data collected. Unfortunately it is far more difficult to access females who are using drugs in the Arab world. Even among drug users, the traditional role of the woman is still in the home, and because of the tradition of protecting her honor, it will be highly unlikely that her identity as a drug user would be revealed. Delimitations Interviews are the primary source of data collection for the study. Interviews with government officials were conducted only with those who were actively involved with HIV programs or policy making in a professional capacity. The data collected to examine the role of culture on the attitudes of young adults was limited to college students studying in a technical college in Bahrain. The sample of high risk individuals is limited to seven IV heroin users. 29 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Definition of Terms AIDS - Acquired Immune Deficiency Syndrome is a group of symptoms or illnesses originating from the HTV infection which causes the immune system to stop functioning. AIDS patient - One who has experienced one or more serious illnesses originating from the HIV virus and their immune system is at an advanced stage of impairment, a blood count below 200 cubic millimeters of blood. Arabian Gulf countries - The countries of Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates. GPA - The Global Program on AIDS is part of the World Health Organization’s efforts to stop the spread of the AIDS virus. Its purpose is to coordinate the global response to the AIDS pandemic, including the development of strong national AIDS programs in developing countries. HIV/AIDS education - These two terms refer to the same thing when used with the word education. Both are referring to education programs designed to give people knowledge as to how they can best protect themselves from contracting HTV, the AIDS virus. The most commonly used term for such programs is AIDS education, however, they are also used interchangeably when discussing health education for the prevention of this disease. 3 0 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. HIV- The Human Immunodeficiency Virus is the virus that causes AIDS. It was not identified until 1983. There are at least two major strains, HIV-1 and HIV-2, with numerous variations. Some people have reportedly remained asymptomatic for as long as eleven or twelve years without experiencing any AIDS- related symptoms. HIV infected person - A person who has tested positive for the presence of HTV but may or may not have experienced any AIDS-related symptoms or illnesses. Intravenous drug user - Any person who regularly injects drugs into their body. M aa’tam - A meeting place for Shi’ite Muslims to mourn the death of their religious leader Imam Hussein. It is also used as a meeting place and a place for social activities. Each village in Bahrain has a maa’tam and so does the capital city of Manama. WHO - World Health Organization, a Geneva based international organization established to promote health awareness worldwide. It has numerous programs to control diseases, increase vaccinations, monitor epidemics and to develop health education programs on a global basis. 31 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Organization of the Study Chapter two will present a review of the literature relevant to this study. It will describe the cultural context for the study by reviewing some common AIDS metaphors and show some of the historical connections between religion and disease. It will also address some of the constraints to AIDS preventative education both in the developed and developing world. Finally, it will take a more detailed look into the specific cultural issues that have impacted AIDS programs in the Arab Gulf State of Bahrain. Chapter three will explain the research setting and qualitative methods used for the study. It will also discuss how the researcher accessed the setting and difficulties of conducting fieldwork in Bahrain. It will also offer a richer explanation of the sample being studied. Chapter four will present the findings of the research, including many excerpts from the interviews and an analysis of the issues being addressed. Chapter five will provide a summary of the findings, and recommendations for further research in this area as well as suggestions for more effective HTV education in Bahrain. 3 2 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter II Review of the Literature This chapter will introduce some of the factors that have been influential in affecting public opinion towards the AIDS virus and its carriers. It will present the relevant literature and discuss in depth the various cultural forces and their historical origins which have affected the way modem day society has responded to this infectious disease. AIDS education prevention strategies in developing countries will be discussed to provide a more comprehensive understanding of the role of culture in the planning and development of AIDS programs worldwide. It will also present a sociocultural description of Bahrain, the country where this study took place. AIDS Metaphors Perceptions of the AIDS vims have been shaped by certain myths or metaphors that are commonly associated with the syndrome. Social science and medical researchers have addressed how these metaphors have influenced societies’ attitudes towards the disease and its carriers and have sought to explain the effect metaphors have had on AIDS education programs and their implications in the development of support networks for AIDS virus 3 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. carriers and their families (Fernando, 1993; Landau-Stanton & Clements, 1993; Murphy, 1989; Ross, 1989; Sontag, 1989). While metaphors are culturally shaped and invariably shift from culture to culture, universally they have negatively stigmatized the AIDS virus and those who are infected with it. Often the underlying medical cause of the virus is overshadowed by the “labeling” of its victims which results in the disease becoming a moral issue rather than a medical one. In the United States AIDS has largely been perceived as a homosexual illness because the majority of its initial victims were male homosexuals. Elsewhere, it has been viewed as a disease of promiscuity or associated with drug usage. These associations of AIDS have linked the virus to what many consider an underclass, or the socially deviant in society. Inevitably such associations affect the quality and degree of medical and emotional support offered to AIDS virus carriers. The following section will discuss the metaphors that are commonly associated with the A ID S virus and examine how they affect public perception of the disease. 34 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The Plague Metaphor The persistent recurrence of “leper” and “leprosy” in AIDS discussions and writings is also a part of this metaphor. Lepers are cast out; they are no longer an integral part of the community. Omnipresent analogies between AIDS and leprosy make it seem acceptable to respond to the newer “plague” in the same way that was acceptable for the older one. (Ross, 1989:38) The AIDS virus shares several features with other infectious diseases that have appeared throughout history. Infectious disease has always evoked fear in mankind, particularly those with no known cure. New viruses that appear by surprise are heightened by fears of contagion and societies have frequently looked outside of their indigenous populations for their origin. It is not unusual for moral judgments to be cast on their victims and quarantine recommended as a way of isolating those who are sick from the rest of society. These aspects of disease have existed alongside most major epidemics from leprosy, dating back to biblical times, syphilis in the sixteenth century, the plague in London in the seventeenth century, and cholera in the nineteenth century. All of these epidemics were not only greatly feared, but their victims were also stigmatized and sometimes quarantined. In particular, syphilis, because of its sexual transmission, elicited accusations of moral turpitude, similar to what is said today about AIDS virus carriers (Fernando, 35 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1993). Its victims were pitied, but nevertheless, stigmatized. AIDS, not unlike other diseases, has been the target of a myriad of metaphors which have been imbedded in the psyche of mankind for over a thousand years. Sontag (1989) describes how the diseases that were the most feared were those that destroyed the physical appearance of the body such as leprosy, syphilis and cholera. It was the diseases that grotesquely transformed the human body which were most subject to being labeled as plagues. AIDS, unfortunately, falls into this category. Murphy (1989) cites AIDS as sharing some common plague-like features because it appeared by surprise and it is incurable, but since AIDS is not spread by casual contact, it needn’t inspire the same level of fear of interacting with people such as the bubonic plague did. Murphy (1989) also states that individuals can protect themselves from the virus by education or having access to safe sex materials or sterilized needles for drug users, so there should be no fear or superstition towards contracting the virus. However, even with such knowledge, people still possess an irrational fear towards the virus and its carriers. Some express distrust towards the medical community’s information about AIDS, which results in stories of bizarre ways in which the disease can be transmitted. 36 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The irrational fear of AIDS in “plague” thinking suggests that AIDS may be, in commonsense consciousness, the disease of the nuclear age. AIDS brings to the individual, like the nuclear threat that looms over our culture, the imminent threat of total annihilation. The AIDS retrovirus can suddenly appear in one’s body as if coming from nowhere, and by the time it appears, it is too late for the body to defend itself, even against otherwise nonfatal opportunistic infections. (Murphy, 1989: 56) In Susan Sontag’s (1989) discussion of AIDS metaphors, she affirms that plagues are almost always viewed as judgments on society for sin, and particularly sexually transmitted diseases, which have been cast as punishments not just of individuals but of a group. Most epidemic diseases have been viewed as signs of “moral laxity” or “political decline” as well as being associated with foreignness (Sontag, 1989). Sontag also tells how plagues almost always come from somewhere else. She describes how when syphilis reached epidemic proportions in Europe at the end of the fifteenth century, even its name was changed to make it appear it came from elsewhere. The English named it the “French pox” and to the French it was “morbus Germanicus.” It was named the “Naples sickness” to the Florentines and the “Chinese disease” to the Japanese (Sontag, 1989). Sontag confirms a link between imagining disease and imagining foreignness. 3 7 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. This is apparent when reviewing the perceived origins of the AIDS virus in America and other societies. In the United States, it has been publicized that AIDS came from Africa, and the Haitians have been blamed for “importing” the disease to America. In other countries, the African theory is also publicized, and, similar to the United States, groups outside of the indigenous culture are held responsible for “bringing” the virus into the country. The groups who are blamed are nearly always poor and are minorities. This social division of AIDS carriers by those who make health policy or who are health professionals and by the media creates an “us” and “them” division. AIDS is seen as something that always happens to someone else. Ross (1989) defines this as the metaphor o f otherness or of the divided community: “The metaphor of AIDS as otherness permits people to accept less treatment for those who belong to that other group than they would demand for themselves” (p. 38). Some of the elements of the plague metaphor give rise to further metaphoric language that has been associated with the virus. While these metaphors are distinct in their own categories, they should be viewed within the larger context of the “plague” metaphor as they contain direct or indirect meanings that have historically been associated with plague-like illness. 3 8 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. AIDS as Homosexual and Heterosexual Promiscuity In the United States the AIDS virus was initially associated with homosexuality so researchers overlooked symptoms of the disease in intravenous drug users, in recipients of transfusions, in hemophiliacs, in women, and in babies and children (Landau-Stanton & Clements, 1993). Homosexual sex was the major mode of transmission that was emphasized. According to Landau-Stanton & Clement (1993), the focus on the gay community allowed the disease to spread among IV drug users and blood recipients before blood banks began screening donors. Also, education programs were not being developed or targeted to populations outside of the gay community. This focus produced increasing homophobic reactions among the population. Fernando (1993) describes how the name for the disease “Acquired Immune Deficiency Syndrome” has contributed to the stigmatization of persons with AIDS. The usage of the word “acquired” implies the disease was acquired primarily through homosexual promiscuity and by heterosexual promiscuity as well. Blendon, Donelan, and Knox (1992) argue that it is obvious that the social reaction to AIDS is not a reaction to either the disease 39 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. or the virus, but to the putative manner in which the disease is acquired. Fernando (1993:9) adds that, “It is a reaction to the lack of virtue of the diseased (sexually transmitted disease) of a particular order of unnatural immorality (gay disease), defined and promulgated by the medical establishment itself.” He states that the virus has been given almost “demonic” characteristics. Prevention in the United States started in San Francisco where condoms were first publicized as a means of prevention or of “safe sex.” Landau- Stanton & Clements (1993) state, “HIV infection became linked in people’s minds with sex, creating still another metaphor.” They argue that although the disease was spreading at a parallel pace in the drug community, the publicity was focused on sexual transmission. This may also have been due to the gay community’s ability to organize AIDS awareness groups and publicity both at the political and social level. The sex metaphor has become the principal image for AIDS in people’s minds today. This sex metaphor introduced all the “psychological, social, and cultural complexities of human sexuality” (Landau-Stanton & Clements, 1993). They also cite that the epidemiology of syphilis has not been sufficiently applied to AIDS education and prevention programs and are doubtful that education on a behavioral level 40 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. will actually be sufficient to reduce the spread of HIV, particularly in populations where compliance is uncommon. Some of the results of this exclusive linkage of AIDS and sex have been witnessed in calls for the return of stricter sexual mores and a return to monogamous relationships (Landau- Stanton & Clements, 1993). This has made educational programs more complex because of the sensitivity in certain cultures towards openly discussing sexual behavior. Openly promoting condom use is an example of this. Effective prevention requires a solid knowledge of the culture for which an educational program is being developed (Landau-Stanton & Clements, 1993). Fernando (1993) believes that moral preoccupation with sexual promiscuity has kept AIDS classified as a sexually transmitted disease. He cites that it is mistaken to label it as such because although the disease can be transmitted sexually, the virus has been isolated in the blood and specific sexual activity is only one mode of transmission. He fears that this classification overlooks other groups in the population that may also be at risk for contracting the disease such as hemophiliacs, transfusion recipients, and intravenous drug users. He also criticizes the scientific community for putting people into risk categories such as homosexuals and IV drug users 41 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. because the disease is a behavior-driven disease and it transmitted by blood to blood contact. He argues for the classification to emphasize the behaviors that cause AIDS virus transmission, rather than focusing on a particular population. Fernando (1993) cites other researchers in his work (Fumento, 1990 & Wellings, 1983) who have argued against the classification of AIDS as a sexually transmitted disease. None of these researchers have denied that sexual transmission is possible; it is the fact that this has been emphasized over the specific activities that cause transmission. If AIDS is a sexually transmitted disease, how do we account for intravenous drug users, blood transfusion recipients, and hemophiliacs who become infected with HTV without any reference to sexuality? In Western countries, particularly in the United States, these categories comprise a substantial (statistically significant) number. It is important to insist on the blood-borne nature of the transmission, even where sexual activity is concerned. A clearer appraisal of the blood-borne nature of the disease would have led to more realistic and appropriate preventive strategies rather than to inaccurate classifications of risk categories. STD classification has also led to a moral inquisition about sexual behavior. (Fernando, 1993:19) In Susan Sontag’s(1989) discussion of AIDS metaphors, she notes that moralizing about epidemics in the twentieth century has become something of the past with the exception of sexually transmitted diseases. She offers the 42 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. example of why polio was viewed as an epidemic but not a plague because those it afflicted were children, so it was seen more as a disease of the innocent. However, AIDS is viewed as a disease of the guilty, a punishment for indulgence or moral laxity. The unfortunate consequence of this metaphor is that it has brought about moral judgments on sick people who in this time need help rather than condemnation. Most people today view AIDS victims with pity but also with the notion that they brought it on themselves by their sexually promiscuous behavior or their indulgence in IV drugs. AIDS as a Self-Inflicted Illness Getting the disease through a sexual practice is thought to be more willful, therefore deserves more blame. Addicts who get the illness by sharing contaminated needles are seen as committing (or completing) a kind of inadvertent suicide. (Sontag, 1989:26) The concept of self-inflicted illness has become very popular in American society (Landau-Stanton & Clements, 1993). The authors observe that smoking, obesity and substance abuse are viewed as avoidable behaviors; therefore, the poor health that accompanies them is perceived as well- deserved. When this concept is combined with behavior that is either illegal 4 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. or considered “morally” corrupt, blame and even a punitive attitude towards the patient can result. This kind of attitude can eventually affect the emotional support and medical support the patient receives. Landau-Stanton and Clements (1993) have shown how this attitude is developed. First, the illness is viewed as contracted by a self-chosen risk behavior which makes one accountable for the disease. This result is self-blame and the thinking that it is a self-deserved illness. The patient receives moral, instead of medical treatment because health professionals and society grow to believe that the patient is non-deserving of medical or social resources. Compassion is reduced for the sufferer when the behavior that puts one at risk is viewed as immoral. The authors suggest that this kind of thinking ultimately limits the potential medical and emotional support the AIDS patient receives. The concept o f self-inflicted illness is also accompanied by the idea that it is some form of punishment for engaging in immoral or illegal behaviors. The punishment metaphor is commonly associated with the AIDS virus. AIDS as Punishment for Sin It is not surprising that a disease that has been so strongly linked to moral turpitude is viewed as a punishment. History is filled with accounts of diseases or plagues perceived as punishments for sinful acts. Both the Bible 44 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and the Koran speak of God punishing with diseases and plagues. Historically illnesses, with the exception of personal accidents or injuries, were seen as judgments on communities rather than individuals (Sontag, 1989). The metaphors applied to syphilis were similar to those that are currently associated with AIDS. Syphilis was perceived as retribution for the moral corruption of an individual and the community. Sontag (1989) states how sexually transmitted diseases are commonly viewed as punishments on both individuals and the group for the “general licentiousness” of their society. However, this meaning is not only attached to venereal diseases, any catastrophic epidemic was perceived as a sign of moral laxity or political decline of a community (Sontag, 1989). Sontag offers examples of the cholera epidemic of 1832, which Methodist preachers in England connected with drunkenness, and tuberculosis was seen as a disease of the poor and later linked to alcoholism. The association of illness with sin reflected the adoption of middle-class values of society such as self-control and cleanliness. While later cholera was viewed as a result of unsanitary conditions, it was still regarded as punishment for sin (Sontag, 1989). In the twentieth century, according to 4 5 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Sontag (1989) it has not been common to moralize about epidemics with the exception o f those that have been sexually transmitted. AIDS serves this metaphoric usage because it is not only seen as a punishment for moral laxity, but for homosexuality which is strongly condemned by most religions. The resurgence of traditional metaphors that have been applied to illness and epidemics throughout history reflect some of the present social concerns of society. The association of AIDS with foreignness, that it was brought from Africa or Haiti, and its link to drugs, sexual promiscuity and homosexuality, gives support to conservative political agendas that highlight fears of unabated immigration, abortion, and the “family values” platform. The idea of self-inflicted illness can be understood in terms of the current popularity of practicing a healthy lifestyle which includes self-discipline and moderation, behaviors that appear contrary to the AIDS sufferer who is perceived as indulgent and lacking self-discipline. Looking closely at the historical perception of infectious disease, and given the resurgence of religious fundamentalism both in the East and West, it is not so difficult to see how AIDS has come to be viewed as a punishment for the sinful. 46 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Religion and the AIDS Virus The metaphoric language that has been associated with the AIDS virus has its origins in the deep-rooted religious beliefs that are at the foundation of both Eastern and Western societies. The Judeo-Christian traditions of the West and the Islamic beliefs of the East have been a substantial force in the shaping of mankind’s attitudes towards disease throughout history. While there are differences in the doctrines of these three major religions, they share a common ideology in their perspective on marriage and sexual relationships. These religious doctrines clearly state what constitutes moral and immoral behavior. Homosexuality, drug usage, and sex outside of marriage are strongly prohibited by these religions. Since the AIDS virus has primarily been spread by behaviors that religious doctrine would define as immoral, those who are infected have been subjected to negative stigmatization. Ironically, the negative stigmas that have resulted from religious beliefs have also been countered by calls of compassion towards those who are ill by religious leaders themselves. It is critical to have an understanding of how organized religion has responded to this epidemic because of its pivotal role in influencing the public’s perception and response to the virus which 47 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. directly affects health policy, health education and support networks for AIDS patients and their families. AIDS and Religious Doctrine Islam, Christianity and Judaism emphasize the importance of marriage in their religious scriptures. Marriage is viewed as a sanctimonious relationship between a man and a woman for the purposes of procreation. Islam views marriage as a favor from God that should be followed whenever possible. And God has made for you mates (and companions) of your own nature, and made for you, out of them, sons and daughters and grandchildren, and provided for you sustenance of the best: will they then believe in vain things, and be ungrateful for God’s favors? (Koran, 16:72) Islamic statements have also referred to marriage as a way of protecting men and women from immoral behavior by legitimizing sex only through the marriage relationship (al-Awwa, 1992). The Believers must win through, those who humble themselves in their prayers; who avoid vain talk; who are active in deeds of charity and who abstain from sex, expect with those joined to them in the marriage bond, or (the captives) whom their right hands possess, for they are free from blame, but those whose desires exceed those limits are transgressors. (Koran, 23:1-7) 48 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Both the Bible and the Torah also encourage marriage relationships: Then the Lord God said, “It is not good that the man (Adam) should be alone; I will make him a helper fit for him.” (Bible, Genesis:2:18) This at last is bone of my bones and flesh of my flesh; she shall be called woman, because she was taken out of man. Therefore a man leaves his father and his mother and cleaves to this wife, and they become one flesh. (Torah, Genesis: 2: 21 passim) While the religious scriptures strongly show interest in marriage, they also issue harsh condemnations for adulterers and homosexuals. The woman and the man guilty of adultery or fornication, flog each of them with a hundred stripes. Let not compassion move you in their case, in a matter prescribed by God, if ye believe in God and the Last Day: and let a party of the Believers witness their punishment. (Koran, 24:2) Then you shall bring them both out to the gate of that city, and you shall stone them to death with stones, the young woman because she did not cry in the city, and the man because he violated his neighbor’s wife; so you shall purge the evil from the midst of you. (Bible, Deuteronomy 22:24) If a man lies with a male as with a woman, both of them have committed an abomination; they shall be put to death; their blood is upon them. (Bible, Leviticus-20:13) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Of all the creatures in the world, will ye approach males, and leave those whom God has created for you to be your mates? Nay, ye are a people transgressing all limits! (Koran, 26:165-166) The use of intoxicants has also been condemned by the major world religions. This is clearly reflected in Islamic statements referring to the use of intoxicants. Ye who believe! Intoxicants and gambling, (dedication of1 ) stones, and (divination by ) arrows, are an abomination, of Satan’s handiwork: eschew such abomination, that ye may prosper. (Koran, 5:93) The above citations from these three religious doctrines share the common theme that sexual relationships outside of marriage are prohibited as well as the use of intoxicants. Severe punishments are prescribed for those who disobey. Additionally, they condemn homosexuality with equally punitive language. Unfortunately the AIDS virus has come to symbolize participation in behaviors that are prohibited by these major world religions. This, in effect, has created conflict for organized religions because in their 1 “dedication of’ in this phrase refers to ancient columns and stone slabs that were used for superstitious rituals in the pre-Islam era. 50 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. issuance of moral condemnation, they are also required to show compassion for the ill. Religion and Morality: Compassion or Condemnation Religions have always encouraged their followers to show compassion for the sick. In the Christian Middle Ages when the plague was viewed as a punishment for sins, religious leaders prescribed prayer and penance for its sufferers but at the same time insisted that those who were stricken be cared for (Jonsen & Stryker, 1993). This was a common response from the religious clergy towards epidemic disease which remained constant until the cholera epidemics in the United States in the nineteenth century. By the third outbreak in 1866 scientific inquiry began to take hold belongside theological explanation, as scientists identified contaminated urban water as the source of contamination (Jonsen & Stryker, 1993). Subsequent epidemics, with the exception of sexually transmitted ones, were rarely subject to theological commentary. AIDS and Morality in the United States The AIDS epidemic, however, has not been spared from theological interpretations. In feet it has created a conflict for religious authorities because the groups it has most commonly attacked have been male 51 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. homosexuals in the United States, and IV drug users, both considered to be committing evil acts against God. Its associations with promiscuity and sexual deviance has made it particularly vulnerable to the “divine providence” interpretation. Those who have engaged in such sinful acts are seemingly deserving of such a punishment according to some adherents of Christianity, Judaism and Islam. But as the virus has spread outward to other communities, major religious denominations in America have not adopted this position. Contrary to what had been expressed in earlier times during epidemic outbreaks, some Christian and Jewish leaders in the United States declared that God does not punish by disease (Jonsen & Stryker, 1993). But the AIDS virus did create problems for religion because many homosexuals who had previously been condemned by religious doctrine were now needing care. The reactions to this complex dilemma varied from what Herek and Glunt (1991) defined as two psychological dimensions, pragmatism/moralism and coercion/compassion. They based their concepts on a telephone survey they conducted on AIDS-related attitudes and found that the responses to certain questions such as distribution of condoms and clean needles brought about a 52 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. a variability of opinions. Those who endorsed such policies were labeled as pragmatists as they believed action was needed to prevent the spread of the virus regardless of any moral concerns. Those who rejected them were defined as moralists, possibly viewing the disease as a punishment from God. hi addition to presenting the moralist and pragmatist point of view, Jonsen & Stryker (1993) also defined those in their telephone survey who saw the infection as a punishment from God as having a coercive orientation, blaming individuals for the infection themselves. They favored coercive action such as quarantine, and those who rejected such a stance were defined as having a compassionate orientation. Jonsen & Stryker (1993) used this typology to define the various responses of religious organizations to the epidemic. In regards to the first dimension, pragmatism/moralism, the religious organizations have generally favored moralism over pragmatism, rejecting policies that supported distribution of condoms and clean needles for IV drug users. They have also been unwilling to openly discuss methods for safe sex out of fear that such discussion would appear to be condoning such behavior. Their focus has been on the moral prohibition of sexual behavior outside of marriage and of homosexuality rather than techniques to avoid infection (Jonsen & Stryker, 1993). In their attitudes towards HIV infected persons, 53 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. religious institutions have shown greater diversity in their opinions. Certain fundamentalist groups such as the Moral Majority have supported punitive policies towards infected persons and towards groups affected by the epidemic. This reaction was labeled by Herek and Glunt (1991) as punitive moralism. However, the Catholic church has officially urged compassion for people with AIDS while it refuses to support education about condoms (Jonsen & Stryker, 1993). AIDS and the Catholic Church in the United States The Catholic church in the United States encourages support and compassion for those infected with AIDS, but rejects ‘safe sex’ education, instead advocating adherence to God’s laws of chastity before marriage and opposition to adultery. Fear of appearing to be “soft on sin” has restricted some of the possible activities and support the religious communities could offer in the realm of education for prevention, however, compassion for the sick has allowed some religious organizations to provide care for those with AIDS (Jonsen & Stryker, 1993). In 1987 the Catholic bishops of California issued a letter to remind their followers that those suffering from AIDS should be treated with the same love shown by Jesus for the lame, lepers, the blind, and others that he healed. 54 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. They extended their support to the homosexual community, particularly to those who had been separated from the church. It endorsed the obligation of Catholics to care for those with AIDS and not to discriminate against the infected. It also advocated, in line with Catholic teachings, abstention from sex as the main mode of prevention. It even stated that it was aware that not everyone would follow this morality so it could tolerated the mention of condoms in its educational programs about prevention. Their position was justified by reference to a traditional doctrine of moral theology - the toleration of a lesser evil in order to prevent a greater evil (Jonsen & Stryker, 1993). However, this new position was also criticized by some leading authorities in the Catholic church. Currently their position on the teaching of condom use appears to be divided into two positions: one which permits education about condoms and the other which advocates abstinence as the mode of prevention but does not explicitly prohibit education about condoms (Jonsen & Stryker, 1993). The Catholic church continues to provide a network of social services to provide assistance to person with HTV or AIDS. Their response has shown how religious leaders and institutions can be instrumental in AIDS education 55 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and support even when the lifestyle or behaviors of those who contract the disease go against deeply ingrained theological traditions. According to Jonsen & Styker (1993), it is imperative that societies elicit the support of religious groups to fight against the AIDS epidemic because even with their conservative doctrines they can contribute significant energies and resources. Their prominent role in influencing pubhc attitudes can be instrumental in challenging prejudices and discrimination against those infected with the AIDS virus. This is true worldwide and particularly in traditional societies that are governed by their religious beliefs such as Latin America, Ireland, and the Islamic countries of the Middle East. HTV/AIDS Prevention in the Developing World The WHO has worked worldwide with local health ministries to ensure that education to prevent HIV transmission exists in every country. However, agreement on sex education programs, their content, to whom they are targeted, condom distribution, needle exchange programs are highly debated issues because of differences in culture, religious beliefs, differing political systems, and ideologies that exist even within supposedly homogeneous societies. 56 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The paradox of HIV infection is that on the surface it is the most easily avoidable of all lethal infections, acquiring it is the result of known, specific forms of behavior. Furthermore, the use of a simple barrier device during intercourse, that is, the condom, is known to be quite effective, as is the use of a sterile needle during an intravenous drug injection. The patterns of risky behavior that prevail among members of specific groups (homosexuals, bisexuals, intravenous drug users, and adolescents) and preventing vulnerable behavior in the heterosexual population at large are the avowed goals of public education programs. But although there is broad consensus about the goals of educational programs designed to control the epidemics in both the developed and the developing world, dissension and controversy swirl around the specific objectives, appropriate targets, and nature of the messages to use. (Sills, 1994:175-176) According to Sills (1994) one of the main problems that educators have faced is the universal dislike of the explicit language needed to assure safe sexual practices. He offers examples of sex education programs in the UK which were met with hostility because their language was considered offensive, and how in the United States the need for AIDS education has exacerbated the controversy over what constitutes proper sex education content in the schools. Fineberg (1988) defines the controversy by two perspectives: the moralist view which follows religious doctrine more 57 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. carefully, and perceives condom education and needle exchange programs as condoning sinful behavior, and the rationalist view that sees that these behaviors are a reality and that education is needed to make such behavior safer. The social and religious obstacles that have slowed the development of AIDS education programs in the West are intensified in developing countries because of a shortage of economic resources. Mann (1992) notes that only six percent of worldwide expenditures of AIDS are spent in the developing world while the developing world accounts for eighty percent of all HIV infections. Stronger links to tradition, low-status of women, religious conservatism, cultural taboos, cultural rituals, and political agendas have also affected the development and content of AIDS programs in the developing world. HIV/AIDS Prevention in Asia In India, AIDS education through the mass media has been partially successful in reaching the more educated segment of the Indian population according to a study conducted in Calcutta (Porter, 1993). The study examined the knowledge of AIDS among university students and found that while most of the respondents had heard about the disease through the mass 58 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. media, very few had received information about AIDS from educational or religious institutions. Incorrect beliefs about how the virus was spread were common. About 20% of the men did not know that the infection could be acquired through blood transfusion, and an equal percentage of women did not know that the virus could be spread by using contaminated needles. The lack of knowledge regarding transmission may also contribute to discrimination against infected individuals because individuals may feel at risk by the mere presence of an HTV infected person. Only 5% of the respondents questioned mentioned condoms as an effective means of preventing transmission of the virus (Porter, 1993). The author mentioned that condoms are sold openly on the streets of Calcutta and in other large Indian cities but that prostitutes in some areas are reluctant to use them. Perhaps they believe that clients may not want to use condoms or they are unaware of the risk of contracting HIV. Since newspaper and television were the most common sources of information about AIDS, the less educated are not as likely to be reached because of high rates of illiteracy and lower socio-economic status. In another study Jacob (1989) found illiteracy and lower socioeconomic class to 59 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. be associated with a lack of knowledge about AIDS. Prostitutes and homeless people in Calcutta revealed little to no knowledge about the disease. This study showed that educational efforts are bypassing the less educated groups which are possibly at a higher risk, particularly commercial sex workers. While the social environment of India is diverse, there is largely a climate of sexual conservatism among the population. In order for AIDS education to be effective, education interventions need to be designed to reach all segments of the population, and more comprehensive information regarding transmission of the virus and the use of condoms must be included if India is to prevent a major AIDS epidemic. Thailand has had to actively initiate a number of AIDS educational prevention programs due to the dramatic and continuing increase of HIV infections in the country. The first approach to AIDS education has been to target the high risk groups and high risk areas of the country by the use of mass media which included television, radio, and posters. Government and non-governmental organizations have been involved in the country’s efforts at HTV/AIDS education. The Thai government openly acknowledges the seriousness of the AIDS problem and has established an AIDS Prevention and Control Center which is 60 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. headed by the Ministry of Public Health. It runs an intensive educational campaign that makes use of all forms of media, including the use of mobile AIDS units to provide information. The Thai Red Cross also runs a prevention program for prostitutes and drug users and conducts HIV testing and provides hospital care for people with AIDS. According to Maticka-Tyndale (1994), men, prostitutes and injecting drug users in the cities of Bangkok and Chiang Mai were the initial targets of the country’s AIDS prevention programs, but recently rates of HIV have increased and spread to areas in the northeastern region of Thailand. A study of women living in rural villages in the northeastern region of Khon Kaen province was conducted between 1991 and 1992 and found that women had received most of their information about AIDS from television and radio. The results also indicated that general knowledge regarding modes of transmission of the virus were good. Prostitution and contaminated needles were seen as the major modes of transmission by these women. However, focus group discussions combined with surveys and observation revealed that this knowledge had not been applied to their own personal lives to help them avoid HTV infection. 61 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Few women identified themselves at risk even though they recognized that their husbands may have frequented prostitutes. Women who reported condom use as a method to protect themselves from infection only did so for brief periods immediately following their husbands’ visits to prostitutes. They believed the risk of transmission was short-lived. The majority of women knew how to obtain condoms but half indicated they were too embarrassed to buy them. Women indicated awareness of the risks their husbands were taking by going to prostitutes but they did not extend the risk to themselves and therefore did not take necessary precautions to protect themselves. There needs to be clearer and more comprehensive education so that areas of ambiguity can be eliminated. Of particular importance to these women is to have knowledge as to how HIV can be transmitted to them, and how they can best protect themselves from infection. Cultural inhibitions about purchasing condoms and discussing condom use with their partners should also be addressed. Additionally, they need to realize that the lack of outward symptoms and a negative blood test do not necessarily negate HIV infection for the present and future. The focus groups combined with survey and observation provided an opportunity for researchers to evaluate the 62 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the effectiveness of current health educational initiatives. The results showed the need for more specific health initiatives to prevent the spread of HIV. They also provided the researchers with the knowledge as to best avenues for providing this information. Researchers found that village women trusted those who worked in the health and medical profession and their village leaders. This suggests that AIDS promotion might use the “existing infrastructure of leadership, health, and medical services to reach villagers” (Maticka-Tyndale, 1994:217). Researchers also found that women applied stories they had seen or heard on television or radio more directly to their own lives than abstracted rules and information regarding HIV transmission. Using scenarios that relate directly to these women’s lives may be a useful method for imparting AIDS information. Stories could be used by health workers or village leaders as part of a village education program (Maticka-Tyndale, 1994). Follow-up or evaluation of health campaigns is a necessary means to conclude what has been effective and what has not. This study made use of three methods of evaluation; surveys, focus groups and observation. The rich information that emerged demonstrates the benefits of utilizing a triangulated methodology when examining a topic of such importance. 63 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Other studies show the need for more education among lower socio economic groups, particularly commercial sex workers and their clients in Thailand. Berer (1993) found that sex workers from lower-priced brothels in Thailand were reported to have a higher incidence of exposure to H TV because they see more clients to earn a living and clients in lower-priced brothels more frequently refuse to wear condoms than those in higher-priced brothels. In lower priced brothels, it was reported that 36% of the women had HIV, and only 5% had the infection in the higher priced brothels (Berer, 1993). Prevention programs need to consider the economic and cultural realities in which these women live in order to design successful intervention strategies. It is estimated that there are half a million heroin addicts in Thailand, of which 400,000 live in Bangkok (Ismartono, 1989). Transmission of H TV among injecting drug users in Bangkok increased from one percent in late 1987 to 15% in March 1988 to 43% in the fall of 1988 (Des Jarlais et al., 1994). As a result, education programs that targeted this specific group were implemented. Education occurred in the form of posters in drug abuse treatment centers, and counseling drug users not to share their injection equipment and to purchase sterile injection equipment at the local 64 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. pharmacies, which is legal in Thailand. Free bleach, an easy method for sterilizing needles, was made available in Bangkok’s drug rehabilitation centers. Health officials also educated users about HIV and sexual transmission, distributed condoms and provided HTV testing (Des Jarlais et al., 1994). In the fall of 1989, 92% of the subjects reported that they had changed their behavior to reduce the risk of contracting HIV. Fifty-nine percent reported that they had stopped sharing their injecting equipment because of concern about AIDS and the seroprevalence of HIV stabilized to thirty-nine percent. By 1990 seroprevalence of HTV infection in drug users dropped to 34% (Stimson, 1995). This study took place over a two year period, 1987 to 1989, and showed that drug users will change their behavior if given the right information as to how to reduce the risk of contracting HIV. Thailand has worked to develop effective education campaigns that have targeted this specific group. Although HIV is increasing in Thailand, it appears to have stabilized among the drug injecting community. Indonesia, which has a much lower incidence of HIV infection, is at risk for a larger epidemic if the country does not develop more comprehensive AIDS educational interventions. A study that was conducted in 1991 (Fajans et al., 1995) examined the knowledge and risk behaviors of clients of female 65 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. commercial sex workers in Bali, Indonesia. The study found that the clients, who were from varied socioeconomic backgrounds, had low levels of knowledge about HTV transmission and prevention, multiple sexual partners and indicated low frequencies of condom use with these partners. Men who regularly visit commercial sex workers are at risk of spreading the virus throughout the country. Men reported that they use strategies such as partner selection when visiting commercial sex workers and therefore believe that condom use is unnecessary. It is evident that a multi-faceted AIDS campaign which targets specific groups, particularly sex workers and their clients is necessary to prevent spread of the virus. An effective campaign will need to include mass media, which may challenge current Indonesian cultural norms (Fajans et al., 1995). Educational messages will also have to target low price sex workers in as simple language as possible so the message can be easily understood by those with low levels of education. Hong Kong has used the mass media to produce advertisements promoting condom use which have been shown in cinemas and on television(Wong et al., 1994). But in mid-1993 when interviews were conducted with commercial sex workers and their clients, it was revealed that 66 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 18.5% and 22% of sex workers and their clients never wore condoms, and 55% and 50% seldom wore condoms with paying and non-paying partners respectively (Wong et al., 1994). In this study, only 38% of the sex workers always used a condom with their clients and the percentage decreased with those aged over thirty perhaps due to longtime habits or the need to be more desirable because of their age. An additional increasing concern to health officials is the number of sex workers who do not use condoms with non-paying partners. If their non paying partners are involved in high-risk behavior, the virus could easily spread to them and their clients. When clients were questioned about whether they would be willing to use condoms, 27% to 43% of the male clients indicated that they would use condoms if requested or provided by their partners. This study underscores the need for further condom promotion including making them readily available in commercial sex establishments. In addition to condom promotion, health services such as counseling, unprejudiced treatment of sexually transmitted diseases and accessible clinic hours need to be to be made available in Hong Kong in order to prevent further spread of HIV on the island (Wong et al., 1994). 67 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The high risk groups for HTV transmission in the Philippines are commercial sex workers and overseas contract workers. Commercial sex workers, known as “hospitality” girls are required to be tested regularly for H TV . As a result of the high numbers of this particular segment of the population being tested, more than 50% of the HIV positive cases in the Philippines are found among commercial sex workers (Tan, 1993). According to Tan (1993) this reinforces cultural biases that associate women with sexually transmitted diseases which in Filipino means “women’s diseases. Sex workers come from socially disadvantaged backgrounds which puts them at additional risk for H TV infection. When workshops were offered to sex workers, those who did not finish primary school showed little change in their knowledge while those who finished high school showed substantial improvement. The Health Action Information Network project provided several workshops for each sex worker and intensive interpersonal counseling. Most of their target audience had not finished primary school. Evaluation of the workshops confirmed a need for ongoing AIDS education, as the “one time” HIV prevention strategy was not as effective as health officials had hoped. 68 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. There is also a non-governmental organization that is a drop-in center for street children and sex workers in Manila to provide social support, but no studies to date have been conducted on the effectiveness of this center. Since sex workers start young, most of the reported cases of HIV are found in the 15 to 30 age group for women as compared to the 20 to 40 age group for men. Health officials fear that sex workers who are infected may go underground, either migrate to another city or return to their rural villages where they could spread the infection. Overseas contract workers also report engagement in sexual activities but do not believe themselves to be at risk for H TV (Tan, 1993). The economic situation of the Philippines has affected the quality of social services, especially in the areas of health and education. Cultural barriers to HIV education also exist because of the conservative Roman Catholic religious environment. The conservative religious culture limits the open discussion of sexuality in the media, and also reinforces denial, scapegoating and stigmatization (Tan, 1993). Women’s ability to initiate risk-reduction behavior with their partners is limited by the culture, particularly the idea of “machismo” which is an integral part of the Filipino culture that supports male domination over 69 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. women. The social consequences of H TV disease will be the most adverse for the poorest Filipinos, and given the stigma attached to the disease, the extended family system may not be supportive to those who have the disease (Tan, 1993). If a comprehensive and effective HIV prevention program does not target these two high risk groups, the social and economic costs will be staggering for a country that is already in financial crisis. Some of the culturally suitable strategies to promote HTV prevention materials to Asian communities in America may prove useful in Asian countri The Asian Pacific Health Care Venture, Inc. of Southern California sponsored a forum to discuss culturally suitable methods of HIV education prevention for Asians and Pacific Islander communities. Prevention methods included the use of peer educators who are knowledgeable about their community and to promote their educational message through items that are commonly used in the community such as the Chinese Red Envelope which is used in the new year to give money. Information on safe sex would be enclosed in the envelopes and distributed throughout the year. Chinese fortune cookies were used by one group that included an HIV testing antibodies message and phone numbers inside the wrapped cookies. 70 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Another tool proposed was to print HIV educational messages on the back of trick cards which are small pieces of paper used for exchanging phone numbers in bars. The messages on these materials was always offered in their native language. The need to gear educational efforts towards nonliterate as well as literate members of their population was also stressed. Members of the forum believed that by offering a more private, non-Westem approach to AIDS education, they might have more success (Yep, 1994). Some common deficits of the above mentioned programs have been the difficulties of targeting groups from lower socioeconomic, less educated backgrounds, particularly commercial sex workers and their clients in Asia’s larger cities. Educational materials tend to overlook non-literate populations, who are often engaging in high risk behaviors. Follow-up, evaluation, and the provision of counseling and health services are often missing components of health educational programs in countries with less developed economies. Health campaigns have been implemented but there is still a need for more comprehensive, explicit educational programs, particularly ones that are on going, rather than “one shot” programs. Culturally-suitable methods such as the programs in northeast Thailand have had higher degrees of success, but also demonstrated the need for a variety of educational approaches, one being 71 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the focus group, which lent itself to a broader, more open dialogue regarding the knowledge, practices and beliefs of the target audience. Such information is essential if health educators are to ensure preventative education is effective. HTV/AIDS Prevention in Africa The WHO estimated that more than eight million adults in Africa were infected with HTV in 1993 and it was predicted that five million children would soon be orphaned in ten East and Central African countries (Kalibala & Anderson, 1993). The majority of HIV infections on the African continent have been transmitted through unprotected heterosexual intercourse. In some regions of Africa, twenty-five percent of urban adults are HIV-positive. Africa has lived the longest and been hit the hardest with the virus. Initially the epidemic spread through the urban centers of Central and West African countries, but now it has spread throughout the continent, including rural areas. There is evidence that socio-cultural factors have affected the transmission of the virus. Rapid urbanization, the separation of male migrant laborers from their families, and the lack of economic opportunities for women and general ill health and poverty have weakened the marital relationship and increased 72 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. rates of prostitution (Scott et al., 1994). Modernization has also led to an abandonment of the tribal moral customs and resulted in the spread of sexually transmitted diseases (Grmek, 1990). Sterilized needles are often unavailable for the purpose of injecting drugs and for the numerous vaccinations given to prevent the spread of contagious diseases. Even though disposable syringes are used, African nurses and village doctors utilize old syringes because of lack of resources to purchase enough new ones (Grmek, 1990). Because of the rapid and increasing infection rates, educational efforts have been widespread throughout the continent, however, socio-cultural attitudes, beliefs and practices have affected the interpretation and effectiveness of HIV/AIDS educational programs. A Knowledge, Attitudes and Practice (KAP) survey that was conducted in Rwanda indicated that 66% of the respondents believed that they were at no personal risk at contracting the AIDS virus. Respondents demonstrated knowledge of the disease and how it was transmitted, but felt it belonged only to those who were prostitutes or “promiscuous” males (Scott et al., 1994). Some of the early AIDS campaigns in the region used poster drawings of what were meant to be prostitutes accompanied by warnings to men to be faithful to their families. Such a prevention message resulted in the blaming 73 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. of prostitutes as the “guilty” ones for spreading the virus. It may have also discouraged other possible high risk groups from viewing their own behavior as high risk (Scott et al., 1994). None of the respondents in the Rwanda survey mentioned using condoms during intercourse as a means of protection from the virus. An anthropologist (Taylor, 1990) believed that the survey was flawed because it neglected to ask Rwandans why they did not use condoms and this information was essential to conducting a successful educational campaign. Rwandans believe that to be a moral person it involves “gifts of self’ which constitute the exchange of fluids in sexuality and reproduction. Condom use is resisted because it restricts or blocks this important exchange between partners and prevents fertility. Power dimensions and gender roles also effect prevention behaviors. Women from Kigali, Rwanda with steady partners have little economic independence and have little control over sexual decision making (Straten et al., 1995) Anything perceived to block their fertility is considered to undermine their cultural role. Successful prevention strategies have included couple counseling in which a higher rate of cooperation was found when both the husband and wife were counseled together regarding safe sex practices 74 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. (Straten et al., 1995). An important lesson to be drawn from this cultural information is that HIV/AIDS health educators need to have sufficient information of the culture in which they are working to provide effective information and dialogue to prevent transmission. Additionally, follow-up or evaluative studies need to include a qualitative research component in order to render essential information about the target population that quantitative studies may overlook. In Zimbabwe, religious and social norms emphasize the importance of reproduction, and men and women are not considered to be adults until they have had children. If a couple dies childless, it is believed that they can not be accepted into the spirit world of their ancestors and that they will wander the earth as disturbed spirits (Mutambirwa, 1991). These beliefs make it difficult for women to insist on using condoms and not to have children if they are HIV positive (Scott et al., 1994). Another example of a cultural belief that affects AIDS education in Zimbabwe is the sexually transmitted disease “runyoka.” This fatal disease has similar characteristics to AIDS and locals believe that it is a curse that a married man places on his wife to punish any man who enters into a sexual relationship with her. There is also the belief that it may strike a man who 75 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. has sexual relations with his wife during a time which is considered “taboo” such as during menstruation or following a miscarriage. In a 1991 survey conducted in Zimbabwe by Save the Children, it was indicated that twenty-five percent of the respondents from rural areas believed runyoka was the same as AIDS (Scott et al., 1994). The problem this has created is the strong stigma attached to those who have the disease runyoka is also put on those who have contracted the AIDS virus. They are seen as guilty of involvement in illicit relationships. Additionally, the belief that the two are the same disease may lead women to believe that if they are faithful to their husbands they can not be infected with HIV and therefore will not take the necessary precautions to protect themselves. These examples give evidence to the critical need for AIDS programs and organizations to explicitly understand the socio-cultural context of the areas in which they are implementing programs. While it may be difficult for educators from the outside to have such an explicit understanding, certainly local health educators can contribute greatly by using their knowledge of the culture to project possible obstacles to successful implementation of HIV/AIDS educational programs. 76 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Studies on HIV/AIDS prevention in Tanzania indicate that levels of knowledge of A D D S have little impact on behavior change. Principal preventative strategies have focused on the reduction of the number of sexual partners and the use of condoms (Kapiga et al., 1995). An increase in the use of condoms has been reported among sex workers, but a very small percentage of housewives reported ever using condoms. Most of the respondents indicated that they did not use condoms because men did not like them and that men’s negative attitudes about condoms were the main reason women did not use them. This finding shows that the effectiveness of any prevention program to promote condoms should also include efforts to change male attitudes towards condom usage. It is also necessary to stress the empowerment of women to allow them greater latitude to discuss with their partners matters related to sexuality. In 1992 the Islamic Medical Association of Uganda designed an HIV/AIDS prevention project. An initial survey was conducted to assess knowledge, beliefs and practices among the Muslim population in Uganda. The findings indicated the less than ten percent of the population knew that condoms could protect against HIV transmission. In the mid to late eighties HTV prevention efforts involved public education and the mass media. The 77 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. content focused primarily on the provision of knowledge of the virus and how to recognize signs and symptoms of AIDS (Kagimu et al., 1995). Despite this educational campaign, by the nineties, AIDS has increased dramatically in Uganda. The importance of using the religious leaders (Imams) to disseminate AIDS information was recognized early on, but they tended to speak about AIDS as a punishment for illicit sexual relationships rather than deliver specific AIDS prevention messages. Programs to stress condom promotion are controversial in Uganda because of the conservative religious environment. Certain practices of the Muslim community such as polygamous marriage, male circumcision and ablution of the dead could put individuals at risk of HIV infection. Specific educational messages need to address these practices so they can be done without risk of HIV infection. In 1992 the “Family Education and Prevention Through Imams Project” began. Ten Imams received intensive training in HIV/AIDS and community education skills. Subsequent to their training, men and women were selected by the community at each mosque and were trained as family workers. They are responsible for fifteen families whom they visit every month to provide education and motivation for behavior change (Kagimu et al., 1995). 7 8 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Although the program is still new, it appears to have been met with enthusiasm. Both Muslim and Christian religious leaders are still reluctant to promote condoms because of the belief that they are for use outside of marriage and therefore promote sexual promiscuity. However, the project has encouraged some Islamic leaders to discuss condom use because of the severity of the AIDS epidemic in Uganda (Kagimu et al., 1995). Deep-rooted cultural beliefs that are often misunderstood have indeed affected HIV/AIDS educational prevention efforts in Africa. The examples above demonstrate the importance of health educators not only understanding the culture but using what is within the culture to facilitate prevention education. HIV/AIDS Prevention in the Caribbean and Latin America Brazil has the largest number of AIDS cases in Latin America of which 78% are found in the country’s two largest cities, Rio de Janeiro and Sao Paulo (Genasci, 1988). In the early days of the epidemic, the government, faced with huge foreign debts and the majority of its population living in poverty, did not recognize the disease as a priority, but in 1987, because of the increasing HTV infections, the government embarked upon a multi-media 79 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. campaign which included the distribution of pamphlets in airports, posters, newspaper and television. The same year the government made it mandatory for blood banks to test donated blood. In Brazil, 15% of AIDS victims were infected by blood transfusions and 70% to 80% of hemophiliacs are estimated to be infected with HIV (Genasci, 1988). The city of Sao Paulo trained health workers and opened the country’s first walk-in AIDS clinics in 1988, but Rio had not set aside any funds to combat AIDS. The government’s slow response to the epidemic left much of the treatment up to private companies to educate their employees. The Brazilian family planning organization distributed condoms and pamphlets to prostitutes and homosexuals. Brazil’s largest television network also organized a public education campaign that stressed that AIDS is not only limited to high risk groups. While most of the public education has been left to the private sector, the government did allow AIDS and sex education to be put into the curriculum of public schools in the late 1980’s, which was controversial for a long time because Brazil is a Catholic country. One of Brazil’s high risk populations are the country’s street youth who live on the streets of Brazil’s cities. Between 7 and 17 million youth work, and up to 7 million children and adolescents five on the streets of Brazil’s 80 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. cities (Raffaelli et al., 1995). Research has shown that the early and frequent sexual activity that street youth frequently engage in, often for survival, puts them at risk for HIV infection (Raffaelli et al., 1995). In a study conducted on street youth in 1994 (Raffaelli et al., 1995) street youths’ expressed a high level of knowledge about AIDS but also held many misconceptions about its transmission. Most of their information was obtained from the media. The most common risk reduction strategies used by street youth were a reduction in the number of sexual partners. Condom use was reported by less than a fifth of the sample studied. The findings of the study indicated that Brazil is in immediate need of HIV/AIDS prevention programs that will reach this segment of the population and promote risk reduction strategies. According to Luna & Rotheram-Borus (1992), In order to persuade street youth to change their behavior it is important to meet their basic survival needs. Before youth can be convinced to take precautions against a disease that may not affect them for several years, they must be given adequate food, clothing, shelter, and medical care so that they have a positive sense of security and survival in the present (pg-8). si Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Prevention strategies require an on-going effort and evaluation to be certain this population is being reached and changes in behavior occur. This particular social problem demonstrates the complexity of the task health educators face when developing strategies for HIV/AIDS education. The social context of the disease requires a multi-dimentional approach in order for prevention education to be successful. HIV/AIDS prevention efforts in Honduras have included the targeting of commercial sex workers. One study (Fox et al., 1993) took place over a ten- week period where CSW’s were given a series of talks by ministry of health officials and free condoms were distributed. This intervention strategy was successful for the time it was applied as there was a noted decrease in STD’s for the time the study took place (Fox et al., 1993). It was also observed that women who charged higher fees were more likely to insist on condom use. Younger women generally charge higher fees and are better able to negotiate with their clients. The findings of this study indicate the need for HIV/AIDS programs to consider psychosocial issues among commercial sex workers such as self-image and the power to negotiate(Fox et al., 1993). Information gained from this study parallels that of studies of commercial sex workers in other countries and the importance of not only educating these women about 82 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. HIV/AIDS, but also the need to inform the clients of CSW’s of the risk they too are taking for themselves and their families. The Caribbean region has large numbers of HIV infected people. At the outset of the AIDS epidemic, Haitians as a group were considered to be high risk for HIV infection. But today, all the different islands in the region have reported HTV/AIDS cases and efforts to educate their populations. Trinidad and Tobago have had AIDS prevention programs since the mid-1980’s. Educational programs included posters and television spots. More imaginatively, they have used the arts to promote HIV/AIDS education. Local playwrights have used AIDS as the theme in their stories and songs have been written about the disease (Ransome, 1990). The plays and songs circulated throughout the villages on the islands. This campaign was met with enthusiasm, and although no evaluation has been published regarding the effectiveness of this approach, plays have been an effective means of publicizing prevention messages about HTV/AIDS in other regions of the world (Maticka-Tyndale, 1994). More recently, in 1990, health officials realized the necessity to target small community groups in the context of the family. Community workers were sent to talk to women without primary school infection about HTV (Ransome, 1990). The focus of the new health 83 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. campaign is still on HIV/AIDS prevention, but there is an additional focus on the need to care for those who have HIV infections and to avoid stigmatization of patients. All of the Latin American and Caribbean countries have reported HIV infections and AIDS cases. The struggle to implement widescale, comprehensive health campaigns that also address the social context of the disease is a challenging task. And to do so effectively requires funds that many of the countries of this region lack. NGO’s and other outside agencies have contributed to the effort, but the problem remains immense. Fortunately, the countries of the region all agree on the urgency of such efforts and have taken steps to increase their prevention programs. HIV/AIDS Prevention in the Middle East The Islamic countries of the Middle East, particularly the Arabian Gulf countries, have low infection rates compared to other regions of the world (WHO, 1994), perhaps because of their strict adherence to Islamic traditions which have been reinforced over the past twenty years due to the increase in Islamic fundamentalism in the region. This religious conservatism has served to reinforce religious traditions, particularly among the youth, as religious 84 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. fundamentalism is often associated with an identity that is anti-western and more recently with political platforms that propagate democracy as a replacement for the autocratic regimes in the region. As a result, the traditional religious attitudes towards sexuality which have always been in place in the Middle East have become even stronger in the pursuit of this new identity. Within what are outwardly presented as highly puritanical societies that favor segregation o f the sexes, the adornment of traditional Islamic dress by the women, the black “abaya’, the headscarf or “hijab” and in some cases a black veil to cover their faces, and the value attached to marriage and women’s virginity, it would appear to an outsider that the countries of the Arabian Gulf have little to worry about when it comes to any kind of sexually transmitted disease, especially HTV/AIDS infection. Prostitution is highly illegal, and in some of the more conservative Gulf States, violators of this law can be sentenced to death. Death is also the penalty for the importation of drugs to Saudi Arabia. These are some of the possible reasons that HTV/AIDS infection rates are lower in this region of the world; however, HTV infections have been reported in all of the Arabian Gulf States. 85 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Under the guidance of the World Health Organization’s Eastern Mediterranean bureau the Arabian Gulf countries have implemented HIV/AIDS education programs. Each country’s approach has been different depending on the degree of conservatism within their own governments but the social obstacles to HTV/AIDS education prevention that they have faced are similar in nature because of their shared religion and traditions. Social and cultural taboos prevent the open discussion of sexuality, sex outside of marriage, homosexuality, and drug use which inevitably restricts the kinds of messages and dialogue that health educators can utilize for HTV/AIDS campaigns. At the core of the debate is the fear that if the society speaks openly about sexual behavior taking place outside of marriage, and publicly promotes the use of condoms then it may appear as though it is condoning such behavior. The governments would not only risk falling into discord with large numbers of the local population, but also with the religious leaders whose support is critical to the governments of the region. Religion, unlike in the West, is not separated from the state in the Islamic Middle East, therefore such support is essential for governments to maintain their legitimacy. Thus, the governments have to weigh the religious communities 86 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. attitudes carefully and hopefully receive their full cooperation before embarking on education of a sexual nature. There is far less literature available on HIV/AIDS prevention efforts in this part of the world as compared to other regions. A recently published study of Egyptian physicians’ knowledge about HTV/AIDS that was carried out in Egypt and in Saudi Arabia revealed deficiencies in their knowledge about AIDS, especially modes of transmission (Sallam et al., 1995). The study was limited to Alexandria in Egypt and the Asir region of Saudi Arabia. It demonstrated the need for physicians to have more comprehensive knowledge about H TV transmission since they are in the position to disseminate information to the general public, and being fellow Muslims, are able to do so in a culturally suitable manner (Sallam et al., 1995). The island of Bahrain, the smallest of the Arab Gulf states with an indigenous population of less than 500,000, lies adjacent to Saudi Arabia, and to the west of Iran. The country is ruled by an emir from the Al-Khalifa family which has been in power for over two hundred years. While the government has remained resistant to calls by its citizens for democracy, Bahrain is still considered to have the most socially open environment of the Arab Gulf States. At a surface level, this is indeed true. Social problems are 87 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. often addressed in the form of talk shows on the radio, or in newspaper columns. In contrast to the strict social atmosphere that prevails in the neighboring country of Saudi Arabia, men and women work and study together in Bahrain, alcohol is legal, there are no official dress codes for women and there is a sense of religious tolerance demonstrated by the presence of several Christian churches on the island. However, among this “relatively” open Islamic society, is a highly conservative majority Shi’ite Muslim population that harbors strong feelings of animosity towards the government. The Shi’ite Muslims are one of the more traditional Islamic sects, who tend to support the stricter interpretations of the Koran2. The majority of the Shi’ite Moslems in Bahrain live in villages in a lower socioeconomic standard than the rest of the population, particularly the ruling government and its family members who are from the Sunni sect of Islam. The employment policies of Bahrain’s ruling family have long favored the ruling elite and the 2 The two main sects of Islam are the Shi’ite and Sunni sect who primarily differ in their agreement on who lawfully succeeded their Prophet Mohammed. The Shi’ ites believe it was the Prophet’s cousin Ali, and the Sunnis believe the rightful successor was politically appointed. There are numerous other differences between the two sects, but this is their main dispute. The Shi’ites occupy most of Iran, and are found in large numbers in Iraq. Small groups of them also live in Saudi Arabia, in the region of Qatif. They are the majority in Bahrain. There are also various sects of Shi’a Moslems, the Twelver Shi’ as being the largest. Another very traditional Islamic sect are the Wahabis, who are Sunnis and live primarily in Saudi Arabia. There is a history of animosity between the Shi’ite groups and the Wahabis. 88 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. merchant families (Franklin, 1983). Many of the young Shi’ites in Bahrain are currently unemployed and if they do work the salaries are considerably low. This problem has been exacerbated by the large foreign labor population on the island. Historical dependence on foreign workers, both skilled and unskilled has been strong, but is now having repercussions. The need for such laborers is diminishing, but the business community has become so accustomed to paying low salaries to migrant workers that they refuse to hire Bahrainis because they fear they will ask for higher salaries. The problem is compounded by the minority Sunni government’s accumulation of the majority of the island’s wealth, and thus control over employment. Increasing unemployment has put pressure on the government to reexamine its labor policies (Gulf Daily News3 , January 19, 1995). It has also increased political tensions on the island. Between August 1994 and April 1995, civil disturbances began on the island by those calling for a more democratic form of government and fair employment practices (Gulf Daily News, Jan. 19, 1995). Amnesty International reported that in 1995, thousands of people were arrested, including women and children, and that many have been held without trial. Torture and poor treatment of detainees 3 This is the most popular English language newspaper on the island of Bahrain. 8 9 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. continues to be reported and is believed to be widescale and systematic (Amnesty International, 1995). Unemployment and underemployment have been cited as possible factors contributing to intravenous drug use on the island, especially within the Shi’ite villages. In a study of 242 intravenous drug users in treatment at the government hospital, it was revealed that almost half of the respondents were unemployed and the others earned less than 200 dinars per month, a very low income for Bahrain (Al-Haddad et al., 1994). Of these 242 intravenous drug users, 21.1% were confirmed as HIV positive (Al-Haddad et al., 1994). If social conditions worsen, drug use may increase among the lower socioeconomic groups in Bahrain. Even among this traditional population, there is a risk for sexual transmission of HTV. The Shi’ite population generally favors maintaining a strict religious lifestyle for its men and women. Segregation of the sexes is strictly adhered to in the villages and many village women do not complete secondary school and still tend to marry younger than the rest of the population. Both men and women are expected to be virgins when they marry, but the importance is placed on the woman’s virginity as she upholds the honor for the entire family. This is true for both Shi’ite and Sunni sects of 90 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Islam. The culture in Arabia is based on honor and the fear of shame, thus the acts of one individual can defame the entire reputation of their family. Honor for the female consists in modesty and faithfulness, the bearing of children, sons once again above all. Immodesty or unfaithfulness forfeits her honor and shames the men in the family in whose keeping this honor is vested. (Piyce-Jones, 1989:36-37) For the more traditional families, particularly those in the villages, this cultural tenet has resulted in restricting women’s movements outside of the home, preventing any contact with the opposite sex outside of immediate family members and an objection to any innovations that give women a greater deal of freedom. Some families are so obsessed with their honor that their daughters remain secluded until they are married. These traditions have affected sexuality in two ways. Certainly one of the reasons why the Arab countries have reported lower incidences of HIV infection than other countries is the limited contact between men and women prior to marriage. Sexual relationships before marriage are so strongly taboo for young Moslem women, that the chances of sexual diseases being spread because of sexual activity among the young women is virtually negligent. 91 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. However, the result of these restrictions is that young Arab men and even married Arab men frequently travel to Asia or Europe in search of the sexual encounters of which they are prohibited at home. This is a way they can fulfill their sexual desires and not risk shaming their families or someone else’s family. The result, however, has been that A D DS has been contracted by such encounters and brought back to their own country, in some cases, to their own wives. According to Patai (1983), visiting prostitutes and homosexuality are common occurrences in sexually oppressive societies. Sex with a prostitute is outside of one’s own kin group which is preferable because sex within the kin group before marriage would reduce the girl’s chance of getting married and bring shame to her family (Patai, 1983). These patterns have also been known to continue into married life. Sexual prowess among men is viewed as the assertion of male virility while the same actions among women would be cause for divorce, bring shame to the family, and in the stricter Islamic countries, be punishable by death. Patai (1983) cites in his research that Arab male students had twice as many encounters with prostitutes when compared to their American counterparts over a period of one year. Patai (1983) also discusses how even Arab writers have discussed how the existent sexual 92 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. taboos have forced young people to find outlets in homosexuality and other “unnatural” sexual practices. The fear of being shamed prevents some who are HIV positive from disclosing this information to those who are close to them. Sometimes, such information is even kept from family members (see chapter four). Gulf countries are even reticent to publicize AIDS statistics, and more so to openly discuss the behavior that has contributed to the spread of the AIDS virus. The WHO has had to promise to keep AIDS statistics confidential in order for Arab countries to be convinced to accurately report AIDS cases and HIV infections (Interview, Physician A, 1993). No Arab country wants another country, particularly an Arab neighbor to be able to point the finger at them as being a state of apostates. Bahrain, however, has been more open that the other Arabian Gulf countries to discuss among themselves the real health risks of HTV transmission that exist on the island. This was demonstrated in a conference held in April 1994 in Bahrain which dealt with the issues of HIV counseling and education in a conservative religious society. Health officials must publicly acknowledge that sexual activity outside of marriage, homosexuality and drug use do occur in Bahrain and need to be addressed in the context of HTV prevention. There is also a need for H TV 9 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. programs to reach members of the population that may not perceive themselves to be at risk, particularly women. In a society where sexual activity is not openly practiced or discussed, the issue becomes invariably more complicated when decisions must be made as to how to reach these specific groups and how to offer explicit AIDS education without offending individuals or appearing to be condoning sexual activity. Bahrain is a relatively open Islamic country and is liberal in many of its laws when compared to other Islamic countries. Government health officials can not be expected to change the political or economic situation of the country’s high risk groups, but they can seek to have a more comprehensive understanding of high risk behaviors and the contributing factors so they can effectively develop and implement AIDS prevention education programs for their population. The World Health Organization of the Eastern Mediterranean region and Bahrain’s health officials gave careful consideration to the local cultural attitudes and beliefs about sexuality and how these traditional beliefs could be utilized to facilitate AIDS prevention education. In chapter four, Bahrain’s efforts at HIV/AIDS prevention education are presented as a part of this study. 94 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter Summary This chapter has sought to explain some of the universal forces that have influenced public opinion towards the AIDS virus and its carriers. It began by examining the most common metaphors associated with the virus and attempted to show evidence of their link to infectious disease throughout history. An explanation of the origin of these metaphoric associations is given in the following section by examining the role of religion and how metaphoric ideas have emerged from Judeo, Christian and Islamic beliefs towards disease and human sexuality. The inherent conflicts and challenges that the AIDS virus has created for religions and religious leaders is also described in this section. This is followed by a description of the role of culture in HIV/AIDS prevention programs in developing nations and discusses some the successes and failures of these programs. The regions discussed were Asia, Africa, South America, the Caribbean, and the Islamic Middle East. Every region has used its media to increase awareness about the AIDS virus. Education in the media has been effective in spreading messages about HTV to populations, but has not been successful in providing detailed information about the virus. Surveys conducted in India and Thailand indicated that some segments of their populations knew about 95 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. HIV/AIDS but did not know exactly how the virus was spread. Lower- socioeconomic groups demonstrated the least knowledge of the disease in all regions, and have faced economic and cultural obstacles that have affected prevention practice. Commercial sex workers in Thailand and Indonesia have not always had access to condoms or felt the use of condoms would affect their business. The social position of women has also affected their ability to initiate condom use. Female dependency on men for their livelihood, tribal beliefs or superstitions about fertility, traditional gender roles regarding sexuality, accessibility and economics have all contributed to the lack of condom use among couples. The targeting of specific high risk groups has been more successful in Thailand than in other countries, possibly due to Thailand’s concerted efforts to reach drug users and commercial sex workers. Thailand has tried a variety of approaches outside of the media to target high risk groups and populations in rural regions. These methods have proved more effective than “one shot” programs. Educational efforts have been immense in Africa because of the rapid increase of infection rates. Innovative prevention efforts have been tried in Rwanda where couples’ counseling was used to discuss safe sex practice. 96 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. However, cultural beliefs about fertility and superstitions have inhibited prevention practices. HIV infection rates have soared in Uganda, where educational efforts have been conservative. Uganda’s campaign of the mass media provided knowledge about the virus to the general population, but did not deliver enough prevention information to be effective. Uganda’s AIDS prevention programs have been similar to those of the Islamic Middle East in that programs to promote condom usage were non-existent because of the conservative religious environment. Currently, because of the severity of the AIDS epidemic in Uganda, some Christian and Moslem leaders have encouraged the use of condoms. The Middle East region has implemented HIV educational programs that have primarily used the media for the dissemination of information. Studies showed that there needs to be more explicit information of transmission and prevention methods. The conservative religious culture has affected the publication of explicit prevention strategies to the general population, including high risk groups. The adherence to Islamic beliefs is the key message for HTV prevention in this region. Brazil has used the mass media for most of its AIDS educational programs, and the private sector has also participated in education because of 97 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the lack of government funds. Brazil’s biggest challenge has been to target its large population of street youth who live on the streets in Brazil and regularly engage in high risk behaviors. While this group has reported high levels of knowledge about HIV, they also held misconceptions about the virus. Efforts at prevention in all regions have been more successful when conducted in small groups where discussions about HTV transmission and prevention can occur openly, and where explicit detailed information is provided. Knowledge of native cultural practices is imperative and programs must be on-going for AIDS educators to be effective. Follow-up and evaluation are frequently missing components of health education programs in developing countries. The chapter concludes with a discussion of the Islamic culture of the Middle East and how this affects attitudes towards sexuality. It also presents a brief description of the socio/cultural and political environment of the Arabian Gulf State of Bahrain, and risk considerations for HIV transmission. 98 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter III Methodology Introduction This chapter will discuss the research methods employed for conducting this study. The chapter will be divided into seven sections that present various aspects of the data gathering process: selection of the problem, the research design, data gathering methods, the setting, the selection of respondents, access, data analysis and interpretation. Selection of the Problem AIDS has been and continues to be an issue of global concern since its recognition in the early 1980’s. AIDS cases were initially diagnosed in North America and in Africa, however, by the late 1980’s the AIDS virus had been identified on every major continent in the world. Its earliest victims were primarily male homosexuals and intravenous drug users which served to create a stigma around the disease as being an illness that affected those who lived on the fringes of society or belonged to a social underclass. When the disease was first publicized in the early 1980’s health officials and 99 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. government in the United States were criticized for not doing enough for AIDS prevention and not allocating adequate funds for AIDS research because of the perceived prejudice towards those carrying the disease. By the mid to late 1980’s AIDS had become a major topic of public concern. More recognition was given to the seriousness of the problem and to the prejudice surrounding its victims. Celebrities in the US took up the AIDS problem as a social cause and launched benefits to help raise funds for AIDS organizations and research. The media had increased its coverage of the problem and government followed by a wider allocation of funds into AIDS research. In developing countries, A D D S was showing itself by the increasing numbers of mortalities of young to middle aged people. African cities were seeing families with children dying from ADDS. Drug using communities throughout southeast Asia and the Middle East were also witnessing an increase in the numbers of HIV infections. Globally, there was public concern over this new and life-threatening virus. As a university lecturer living in the Arab Gulf country of Bahrain from 1987 to 1991, the researcher observed that there was little to no public acknowledgment of the AIDS virus at that time. The media did not address the issue as an indigenous problem but rather a illness that has affected 100 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. countries outside of the Arab world. However, by 1993 when the researcher returned to the Arab world, the first thing she noticed was the widespread coverage in the Arab newspapers about the AIDS virus. There were articles publicizing AIDS lectures at various companies and AIDS educational campaigns sponsored by the Ministry of Health in Bahrain This new openness corresponded to the more open social and political environment that had emerged in Bahrain following the Gulf War of 1991. New information was constantly being broadcast into the one time highly controlled media of Bahrain. Cable News Network began at the onset of the Gulf War and had continued to be broadcast into Bahrain. With these new open communication channels, the local population was no longer sheltered from either political or social global issues. In the opinion of the researcher, it was this new social and political environment combined with a concern over the rising number of HIV infected individuals in Bahrain that prompted the Ministry of Health to launch an AIDS public awareness campaign. The researcher’s initial interest in the AIDS problem centered around the issue of presentation of the educational content. How was a conservative religious country going to openly discuss how HIV is being transmitted in their own society and how they can take precautions to prevent transmission, 101 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. particularly in the Arab world where pride and reputation are so important? Arab countries generally do not publicize their own social problems, not to each other nor to the outside world. Secondly, the researcher was interested in how the religious leaders were going to cooperate with an HTV/AIDS campaign and what kind of role they were going to have, if any, in the HTV/AIDS campaign? Finally, the most critical question to the researcher was how were high risk groups going to be targeted or were they? Was this campaign going to be an ongoing serious effort at AIDS prevention or was it simply aimed to pacify health officials’ concerns or World Health Organization objectives?1 To answer these questions was to going to require discussions with government officials, some assessment of public opinion and a close look at the attitudes and behaviors of high-risk individuals. It was uncertain to the researcher if this would be possible in Bahrain. Perhaps health officials would not want to discuss Bahrain’s AIDS problem with a foreigner, and how would a foreign researcher ever gain access to high-risk groups and then gain their trust? The obstacles appeared numerous but the decision was taken to 1 The Eastern Mediterranean Regional office of WHO has played an important role in providing materials for AIDS education in the region. Officials from WHO regularly meet with Ministry of Health officials to discuss educational strategies, targets and objectives. 102 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. pursue the topic, with the hope of conducting a promising and relevant study of the issues surrounding AIDS education in Bahrain. Research Design A qualitative research design was chosen for this study so that the researcher could gather the detailed information necessary to sufficiently address the issues raised in the research questions. Qualitative research studies are often cited as producing in-depth information and holistic insights into phenomenon that could not be captured in a purely quantitative study (Lofland, 1984; Marshall and Rossman, 1989; Patton, 1987; Strauss and Corbin, 1990; Yin 1989). Strauss & Corbin (1990) explain that some studies lend themselves more towards qualitative research, such as research that is looking into individuals’ experiences like an illness, or a religious conversion, or addiction. Qualitative research can be useful in discovering and understanding what is behind, or more intricate details of the phenomenon being studied. When looking into AIDS education, this type of inquiry was especially useful to enable the researcher to understand the beliefs and attitudes of those involved in AIDS education and counseling in Bahrain, and to understand the cultural 1 0 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and social forces that have shaped their ideas. The use of a qualitative approach allowed the researcher to show the prevailing ideas, prejudices, and perceptions of Bahrain’s young adults towards the AIDS virus and its carriers. It also enabled the researcher to discover the attitudes and behaviors of those who were using intravenous drugs in Bahrain and if they were putting themselves at risk of contracting the AIDS virus. The Selection of Respondents The sample of respondents was taken from three different populations. To answer the first question regarding how culture has affected the implementation and content of AIDS programs in Bahrain, it was necessary to determine who was involved in AIDS education on the island. The researcher began by contacting the health education officer at the Ministry of Health, who played a key role in the development of strategies for AIDS education in Bahrain. She referred the researcher to other physicians who were members of Bahrain’s National AIDS Committee, a group that was formed to determine AIDS policy, educational aims, counseling, problems etc. The researcher learned which doctors were most active on this committee and sought to interview each of them. In total, the researcher interviewed 104 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. four government physicians to gather information to answer the first question. One was the health education officer, one was the director of the AIDS committee and chief of medical staff at the largest government hospital in Bahrain, one was a leading psychiatrist who was in charge of AIDS counseling, and one was a doctor who had worked with drug users, and had conducted his own research on AIDS in Bahrain, and had given numerous AIDS lectures on the island. The interviews were held in English as all of the doctors had excellent command of the English language. All of these doctors were well known on the island, especially to those who had been in the drug unit or had contracted AIDS. All of these doctors play a vital role in AIDS education and counseling on the island. To address the issue of attitudes towards AIDS and its carriers, the researcher selected post-secondary students from three classes at the Bahrain Training Institute where she was an instructor during the year of her fieldwork in Bahrain. Worldwide young adults are a group considered to be at risk for HIV transmission. According to a study of IV drug users (Al- Haddad, 1994), the majority of drug users fell between the ages of twenty and thirty years old. Of this group, the highest rate of seroconversions were found among those in their early twenty’s. 105 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Young women may unknowingly be involved with or married to someone who may put them at risk. Even in the sexually conservative environment of the Arabian Gulf countries, there are young people who engage in sex before marriage and sex outside of marriage. Often it is young men who prefer to travel outside of the Gulf to have their sexual experiences rather than risk getting involved in a highly prohibitive sexual relationship in their own country. Each group of students selected for the study were enrolled in Bahrain Training Institute’s post-secondary vocational training program. This student population generally comes from the poorer segment of Bahrain. All of them were Shi’ite Moslems who came mostly from villages. Shi’ites like these students, however, make up the majority of Bahrain’s population. One of the groups were the researchers’ own students and the two other groups came from another instructor. There were approximately thirty students who participated in answering the six questions the researcher had asked regarding attitudes towards AIDS in their country. The questions were asked and answered in Arabic and later translated by Bahrainis who had a highly proficient knowledge of English. The researcher believed thirty respondents would be enough to yield information about students’ attitudes and offer 106 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. insights into how the culture has affected their attitudes and beliefs. While this sample was not enough to make generalizations about all students, it does offer some insights into the attitudes this particular group of students has towards AIDS and those carrying the virus. The questions were short but called for in-depth explanations in their answers. This decision to include students was not viewed by the researcher as the central focus of the study but rather to augment the numerous comments made by the Ministry of Health regarding the cultural attitudes of those who would be receiving their AIDS information. The students’ comments offer the reader more insight into the kind of thinking which prevails among the local population to help understand further the rational behind the physicians’ planning of AIDS content and implementation. The final group of respondents included in this study were IV drug users who injected drugs regularly. Initially the researcher had planned to conduct lengthy interviews on more than one occasion with at least 15 drug users. The researcher believed this number would allow for in-depth study of each individual and offer a variety of insights into the drug culture in Bahrain. Unfortunately, due to the challenge of locating the users, establishing trust, and then conducting an interview, an enormous amount of time was spent 107 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. doing fieldwork for this section of the study which resulted in a much smaller number of respondents and data than the researcher had originally intended. Over the period of one year the researcher was able to conduct interviews with seven drug users. The researcher had hoped to gather at least ten interviews, but two of the potential interviewees had been arrested before the researcher had the chance to interview them, and one other proved too difficult to arrange a meeting time. However, the results of the seven interviews yielded substantial information because the depth and time spent with the users. The interviews were conducted in English if the respondent felt comfortable with English, otherwise Arabic was used and the key informant served as a translator. Six of the drug users were single men and one was married. There are female Bahraini IV drug users but they constitute a very small percentage of IV drug users according to physicians at the Ministry of Health (1994) and they are difficult to locate because they do not tend to go out to the areas where drug users congregate, rather they stay home and usually have a boyfriend or husband who is also using. They were identified by the researcher’s key informant who knew them from growing up in the same area as some of them did. The key informants other links to them can not be revealed to protect the confidentiality of the respondents. 108 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The majority of those interviewed for the study from each of the three groups were male. One of the four doctors interviewed was female. Four of the thirty students that answered the questions were female, and none of the drug users were female. The female perspective of these issues is an extremely important one that unfortunately is not documented in this study. The institute where the researcher gathered information on the students has only recently had female students. It is a technical college where the majority of students are male. The percentage of drug users in Bahrain who are female is very small and the researcher was unable to locate them. She was told by one user who knew a female that she was married and would never admit her drug problem to the researcher. Because there are so few female drug users (the actual numbers were not revealed to the researcher, but she was told there were very few), it is likely they would not directly share needles with groups of friends as the men do. Most probably, female drug users are married to male drug users and get their injections from their husbands. They may not have direct knowledge as to who has used their needle prior to them. Women are often unknowing victims of this virus or are unwilling to take precautions out of fear that they will be abandoned by their husbands (Mwale 109 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. & Bumard, 1992). Studies that are devoted solely to women’s perspective on AIDS have been done, but not inside of the Middle East. Method of Data Gathering For this study interviews were the most frequently used source of gathering information from the respondents. The data was collected by conducting informal semi-structured interviews, which were recorded if the respondents permitted, transcribed and then analyzed. In some cases only notes were taken because the respondents did not feel at ease being recorded. Each of the subjects were interviewed on more than one occasion, usually for follow-up questions or to verify further information the researcher received. The interviews were then coded and studied to determine common patterns that showed areas of concern of the various respondents. Certain themes that continually emerged in the interviews are presented and discussed in chapter four of this study. Other methods of data gathering for this study included a small open-ended questionnaire and participant observation. The interview questions were developed by identifying the main research questions which related to how culture has influenced AIDS educational programs in Bahrain in terms of content and implementation and how culture has affected students’ attitudes towards AIDS and HIV carriers. The third 110 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. area of concentration was to look at the effect, if any, Bahrain’s AIDS education has had on IV drug users. To obtain information to address these questions it was necessary to interview individuals from three distinct groups; government physicians who are responsible for AIDS policies and education; students’ between the ages of 18 and 25; and intravenous drug users. The researcher developed a general interview guide to assist her in her discussions with the Ministry of Health officials. The researcher began by eliciting a general discussion of the topic of AIDS and AIDS education in Bahrain, and then asked specific questions to help the researcher uncover the issues that related to the research questions. Marshall and Rossman (1989) state: Typically, qualitative in-depth interviews are much more like conversations than formal, structured interviews. The researcher explores a few general topics to help uncover the participant’s meaning perspective, but otherwise respects how the participant frames and structures the responses. This, in fact, is an assumption fundamental to qualitative research - the participant’s perspective on the social phenomenon of interest should unfold as the participant views it, not as the researcher views it (pg.82). in Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. During the first interviews with the ministry of health officials, the researcher let the physicians each tell their own story regarding their perspective on the development and content of AIDS education in Bahrain.2 The researcher returned to each of the physicians on various occasions for follow up information. The researcher also attended a conference where health officials presented some of the cultural aspects to AIDS counseling and education in Bahrain. This helped the researcher to triangulate the data collected from the interviews. The research also analyzed the content of four AIDS education pamphlets to understand the types of messages the government is publicizing about AIDS prevention. The pamphlets were translated from Arabic to English by a professional translator who is employed with United Press International in Kuwait. Six short open-ended questions were administered to the students to find out information about their attitudes towards HIV and its carriers.3 The questions were completed in the classroom over a period of thirty to forty-five minutes. The question sheets were in Arabic and the students were instructed to answer the questions in either Arabic or English, whichever language they 2 See appendix for initial interview guide 3 See appendix for questionnaire and translation 112 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. preferred. All of the students chose to answer the questions in Arabic. The students were told that writing their name on the question sheet was not required so they would not have to be concerned about their identity being known to the researcher. The researcher also engaged in dialogue regarding their knowledge and attitudes about AIDS at various times during the term. The students’ answers were then translated by the Bahraini secretary at Bahrain University’s English Language Center and given to the researcher for analysis. The researcher recorded notes throughout the term regarding the students’ various comments about AIDS. To find out about the attitudes and behaviors of high-risk groups, the researcher also interviewed IV drug users who were regularly injecting heroin. Interviews had to be conducted in depth and the researcher had to frequently return to the respondents with further questions. Observation was also used as a data gathering technique for this segment of the study. The researcher spent time with the drug users in their own environment in Bahrain. Most of the interviews with the drug users were conducted in English When Arabic was used, the key informant helped translate the information. The key informant’s assistance as translator was crucial because he was accepted by his peers as trustworthy and he also understood the terms 113 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. used by this subculture. More information about access will provided in a later section. The Setting The research took place on the island of Bahrain, which is located in the Arabian Gulf, east of Saudi Arabia and west of Iran, from July 1993 to July 1994. The setting for the interviews with Bahrain’s Ministry of Health physicians was in their professional place of work which was sometimes in the Ministry of Health, or the local Sulmaniya government hospital or the regional health centers. Observation and informal discussions with physicians also took place at an AIDS conference in Bahrain which was cosponsored by the World Health Organization in April of 1994. The discussions and informal questions with Bahraini students took place inside the Bahrain Technical Institute, a vocational training institute for post- secondary study located in Isa Town where the researcher was employed as an instructor for the year this study took place. Discussions were held inside the classroom and on some occasions in the researcher’s office. The necessity for confidentiality regarding the places where the drug users were interviewed prevents the provision of explicit information. It can be 114 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. said that all the IV drug users were interviewed in Bahrain at various times of the day and night and in different locations. Interviews were held whenever an individual agreed to talk to the researcher about his problem and usually the researcher was the only one present at the interview. If translation was necessary, then the key informant who helped the researcher obtain the interviews was also present. The researcher had been introduced to the key informant four years prior to this study. He was a good friend of a friend of hers and was known to be a trustworthy individual. He spoke English well and the respondents felt very comfortable with him. More information regarding the key informant is found in chapter four of this study. The researcher was often escorted by the key informant to places that may have been known as “dangerous” for the researcher to be in order to locate certain individuals for the interviews. On these occasions the researcher would remain in the car until the key informant located the interviewee and arranged a safe location for the interview. Access Access to the different groups interviewed was not a difficult matter with the exception of the drug users. The government officials were extremely 1 1 5 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. helpful and very willing to be interviewed. The problems the researcher had anticipated regarding the government doctors’ willingness to discuss AIDS were non-existent. The doctors were surprisingly open and candid in their responses. The researcher was able to call and make appointments with each of them personally and they offered to help the researcher in whatever areas needed. They also welcomed the researcher to share her findings with them, which she did at the conclusion of her study. Gaining access to the students was simple because the researcher worked with them on a daily basis. However, to conduct this study, the researcher needed to request permission from the director of the institute. She explained her study to him and he was supportive of the project. The students willingly answered the questions during a thirty to forty-five minute time period. The most challenging of the three groups to gain access to were the drug users. In Bahrain drugs are highly illegal and drug users are frequently arrested and sent to jail, so drug use is not something that is easily publicized. Additionally, in Arab society, reputation is very important, so it was unlikely that drug users would admit their drug usage to a stranger. Any behavior that could bring shame to the individual or his/her family would be kept very discreet. It would not have been possible to locate the drug users, cultivate 1 1 6 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. their trust, and speak to them in a safe environment without the help of the researcher’s key informant who was a drug user himself, but also a good friend of a friend of the researchers. This study could not have been conducted without his help and enthusiasm for the project. While the researcher never sought permission from the Ministry of Health to conduct the study, she informed them of what she was doing. They asked few questions and commented that such a study was necessary and could produce important results. Even with the help of the key informant, finding the appropriate time to interview the users was difficult. Most of them said they would be pleased to talk with the researcher, but it took time for them to feel at ease openly discussing their addiction. If the researcher tried too quickly to interview them, the responses were not natural and limited to very short answers. However, when the researcher waited until she knew the user, and found a time when she and the user were “hanging out” in the same location, she could engage him in a conversation. Three of the interviews were scheduled as appointments and four of them took time to find the appropriate moment to engage in the conversation. The researcher was trusted because of her friendship with the key informant, who was well thought of in his group. The issue was more of a shyness on the respondents 117 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. part to discuss what they would consider a shameful part of their lives. They never allowed the researcher to see them using drugs, and if someone came to bring them drugs they always tried to hide such an incident from the researcher. The researcher spent numerous hours with the drug users, much of which was spent listening to them talk in Arabic with their friends, just to get them accustomed to her being there. After nearly three months of contacting users and talking with them, they began to refer to the researcher as a friend and when the researcher did not come around for several days, they exhibited concern about her absence. After knowing this group of drug users for a period of nearly one year, the researcher felt the need to withdraw for reasons of objectivity. She had become close to them and someone who they liked to confide in. The only one that expressed a true desire to stop using was the researcher’s key informant, who at present has been straight for eight months. The others continue to use and for some their problem only worsens over time. More details of how access was gained are presented as part of the study in the section on high risk groups in chapter four. Researchers that engage in ethnographic fieldwork in a criminal setting are often faced with ethical issues. Soloway and Walters (1977) in their 1 1 8 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. fieldwork with heroin addicts in Lexington, Kentucky stated the importance of such fieldwork yet also highlighted some of its complications: For the anthropologist who wants to study drug addicts qua drug addicts, who wishes to look at the process of people being addicts, it is necessary to move out of the institutional setting and onto the street. This move involves enormous ethical and legal issues, as well as very real emotional and physical hazards. However, it is necessary that anthropologists confront and resolve those complications if meaningful urban anthropology in modem American culture is to be done. If addicts are studied at Lexington, then the result is a study of patients. If addicts are studied in jail, the result is a study of prisoners. If the ethnographer’s goal is to understand addiction, he must resolve himself to entering the natural habitat of the addict - the streets, the back alleys, the shooting galleries (pg. 163). The nature of this study was to gain understanding of the heroin users attitudes towards AIDS and the kinds of behaviors they engage in that may cause the spread of the AIDS virus. To undertake such a task it was necessary to enter their world in order to fully understand them. However, there were some differences that may have made it safer for the researcher to participate in such fieldwork in Bahrain. Unlike the United States, the crime rate in Bahrain is extremely low. Heroin users are not likely to have access or cany guns, as such weapons are illegal in Bahrain. The streets of Bahrain are safe, even in areas where drug users may gather. The key informant took 119 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. considerable care in making certain the researcher was not in an area where the government police would have come, although he knew she would probably have been safe. Bahrain is small, and some of the users had previous knowledge of the researcher because she had taught in Bahrain for a number of years. In one situation she had taught the younger brother of one of the users. They viewed her as a university lecturer who was a good friend of the key informant. Another difference in Bahrain, is that drug addicts, while they share the problem of addiction with others worldwide, their culture is quite different from the stereotypical drug culture in the United States. Drug users often come from religious families, showing respect for their parents, and normally do not commit crimes outside of the possession or selling of illegal drugs. They are generally passive, non-violent individuals. Information such as location of places where the drug users were interviewed or even some important points of their culture have to be omitted to honor the confidentiality of the study. Since Bahrain is a small, non-democratic country, certain groups or individuals can be easily identified by the mere mention of a place they may frequent. The researcher has omitted anything that could reveal who these individuals are. In the presentation of the 120 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. findings the actual names of the users were also changed to protect their identity. Data Analysis and Interpretation The analysis of the study began with the transcription of the interview data. The interviews with the government officials were recorded. The other respondents in the study refused to be recorded because of their fear of being identified. After the interviews were transcribed, they were studied carefully for themes that related to the research questions as well as other areas that may have been relevant to the researcher’s topic. Marshall and Rossman (1989) state: Data analysis is the process of bringing order, structure, and meaning to the mass of collected data. It is a messy, ambiguous, time-consuming, creative, and fascinating process. It does not proceed in a linear fashion; it is not neat. Qualitative data analysis is a search for general statements about relationships among categories of data; it builds grounded theory (pg. 112). The formal analysis began after the researcher listed, color-coded certain themes that emerged throughout the interviews. Many categories emerged, some were merged with others as the researcher began structuring the themes to support a conceptual framework for the study. Because the process of 121 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. analysis is not a linear one, the researcher had to continually refer to research questions, a conceptual framework, the review of the literature in order to establish a basis for organizing and categorizing the collected data. The responses made by the students were translated and coded into categories as the interviews were. They were also triangulated with the interview data to support the emergent issues from the interviews and to present another dimension to the research. The process of coding followed the procedures of open coding listed in Strauss and Corbin (1990). One issue that occurred in the analysis of the data was the necessity to determine if a response was stated to the researcher because the individual really believed it or he/she was trying to please the researcher. This happened with the drug users. It was not unusual for the researcher to check information with the key informant, to verify whether he thought it was true in situations where the data was in question. Some of the drug users wanted the researcher to believe that they were taking precautions about needle sharing when in fact they were often sharing contaminated needles. This kind of information could be verified by the key informant or through additional questioning of the respondent on another occasion. The researcher also had to carefully listen to responses made by the Ministry of Health officials 122 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. because on some occasions they appeared to offer “official” explanations but later would reveal the actual situation. Informal discussions with the physicians at the Ministry of Health were very useful to the researcher to help verify statements made by other physicians and even themselves in a formal interview setting. The data analysis was an ongoing process that began in the early stages of data collection and continued throughout the study. The researcher believes that the number of hours spent with the respondents positively affected her ability to interpret and analyze the data related to that particular group or individual. The researcher’s position as an instructor gave her unlimited access to students and offered her the time needed to understand their ideas and beliefs. The same was true for the drug users, the longer the researcher stayed with them, she was able to pick up subtle information that may have been missed in the early stages of her fieldwork with them. However, the necessity of working within the tight schedule of the government physicians and the researcher not being a member of the Ministry of Health, allowed the researcher to gather information only in areas that were “officially” permitted. When analyzing this data, at times there appeared more questions than answers, even when the most critical issues were addressed. This problem 123 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. was somewhat ameliorated by the interviewing of the various doctors and the three distinctly different groups. The information provided from all of these sources enabled the researcher to develop a more comprehensive understanding of this sensitive and often complex topic. Chapter Summary This chapter explained the rationale behind employing a qualitative research design for this study and the details of how the study was conducted. The selection of the problem, research design, data gathering techniques, setting, the selection of respondents, access to respondents, and the analysis of the data were the salient issues addressed in this chapter. A qualitative method was selected to conduct this study because it was the most appropriate approach to help the researcher understand both the beliefs about HIV by the different groups questioned, and to explore the cultural and social forces that shaped their responses. Interviews allowed the researcher to probe, explore and question the responses offered by the interviewees. The three different groups of respondents, doctors, students and drug users, were chosen to allow the researcher to understand the AIDS situation in Bahrain from different perspectives. The drug users were the most difficult of the groups to access and the key informant played a critical role in helping the 124 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. researcher obtain the interviews. The researcher’s position as a female conducting the interviews with men from a conservative Islamic culture resulted in limiting the scope of the discussions to drug use only. The issues of risky sexual practices were not addressed in this study. The process of data analysis focused on the development of themes from the interview data to support a conceptual framework for the study. 125 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter IV Analysis and Interpretation of Data Health Education in Bahrain All health education programs in Bahrain are designed and implemented by the island’s Ministry of Health. The Eastern Mediterranean office of the World Health Organization (WHO) which is located in Alexandria, Egypt also assists the Arabian Gulf health ministries by providing health related literature, organizing conferences, planning programs, consulting and research. Health education programs in Bahrain are divided into two categories, those which are designed for the formal educational system and integrated into the school curriculum, and those which are classified as public health campaigns that target the general population. In the case of the former, the Ministry of Education is also involved in determining the content and level in which the designated program will be implemented. Public health campaigns are also developed, designed and implemented by the health education office of the Ministry of Health and sometimes assistance is provided by WHO. The Minister of Health, who sits on the state’s Cabinet 126 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. with other ministers, has the final authority to approve or reject any part of a public health campaign. Bahrain’s health education office refers to their public education efforts as campaigns because each health campaign has a specific focus and is of a short duration. Some health topics may be repeated within the same year. Bahrain’s health education office selects a dozen or more health issues annually, and designates certain times of the year when they will implement a health campaign. The campaign consists of daily newspaper articles on the topic, programs on television and radio, lectures presented to companies, organizations, women’s groups, schools and the university. The topics chosen are usually a disease which may be a current threat or an on-going health related problem for the country. For example, diabetes is common in Bahrain, so the Ministry of Health has presented a series of articles in the newspaper and programs on television to spread information about the disease. They have also implemented programs on sickle-cell anemia, anti smoking, personal hygiene, hepatitis B, nutrition, pre-natal care and more recently HIV/AIDS. Each topic is covered over a one to two week period by * means of mass media, public lectures and the provision of pamphlets. 127 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Bahrain also has a health hot-line that has prepared messages each day that relate to one or more health issues. No health education topic has been as controversial as the HIV/AIDS education campaign in Bahrain. This is undoubtedly due to the nature of transmission of HIV. The AIDS virus (HTV) is transmitted through an exchange of bodily fluids. The virus can be carried in semen, vaginal secretions, and infected blood; therefore, intravenous drug users, prostitutes, homosexuals or individuals who have unprotected sex are considered to be at risk for contracting HTV. When the virus was first recognized, doctors also included hemophiliacs and those going for blood transfusions in this risk category, but nowadays since most countries carefiilly screen blood before transfusions, they are no longer considered at risk. Health campaigns worldwide have aimed to make people aware of these common modes of transmission so they can take precautionary measures to prevent the spread of the AIDS virus. Because the most common modes of transmission are by drug use with infected needles, or sex outside of the marital relationship, and such behaviors are considered highly sinful in Islam as in most of the world’s religions, the Islamic countries of the Arabian Gulf region condemn those who commit such acts as sinners. This perception has 128 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. contributed to the stigmatization of HIV/AIDS patients among the general public and even among some health care workers. Prior to Bahrain’s HIV/AIDS campaign the more conservative members of Bahrain’s Ministry of Health felt that HIV/AIDS was not a problem for Bahrain, and that those who contracted the virus deserved it and should possibly be quarantined. The following section will describe in detail Bahrain’s HIV/AIDS campaign, and highlight some of the cultural issues that have affected the development, implementation and content of their HIV/AIDS education campaign. The Emergence of an HIV/AIDS Campaign HIV/AIDS was written about and discussed among health professionals in Bahrain as early as 1985 when the “Bahrain Medical Bulletin” a medical journal produced in Bahrain published an article by Dr. Ali Mattar (1985), that stated a significant number of HIV cases had been reported from the Arabian Gulf area where blood had been brought from other countries. It said that Bahrain was somewhat protected from such exposure because most of its blood supply came from local donors. The article described the seriousness of the AIDS epidemic worldwide and concluded by saying that Bahrain should be careful to continue to monitor its blood supply. It also stated that up until that time there were no reported AIDS cases in Bahrain (Mattar, 129 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1985). Drug use or sexual transmission was not mentioned as a mode of transmission in the article. However, this article was important in that it was one of the first public acknowledgments of AIDS in the Arabian Gulf region, even though it was presented in a journal for health care professionals rather than the general public. The following year the first Gulf wide conference to deal specifically with the topic of HTV/AIDS took place in Kuwait in February of 1986, and was sponsored by the Kuwait government and the World Health Organization. The conference was attended by numerous health professionals and scholars from the entire Eastern Mediterranean region. The goals of the conference, which were articulated by Kuwait’s Minister of Public Health, Abdul- Rahman Al-Awadi in his inaugural address, focused on the following issues: 1) To inform all doctors and all categories of health workers on the latest medical information about the disease. 2) To provide an exchange of viewpoints between doctors and medical personal on methods of preventing the spread of AIDS into the countries of the region. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 3) To create public awareness of the disease, its mode of transmission and methods of prevention.1 The conference also established a theme for the HTV/AIDS education campaigns. Adhering to one’s religious beliefs was presented as the mode of prevention as HIV/AIDS was described as a disease affecting those who abandon their religion. AIDS was also decreed as a disease of immorality associated with the sexual promiscuity of western societies.2 Homosexuality was identified as the major mode of transmission and those who contracted the virus were blamed for it presence.3 We observe many so-called emancipated and progressive societies in which currents of irresponsible promiscuity flow, and wherein various forms of unsanctified sexual relationships are practiced. This unchecked sexual liberation has been the cause for the spread of a wave of homosexuality in many parts of the world. You are not doubt aware, my brothers, that all the divine religions, in general, and our true Islamic religion, in particular, have incited their followers to shun immoral acts, no matter how insignificant. Despite this, the current of immorality has resulted in the abandonment of religion, culminating in no less than in the abandonment of self. (Minister of Health, Kuwait 1986) 1 For a more detailed presentation of the conference’s goals see the transcript of the “Inaugural Address” in the Appendix section following chapter five of this study. 2 See “Inaugural Address” 3 During the first several years following recognition of the AIDS virus in the USA, doctors also felt that it was exclusively a disease for homosexuals and drug users. 131 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In this speech, Kuwait’s health minister does not mention that the disease can be transmitted heterosexually nor does he explain exactly how the disease is transmitted. Perhaps this is because the speech in only the inaugural address and he is leaving the details to other presenters. In the Arab world, particularly the more religious Gulf countries, it is not uncommon to hear references made to the West when discussing the social and moral decline of societies. These references may be made by religious leaders who are genuinely concerned about the breakdown of traditional values within their own societies and therefore refer to western societies in this context to remind the people of the importance of maintaining their own religious values. Similar concerns are sometimes used by political leaders in efforts to legitimize their own leadership. This is seen more commonly in religious governments such as Iran or Saudi Arabia. Throughout the Islamic Middle East behavior that goes against religious doctrine is often viewed as having originated from the West. It is not always stated explicitly, but indirectly as exemplified from the above statements made by Kuwait’s health minister in 1986 by the usage of words “emancipated” and “progressive” in his inaugural address at Kuwait’s first conference on AIDS. The word “emancipated” possibly refers to a society 132 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. that is governed by secular law rather than religious law or to a democratic society. In its general sense the word refers to freedom. The speaker who expressed this does not make specific statements as to the type of freedom he is referring to but one may gather the impression that it is a moral or sexual freedom he is addressing. The use of indirect language, something which is common in the Arab world leaves the task of interpretation to the listener. But obviously the one who spoke these words believed that emancipation was not something that would define Arab society and that with emancipation comes sexual promiscuity. The word “progressive” evokes images of a technologically advanced society, a society with highly educated members making contributions to its development. Again, sexual promiscuity is associated with this type of progress and freedom. These words are important to understanding how the AIDS virus is viewed by both officials and the population at large. AIDS is seen as something evil coming from outside, something associated with sin and something associated with western values4. It is also a common point of view that plagues or infectious diseases are viewed as coming from somewhere “outside” or from somewhere “foreign.” Sontag, 4 The association of AIDS with immorality and punishment for sin has also been a common viewpoint in western societies. See D. Fernando, 1993 and A.R. Jonsen & J. Stryker, 1993 for more information. 1 33 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. (1994) discusses this association of disease with “otherness” in detail in her discussion of AIDS metaphors. The challenge this posed was that once the virus was officially inside the Gulf states, health officials had to publicly acknowledge the presence of the disease and find methods of presenting prevention programs in a way that would be accepted by a traditional religious society. Initially it was a major feat for Gulf countries to merely acknowledge the presence of AIDS among their indigenous population. The conference itself was a important turning point in that it was the first time the Gulf region openly discussed the possibility that they may soon have to encounter this virus. However, it was equally important to assure those present that the country hosting the conference at that time had not had a single case of the AIDS virus: “Before closing, I would like to assure our fellow citizens and expatriates in Kuwait that the country is devoid of AIDS” (Minister of Health, Kuwait 1986). Such a statement would be impossible to confirm unless the entire population of Kuwait were tested for HIV, but because the disease is so strongly associated with moral misconduct, to publicly acknowledge its presence would have been perceived as bringing shame to the country, company, or family whose members may carry the virus. 134 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Not all members of the health professionals held such conservative viewpoints towards the virus. Some physicians in Kuwait and Bahrain demonstrated a more moderate approach to the disease. A doctor from the Faculty of Medicine, University of Kuwait presented his perception towards the disease. Should the society wish to tackle the problem of sexually-transmitted diseases, we will need to examine our attitudes towards these diseases and those who become afflicted with them. Society wants to believe that only homosexuals, the promiscuous, drug abusers and certain other “undesirables” suffer these illnesses. The knowledge that the upright, stable, heterosexual university professor can also suffer generates panic and fear. Social attitudes play an important role in perpetuating the disease an its eventual control. (M. M. Khogalil, University of Kuwait, 1986) This doctor’s remarks demonstrate the different perceptions of health professionals within the same country who both share the same religion and culture. This dichotomy between the conservatives and the more moderate physicians created some discussion over the nature of the content of HIV/AIDS educational messages. The above examples were taken from Kuwait, but they were made at a Gulf wide conference and the Bahraini health professionals have dealt with the same problems. 135 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. One Bahraini doctor who had worked with Bahrain’s drug unit as a government physician and now gives the majority of the lectures on A D D S confirmed the sensitivity of public discussion of HIV/AIDS. Well, actually from three years back, from that time the situation in our country was that nobody could talk about AIDS, that was really a difficult situation. I was working at the psychiatric hospital for a few months at that time and I met some AIDS patients and usually all of them from that time were drug users. The source of their infection was drug abuse, sharing needles and I just asked myself how can we help the situation. This time I was reading a lot about AIDS, about the mode of transmission and how can we protect the people. I would sit with those people, drug abusers, and talk to them about this problem and gradually we had a program (Physician C, interview, 1993). Part of the difficulty in designing the HIV/AIDS campaign was that members of Bahrain’s Ministry of Health did not easily agree on the methods or content of conducting an HIV/AIDS education campaign. The individuals opinions varied from those who were extremely reticent to even acknowledge the presence of the virus to those who were ready to do anything and everything to prevent its spread (Physician C, interview, 1993). The moderate viewpoint was to offer educational information but in a highly conservative manner that lacked the explicit language that is often seen in 136 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. western HIV/AIDS educational materials such as “practice safe sex slogans” and detailed descriptions of condom usage. It was the moderate viewpoint that prevailed. There had been an AIDS national committee before the public AIDS campaign began, but it appeared to have become much more active when new committee members replaced some of the older ones. There is a national committee for AIDS, it was formed long back and before chaired by the ex-undersecretary, then later o n , maybe one year ago, or not more than one year ago, we installed a new committee chaired by Dr. Haddad. He is the chairman of the psychiatric hospital, chief medical staff of Sulmaniya (the government hospital) and now he is chairing the committee. From this committee we became very active and now we have a sub-committee which is health education for AIDS, which I am chairing. From these members we sit together and we decided it is time, we have to educate the people. (Physician A, interview, 1993) The AIDS committee, of which the health education officer is a member, is part of the Ministry of Health, and has the responsibility of formulating policy related to AIDS. For example, if a Bahraini is found to be HTV positive, then one or more members of the AIDS committee will explain how to deal with his/her sexuality, how to protect family members from the virus, and how to protect him/herself. Counseling at the Ministry is available to 137 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the individual and family members. If a non-Bahraini is found to be HIV positive, he/she is given notice to leave the country. In July of 1994 there were a total of five Bahrainis who did HTV/AIDS counseling and the Ministry of Health was hoping to train more. All HTV/AIDS counseling is controlled by the Ministry of Health and any type of education or health education planning must be approved by the government of Bahrain. The decisions of the ministries are concentrated among a few powerful leaders within each ministry. Clearly in the case of Bahrain, progress in the area of HTV/AIDS education was a result of the few doctors who took over the AIDS committee in the early 1990’s. Many factors may have accounted for the delay in Bahrain’s HIV/AIDS public health campaign. The problem was discussed among the Gulf leaders as early as 1985. Other countries began HTV/AIDS campaigns in the mid to late 1980s. Why did it take Bahrain nearly seven years from the time the problem was first discussed to implement a public health campaign? A key problem that is evident in Bahrain and throughout is the highly centralized decision making process and the strict government control over public information. Should one or more members of any governmental organization be highly conservative, conservative policies will ensue. In the 138 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Islamic countries of the Middle East, such policies emerge as Islamic fundamentalism. The perceptions of HTV/AIDS as a disease of foreignness and a disease of immorality, and the lack of agreement on what constituted appropriate HIV/AIDS education and if were even necessary were also factors in the late start-up of HTV/AIDS education campaigns in the entire Gulf region. The stigma attached to the disease also contributed to underreporting of the virus that was particular to the region (WHO, 1994). WHO had to promise confidentiality regarding the numbers of reported HIV cases in the area in order to promote more accurate reporting of the virus. Despite some of the cultural obstacles, in December 1992, Bahrain launched its first HTV/AIDS information campaign. The initial campaign lasted between one and two weeks and corresponded with the December 1st, World AIDS Day, a day set by the World Health Organization for the dissemination and promotion of HIV/AIDS prevention information. While most of the rest of the world had already begun HTV/AIDS education in the mid to late 1980’s, there was little public discussion of HIV/AIDS in Bahrain outside of a few academics and professionals in the health care industry. No one explanation was provided as to why Bahrain decided to implement 1 3 9 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. its HIV/AIDS campaign in 1992, but there are a number of plausible explanations. Between the years of 1988 and 1991, Bahrain began to see an increase in HIV cases on the island among its drug using population. During this same time period, some staff changes were made within the Ministry of Health which promoted some of the more progressive thinking doctors into key decision making positions and as members of the country’s national AIDS committee. Additionally, a number of HTV/AJDS conferences had been held around the Gulf and the World Health Organization’s regional office in Alexandria, Egypt had produced a number of materials on HTV/AIDS in Islamic countries as part of their Global Program on AIDS. It is likely than one or more of the above events influenced the start up of Bahrain’s HTV/AIDS campaign. HIV/AIDS Campaign Objectives As of November 1995 Bahrain’s health education office had conducted four HTV/AIDS campaigns, each of a one to two week duration. The first campaign took place in December 1992, the second one in June 1993 which was meant to coincide with summer holiday season, during which many Bahrainis travel outside of Bahrain. The last two campaigns took place in December 1993 and December 1994 which corresponded to the World 140 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Health Organization’s AIDS day. There was also a campaign held in December 1995. The health education officer spoke about the HIV/AIDS campaign: My goal was to have an AIDS educational campaign twice a year, but I was outside of Bahrain this past year so we were not able to implement one prior to the summer holiday. However, I hope to do one again before this next year’s summer holiday. (Physician B, telephone interview, 1995) HTV/AIDS educational literature is available on a year-round basis at the Ministry of Health and at the local government health centers. Bahrain’s telephone company also has a health hot-line in which callers can call anytime to hear health messages about HTV and other diseases. Bahrain’s health education officer explained the two primary objectives of Bahrain’s HTV/AIDS campaign. The first objective was to reduce the number of HTV positive cases on the island. The second objective was to change the attitudes, behavior and misunderstanding of the vims. This second objective refers to peoples attitudes towards HIV/AIDS vims earners. There is a lot of fear surrounding the disease and ambiguity as to how HTV/AIDS is transmitted. The educational information provided to achieve the above objectives will be examined later in this chapter. 1 4 1 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Target Audiences and Media Used Bahrain’s health education officer expressed that it was the Ministry’s goal to target populations who were considered to be at risk and these included young people, drug users, and people who already had sexually transmitted diseases (Interview with health education officer, 1994). The highest risk group in Bahrain was considered to be intravenous drug users. In the early 1990’s Bahrain’s Ministry of Health claimed that the majority of all HIV infections had come from IV drug use. However, by 1994, this had begun to change as most newly reported HIV infections were coming from those who engaged in unprotected sexual intercourse, both inside and outside of Bahrain (Ministry of Health interview with physician B, 1994). Initially, the first HIV infections in Bahrain came from imported blood, but was soon stopped when blood screening became the norm in the mid 1980s. AIDS among the drug community was thought to have been brought from outside Bahrain by drug users who went to Thailand to purchase opiates, and either used contaminated needles there or engaged in sexual intercourse with an HIV infected person. The virus was spread in Bahrain by their sharing contaminated needles. The decline of HIV in the drug 142 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. community over the past two years is surprising because some Bahrainis believe the incidence of drug use on the island has increased, particularly among young teenage boys.5 One reason for the decline may be due to the knowledge IV drug users have as to how AIDS is transmitted because of their association with their peers who are HIV infected. The statistics could have also been affected by the groups who were tested for HTV, because any IV drug user who is brought to the jail is automatically tested for HTV. Therefore, more HTV testing is done on drug users than other segments of the population. The size of this target group may vary with the numbers of arrests made over a given period of time. As a result this can raise or lower HTV percentages. According to one physician from the Ministry of Health: “Officially we had 181 HTV positive individuals in 1992 and seventy to seventy-five percent of them were drug abusers. This is the mode of transmission here. We have heroin injections” (Physician C, interview, 1993). Unlike western countries where drug users may have engaged in smoking marijuana or trying more mild drugs before going on to injecting drugs, in the Gulf countries heroin is most commonly used because of its 5 All the IV drug users interviewed for this study mentioned they had seen a marked increase in drug use on the island over the past few years. They also spoke about how young many of the new drug users were. They felt it was a result of the current unemployment among the youth, particularly those from villages. 143 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. availability. Heroin is brought to the Gulf countries from Iran, Pakistan and Thailand and made easily available to those who seek it. Those who have money buy it and then share it with their friends. If users do not have the money to buy it they will sell it to make money and use it at the same time. In the sexually conservative Gulf societies, it is not unusual for men to travel outside their country and engage in sexual behavior that is forbidden within the boundaries of their own culture. Because women and men are not free to date or freely mix with each other before marriage, men may resort to visiting a prostitute within the country or go outside Bahrain. In some cases this behavior continues after marriage as cited by Patai (1983) in his discussion of sexual behavior in sexually oppressive societies. One physician from the Ministry of Health spoke about this practice: We have young people who go on tours to southeast Asia, what we may call sex tours, maybe they should be a target group and we should put something in the airport to warn them. Maybe it won’t stop them because this is a young man who comes from a society where sex is very much prohibited, so he goes to a place where it is open, of course he will do it. To hell with all these small pamphlets given by the health ministry (Physician A, interview, 1994). 144 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Another doctor also spoke about this: We tell the women if you feel your husband is going abroad by himself and you are not sure, especially if he is going to Thailand or Bangkok, whatever the Far East, they should encourage them to come to see a physician and you know a lot really do bring them (Physician B, interview, 1993). Thus, it is acknowledged by the country’s physicians that in Bahrain, the high risk groups for contracting HIV infection are IV drug users, prostitutes, homosexuals and anyone who is practicing non-monogamous sex without protection. These are the same basic high risk categories that exist everywhere in the world. Bahrain, however, is unique in that it is most probably one of the few Arabian Gulf countries that would publicly admit that its citizens do engage in such behaviors. However, once the campaign was implemented, it appeared to target the general population. Television, radio and print were used to promote HIV/AIDS prevention messages. Doctors from the health ministry gave lectures about HIV/AIDS to companies in Bahrain, the university and vocational training center, the Red Crescent Society, women’s organizations and even in some of the local villages. These activities occurred during the campaign period of one to two weeks so the public would find HIV/AIDS 145 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. information everywhere during this period of time. Daily articles appeared in the newspaper about HIV/AIDS, radio programs interviewed doctors about AIDS, and had callers call in with questions, and special television programs which hosted doctors from the health ministry to discuss HIV/AIDS were produced. The lectures about HTV/AIDS at the local companies lasted about 45 minutes and HTV/AIDS information pamphlets were distributed to the companies which had HTV/AIDS lectures. Information materials were also given to travel agencies. Apart from the HTV/AIDS campaign period, the Ministry of Health also began conducting workshops for community leaders such as health care workers, teachers, the religious clergy or mullahs (those who speak at Friday prayer) at different times throughout the year. It was the Ministry’s objective to have them serve as a second line of information. The training of these groups took place in the form of workshops that were conducted at the ministry for groups of ten to twenty people. One doctor from the health ministry explained their approach: We thought if we are in the Ministry of Health, we can’t educate everybody here so we need a second line which should be teachers, mullahs (those who speak at Friday prayer). So we started by training these people and discussing with them not by lecturing them, but by taking ten of them and sitting with them, just a 146 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. discussion. If they have anything that isn’t clear, we will talk together. Then we tell them they should take the knowledge and spread it back to the students if they are students and mullahs should speak in their Friday talk or in the mosque (Physician B, interview, 1993). Bahrain’s Islamic society also participated in the promotion of materials during the HTV/AIDS campaign. One government doctor felt Bahrain’s small size was an advantage: Bahrain is a small country. If you know something, it will spread by itself. For example, one society made us a sticker about AIDS. It was from the Islamic society. It said AIDS is dangerous to health, economics and society. They made a lot of sentences like this and printed them themselves and distributed them (Physician B, interview, 1993). Traditional religious meeting places were also used to offer AIDS lectures to men and women. The Shi’a Muslims have a specially designated facility called a maa’tam where they celebrate religious holidays, commemorate the dead, offer religious classes and host a variety of other social activities. These maa’tams are found in every village and throughout the cities in Bahrain. There are separate maa’tams for men and women. The health education officer explained their approach: The women have maa’tams and lots of them go there. We reach them through there and offer lectures on AIDS in these centers. We also reach them through social 147 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. centers whether they are going for learning stitches or classes because they take lessons at these centers. Here we can reach the ladies. (Physician B, interview, 1993). The Ministry of Health named their target population for their HIV/AIDS campaign as those who were engaging in high risk behavior, but in the implementation of the campaign, they targeted the general population, without appearing to focus on any particular high risk group. Campaign Content The content of the campaign lectures covers the historical background of the vims and how the vims is and is not spread. It also addresses prevention issues from a religious perspective. The provision of HIV/AIDS information literature is a large part of Bahrain’s HIV/AIDS campaign. Some of the HTV/AIDS pamphlets are produced by the Ministry of Health and others by the World Health Organization’s Eastern Mediterranean Regional Office in Alexandria, Egypt. This section will look at how the most widely circulated information pamphlets are organized, and the kinds of messages found inside. An analysis of the content will take place in a later section. Complete translations of these pamphlets can be found in the appendix of this study. 148 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The first information pamphlet that has been circulated in Bahrain was published by the World Health Organization in Alexandria, Egypt in 1992. On the cover of the pamphlet it states: The straightforward marriage relationship, based on honesty, religious regulations, and moral behavior protects from AIDS (AIDS Information Exchange Center, Regional Office East Mediterranean, “Message to you dear citizen”, 1992, pg. 1). Beneath the above statement is a drawing of a western looking family with a message in a box below that reads, “With knowledge and fidelity you can avoid ADDS.” The first page of the pamphlet explains that AIDS is all over the globe and that there is still no cure for the disease. It explains that there is now knowledge as to how to prevent the virus and the focus of the booklet is to provide information about the disease. The second page explains that AIDS is a deadly virus and that each individual must be responsible for his behavior. The third page lists symptoms of AIDS such as inflammation of the glands, fatigue and weight loss. The fourth and fifth pages show ways that infections do not occur such as through insect bites or eating or drinking after one who has the virus. Illustrations are used on these two pages to emphasize their points. The sixth page discusses symptoms of the disease 149 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. again and talks about how the virus is transferred. This page states clearly that the “infection comes through blood, sperm, vaginal liquids” It also states that the virus is transmitted through sexual contact between homosexual males if one of the partners carries the virus. It continues to talk about modes of transmission and mentions infection through infected blood by using unsterilized needles and that infection rates are high among drug users. It states that the infection may also be transmitted through the pregnant mother to her baby during pregnancy. The final paragraph asks the question “How to avoid ADDS infection”? The answer simply states that it can be avoided by following necessary precautions. Nowhere in the pamphlet are prevention measures mentioned except in one vague reference to social behavior, but precautionary measures are not stated: Until now no medicine or preventative medicine has not yet been found, but any one can avoid AIDS if he follows the correct precautions. It’s a matter of social behavior that each individual is responsible for, since this behavior could affect the whole society. (AIDS Information Exchange Center, Regional Office Eastern Mediterranean, “Message to you dear citizen”, 1992, page 2) The second information pamphlet presented here was produced by Bahrain’s Ministry of Health in 1992 and was titled “Facts about AIDS”. It 150 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. focus in on facts about AIDS and it presents ten facts about the disease. These facts include global statistics about the virus, the stages of the disease, how the vims is transmitted which includes sexual transmission, infected blood, infected shaving tools. It explains that daily practices do not transmit the vims nor casual contacts in work or school. It states that the most guaranteed way to stop the vims is to avoid homosexuality and have sex only within the marital relationship. It also states to have blood tested before transfusions and to have needles properly sterilized before use. It concludes by stating that AIDS prevention requires knowledge as to how to take precautionary measures. The precautionary measures presented are to follow ones religion. Another pamphlet produced by the Ministry of Health in Bahrain provides similar information to the above description but on the first page it states “AIDS is the anger of God” (Ministry of Health, AIDS committee, “What you should know about AIDS?”, 1992, pg. 1). It then talks about what the disease is and some brief background of the disease. Under transmission of the vims it states that AIDS is related to the lifestyle of the individual and it might be transmitted through male homosexuality or by drug use or infected blood. The pamphlet concludes with: 1 5 1 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. We thank God because AIDS is away from us. It’s because of our religion as we all know that AIDS happens because of homosexuality and drug taking. SO the family should play an important role in raising their children according to the Islamic religion (Ministry of Health, AIDS committee, What you should know about AIDS?”, 1992, pg. 6) The content provided to the public in Bahrain thoroughly covers many areas of the virus, its epidemology, modes of transmission, not to fear AIDS patients, but it lacks thoroughness when discussing disease prevention. Prevention is stated as following one’s religion and avoiding “immoral” behavior. One doctor spoke about the content: Our message is how it comes, what is the source of the infections, how to behave themselves properly and even through the messages there are some religious points, parts of the Holy Koran, maybe parts from the prophet and in between there we have messages from the Ministry of Health and they put it in-between. These are the general messages. We try to get them to control their behavior, we try to use the religious theory because the people still believe in this. Maybe this is the area which will protect them (Physician C, interview, 1993). The brochures discussed in this section were the most commonly distributed HIV/AIDS related literature during the year of 1994 in Bahrain. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. HIV/AIDS Campaign Analysis The Influence of the Religious Leaders The religious leaders in the Islamic Middle East play an important role in the shaping of public opinion. Frequently this is witnessed in anti- government or anti-western rhetoric followed by large demonstrations among the population. The religious leaders are also among the first to be jailed when there is anti-government activity. The support of the religious community has been critical to the success of Bahrain’s HIV/AIDS education campaign because of their ability to reach thousands of people and by the religious community legitimizing the topic of HIV/AIDS it made it easier for health officials to address. Some of Bahrain’s most prominent religious clergy were invited to attend AIDS workshops at Bahrain’s health ministry. The goal was to provide an additional channel of information that would reach large numbers of Bahrainis. One physician from the health ministry spoke about the importance of gaining the support of the religious leaders: I am a B ahraini., I am a Muslim and I know that there is hardly any situation that we have here like Friday prayer, thousands a block and they are ready with their hearts, eyes, ears, just to listen to the clergy, whatever he says they will always take without question, Now this is a person if you educate him, if you cooperate with him he can do wonders. I think for health education, for me as a doctor, that is where we should practice health 153 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. education. But these are things within the culture that not everyone has used properly. We should sharpen our means and with cooperate with these people so they come to our health seminars. We want to reach them. They should at least know what is happening, let him put it however he likes. Last week at Friday prayer, the sheik was saying these are people [AIDS patients] who need to be protected, who need to be helped and that was a very positive attitude. In many ways I felt the way he put it was more convincing than many of our health education campaigns (Physician A, interview, 1993). Two other doctors spoke about how they informed the religious clergy: We targeted many different groups and the religious people were a big part of the campaign. There were fifteen to seventeen, Shi’a and Sunni and most of them were those who speak at Friday prayer. Some of them were very knowledgeable about AIDS and some were not. We offered workshops to these groups to improve their knowledge. The majority accepted it and they even asked for more information. We told them there are many areas they can focus on about AIDS. It is not a matter of the AIDS, but the behavior, because they can influence the behavior of the people which AIDS is really a problem of the behavior of the people (Physician B, interview, 1993). We have the support of the religious community, but it would be supportive anywhere if people know how to approach them. I think one of the key issues is that the majority of people working here are locals and by talking about locals, I mean even an Egyptian who speaks the same language cannot be compared to someone who knows, who is from the local culture. I come from the culture and I know how to communicate Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. with the culture. So do some of the other doctors here, that’s why we are easily accepted (Physician A, interview, 1993). Gaining support from the religious leaders was not a difficult task because they, like some of the physicians from the ministry believe that AIDS is a direct result of the breakdown of morality in the society or a consequence of people leaving their religion. This was confirmed by some of the ministry physicians: I tell the religious leaders that the people are not listening to the religion, if they listen to the religion, they will not get the disease. So if you go from this point, they will be positive (Physician B, interview 1993). This physician means that the people are contracting AIDS because they are engaging in drug use, homosexuality or sexual relationships outside of marriage, which are all against Islam. The same physician presented a personal opinion regarding the transmission of the virus and religion. If you look in the newspaper, on Friday they have a religious page and even on this religious page they talk about AIDS and how Islam, well our prophet said there will be a time when a certain disease will come which you don’t know about and you never hear about and this is because you don’t follow your religion. Now it doesn’t say AIDS but it is something called an epidemic. So our religious people will say that this is something which has been told by our Prophet and one day it will 155 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. come and you will see this day if you are not strict in your religion. (Physician B, interview, 1993). The health ministry’s utilization of the religious clergy in their campaign has not been entirely a pragmatic decision. Some physicians in the ministry do believe that HIV/AIDS is a direct result of not following ones religion and some may view it as a punishment from God as is published on the first page of a health ministry AIDS education pamphlet. There are many questions that remain unanswered regarding the role of the religious clergy. First, it is unknown exactly how many are educating the public about HTV/AIDS. It was reported that a Shi’a religious sheik had given hundreds of young men a lecture about AIDS prior to one of the most important Shi’a religious events, Muharram6 (Ministry of Health, 1993). No one has evaluated the content of the religious leader’s lectures or even knows how many have actually addressed HTV/AIDS so it is difficult to ascertain their effectiveness. Are people learning how to prevent transmission of the virus from the religious clergy? Are they helping to 6 This event commemorates the martyrdom of the Shi’ite leader Iman Hussien and is mourned annually by thousands devout Shi’ite Muslims throughout the world. An important part of the ritual is self- flagellation which is done during a procession. This ritual is renowned for the blood that is spilled in memory of their religious leader. Recently, some governments have started to prohibit the ritual of drawing blood by the use of a sword because of the fear of the possibility of spreading blood that may be contaminated with the AIDS virus. It was outlawed in Bahrain this past year (1995). 156 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. reduce the stigmatization of AIDS patients? Are they preaching compassion or condemnation? These questions are areas that still need to be addressed. The religious community, both the leadership and the local meeting places, have undoubtedly provided the means for health education to reach the traditional segments of the society, that without such legitimacy may never have occurred. When AIDS is discussed in the context of the religion, the people, particularly the very religious people may be more willing to listen to it. Most issues of a sensitive nature can be approached as long as they are done so within a context that is familiar and accepted by the local culture. For example, the discussion of HIV/AIDS by focusing on adherence to the religion as a major mode of prevention. However, this approach may not be comprehensive enough when trying to affect the behavior of high risk groups. Part of the problem with focusing on religion as the method of prevention leaves an enormous gap of information for those who need it the most. High risk groups or individuals engaging in high risk behavior are not the religious segment of the society. The result is that they are overlooked by receiving the least useful information about HTV/AIDS, and those who need 157 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. HTV/AIDS education the least, the religious members of the population, are getting it the most. Disease of Shame hi addition to utilizing the religious leaders as channels for educational information, another implementation strategy included approaching a number of companies and educational institutions to offer HIV/AIDS lectures. The Ministry was successful with most in that the management welcomed their lectures. In December 1993, the Ministry of Health presented two lectures, one for men and one for women at the Bahrain Training Institute, the place where the researcher was employed during the period of this study. Because this was a group of college aged students who most probably would feel embarrassed discussing these issues in the presence of the opposite sex they offered sex segregated lectures. Some of the students were eager to go, and the women particularly appeared eager to hear the lectures. However, according to one institute instructor some students did not really want to attend the lecture. I tried to get my class of men to go to the lecture, but they were making comments like “teacher, we do not need this lecture, we are not bad, we do not do such bad things to get this AIDS. 158 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Another teacher commented on the reaction of one of her female students to the lecture: I liked the lecture very much and I wish we could have more lectures like this. It’s good we can learn about such things, this is important for us. But I can’t tell my father or mother about this because they will be angry that we are learning about this thing at school. There is also the association of AIDS with shameful behavior. Both the male students’ comments and the female student’s comment about her parents reactions show there are still strong taboos around the discussion of AIDS. This was also exemplified by the response of some local companies to having a lecture of AIDS given at their company or AIDS materials displayed in their offices. The last campaign we started we thought we would also include the big companies. For example, I spoke with the National Bank of Bahrain, the Kuwait Bank, BAPCO, BATELCO, a lot of companies. Some of them were really happy, I mean the public health relations officer of this company said “It is very nice of you.” I told them I would like to plan the lecture at the end of June because everyone will be traveling outside Bahrain in July and August so I think it is a very good time to have a lecture. Then I waited two or three days and nobody was answering me. So I called them again and they said “sorry we want to but after we spoke to our staff, they asked us why are we the ones, this is something that does not come except in sex and that means if we let them come and speak to us that we are 159 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. admitting we are doing such dirty things.” This attitude came from the staff, not the administration. But some companies were OK with it. We gave lectures twice to BAPCO, BATELCO and Petro-chemicals. (Physician C, interview, 1993) When we made a poster for AIDS which has the way AIDS is transmitted, I called this travel agency to put this poster in their office, some of them welcomed it, and some of them disagreed with it. (Physician B, interview, 1993) Resistance to HTV/AIDS education still occurs because of the linkage of the disease to shame and sin. Obviously, the population is aware of the disease, but are they aware of aspects of the disease that will serve to protect them or do they just have enough knowledge to believe that AIDS is disease that an individual “acquires” through immoral behavior, and so if they believe they are moral, then they will not get AIDS. The strong association of the disease with sin continues to cast stigma on those who have contracted the virus and as seen from the above remarks, affects some people’s desire to even listen to information about the disease. The ministry’s campaign may be offering epidemiological and theological information about the virus, but how useful is this information in protecting high risk groups? This next section will take a closer look at the content of the campaign to see in which areas in may be most effective in preventing the transmission of the virus. 160 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Campaign Content Religious Approach The content of AIDS prevention information in Bahrain is written to explain how HIV/AIDS is and is not transmitted with adherence to the religion as the mode of prevention. One important aspect of the campaign is that in creating the content it was critical it did not appear as though it was condoning sexual relationships outside of marriage for example by offering explanations how to use condoms. The general theme of the campaign is that if the religion is followed, then AIDS will not be contracted. One member of the National AIDS Committee explained Bahrain’s approach to AIDS education in more detail: These issues may look straightforward to Americans or Europeans, but culturally it might not be accepted here. Take for example, the campaign about wanting to educate people how to use condoms. Now I’m not discussing whether it is right or wrong, but I think the vast majority of people here, that once you talk about how to use the condom, show pictures, etc..., there would be political and social pressures that would make it very difficult for people to come out with pamphlets showing these things because they will be confused with the idea that these are people who are advocating an open use of sex which is a taboo. Right or wrong, this is 161 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the culture and these are the rules. These people have to create different ways. There are also people who say why should we only talk about the use of condoms, shouldn’t we stress on what within the culture is . accepted, like abstaining from sex, which is obviously practiced here to a great extent. These are things that are particular to these parts of the world and are still accepted within the culture as a whole. They are not being put as mottoes or as declarations that can go across cultures, but the culture here that is for sex and using condemns, these are the minority (Physician A, interview, 1993). Another doctor also spoke about the content: Our message is how it comes, what is the source of the infections, how to behave themselves properly and even through the message there are some religious points, parts of the Holy Koran, maybe parts from the prophet and in between there we have message from the ministry of Health and they put it in-between. These are the general messages. We try to get them to control their behavior, we try to use the religious theory because the people still believe in this. Maybe this is the area which will protect them (Physician C, interview, 1993). One doctor explained how they spoke to those who were very strict about the religion: You can go from the positive or the negative side. One person may say “I am very strict, why do you want to talk to me about this, I don’t need it.” So when you talk to him you should talk about the religion. I don’t tell them to speak about AIDS, I tell them to speak about the homosexual and how it is something against the religion. Also, to speak about sex outside of marriage. All of Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. these are forbidden by Islam. If they speak about drugs, I tell them to speak about the religion. It is not just talk about health (Physician B, interview, 1993). Respect for the religion and culture has been an important part of the AIDS campaign and the key to the campaign’s implementation. The government doctors exhibited a keen understanding of what the population would accept and what they would not accept regarding the content of the campaign. Knowing these boundaries and developing the content to fit within these boundaries has aided the campaign’s success. This was made feasible because those who designed the strategy and educational content were local Bahrainis who themselves held similar beliefs to the rest of the society. However within the Ministry of Health, there were varied opinions regarding how sensitive they should be in their approach to AIDS education. While one doctor spoke about the possibility of AIDS being a punishment from God, another disagreed with this approach: It’s very important for high risk groups to have the correct information about AIDS, if they don’t they will believe it is a punishment from God and that one can do nothing about it. We need to explain explicitly to them how AIDS is transmitted (Physician D, interview, 1994). 163 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The doctors do not all agree on what should be presented in the content of the AIDS campaign. Some are more willing to engage in frank and open dialogue, but the majority seem to believe that the public is not yet ready for such a dialogue. Analysis of HIV/AIDS Campaign Literature The complete translations of three HIV/AIDS information pamphlets can be found in the appendix of this study. One pamphlet, titled “Message to you Dear Citizen” was produced by the World Health Organization’s Eastern Mediterranean regional office in 1992. The two other pamphlets discussed in the section were produced by Bahrain’s Ministry of Health in 1992 and titled, “Facts about AIDS”, and “What you should know about AIDS.” These educational pamphlets are always available at the Ministry of Health and at the local health centers throughout the island. Pamphlets are also distributed during the week of the health ministry’s campaign to the different locations where HIV/AIDS lectures are given. The content of the pamphlets differ only slightly in that some have more lengthy explanations as to what causes virus transmission, but common themes are found throughout each of them. The following excerpts will provide examples of the most common themes found inside the pamphlets. 164 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The War Metaphor Since the late nineteenth century the metaphor of war has been strongly used in the field of medicine (Ross, 1989). Bacteria were described as invaders that could kill innocent victims. HIV infection has not been exempt from this vocabulary. This metaphoric language is used throughout the AIDS literature in Bahrain. The following citations have been taken from the first two pages of a WHO produced pamphlet titled “Message to you Dear Citizen,” AIDS Information Exchange Center, pgs. 1-2,1992). Dear Citizen, Since 1981 the world talks about the sweeping disease that spread all over the globe causing pain, fear, disability and death to an increasing number of people. We have knowledge how to avoid it and how to protect ourselves and our families from this killing disease. If everyone of us knows the simple and vital facts about AIDS there will be no reason to worry or fear and we will all know how to avoid it. If we do not know how to gather and exert efforts to stop this disease the number will quickly double which creates a serious threat to humankind. 165 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The language above resembles the rhetoric used by world leaders to stop an invading army, similar to the fear inspiring language the American leadership used to describe the spread of Communism in the 1950’s. Excerpts similar to the above are also found in the pamphlets produced in 1992 by Bahrain’s Ministry of Health. AIDS invades all the continents as it has the capability to transgress social and geographical borders (Facts about AIDS, pg. 1,1992). In the absence of successful treatment and until medical research finds effective medication for AIDS, health education remains to be the strongest weapon in facing the disease (Facts about AIDS, pg. 1,1992). Participate with us in the fight against AIDS and put a limit to this dangerous disease on the International Day of AIDS and every day (Facts about AIDS, pg. 1,1992). AIDS is a very deadly and dangerous disease spreading slowly and surely in the world causing panic and fear to everyone (What you should know about AIDS, pg. 6, 1992). The war metaphor is used to create an enemy and in this case, HIV/AIDS is seen as the enemy. The problem here is that once the disease is perceived as the enemy, the body that houses that enemy is also to be feared. This rhetoric results in heightened fears of contagion, and the AIDS virus carrier 166 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. perceived as one of society’s most dangerous members. This can lead to demands for quarantine and isolation of the “enemy” (Ross, 1989). AIDS as Foreignness Another common metaphor associated with highly infectious disease and plagues has been the invasion of the disease from somewhere else. This is seen in the literature pamphlets published by the health ministry in Bahrain. Reports stated that the disease virus came from Africa and started invading the world through the infected individuals who traveled through northern Europe and Haiti (What you should know about AIDS, pg. 2, 1992). We thank God because AIDS is away from us. It’s because of our religion as we all know that AIDS happens because of homosexuality and drug taking. So the family should play an important role in raising their children according to the Islamic religion (What you would know about AIDS, pg. 6,1992). The strong association with homosexuality and drug taking in this pamphlet would not sufficiently protect someone engaging in unprotected sex within a heterosexual relationship, or would make a woman whose husband has sex outside of marriage feel that she is immune from the virus because she knows her husband is not homosexual, or a drug user. The metaphor of 167 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. foreignness is also a metaphor of otherness, that certain groups are vulnerable to infection, rather than high risk behavior practiced any individual. This association of AIDS as otherness creates an illusion that AIDS only happens to other people, those practicing “immoral” behavior and the association with foreignness makes people believe they cannot get AIDS unless they travel outside their own country. AIDS as Punishment from God The close association of AIDS with promiscuity, homosexuality and drug use has resulted in some viewing AIDS as a punishment from God for immoral behavior. In the Ministry of Health’s AIDS pamphlet titled “What you should know about AIDS”,(Ministry of Health, pg.l, 1992), there is more than one reference to AIDS as a punishment from God. On the first page of the pamphlet, it states “AIDS is anger of God.” The pamphlet concludes with a story from the Koran. God’s words are true. Lute tribe did not believe their son Lute when he blamed them for homosexuality. Lute said, “I am your messenger. Please obey God and follow his sayings and you and me will be rewarded. You ignore the normal life, wives, and you take men in a homosexual way instead. You are not faithful. The tribe said to Lute if you don’t stop talking we will send you out (expel you). Lute to God said, “God save me 168 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and save my family.” God saved him and his family except one old person from his family, a homosexual and God flooded the whole tribe with very heavy rain and the village was destroyed completely. That was a sample of God’s punishment (Verses 159-175). This perception of AIDS as a punishment from God results in those who contract the illness being blamed for the illness as something they deserve from their immoral behavior. In a health campaign, the effect of this message would be for an AIDS vims carrier to feel shame to have the disease and would most likely choose to hide it from others. It also stigmatizes the disease as a disease of shame and labels those who have HIV/AIDS as perpetrators of immorality. It is, however, difficult to separate the disease from such perceptions, because transmission of the vims does affect those who are engaging in behavior that goes against the religion. In a conservative Islamic culture where the teachings from the Koran are commonly the laws of the land, and the Koranic stories are related day after day in the mosques as lessons of morality, it is highly unlikely that this association of AIDS with sin will go away. Unfortunately, propagating the link between AIDS and sin or AIDS as a punishment for immoral behavior may enhance already prejudicial feelings towards those carrying the disease or those engaging in high risk behaviors to 1 69 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. further alienate them from the society. These people will be labeled as “bad” people and people will be afraid to associate with them. If the theological approach is a very strong part of the health education campaign, and the only institution that counsels individuals for AIDS is a government one, it may discourage high risk individuals from voluntary HIV testing out of fear that they will be judged for their behavior. This does not mean this will actually happen when they go for AIDS testing; in fact, the Ministry of Health is very non-judgmental in both their HTV and drug counseling programs, but high risk groups may not perceive them this way if the AIDS campaign content reinforces the association of AIDS with sin. Fidelity All of the AIDS information pamphlets stress fidelity and following the religion as the primary mode of HTV/AIDS prevention. Unlike Western AIDS information brochures where practicing safe sex is mentioned and details are offered as to how to sterilize needles, prevention methods discussed in B ahrain are limited to abstaining from the behaviors that cause transmission of the virus. The straightforward marriage relationship based on honesty, religious regulations, and moral behavior protects from AIDS. [This is followed by a drawing of a family in western attire.] Under the picture it states: 170 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. With knowledge and fidelity you can avoid AIDS (Message to you Dear Citizen, WHO pamphlet, cover page, 1992). The most guaranteed way to stop the virus is to avoid homosexuality and to maintain only legal sexual relations between husband and wife (Facts about AIDS, Ministry of Health, Bahrain, pg.l, 1992). Societies should play a vital role in changing the lifestyle of some individuals especially in regulating the legal sexual relationships and moral attitudes (Facts about AIDS, Ministry of Health, Bahrain, pg.l, 1992). The above AIDS pamphlets also provide information about transmission of the virus, and symptoms of AIDS. However, preventative measures for those who are engaging in high risk behaviors are not presented because the society, or government does not want to appear to be condoning such behavior. Campaign Effectiveness How effective are these educational messages? Bahrain’s Ministry of Health has not conducted any follow up studies regarding the effectiveness of their campaign messages. The health education officer attributed this lack of follow-up to the shortage of staff in the health education office. The current campaign messages may affect those who are not at risk of contracting AIDS, and offer them further knowledge about the virus. But whether they 171 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. will actually change high risk behavior does not seem likely. No methods of protection are offered to those who are engaging in high risk activities. If these are the Ministry’s targeted groups, their message will have to be more explicit to be effective. It is understandable that a conservative religious society may not publicly present explicit prevention information to high risk groups, but for ADDS education to benefit those who need it the most, those who chose to engage in high risk behavior must receive explicit, detailed information as to how to protect themselves. If they are the target groups of the health campaigns, it is essential the content be more appropriate for these groups. Drug users need to be taught how to clean their syringes and those engaging in unprotected sex need to be told the importance of using condoms. The published literature is thorough in explaining many facts about the disease, but it denies individuals information about how they can protect themselves outside of abstaining from the behaviors that cause the disease. It is crucial that more detailed information is provided in order to protect those who do engage in high risk behavior. Recommendations for how this can be done are found in the last chapter of this study. 172 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Health officials have a challenging task to obtain a balance between offering information to protect people from AIDS and trying to keep it within the context of their culture. Some expressed frustration at not being able to use explicit language and felt that the campaign lacked that critical element but did not know when they would be able to proceed otherwise. Doctors implied that there are some conservative officials who will have to compromise before they can take further steps in the development of the AIDS campaign. One doctor reported how this problem affected the content of the campaign: I showed a book about sex education that showed explicitly how to use condoms to another ministry official who I won’t name, and he was shocked that we would even consider discussing such material. (Physician A, interview, 1994) Doctors spoke honestly about areas that the campaign needed improvement and offered suggestions as to how they would go about it. The first area they felt needed more attention was the utilization of their religious community. While they have offered workshops to the religious clergy and have heard reports of talks about AIDS in Friday prayer and in local maa’tams, members of the health ministry believed the religious clergy should be more involved in health education: 173 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The religious leaders have the power in this part of the world and I don’t feel we have used them to their fullest capacity. I would like to see more workshops for them and generally more involvement. The people are ready to hear their message (Physician D, interview, 1994). Here we have a captive audience at the mosque and the maa’tam and we are not utilizing them enough in health education. It’s a very powerful tool and we ought to really think about using it. We need to go to them, to approach these people more. We have not used them enough, we haven’t even scratched the surface (Physician A, interview, 1994). These doctors were adamant about using more of their own cultural resources in the field of health education. They also expressed their dissatisfaction with some of the gaps in their AIDS programs such as the need for more research, more elaboration or explicit information and the importance of conducting follow-up studies to examine the effectiveness of the campaign. We still need more research on high-risk groups, particularly drug users. Also we need to target the high risk groups, drug users, young people who are having sex outside and also the problem is with the explicit explanation of condoms (Physician C, interview, 1993). We need more counseling, a hotline, group counseling, volunteer people, and to have community leaders talk about it, more religious people involved and an AIDS comprehensive educational program in the schools; then 174 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. we are spreading the message. The people are ready to receive this message. We just need more of a campaign, and it needs more elaboration (Physician D, interview, 1994). I think we are missing a lot of the follow up, but again we have only recently begun. For example, how many of these people are literate enough to read the AIDS pamphlets we give out. I also have to check and evaluate the effect of the campaign, do some kind of follow-up or evaluation after six months or a year. Many of the things that we do here lack that component (Physician B, interview, 1994). I think we are still missing some things, but we also have a shortage of manpower. I have a lot of people who work with me and they are giving me alot of support but we need more staff, particularly for follow up regarding the effectiveness of all these campaigns (Physician A, interview, 1994). While all the doctors believed there were areas that needed improvement, they also felt Bahrain’s AIDS program was better than other programs they had seen in the Gulf: We meet with other Gulf countries, and since I’ve worked in this job, I have seen them two or three times and they have programs but I think ours is far better. Even our material compared to their material is more detailed. I think we are more open (Physician A, interview, 1994). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Actually regarding other programs in the Gulf area, I don’t know but I think our steps are increasing. We are opening more areas to talk about AIDS in different groups. There are people coming from Morocco and they are surprised and say “How do you talk about AIDS this freely?” They are visiting other Gulf countries and it’s difficult to find anybody to talk about AIDS. So I think we are open now, or a bit freer to talk to the people (Physician B, interview, 1994). I think Bahrain is farther ahead than other Gulf countries because it is a more open society, we are more accepting (Physician D, interview, 1994). This section of the study has shown how the culture has both constrained and facilitated the development, implementation and content of AIDS programs in Bahrain. The biggest challenges have been in creating materials suitable for the conservative society in which they live and finding an appropriate and effective means to communicate their message, particularly to high risk groups. At this time the campaign’s effectiveness is not known because of the lack of follow-up studies. This is indeed an area which warrants further development. The Bahraini health education officials appeared to recognize the potential of what they can do with their own resources, as well as the present limitations of their AIDS programs. The campaign should be viewed as a work in progress and with continual efforts 176 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. at self-appraisal health officials may find even more effective resources in the culture to help them in the development and implementation of their AIDS education programs. The contrast between the old traditional ideas and the new modem thinking by much of the younger generations sometimes paralyzes governments from making important decisions, not only in areas of social issues, but more commonly seen in the political arena, for fear of upsetting the religious segment of the population. The sensitivity that surrounds the subject of sexuality does not imply that issues of a sexual nature cannot be discussed, rather it means that they must be dealt with in a culturally appropriate manner. For example, when preparing an AIDS lecture during Bahrain’s AIDS campaign week to a group of college students, a Ministry of Health doctor suggested separating the students by sex so each group would feel more comfortable discussing the subject of sex and AIDS: Of course there are cultural issues from the Islamic culture that do affect us. For example, the shyness of women to go to male doctors. Within our religion, however, there are no barriers to the discussion of sex. In fact Islam is obsessional about sex. There is no religion as open about sex as Islam. So religion is not the issue, it’s the culture. (Physician A, WHO conference, 1994) 1 7 7 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The issues of sexual knowledge is still an area where it is difficult to talk about. It is a sensitive area. Sexually transmitted diseases and generally sexual talk about them or the sexual concept of it is a sensitive area and even in my questionnaire I try to avoid it. I avoid sexual questions. Even if there is an AIDS film, they cut from them showing condemns or any explicit sexual information, so this is an area that is really sensitive. How we face the people, well we will need a green fight on it, to talk to the people freely, to do the research we have to talk to them. We need information about their own behavior regarding sex such as how many sexual partners they have, and these kinds of questions we still need information on. (Physician C, interview, 1994) Another doctor confirmed this problem and explained that is also affects the publishing and presentation of research as well: We have a society based on shame. I attended a conference on alcoholism in Saudi Arabia and I didn’t agree with what the presenter was saying. What is written and published on drugs, alcohol, AIDS in this part of the world has to be carefully presented. This is just the way it is. (Physician A, interview, 1994) This kind of shame was seen by the company whose staff did not want AIDS education at their work site because it may have implied they were engaging in activities that could bring about AIDS; the same is true for discussions of sexuality. Once an individual is open about his/her sexual experiences or even has questions about sex, it implies that they are having 178 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. sex, and of course if they are not married it becomes an issue. The taboos towards open discussion of sexuality are linked to the conservative religious culture, and to the importance of safeguarding one’s reputation or honor. How to approach or discuss issues involving sexuality and HIV/AIDS was addressed in detail at a conference given in Bahrain, co-sponsored by WHO, in April of 1994. A group of health professionals got together to discuss HIV counseling practices and techniques for discussing HTV transmission and asking questions about sexual behavior in a conservative religious population. The conference members held very different ideas to the approach that should be used, some more conservative than others, but most were willing to question their own approach and to rethink their initial responses. The Bahrainis displayed a tremendous willingness to discuss the issues, to find suitable methods for counseling individuals who think they may be HIV positive or who are HIV positive. They had workshops and role-plays which allowed them to examine their own attitudes and behaviors. The goal of the conference was to try to expand the numbers of HTV counselors in the health profession in Bahrain so that more counseling could occur in the local health centers. 179 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Religion has played a vital role in the message offered to Bahrain’s population in helping to prevent the spread of the AIDS virus. It has helped facilitate channels of communication that have permitted the government’s health education regarding the transmission of AIDS to be delivered in part by the religious community. The participation of the religious clergy has helped to legitimize the AIDS campaign and bring in to the general population. Careful consideration of the type of content and presentation by the Ministry of Health has also brought the issue into the open without upsetting or offending the local culture. WHO of the Eastern Mediterranean region has also contributed to the development of strategies for teaching about AIDS in the Islamic world. Ultimately each country will have to define its own course, choose its own materials and find the best methods to communicate its message. Other Islamic countries, particularly the more conservative ones can learn from Bahrain’s approach to AIDS education. By including the religious clergy and utilizing their religious resources they have been able to publicly discuss AIDS prevention measures, something that was considered nearly impossible only a few years ago. It is important when critiquing any educational program to view it within the cultural context of the society in which it exists. From a western 180 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. viewpoint there is a risk when studying or analyzing the Arab Middle East to. be overly judgmental about their social norms and values. It is easy to be highly critical of non-democratic, dictatorial societies or of countries where women are not allowed the freedom of their western counterparts. When analyzing the Arabian Gulf countries it should be remembered modernization only began less than fifty years ago. In some Gulf states, education in the western sense of the word, began only thirty years ago. Saudi Arabia has just begun to allow, in certain circumstances the mixing of the sexes in the workplace. Young men and women are not permitted to mix socially, especially if they are unmarried. Women, for the most part, still wear the traditional clothes and are kept separated from the men. Even in Bahrain, most university students voluntarily sit away from members of the opposite sex. Men do have more freedom than women in these societies. Women do not have the mobility men have. They are not allowed to travel by themselves, or to go out at night alone unless for a special occasion. The professional and educational achievements of both men and women in the Gulf states have all been made over the past fifty years, it cannot be ignored that these countries are modernizing at a fairly rapid pace while still m aintaining their religious and cultural traditions. In regard to health 181 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. education issues, it is impressive that today a Gulf country can openly acknowledge the presence of a disease that can be sexually transmitted and talk to its population about methods of transmission and prevention. Although their HIV/AIDS campaign lacks the explicit language that is necessary to protect high risk groups, their overall approach to HIV/AIDS suits their largely religious conservative society. At the present its effectiveness is questionable, but the presence of HTV/AIDS literature is certainly a step in the right direction. The Effect of Culture on Students’ Attitudes towards HIV Transmission and HIV Carriers/AIDS Patients The second area of concentration of the study examined the influence Bahrain’s religious culture has had on the knowledge and attitudes of Bahrain’s college students towards HIV transmission and HIV carriers/AIDS patients. This information was derived from informal discussions with students in a classroom setting, combined with written responses to six questions that the students were given to answer during class. In the few 182 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. studies that have been given to Bahraini students, their overall knowledge of how the virus is transmitted is fairly good; however, their awareness of the modes of transmission is not consistent with their attitudes towards virus carriers(Salah, 1993). The findings below are similar. It will be shown in the discussion that follows that while the students had fairly good knowledge about the disease, the predominating attitude towards AIDS is that it is a punishment for sinful acts and those who carry the disease should be isolated from the rest of the society. Little compassion is exhibited towards carriers of the disease unless the virus happens to infect a friend or a family member. The students’ responses to the questions were similar to one another, with the biggest differences being the degree of elaboration in their responses and severity of judgment towards those carrying the virus. It is possible that the promotion of family values within the context of religion in the government’s health campaign has perpetuated negative stigmas towards AIDS patients, i.e...the close association of the virus with moral turpitude. Devotion to their religious beliefs is reflected in nearly all of the students’ comments. The following questions were designed to elicit attitudes towards the disease and its carriers rather than actual knowledge of the disease. 183 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1) Please explain what you know about the AIDS virus? 2) Explain how or where you learned about the AIDS virus? 3) Who is most likely to get AIDS in your country? 4) If you were a health official in your country, what kind of policy, if any, would you have towards AIDS infected people? 5) What would you do if someone you knew had AIDS? Would you continue to have a relationship with him/her? 6) How can you keep yourself from contracting the AIDS virus? The following themes emerged from the analysis of the students’ responses to the above questions. Knowledge of HIV/AIDS The students responses to the first question indicated that they did have an understanding of the virus. Most students knew that the disease affected the immune system and that there was no cure for the disease: AIDS means the body cannot defend itself which means it cannot resist microbes and disease which attack the body, then the person will have AIDS and die. It is a disease worse that cancer and I don’t think it will have medicine for a long time. It is a strange disease and its symptoms show very late, which means it does not allow you to find the patient. 184 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. It is a virus that catches the immune system in the human body which makes him unable to resist other diseases and viruses, then easily he can catch any sickness and at the end he will die. The AIDS virus affects the immunity in the body then the body loses the immunity against disease, then it is possible for the body to catch any dangerous disease which may make the patient lose his life. In the educational literature provided by the Ministry of Health, there were clear explanations as to how the virus is transmitted and in all of the brochures there was the mention of death. The disease was presented as fatal and as destroying the immune system. The campaign seems to have been useful in promoting knowledge about the disease. Since all of the media is controlled by the state in Bahrain, any HIV/AIDS information received from the newspaper, radio, television or pamphlets came from the Ministry of Health. When the students were asked where they received their information about HIV/AIDS, most cited the media: From some pamphlets they gave me at work and from some information from radio and television. From the radio and many other information inside the country. I know about AIDS from TV, radio, newspaper and magazine. 18S Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. By magazines, newspaper and information pamphlets. I knew about ADDS from television and by reading newspapers. None of the students mentioned receiving any information about AIDS from their friends. Newspapers, television and radio appeared to be the popular channels of information about HIV/AIDS. Association of Sickness with Sin and Foreigners The most common responses to the third question were that those who were most susceptible to contracting AIDS were individuals who were not following Islam, by indulging in sex outside of marriage, practicing homosexuality and using illegal drugs. The students used the word “haram” in Arabic, which describes an action that is prohibited by the religion, when referring to the above behaviors. Both in the oral and written responses to the questions, the students referred to those who catch AIDS as engaging in “haram” or “illegitimate” or “illegal” sex. One respondent said: A person who gets AIDS is one who is not straight and who is away from God’s instructions...Also one who goes the wrong way by engaging in illegal sexual relations. Moreover, using drugs with dirty needles that have AIDS microbes. Another respondent added: 186 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A person who is outside Islam is most likely to get AIDS and a person who drinks alcohol and uses drugs. This second person didn’t speak about sex but mentioned alcohol because alcohol is prohibited in the Islamic religion and AIDS is associated with actions prohibited by the religion. Other responses did not mention alcohol but were very similar in tone, most referring to those who do not adhere to their religious beliefs as being the targets of the AIDS virus. Other individuals responded: A person who doesn’t follow Islamic instructions will do abominable things which cause the transmission of this disease. Most people who get HIV are practicing illegal sex and are people who use drugs and those who do not follow the religious rules. One respondent wrote: In my opinion, the people who catch the AIDS virus have a weak spirit and the devil follows them everywhere so they go the wrong way. The people who follow the joy in this life and care about nothing else, they are the ones who will mostly catch AIDS. Unemployment in our country is also an important reason to go the wrong way and destructive way. 187 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. This individual did not go into any more detail about how unemployment may cause AIDS although he may mean that people will have more time on their hands so they risk getting into drugs or other behaviors prohibited by the religion. AIDS virus carriers are viewed as sinners who have left the religion and engaged in illegitimate sexual relationships or drug use. AIDS was presented in all of the educational literature as being a disease that affects those who leave the religion. It’s strong association with immorality and infidelity that were discussed in the educational materials are now part of the students ideas about the virus. The religious leaders are also conveying to the population that if people follow the religion they will not get AIDS. This also came from the Ministry of Health’s lecture to the religious clergy. Because sexual relationships outside of marriage and illegal drug use are prohibited in Islam, as they are in other religions, and they are also the most common modes of transmitting the AIDS vims, the religious clergy is using this information to get people to follow the religion more carefully. However, such pronouncements also inspire harsh judgments on individuals who are suffering from the vims. The labeling or stigmatization of vims carriers attenuates their already damaged feelings of self-worth by alienating them further from the society. Because 188 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. of the influential role religious leaders have in Islamic societies, they can easily affect people’s attitudes towards AIDS virus carriers in either a negative or positive way. Severe condemnation of the behaviors that cause the virus can be interpreted as condemnation of the disease carriers themselves thus bringing about further stigmas and alienation. Preaching compassion towards the sick will obviously improve the emotional support offered to AIDS patients and may result in additional modes of support for AIDS patients. Since these students are strict Shi’ite Muslims, they are earnest to do what is right according to their religion. Thus, it is important that the message the Ministry of Health wishes to convey to the religious community contains a wide range of information that will help to promote AIDS prevention and offer support to AIDS victims and their families. Some students believed the AIDS virus did not exist in Bahrain. When this was mentioned in the class discussion, the others were quick to correct them. They believed that AIDS only belonged to foreigners and not Bahrainis. In the written responses some students held the foreigners responsible for the spread of the virus: The ones who don’t follow the traditions and customs are likely to get AIDS because they have sex, especially with the foreigners because it is not going around the nationals. 189 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Another respondent said: First, AIDS did not originally exist in my country, therefore it is brought from outside, drug smugglers or drug users or those who go to satisfy their sexual desires. Also do not forget the foreigners who bring the virus here. Most of the students knew that there are HIV positive Bahrainis, but still associated the virus with something that was brought from outside Bahrain by foreigners or by Bahrainis who traveled to foreign countries. The next question examined the students ideas about what should be done, if anything, with those who have the AIDS virus. Heightened Fears of Contagion Most of the students believed in quarantining AIDS patients out of fear of physical or moral contamination. Because Bahrain is a small island, the students were worried about having close contact with AIDS patients. Even though the majority of students understood how AIDS was transmitted, they did not feel comfortable living in a society with AIDS carriers. They also felt that AIDS patients posed a risk to society because it is difficult to know if a person has the virus by looking at him/her. Secondly, they believed that by 190 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. quarantining the ADDS patients, they would have time to reflect on the evils that caused their disease which would eventually bring them closer to God. They also feared those who had ADDS may spread the vims out of revenge or that they could be a corrupting influence to the society. All of the students felt strongly that foreigners who have the vims should be forced to leave Bahrain. Currently there is a government law that any expatriate who is HIV positive cannot remain on the island. However, while the government does not advocate, or practice quarantining HIV carriers or AIDS patients, some students believed it was the best policy for AIDS patients. Some of the more lenient responses said: We must return all foreigners to their homes, and with regards to Bahrainis we have to open special care centers for them which will take care of them and in case the disease gets very serious, we have to keep them in the center and we have to tell them not to transfer this disease and we have to punish them if they do by keeping them away from the public. We should also ask them to warn others about this disease because these people know about the disease and its real meaning after they catch it. One respondent expressed compassion towards AIDS patients: There is a human feeling which our religion always focuses on and it doesn’t matter the color, the sex, the status or the relation of the vims carrier. All of them are human and we have to give them the necessary 191 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. treatment with care and the human shouldn’t leave his brother human and it doesn’t matter the nationality. However, the majority of the respondents believed in a more strict quarantine for AIDS patients. This shown by the five respondents’ views below: We should make special hospitals for AIDS people, and isolate them from the community, especially the homosexuals so that they do not transmit this disease. We must also urge citizens not to travel to infected places with this disease like Syria, India, Western countries, and African countries. For the foreigners, we must send them to their countries very fast, and for Bahrainis we have to quarantine them in a special hospital. I will quarantine them in a special place because this disease easily transfers. I will make a special ward for them is the hospital. I must follow the expression which says protection is better than a thousand treatments, so I will order to quarantine them in a place that has everything they need which makes them have a normal life so they will feel they are people also who have rights and so they get the best treatment and care. We should dismiss all the sick ones and carriers of this disease by detaining them in places so that they are not allowed to mix with people who are not sick. Some students believed AIDS patients should be encouraged to be more devout Muslims: 192 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. For foreigners we should send them back to their countries and for brother citizens we should first give them confidence in themselves and teach them to believe in God. I’ll make health and religious lectures which advise the public to be aware of forbidden things, and to come back to God.. The one who has AIDS I will give them care and help them to make them work as normal people. Foreigners should be returned to their country and there should be a special established department in hospitals to take care of them and advise them to turn to God in repentance and follow the right way. For Bahrainis, we must give them hope in recovery and remind them to turn to God in repentance. The foreigners must be sent home without return. The above range of responses were typical of the opinions students expressed in the classroom and then wrote down on their papers. They were very concerned that AIDS patients return to their religion, because for them, having AIDS meant leaving ones religion. They could not perceive a religious person as contracting the virus. Out of the two groups that responded, there were only three extreme attitudes: If I am a health official in my country and responsible for policy I will seek to have AIDS carriers killed. 193 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. AIDS patients should be put in special hospitals and anyone who isn’t committed should be killed. I will call the police immediately because if I hide, I will be negligent because he will carry the disease to others and he will destroy the country. I hope everybody who knows about those patients reports them because we don’t want our world to be like Europe with all diseases going around our country. These responses also demonstrate both a fear of those carrying the virus and a belief in punishment for their sinful behavior. When war metaphors are used to depict disease, as they were in the Ministry of Health educational pamphlets, the disease becomes the enemy, as well as the person who is housing the disease. The result of such language inspires heightened fears of contagion because AIDS virus carriers are perceived as “dangerous”, a “threat” or “deadly.” Emotion and fear replace knowledge of the disease. Extremists exist in every society, and when religion is involved, they readily appear with highly charged emotions. The anti-abortion groups of the West believe their extreme reactions are justified because of their own religious convictions. It is not unusual that the topic of AIDS would also inspire intense emotions. The students also took a much more kindly attitude towards Bahrainis who had AIDS than the foreigners. Their responses indicated they wanted 194 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. to save them, especially from falling away from their religion. In Islam, as in other religions, there is a strong belief that the sick should be cared for. This was the first time the students had been asked their opinions about AIDS, so for many of them, it was also the first time they had given any real thought to the issue. They wanted more information about AIDS in Bahrain, and appeared interested in learning about the topic. After discussing this topic with them, it was apparent that their opinions were not rigid or inflexible, rather they needed to be made more aware of the topic to have the opportunity to give it careful thought. As mentioned earlier, their responses were more kindly towards Bahrainis who had the disease than foreigners, and when they were asked how they would react to a friend who had AIDS, they exhibited even more compassion. This is seen in the responses to the following question. Compassion and Repentance The students showed an awareness of how prejudiced their own society is towards AIDS virus carriers and felt they did not wish to see their friends exposed to such sentiments. The majority of students maintained they would continue to have relations with their friend who was infected. Secondly, they believed that their friend should be close to God and repent 195 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. for his/her sins. They also felt their relationship with their friend would continue, providing that their friend did not contract the virus by sinful ways. Only a few respondents spoke of cutting their friendships completely with HIV/AIDS infected friends. Overall, the respondents’ remarks reflected more compassion towards AIDS carriers when the virus was personalized, belonging to someone close to them. The first category of responses listed below shows their ability to recognize how Bahraini society views AIDS carriers and the importance attached to protecting the honor of one’s friend: I will be careful of my friendship with him and I will tell him to go to a hospital for a check-up. I will also tell him not to tell anyone because the community doesn’t have enough awareness of dealing with AIDS people, so they may destroy him. I am not sure if I will continue to see him but I will advise him to go and take all the necessary medical tests and not to tell anyone so that he is not hated among the community’s people . . . and he should repent. I will have limited relation with him and will advise him to get treatment and tell him not to tell anyone because it will result in passing on his story to everyone and then he will be emotionally affected and continue his bad ways. The virus cannot be transferred by touching or by germs, so our relation should continue normally with the carrier or patient because nobody likes him in the society. 196 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In some cases students were not certain whether they would continue their relations with their friend, they were still protective of their friend, not wanting him/her to be shamed by the community. Guarding their friend’s honor superseded the desire to maintain the friendship. Even if they did not wish to continue to visit their friends, they did not want to see them lose their respect from the community. The next category of responses shows the fear of maintaining friendship if the person caught the virus from engaging in activities prohibited by the religion: If the patient is straight and nice, my relationship is not going to change, but I have to be careful. If the person has abnormal sex or uses drugs or has a bad history, then I have to completely ignore him. If this person caught the disease by mistake, I’ll continue visiting him and I’ll try to make it easy for him. Meanwhile I’ll be careful but if this person is from those who practice forbidden things and this disease transferred to him this way, then I’ll cut my relation with him because he is a person who is bad for our society. I’m never going to talk to him, but if he caught the disease by blood transfusion I will feel sorry for him but the relationship between us will not be direct. 197 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The respondents clearly did not want to have friends who were involved in drug use or engaged in anything that was against the religion. Their refusal to maintain friendship was due to this and also due to protecting then- own name in the society. If they go with what they refer to as “bad” friends, then they will be labeled by the society as being the same as their companions which will bring them shame. Also, since the majority do see AIDS as a punishment for behavior forbidden by the religion, AIDS patients are already condemned as sinners. The association between AIDS and sin is so common that respondents often mentioned the need for prayer and repentance in their comments: If I know someone who has AIDS I will advise him to be straight and to read the Koran and to pray. Of course I will visit him and I will pray for him and I will try to help him and make him feel he is effective in this society. I will continue to visit him, but because I am human and human is naturally afraid of death, I won’t be very happy because it is normal that the human is afraid of a lion, even if the lion is inside the cage. I will help him and advise him to repent and become close to God. The responses in this section helped the students to personalize the AIDS virus by bringing it closer to their own lives. In contrast to the comments in the above section about quarantining AIDS patients, not one student spoke 198 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. about quarantine when it related to a friend having the virus, and most believed that they would continue their friendship, although in some instances the friendship would be limited. The students did not want to lose their friendships, but felt compelled to do so if their friends had gone against the religion. Even then, they wanted to protect them by telling them not to share the information of their sickness with anyone for fear they might be shamed by the society. The friends also showed concern for their spiritual development. They felt it was important for AIDS carriers to pray, to read the Koran and to repent for their sins. In the next section the students discussed how they could best protect themselves from the AIDS virus. Adherence to Islamic Beliefs The students believed that following their religion is their best form of protection from contracting AIDS. All of them mentioned being straight, which means following the religion and not mixing with those who are engaging in behavior that is prohibited by the religion, as the surest mode of prevention. Unlike Western AIDS campaigns which utilize the slogan “Practice Safe Sex”, such phrases do not exist in these Islamic countries. Not one student mentioned using condoms as a prevention method, which reflects what health officials noted about their HIV/AIDS campaign, that 199 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. teaching about religion, not condom use is more suitable for the culture. This religious conservatism was denoted throughout the students’ responses to this topic. These were some of the comments the respondents made regarding protecting themselves from the virus: I must stay away from prohibited ways, and stick to Islam’s instructions. For example, stay away from Western customs which are normal in their life like drinking whisky, mixing of the two sexes, because these customs are the most important reasons for falling in the wrong. It is important not to have sex with a woman who is not your wife and make sure that any blood you receive is safe. Stay away from all homosexual relations and adhere to Islamic instructions. Do not mix with AIDS people and drug users or alcohol drinkers and do not go to countries that this disease has spread and do not socialize with bad people because they can shift the person from the straight path. All of the remarks above fell into the category of following one’s religion. Traveling outside their own country to the West was also feared because the West is viewed as a place that is morally corrupt. There is a saying in Arabic that says “if you sit with people for forty days, you will become like 200 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. them.7 ” Thus, all the respondents placed importance on not keeping friends who were not straight or who they labeled as “bad.” The contrast between the kind of thinking that exists in a religious society and a secular one is easily observed in the students’ responses. Comments made by these students are more similar to comments that one might expect to come from a fundamentalist religious community in the West. Their responses certainly would not be the norm if one were to ask the same questions to a group of students from an American university. Probably the biggest difference is that in the US, the students are made very aware of taking precautions against the transmission of the AIDS virus by using condoms - not to imply that condoms are always used. American university students can be seen wearing T-shirts with the slogan “Practice Safe Sex” across the front. The dialogue in the West is far more explicit and the atmosphere generally more open to discussion of alternative lifestyles. In a society as traditional as the Arabian Gulf countries, such explicit language would cause tremendous opposition by the religious leaders and mainstream society. This is not because they are unable to discuss sex, as the Koran openly talks about sexuality in terms of the importance of sexual 7 This expression is attributed to the Shi’a leader Iman Ali and is often used by the Bahrainis. 201 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. pleasure for the man and woman in the marital relationship. But by mentioning sexual behavior publicly, particularly in the context of AIDS, the religious leaders could risk appearing as though they are condoning sexual behavior outside of marriage. The problem that the Gulf countries must now face is how do they talk about sex in an explicit fashion to ensure that individuals who do have different sexual partners are taking precautions when the society at large is conservative, traditional and may take offense to such discussions. As in any society, not everyone is following the religion, despite their traditional outlook. In more traditional societies people find discreet ways to satisfy their sexual desires which may include traveling outside their own borders or engaging in secret relationships inside their own country. Women in particular are at enormous risk because they may not feel comfortable asking their future husband about his sexual past, because presumably he should have no past, or they may not be aware of their current husband’s sexual life outside of marriage. It is crucial that they have explicit sex education to understand how they themselves could be involved with a high risk partner. There are many issues that must be confronted in a society where public discussion of sex outside of a religious context is prohibited. The health 202 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. officials are aware of these obstacles and are trying to work with the resources they have rather than what they have not. Frequently articles are published in the Arab newspapers regarding AIDS statistics in other countries as well as discussions of the dangers of the virus. The students, with a few exceptions, seemed very aware of how HIV/AIDS is transmitted, and also expressed a high level of fear about the disease. They also held close metaphoric associations between AIDS and sin, and AIDS as a self- inflicted illness. Other associations of AIDS with foreignness were also common. These ideas, given what has been written about mankind’s historical impressions of infectious disease, are not surprising or unpredictable. Furthermore, they are not unique to this traditional society, rather they have been echoed even in so-called secular societies since the initial publicity of the AIDS virus. Students explained to the researcher that although they had not attended any formal lectures about AIDS, they had heard about AIDS on television and read about it in the newspapers. The above responses indicate that the students’ attitudes were probably shaped by the HIV/AIDS prevention messages publicized by the Ministry of Health, with the exception of quarantining AIDS patients. This could have been the direct result of the 203 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. presentation of AIDS in the educational literature as an enemy to be feared. Such a dreaded enemy would therefore need to be quarantined. The primary mode of prevention mentioned by the students was to follow their religion because AIDS was viewed as a result of not following one’s religion. This was a dominant theme in the health campaign. HIV/AIDS virus carriers are viewed with a stigma and the students were well aware of the stigma and therefore wished to protect their friends from such a stigma. The emphasis on moral behavior by the Ministry of Health, and direct reference to HIV/AIDS being caused by immoral behavior has perpetuated negative stigmas of HIV infected people. The Ministry of Health’s HIV/AIDS campaign has clearly affected the students’ ideas about the vims since the most common mode of AIDS information was defined as newspaper and television by the students. In fact, the student’s ideas about the vims were nearly identical to those propagated by the Ministry of Health. Students demonstrated an interest in the subject and wanted to learn as much as they could about AIDS, although they believed that they were at no risk of contracting the vims themselves. The highly centralized system of health education planning combined with the homogeneous culture most likely contributed to the uniformity of the 204 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. students’ responses. The content of the health campaign was carefully chosen based on what was culturally appropriate HIV/AIDS education for Bahraini society. The students demonstrated satisfactory knowledge of the disease with very strong attitudes and stigmas attached to virus carriers. Their knowledge regarding prevention was to abstain from the behavior that causes virus transmission. An important part of the Ministry of Health’s HIV/AIDS campaign objectives were to educate high risk groups about the disease. This next section will examine the state’s success in this area. Intravenous Drug Users and HIV Transmission in Bahrain Introduction Intravenous drug use has been a primary source of infection for heterosexual and perinatal cases of AIDS worldwide (Des Jarlais and Hunt, 1988). Until recently, the predominant source of HIV transmission in Bahrain has been intravenous drug use (Interview with physician C, Ministry of Health, 1994). Intravenous drug use is a serious problem in Bahrain and 2 05 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. drug users continue to be at risk of HIV infection. Low socioeconomic status is commonly associated with drug use in Bahrain. A twelve month study conducted at Bahrain’s drug rehabilitation clinic of the state Psychiatric Hospital revealed a seroprevalence of HTV at 21.1 percent among a group of two hundred and forty male intravenous drug users (Al-Haddad et al., 1994). Nearly half of the respondents were unemployed and the others earned less than two hundred dinars (500 dollars) per month, a salary considered low by Bahraini standards. The following information is based on informal discussions and semi- structured interviews with seven male FV drug users that were conducted from November 1993 to July 1994. Six of them were currently using drugs and had been doing so for at least seven years, and one of the seven had stopped using drugs for a little over one year following his stay in jail. The discussion that follows does not attempt to generalize these findings to all IV drug users in Bahrain. The behavior and attitudes shown are representative only of the group studied. The information presented shows the kinds of results a qualitative study can yield which can be useful in developing more effective educational strategies to reach high-risk populations. 206 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. This next section will present each of the seven respondents’ stories, emphasizing how their knowledge of HIV/AIDS developed, and if they had enough knowledge to protect themselves from virus transmission. For those who were HIV positive, it will look at the knowledge or lack o f , that put them at risk for contracting HIV. It will also look at their behavior to see if any of their practices have been modified because of their knowledge of HIV. The section will conclude with a discussion of the general themes that emerged with their stories. The first story highlighted below is that of Sami, who acted as a key informant for this study and has been a heroin user for seven years. Sami Sami, 25 years old, was a longtime friend of a good friend of mine and was referred to me as someone who would be very useful to help me locate IV drug users for this study. Sami had been a heavy heroin user for seven years and had gone through drug rehabilitation programs twice over the past two years. He had supposedly been straight for some time and was described as being a bright guy who just slipped into the wrong crowd. He was eager to help and claimed it would be easy to get IV drug users to interview because “he knew so many of them.” 207 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Sami had a warm, outgoing personality and had many friends. He was very much at ease with women, and did not appear awkward or uncomfortable talking with me. He was athletic and had won many of Bahrain’s athletic competitions. His personality and looks did not seem to fit the stereotypical drug user, which was later confirmed to me following my meetings with other IV chug users. However, he was thin and his cheeks were drawn into his face as is common with heroin users. It was not until my fifth or sixth meeting with Sami that I realized he was still using heroin. He was reluctant to admit it in the beginning out of fear that I would not trust him; however, when I asked him directly if he was still using, he replied yes, but that he had hoped to quit. Sami’s friends trusted him greatly and he seemed well liked by everyone, but his friends were also initially reluctant to discuss their drug problem with me. They did not wish anyone outside of their group to know about their problem, possibly because they felt ashamed about their addiction. Sami told them that I was a researcher and that whatever information I gathered would be confidential, but it was not until I became a familiar face with his group that his friends were willing to discuss their drug use. I knew Sami for ten weeks and had seen him many times before I was able to get my first 208 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. interview with his friend. Since his friends had been accustomed to seeing Sami with women, they did not seem surprised by my presence. At first Sami introduced me as a friend, then later told them individually that I was a researcher. He preferred to tell them that after they knew me rather than as an initial introduction. Meanwhile, I had numerous discussions with him about AIDS, his own behavior, and the drug situation in Bahrain. He trusted me from the beginning because of his long-term friendship with my close friend and with each of our meetings he opened up more. He loved to talk and sometimes wanted to spend hours talking about the drug situation, his own difficulties with addiction, and social and political problems in Bahrain. However, he never allowed me to record him, and when I started to take notes about what he said, he would become uncomfortable and guarded in his responses. So I quickly learned to keep information in my head and jot it down any place I could. I told him I was doing this and he just laughed at me. But he continued to offer me a wealth of information as well as first hand insights into his own drug related practices. Sami was the easiest of the drug users to talk with because of his genuine openness and good command of the English language. One of the first questions I asked him was why he was using drugs. He responded by saying: 209 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Truthfully, I hate drugs. They have ruined my life here and killed or brought AIDS to my friends. They have taken me away from my family too. I want to stop but it is tough, when I see them I want to use. Also, when I get angry or someone upsets me I want to use. After my family took me to the drug unit two years ago and I stayed there for eleven days, I become afraid to be a heavy user again. I don’t want to go back there. But sometimes I still use. These days we are trying not to use, my friends and me, but when someone comes with brown sugar (another name for heroin) we don’t say no. Really, I feel ashamed from this thing, everyone looks at me like I am a criminal and they talk badly about me. I don’t care so much about what they say about me, but I don’t like to give my family a bad name. Sami and his group of friends did not use heroin everyday. They were recreational users, or used it when they could get it and then stopped for a while, then started again. All of them had started using because they had had friends or older brothers who used. In Bahrain, it was not uncommon for drug users to have many friends who do not use drugs. The problem, however, is that young teenagers want to imitate the behavior of the older users. This is how Sami explained to me that he first became a user. I had many friends who were using and sometimes they asked me to keep their drugs for them. I did not care about doing that, they were my friends and I was not worried. They always told me not to touch their drugs, but one night after my family went to sleep I went into the bathroom and decided that I wanted to inject the drug. I was a little bit nervous, but I injected a lot, later 210 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. they told me I injected way too much. I got so sick after I injected the drug, and actually I hated it, I never wanted to do it again. But then I learned that that feeling is normal in the beginning and after you get a great feeling, so I did it again. When I asked Sami if he thought that other drug users began the same as he, he told me: There are many different ways they begin using, but sometimes it is because they are selling drugs and then start using later. My friend was bringing drugs from Thailand into Bahrain, and he had never used before, his older friends had him go to Thailand. He wasn’t very smart and did whatever they wanted him to do, but you know today he is fucked up all the time. He uses every day. Because the drug is expensive, most Bahraini IV drug users are not daily users, rather they use periodically. During the nine months that I knew Sami and his friends, the longest period that passed without their using was two weeks. I also frequently saw young men who were not users around Sami and his friends, and some of them were with Sami when he was using drugs. I asked him once if it bothered him that these young guys could start using because of their association with him and he said: No they will not start to use because they are always upset with me because I use. They tell me not to use but they don’t use. They always come around me, what can I do? 211 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. I felt Sami responded sort of defensively to my question as though he knew it was not right that his young friends watched him inject drugs, but it was something that he and his friends had never before questioned. Sami’s background was different from the others in his group. He was Shi’ite Muslim like the others, but he came from a wealthier background than his friends. Most of his friends were childhood friends whom he had made when his family lived in Manama, the capital city. His father was a successful businessman and until last year, his family had tried hard to get him to work. They had offered to buy him any car he wanted as long as he would be straight and work with them. But Sami wasn’t interested; instead he preferred to spend his days hanging out with his friends. His family was slowly losing hope for him. He often slept outside his home with his friends, and stayed up late in the local bars drinking or using drugs. When I asked Sami how he thought AIDS was transmitted in Bahrain, he said: AIDS first came to Bahrain from people sharing drugs in Asia and sharing needles, then they returned to Bahrain with the virus. Here they keep the needle for a long time and they will share needles if they want to use badly. You can buy syringes here on the black market, but maybe you want to use and you don’t find them. These syringes are taken from the hospital for those who have diabetes and sold here for 500 fils. 212 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Sami was aware that AIDS was transmitted by using contaminated needles and that many drug users in Bahrain were HIV positive. His above comment also indicates that the addiction is stronger than fear towards contracting the virus. Since Bahrain does not permit syringes to be sold in the pharmacies, users who do not have easy access to clean needles, will use contaminated ones. Often a drug user will not take time to look to buy a new syringe if he is in a hurry to use. Sami explained to me that he learned about AIDS and using contaminated needles from his friends. I never heard any lecture or anything about AIDS, but I know so many people who have it and they said they got it from sharing needles. So I started to get afraid. In fact one guy I shared with him only six months ago, and he was safe, but now I hear his two brothers have AIDS and maybe he does too. You know, this makes me afraid. Sometimes I read in the newspaper about AIDS, so now I start to be more careful. Unlike the students interviewed in the previous section, Sami’s primary source of information about HIV came from his peers. His comment about knowing many people who have AIDS shows the virus is part of his sub culture and he does not have the fear of association with those who have the 213 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. virus. AIDS to him is something that happens to people he knows, but there is a possibility that some denial exists regarding his own risk of contracting the virus. While Sami knew that AIDS was contracted by using contaminated needles, he still continued to share with his friends. I have my own needle that I use, but sometimes I share with my friends. I know who is sick and who isn’t and I only share with those who are not sick. You see, Bahrain is small and it is easy to know who has AIDS because they test them every time they go to the jail. All my friends have been tested in the jail and I know they are OK. Before no one cared about getting AIDS but now we are more careful than before. I asked him how he was being more careful if was still sharing needles. Sometimes we wash the needles with water or clean them with alcohol. But really I know who is sick, I know my friends are safe, they are also careful. When I mentioned that AIDS was very prevalent in the drug community here and that it was possible that everyone felt safe using with their friends, he still adamantly asserted that his friends were safe. I asked him when the last time was that he had an AIDS test and he said over one year ago and that all of his friends had been tested within the past year to year and half. He was not sure exactly how a syringe should be cleaned to kill the AIDS virus, nor was he aware that AIDS test could show up negative during the first six 214 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. months someone was carrying the virus. The information about the virus that is being shared among friends is that AIDS is transmitted from needle sharing, and that needles should be cleaned. There is not enough information, however, about the importance of proper sterilization to ensure prevention. Additionally, the belief that all of his friends are safe because they were tested a year ago will put Sami at risk. Sami’s general knowledge about the transmission of HTV was not enough to protect him from contracting the virus. During the time I spent with Sami, he often arranged interviews with other drug users, but frequently they did not show up, or they came but were using so heavily it was not possible to conduct the interview with them. Sami felt that the drug situation in Bahrain was getting worse because of the serious unemployment in Bahrain. Here our government does not care about us, they only care to make money themselves. So many of my friends can not get jobs so they sit around all day. Some of them sell drugs to make a living. The life here is so boring for a young person, so it is easy to go to the drugs. Before there were more chances in Bahrain for us, but now everywhere you see Indians and there are no jobs for us. Sometimes I feel the government wants to see the Shi’a on drugs because then they can control us. They don’t want us to have anything. 215 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Sami’s sentiments were common throughout Bahrain. In the five years I had worked in higher education in Bahrain, the students expressed similar feelings regarding the unemployment situation and the increase in drug use on the island. The drug problem had worsened, particularly in the villages according to Sami. Certain villages were now known as having large groups of drug users. Sami was eager for me to talk to other drug users to confirm his own opinions about drug use in Bahrain. One day Sami told me to meet him because he was bringing someone with him who was HIV positive and this man was willing to talk with me. This interview with his friend took place late one evening when his friend arrived at a predesignated meeting place. His friend’s English was not very good, so Sami helped to translate for me. Yousif Yousif had been HIV positive for three years. He was a Persian with no passport, but his family had lived in Bahrain for many years. It is not uncommon to find Persians living in Bahrain without passports as the government does not easily issue them passports. Yousif was 34 years old, but looked older. He was comfortable with my writing down the interview 216 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. but did not wish for me to record it. I began by asking him how he found out that he was HIV positive. The police caught me for selling drugs three years ago and they took me to the police center for questioning. There they beat me with a rubber hose and kept me handcuffed while they questioned me. A nurse came there every Wednesday to take blood from the drug people, and they test it at the hospital. One day I was there and they came to me and said “Come and take your clothes, we will change your room.” They took me to a room with other ADDS people. They told me I was dirty and had this virus. They put all of the AIDS people in one small room there. There were eleven of us in one room with one toilet. It was very hot there, no fan. After some time there they took me to see a doctor and he told me not to be afraid and not to share needles anymore. I stayed in that jail for one and a half months. If someone was sick, and they asked to go to the hospital, they hit him too much. When they see drug people, they talk to them like rats, so badly. I asked Yousif if he knew about AIDS before he contracted the virus. He responded: If I knew about AIDS I would have been careful, but I didn’t know about the AIDS before.. Some people use when they are sick and they want to share needles, they don’t care if they make others sick. Also, some people are tired and they want to use, so they don’t care, they say “Leave the AIDS (I don’t care about AIDS), I am not happy in this life anyway.” When I use now, I say to them I have the AIDS, so I will use last, but some people don’t tell them. 217 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Yousif contracted HTV in the late 1980’s when it was just beginning to increase in Bahrain. At that time, there was no Ministry of Health HIV/AIDS campaign, nor was there information about HTV being circulated among his peers. Sami was almost nine years younger than Yousif, so he had been exposed to a lot of those who contracted the disease earlier, but Yousif did not know about AIDS when he was sharing contaminated needles. Like Sami, Yousif also had strong feelings about the government of Bahrain. He had many grievances and blamed them for the drug problem in Bahrain. If they give you a job here you don’t make more than 100 Bahraini dinar (apx. $270.00) a month, and that’s if they give you a job, but maybe not. I want to live, to eat, and I can’t find a job. This area in Manama, the government hates this area, they stop them from working here, it’s a Persian and Bahraini area and the people are close but the governments hates us here. Some people go for drugs outside, so they bring AIDS back, now we see teenagers who are using, and the people are selling to them to make money. He also wanted to see more support for people who had AIDS. He felt the government really did not care about those with AIDS. Here there is no support if you have AIDS. The doctor saw me only one time and explained to me about AIDS and told me not to share needles anymore and to use protection in sex. When I tried to return to see him, his 218 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. secretary was very rude to me and said “why do you want to see him, he can not do anything for you.” That was one month after I first saw him, and I did not go for him after that. Here you cannot talk about AIDS because the people will look at you badly and your family will lose face. Only my mother knows about me, no one else. Yousif continues to use heroin feeling that there is no hope to prolong his life. New information about AIDS such as ways to live healthily with HIV does not reach Bahrain, and even if it did, it is hard to say whether HIV positive drug users like Yousif would trade in their habit for a longer life. For Yousif, there are possibly some benefits to remaining a drug user. At the time of this study, the only counseling for HIV carriers that is done takes place when the person first discovers that they are HIV positive and then one of the physicians from Bahrain’s AIDS committee with speak with them. There are no support groups for the individual or his/her family. In many cases, family members are not aware of the one who is sick. So much is covered up out of fear of shame, that those who carry HIV are left to feel that they have nothing left in their lives. Yousif can not speak openly about his disease with anyone except his drug using peers. The support he feels from other drug users, by being able to admit that he has the virus and they 219 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. continue to be friends with him, may also contribute to his continuation of drug use. His support system has been developed within the drug culture, and that seems the only place where he can be himself without fear of being stigmatized by a society that would view him as a pariah. Both Yousif and Hasan, whose stories are presented in the next section, felt hopeless about their lives. Believing they would soon die, they felt even more inclined to continue using drugs. Hasan, the second HTV positive respondent spoke about the difficulty of stopping his heroin addiction. Hasan Hasan was 43 years old and had been diagnosed as HIV positive in 1991. He was a tall, attractive man who brought his son with him when he came for the interview. He told me his son did not know about his illness and asked his son to go outdoors while we spoke. He spoke English well and thought carefully about each of his responses. He began by saying: I came from the jail three weeks ago and I have already started using heroin again. I want to stop but I want to know how do you stop? When I see it I want to use. My family says to me “Oh we are happy you are straight now, since you came from the jail.” I use because it makes me happy, I know myself, if I have a good job, then I won’t use, but now I can’t work because I have another case coming up and if they find out, no one will hire me. 220 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Many drug users have been arrested and released and are waiting to go to trial for sentencing. It can take one year or more for a drug case to be heard in the courts so often drug users do not work while they are waiting to go to jail. I told Hasan that I knew he was HIV positive and I asked him if he knew how he got AIDS? Before I had heard about AIDS but I did not know exactly how you get it. I thought it was something you get from kissing or sex. I didn’t know that you could get it from sharing needles. When I used with my friends they looked healthy, I couldn’t see they were sick. But I think that is where I caught AIDS because they traveled to Bangkok and India to bring back the drugs to smuggle them in and sometimes they made, I’m sorry for this, sex with the ladies there. I lived in this house in (one village in Bahrain) with friends there, it was there that I caught AIDS. Hasan, like Yousif, did not know how AIDS was transmitted at the time he contracted the virus. He also saw that his friends were healthy when he shared needles with them. Although he had only known that he was HIV positive for two years, he felt he had contracted the virus much earlier. I asked him how he learned that he was carrying the AIDS virus. They told me in the jail. They said come on and take your things, we are changing your room. They moved me to this room 14, a small room, exactly 9 x 9 ,1 know this because I measured it, and they kept me there. It was very dirty. They just told me directly that I had this virus in me so they put me in this other room with about 221 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ten to eleven people there. They talk to us badly like “you dirty people,” well I won’t say the bad words they said to us. Hasan also said that it was not only AIDS carriers who were treated badly at the police interrogation center but that torture was widely used there. They, the government says they want to make the people good and they want us to take responsibility. They took my certificates in the jail and they did not believe my former salary. When they took me to the police center they wanted to know from where I got drugs. They beat me, then more questions, more beating. They beat you with a thick rubber hose maybe 5cm. and they said bad things to us and they spit on us. They beat us on the feet, two of them, and they hit us every few hours the first three or four days. They want to know from where we buy the drugs. They have a special chair they put you in with your feet up and your body back, and you are tied in it while they beat you. They took us and kept us outside when it was freezing and then put us in a very hot room when it was hot. After three days you go to the court, there is not lawyer like you have in the US. If you have been beaten too badly, they keep you inside and only bring a paper to the court. They can keep you there as long as they like. There is no law here, they can do what they want. Hasan’s account of the treatment in the jails was retold again and again by other respondents who had been in the jail. When I asked Hasan if he received any kind of help or counseling for AIDS he spoke more positively than Yousif had about the Ministry of Health. 222 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The doctor at the ministry explained everything to me about AIDS. He also said he wanted to talk to my family. I was afraid for this but he said not to worry about this. Another lady talked to us, to my wife to explain everything to us. She was very good and said we don’t have to be afraid of catching AIDS from kissing or drinking, just use condoms for sex. They were very nice with us. When I asked what kind of support he would like to see for HIV carriers in Bahrain, he responded: I just want the people to trust us. I say I want the people to trust me, I’m not going to hurt anyone. Maybe when I get work, the people will talk and try to make a problem. I want people to read about AIDS, and to know that we are human. We need the world to find a cure for this, but I don’t know what is going to happen tome. Hasan was also aware that having HIV would stigmatize him in the community. He did not want people to know he had the disease. Hasan also offered his opinion as to why more young people seem to be using drugs: Maybe it is because of unemployment here, I do not know, maybe these are lazy people, but we do have more and more foreigners here and they are taking all of the work. Anyone who wants to find work must try very hard, but it is not easy because the life now is hard here. The government should try to help the young people here and find for them work. That might help to keep them away from the drugs. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Hasan hoped that he would be able to stop himself from going back to using heroin. I saw him a few weeks after this interview and he confided in me that he was using again. Then I did not see him until shortly before I left Bahrain, about six months after this interview. When I first looked at him, I did not recognize him because he had lost so much weight. He looked so completely emaciated that I asked him what had happened, fearing that he had become ill from AIDS. He told me that he had been heavily using these days and that was why he had become so thin. That was the last time I saw Hasan. Nader Nadar was 28 years old and had been a drug user for seven years. He came from a poor family in a Shi’a village. He first got involved in drugs by selling them to make extra money, then he started using them. Sometimes he would go to Thailand and bring the drugs back to Bahrain. The police caught him and put him in jail for a period of time. He was out of jail at the time of the interview, but the police were still holding his passport. It was hard to find the right time to interview Nader because he was always using drugs. Sometimes he could hardly speak coherently because he 224 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. had been using so much. One day after I’d seen him many times, I asked him if he would speak to me about drugs and AIDS. He was familiar with my project because Sami had told him but he was sort of shy around women, and usually did not speak to me more than a greeting. The interview with Nader was conducted in two parts because I wanted to recheck the information he originally told me. I first began by asking him why he was using drugs. He replied: I just want to find work and I can’t. The government has my passport and I can’t work without my passport. Before I got into trouble with drugs, I went to the UAE and worked, but I fought with my manager there so I left. I’m not happy in this life and my father can’t give me money. I’m not happy, I need to make money. So you sell drugs? First I started to sell, then after I used them. Now I get them from friends, they give them to me to use and I sell and use them but not get any money. When I asked Nader about AIDS, he responded: I hear about AIDS from people sharing needles. I know you can catch AIDS from sharing needles and sex. Yes, I am afraid from this. But I know who has AIDS because they test their blood in the jail. They know who has AIDS. Bahrain is so small it is easy to know who has AIDS. 225 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Nader also knew about AIDS from his peers, and like the others, believed that he knew who had AIDS because they tested their blood in the jails. Then he spoke about sharing needles: Sometimes I share needles if my friend wants to sell, then I want only to try. I clean them with Dettol everytime. Before we used only water, but now disinfectant. If we do not have Dettol, we use hot water. I asked him how he felt about the people who have AIDS? Nobody wants to sit with them because they have AIDS, the people say “see that man, he has AIDS, don’t sit with him.” For me I say sit with them, if people act like this how can he stop using drugs. I tell them that maybe one day they will find an answer to AIDS. Nader, like Sami, did not have any fear about being with people who had the virus, and was also aware of the stigma they had because they were virus carriers. Nader seemed to know how AIDS was transmitted but was not convincing that he always cleaned his needle. I asked Sami if he believed Nader’s answer was the truth regarding sterilization of his needles and he told me he did not believe him, that he was possibly just trying to tell me what he thought I wanted to hear. Nader also appeared confident, like the other respondents that he could tell who had AIDS and who did not. 226 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Amir Amir was one of the seven interviewees that I knew for many months before I interviewed him. He was 25 years old. He had had a problem over money with Sami because he took some money of Sami’s and used it to buy heroin. Amir had also been in jail and the government was holding his passport. He began talking to me when we started this interview. He approached me to tell me that he had not used heroin for twenty days. I told him that I though that was great and then I asked him why he used. You know I’m OK with my family but I don’t have a job. I sit in my home and when I go out and talk with my friends, they’re talking about drugs, so in my brain I want to use. There is no talk about the future, no talk about life, just drugs. Just now they took my passport and you can’t work without one, they always check. I am waiting for my case. You know sometimes they keep people waiting three or four years until their case goes to court. So many people, like me have nothing to do, so the using becomes more and more. Then you get more drug cases and the problem just becomes worse. We then began to talk about ADDS in Bahrain and Amir responded: I have my own needle and I buy it from the black market. Sometimes I use the same needle for two weeks. I don’t like to sit with anyone because they don’t tell me that they are sick. I mean, I know my friends are not sick because they were tested in the jail. AIDS makes me afraid because I know you can get it from needles. 227 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Amir was the only drug user who indicated that he did not like to sit with anyone and use because he was not sure of who was sick. He also believed that his friends were not sick which implies that he would share needles with his friends. When were you last tested for HIV? I was tested about a year ago in the jail. I spoke with Amir about how he learned about AIDS? I learned about AIDS from my friends who are using. Sometimes we talk about who is sick. Amir’s knowledge of the virus came from his friends who were other drug users. He was also afraid of contracting AIDS but believed he was not at risk by using with his friends. Are you saying that you have always used your own needle? No, before I did not care, but these days I care because I know many who caught AIDS. I share now only with my friends because I know they are not sick. A m ir stayed off heroin for nearly one month, then he went back to using it. Sami later told me that he had gotten heavily into it again, and used whenever he could and that he did not take any precautions about cleaning needles. 228 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Sami also confided that the usual way most of these drug users cleaned their needles was just to rinse them with warm water. Fadel Fadel had used heroin for nearly 15 years. He was 32 years old, and came from the capital city. I spoke to him on only one occasion about AIDS and he was quieter and spoke less than the others. I began by asking him when and where he first heard about AIDS. In 1989 I heard about AIDS from my friends. I heard that there was a disease from drugs and sex. In 1993, the police caught me and put me in jail. There they have one room for the AIDS people and that’s when I was tested. Oh, too much AIDS there! I don’t know about outside, but I know many inside the jail. Fadel’s knowledge about the virus also came from his friends. I then asked him if he was taking any precautions not to get AIDS. He responded that he still shared needles if he knew they did not have AIDS. When I asked him how he knew, he answered: Only my feeling. I know too many people who have AIDS. I know who has because Bahrain is small and some of them I hear about it from others, and some say it to me directly. Fadel also believed that he was safe to share needles with his friends because he felt that he could tell who was sick, and who was not. 229 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. He also told me that he was not afraid of AIDS. I am not afraid of AIDS. I have been tested four times between 1985 and 1993 when I was arrested. This disease comes from God. What can we do. Everyone is sharing because we can not get syringes. Some people do not even care. I buy them from the black market for 500 fils. Before I did not really thing about AIDS but now I care about it. The government has stopped the pharmacies from selling syringes. Fadel was the first of the respondents to associate the AIDS virus with religion. Maybe the others did too, but they did not mention it during the interview. Fadel also told me that he believed all of the drug problems come from the government because everyone is looking for jobs and there are no jobs, so they start to sell drugs. After they sell the drugs they begin to use them. Fadel was hoping that he would go to jail soon because he felt that jail was the only place where he could stop using drugs. He did not wish to speak too much about the topic of AIDS and I felt he just wanted to finish quickly. He concluded by telling me that he felt it was important that the government sell syringes openly to stop the AIDS problem. Tariq Tariq was a drug user for three years and quit heroin in 1991 because he had had a bad car accident and lost his best friend. He went to jail for a year 230 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. in 1992 and came out saying that he would never use heroin again. Recently I have heard reports that he is still not using and is now gainfully employed. Tariq had worked for a short time in America and returned to Bahrain because his visa expired. I asked Tariq if he ever though about AIDS while he was using drugs. Well, when I was in the US, I went to hookers, so at this time I was thinking about AIDS. In one case, I woke up in the morning and I felt ill so I went to the doctor for a complete check up. But when I was on drugs, I never thought about AIDS. I asked him if he shared needles when he used drugs. I shared with my friend and we cleaned the needles with hot water. We had one needle and I cleaned it after he used it. At that time, I did not know too many people who had AIDS. I knew that they got AIDS from needles and sex or maybe from long kissing, like French kiss. I also know that it is more difficult for a man to catch AIDS from a woman, but for women it is easier to catch. Tariq told me that he acquired information about AIDS when he was in America but he still was not certain that he knew all the details about transmission. Tariq’s knowledge about AIDS was not comprehensive enough to keep him from contracting the virus. Tariq’s English was very good, and he was open with me, so we talked alot but he was more 231 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. interested in talking about the government’s treatment of the AIDS people in the jails. I saw how they treat the AIDS people in the jails. One guy, he was so sick and they treated him so badly. There were about 17 people in the jail with AIDS. These people were my friends and I don’t care if they are carrying the virus, I loved them too much. They make a separate room for them and they beat them and they treat them like they are animals. Some of them, they chain their hands like they are animals. You know the government here can do whatever they want, there are no rules here. Tariq, like the other respondents, felt compassion towards those who had HTV and were very comfortable having them as friends. His concern for those in jail was also similar to the other respondents’. Tariq was the last of the high risk group of drug users that I interviewed. He tried to help me find more drug users because towards the end of my stay, Sami had left Bahrain for Europe so I was not able to make the connections on my own. Tariq took me to interview another friend of his, but as we approached his home, the police were waiting in a car nearby. Tariq felt they were watching the house so he suggested we try another time. He then stopped trying to help me because he felt that he had been out of jail for such 232 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. a short period of time that he did not want to jeopardize himself by being seen contacting drug users again. Peers as Primary Source of Information Several important themes surrounding the issues of knowledge, prevention and practices emerged during the interviews and discussions with drug users. Peers provided the main source of knowledge about the virus to the drug users interviewed for this study. But their practices did not indicate they had enough information to protect them from the virus. Those who were HTV positive did not have enough information about how AIDS was transmitted prior to their contracting the vims. This is possibly due to two factors: Bahrain did not begin publicizing information about AIDS until only two to three years ago, and their exposure occurred before there were so many drug users who were HIV positive. It is possible that the reason peers are the primary source of information is because they are aware that there are so many drug users, like themselves, who have the vims. The kind of knowledge they need to protect themselves includes proper sterilization of needles and syringes, so even if they had been exposed to the public AIDS information campaign, it probably would not have provided them with 233 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. enough detailed preventative information to help them as the campaign does not publicly discuss this information. Insufficient Information Even those who were not HIV positive still demonstrated a lack of knowledge about the AIDS virus. They knew the basic facts that the virus could be transmitted by the sharing of contaminated needles, but they did not seem to be aware of how to properly sterilize their injecting equipment, nor did they have knowledge regarding the importance of regular HTV testing. Respondents held too much confidence in the testing of drug users in the jails which seemed to be their only assurance that their friends were safe. Not one of them went for voluntary HIV testing regularly and they all trusted their friends, believing that their friends were not infected. High Risk Practices All of the respondents said that they still shared needles, except those who were HIV positive and they said they shared but that they always went last. Their comments also indicated that they are engaging in high risk behavior without knowledge that they are doing so because of their faith in the system that once their friends had been tested for HTV, then they were safe from exposure to the virus, regardless how long it had been since their friends 234 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. were tested. During my fieldwork I heard at different times about who had drugs and who was using, and learned that all of these individuals shared needles with each other and occasionally with others outside of their main group. When they did share, they said that they rinsed the syringes with water, but rarely disinfected them. According to one physician from the Ministry of Health, (informal conversation, 1994) he reported that Hepatitis B was widespread among the drug community and that had become a very serious problem, far more than AIDS. According to Fernando (1993), in his study of American drug users, he asserts that drug users share and use contaminated needles because there is a scarcity of sterile syringes in the illegal market. This scarcity, combined with a lack of prevention knowledge, will keep drug users as a high risk group in Bahrain. Peer Support Another area of concern was the lack of support for HIV carriers/AIDS patients in Bahrain. HTV respondents felt they could not talk with anyone about their condition for fear of being stigmatized. They knew the stigma and shame that accompanied HTV infection. However, their peers supported them and did not stigmatize them. All of the drug users were very comfortable having HTV infected individuals as friends and showed 235 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. compassion towards them. The respondents mentioned they were afraid of contracting the virus but none exhibited heightened fears of contagion of the virus. Social/Political Discontent All of the drug users mentioned the increase of young teenagers turning to drugs out of boredom or unemployment. These sentiments are not exclusive to drug users looking for someone or something to blame for their habit, rather, many of Bahrain’s young Shi’ite population have expressed similar sentiments about their government and unemployment on the island. The social discontent has notably increased this past year with thousands of young Shi’as taking to the streets in protest of their government’s disregard for their economic situation. The social discontent has also spread to some of the island’s Sunni population. The rising numbers of drug users in Bahrain’s villages is an indication that the deteriorating socio/economic situation of Bahrain’s Shi’ite population may be one contributing factor to the increase of drug use among the country’s young Shi’a population. This increase in drug use may also result in an increase of HTV high risk behavior. 236 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. From the interviews and discussions with IV drug users, the primary issues that emerged were the lack of explicit AIDS education that is targeted specifically to drug users so they will be aware of how to take greater precautions to prevent transmission of HIV to each other and the lack of support at both the medical and community level for those who are diagnosed as HTV infected. Chapter Summary This chapter has described Bahrain’s HIV/AIDS prevention campaigns that began in 1992 and the content of these campaigns. It also presented the results of interviews, both formal and informal with government officials, students and IV drug users to gain a more complete understanding of their views of the AIDS situation in Bahrain. The state clearly recognizes the need for HIV/AIDS education and at the same time has imposed limitations on the content of the campaign because of their own perceptions of the disease and by the more conservative members of the health ministry who believe the society could not accept more explicit HIV/AIDS information, specifically the explanation of condom use as public health message. Health officials believe that they have found a suitable means of conducting their campaign that is appropriate for their conservative 237 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. religious society. But they also stated as a campaign objective to target high risk groups, but their conservative approach resulted in those who need AIDS education the least receiving it the most. Some physicians recognized the need to target high risk groups, but did not state how they thought they could do so and still follow what is acceptable by the local culture. They also acknowledged that they could do more to utilize their own resources, especially the religious community whom they have targeted but would like to involve even more. Ministry of Health physicians uniformly referred to the lack of formal evaluation of the campaign’s effectiveness which is urgent so they can know who their message is reaching and if their message has actually affected behavior changes or not. The content of the HIV/AIDS campaign consists of several metaphors that are often associated with infectious disease, particular HIV infection. The use of war metaphors to describe the virus and the association of the disease with shame, sin, foreignness and infidelity were all included as part of the content of the campaign. Detail description about how the virus is and is not transmitted was also a part of the campaign content. The study showed how the students’ perceptions of the disease were similar to those presented by the government’s HIV/AIDS campaigns in the 238 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. media. Their opinions coincided with those that were found in the campaign materials. Students viewed the disease with fear, some even mentioning that AIDS patients should be quarantined or killed. AIDS is seen as an enemy and those who carry the disease as a threat to the society. Students mentioned that their main source of information about the virus came from newspapers, television, radio and pamphlets. None of the students mentioned their peers as source of information. Student perceptions of the virus as affecting those who are away from the religion and that AIDS is something that happens to foreigners is a result of their close association of the disease with sin and the virus as a punishment from God for not following one’s religion. Students’ were also aware of the stigma the disease carried and some wished to protect their friends from the shame caused by the disease. Repentance, they believed was one way of saving the souls of those who suffered from the infection. It is difficult to confirm whether the students’ perceptions of the virus were formed by the government’s AIDS campaign. It would perhaps be more accurate to say they were reinforced or modified by the government’s AIDS campaign. The strong religious orientation of the students, most who were Shi’a Moslems is at the core of their perception of the disease. The 239 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. government understands the local culture, and for most health officials, share the same values and belief systems, so they are likely building on what already exists. All events, good or bad, they believe are fated upon them. Catastrophes, floods, earthquakes, have historically been perceived as deliberate acts on civilizations to express God’s anger. These perceptions of the disease are not new to mankind. Since biblical times, disease has been viewed as a punishment from God for sin, particularly disease that is associated with sexual promiscuity. Compassion has also been a part of the religious perspective towards disease. Some student’s expressed such compassion when they were asked how they would respond to someone they know who had the AIDS virus. Health officials would have a difficult time presenting another way of viewing this virus. The campaign content is the culture’s perception of the virus. This belief system has been in place well over a thousand years, as the Arabian peninsula is known for its devotion to maintaining its Islamic beliefs and traditions. The campaign did not create the perceptions and opinions towards the disease and its carriers, but rather reinforced the archetypal ideas of the local culture. One of the campaigns main objectives was to target high risk groups. The drug users in this study indicated that their knowledge about the virus 240 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. came from their peers rather than the media. It is possible that some of their information may have come from listening to a television program or reading a newspaper article about AIDS, but they did not mention it in the interviews. The knowledge they had was insufficient to protect themselves from the virus and the detailed information needed was not part of the Ministry’s campaign. Publicizing explicit methods of protection in a conservative religious society is difficult and providing high risk groups with the means to protect themselves is even more challenging given the norms of the society. Drug users continued to share needles because they believed that their friends were not infected. They relied heavily on the HTV testing that was done in the jails, even if the tests results were old, they still believed they were safe. None of the drug users had the same level of fear towards the disease and its carriers that the students’ showed. Drug users knew HIV infected people and expressed a greater degree of compassion towards them. Being aware of the stigma of the disease, they offered support to those who HTV infected. All of the drug users disliked the government and explained that they believed the drug problem in Bahrain was caused by unemployment which was a result of unfair government practices. They also described the 241 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. torture that occurred regularly in Bahrain’s jails and the discrimination and abuse of HTV infected prisoners. The government’s and students’ perceptions of the virus were much more congruous than the drug users. Drug users come from the same conservative religious culture, but have replaced it in favor of their own sub-culture. They no longer share the norms of the local culture with the same devotion. They live as outcasts within their own society and have built their own community with their own cultural norms, ideas, and practices. To effectively target their community with HIV prevention, a new approach will be required that suits their own local culture. 242 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Chapter V Summary, Recommendations and Discussion HIV/AIDS education programs, with great variability in content, currently exist everywhere in the world. All countries have faced some obstacles in the development of HIV/AIDS prevention education programs. In some regions, economics have played an important role and have affected the scope of educational prevention, as in some of the poorer countries of Africa, Latin America, and Asia (Raffaelli et al., 1995). The debate over the content of HIV/AIDS campaigns has not been exclusive to the Islamic Middle East. Christian countries, including the United States, have also encountered a range of opinions as to what constitutes suitable HIV/AIDS educational content. Additionally, the successful targeting of high risk groups has been a complex matter, because information about HIV/AIDS transmission does not guarantee a reduction of high risk behavior, in fact, such changes rarely follow a single educational effort. Furthermore, effective HIV/AIDS campaigns must be accompanied by a deeper look at the socioeconomic and cultural context of the problem that creates high risk behavior. This not only requires a complex analysis of a society, but a willingness on the part of its 243 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. leaders to address and find answers to the myriad of social problems that bring about high risk behaviors. This study has demonstrated that Bahrain has not been exempt from such obstacles. It has been the goal of this research to provide an analysis of some of the most salient issues that have affected the development of HIV/AIDS education in Bahrain. Summary of the Research According to the World Health Organization, the human immunodeficiency vims (HIV) can be found on every continent in the world. Even the countries of the Arabian Gulf, which host some of the most traditional religious societies in the world today, have reported HIV infections and AIDS cases. In Bahrain, the initial infections were the result of imported blood, sexual contact with infected individuals outside of Bahrain, and needle sharing. The vims spread fastest indigenously among intravenous drug users, who in a current study reported a 21% seroprevalence rate (Al-Haddad et al., 1994). Today, HIV is spread in Bahrain by any risk behavior, including the sharing of unsterilized needles and unprotected sexual intercourse (Physician D, Interview, 1994). The problem of drug use remains a serious one on the island because heroin is very prevalent throughout the Middle East and easy to obtain in 244 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Bahrain. The historical drug trade routes he between Thailand and India and continues through Pakistan, Afghanistan, Turkey, Iran, and into the Gulf countries. The opiate drugs, such as heroin, are the most commonly imported so young people who have never experimented with milder drugs may go direct to using heroin as their first experience with drugs.1 Because of its highly addictive quality and the euphoric feeling users experience immediately after injecting the drug, they quickly get hooked on the drug. Another contributing factor to the use of heroin is that users often have friends around them who do not use. This was noted in the researcher’s observations of drug users. Sometimes, very young teenagers would “hang out” with those who were using and were aware that their friends were using. This exposure is what eventually led to many of the young men into using drugs. An additional cause of drug use is the high unemployment rate, particularly among the less educated members of the society. Some get involved with drugs because they have nothing to do, and others begin to sell drugs as a way to make money. Initially they do not use the drug, but after some time, they too become addicted to the drug. 1 The drug users interviewed for this study began using heroin as their first experience with illegal drugs. This was attributed to the easy access to the drug. 245 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Sexual transmission of the virus has become more evident in the past few years in Bahrain. The religious culture prohibits sexual behavior outside of marriage and a woman’s chaste behavior is a strong symbol of honor for a family. The Islamic tradition of preventing the free intermingling of the sexes has had the effect of some young people looking to sexual outlets outside of their culture or to homosexual relationships. It is not uncommon for young Arab men to travel outside of their country and have sexual relationships with prostitutes. While this is still considered to be a sin, it is thought of as preferable to engaging in sex with a local Muslim girl before marriage. While there are strong taboos against homosexuality, a more liberal definition exists of what constitutes homosexual behavior. Such sexual practices endanger the local women who may have husbands who travel alone outside of the country or have had sexual relationships outside of their marriages. Bahrain has had an AIDS committee which consists of various doctors from the health ministry since the 1980s, although their HIV/AIDS educational campaign did not begin until 1992, much later that most of the world. The Ministry of Health was solely responsible for HTV/AIDS and any ADDS policy decisions which included education, counseling and testing. Some of the physicians attributed the slow start up to internal opposition over 246 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the need for comprehensive HIV/ADDS education and what would constitute suitable content for such a campaign. This delay in information may have caused some of the reported ignorance over what causes HIV among IV drug users. Some stated that they were unaware of what caused HIV until they found out that they were infected with the virus. The commencement of Bahrain’s HIV/AIDS education campaign forced the society to begin to discuss and examine behavior that in the past was not openly discussed. The goal of the health professionals involved in the campaign has been to reach as many people possible with their preventative HTV/AIDS message by utilizing different segments of the society as channels for information. HTV/AIDS lectures have been offered to companies, post-secondary institutions, women’s organizations, men and women’s maa’tams, and the local mosques. The health ministry has also conducted workshops to train health professionals outside of the central ministry of health to counsel individuals who request information about HIV/AIDS. It has also held workshops to train some of the religious clergy whose support is essential to the campaign because of their influential role in the society. Every Friday, the Islamic holy day, thousands of people attend the lectures at the local mosques to listen to the messages of the religious leaders. The health 247 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ministry hoped that they would begin to educate the people about HIY/AJDS. Because there has been little follow-up of the health campaign, the exact numbers of religious clergy who have spoken to the people about HTV/AIDS is unknown, but some people have reported that religious clergy have lectured about the dangers of HIV/AIDS during Friday prayer. Their cooperation was elicited by Bahrain’s Ministry of Health, which recognized the importance of the participation of the religious clergy, not only for the dissemination of information but more essentially for the legitimization of the discussion of a topic as sensitive as HIV/AIDS. The health officials, being local Bahrainis themselves, knew how to approach the religious clergy to gain their support. They explained that HTV/AIDS was indeed a religious issue because it came about from people not following their religion. Using the religious clergy and the local mosques and maa’tams has shown how Bahrain has included traditional channels to publicize their information about HIV/AIDS throughout the country. By careful inclusion of these traditional resources, they have not risked alienating the more conservative segments of the population from their educational message. This incorporation of the religion into the campaign has also helped to shape the content of their HTV/AIDS educational messages. 248 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The foundation of Bahrain’s health education message is that HIV/AIDS is spread by not following one’s religion. In addition to the promotion of Islamic values in their HTV/AIDS campaign, the campaign also provides comprehensive information of what the virus is and how it is and is not spread. The issue of prevention is addressed by promoting adherence to Islamic values as the best form of protection against HIV/AIDS. All of the health officials interviewed supported this approach as they agreed that this is what suits their culture. However, some of the physicians felt that it was time to expand the information provided by the campaign so that they could discuss very clear methods to prevent transmission such as condom usage. While condoms are discussed when counseling individuals on prevention of HIV/AIDS, publicly they are not mentioned. Some health officials believe that open discussion of condoms does not belong in their society, that this is something for more sexually permissive societies. The reluctance to openly discuss the high risk behaviors that cause HTV transmission may be partially due to the traditional ideas of honor and shame which are imbedded in Arabian society. To be more explicit in their educational message may imply that their society is not following its religion and such an acknowledgment would bring shame to their traditional leaders and risk criticism from their 249 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Islamic neighbors. An example of this was seen when in the early days of the virus, the Arabian Gulf countries did not accurately report the numbers of AIDS cases to the World Health Organization until they were promised complete confidentiality regarding the reported numbers. The health ministry has therefore proceeded cautiously in its campaign, being careful not to offend anyone. The attitudes that Bahraini students exhibited towards the AIDS virus and its carriers were linked to their religious beliefs and to historical metaphoric associations towards infectious disease. Their responses were similar to one another in their attitudes towards infected people, and the only deviation was in the degree of compassion felt towards the virus carrier. This is probably due to the cultural uniformity of the Bahraini people. The health ministry’s message of following Islamic principles as prevention was reflected in the responses of the students. Students believed that HTV/AIDS was a punishment from God for engaging in sinful behavior, therefore HIV/AJDS attacks those who do not follow the religion. Students also felt that HIV/AIDS belongs to foreigners and was brought from outside of Bahrain. They believed that foreigners who have the virus should be returned to their countries and that Bahrainis should be quarantined in a special area. The 250 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. students used words to describe those who had the virus as “bad” people in need of repentance. They showed greater sympathy for virus carriers when they were asked how they would respond to a friend who had the virus. Most of them stated that they would keep the friendship, but in a limited manner. Another concern for their friends was the necessity of keeping the virus a secret from others so that people could not talk about them in a way to defame their reputation or bring shame to their family. These attitudes towards sickness and disease are attitudes that have been present throughout history. Disease has frequently been viewed as a punishment from God, and thought of as something brought from the outside by foreigners. The persistent conflict of condemnation vrs. compassion is another issue that is rooted in historical perceptions towards infectious disease. The presence of the AIDS epidemic has forced religions to examine their position towards the sick, when the sickness appears to be acquired by behaviors that go against the religion. The students’ comments reflected this belief by their assertions that AIDS carriers should be quarantined and their beliefs that they were “bad” people. However, compassion emerged when they were asked how they would react if their friend had AIDS. Students knew how the vims was transmitted and usually framed it within theological 251 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. terms such as “it follows those who leave the religion” or “those who are with the devil.” Strong associations of evil and AIDS, and AIDS as a self- inflicted illness were present in the students’ remarks. While these attitudes are rooted in historical metaphors, the origins of such metaphors come from the world’s religious doctrines, particularly Islam and Christianity. The close link to such traditional perceptions shows how strong Islamic values and beliefs still are in Bahrain. The information gathered from IV drug users showed a paucity of knowledge regarding methods to prevent transmission of HTV. Users had some ideas as to how the virus was transmitted but were lacking important details as to how to prevent transmission and also held false ideas about who was and was not HIV infected. The two drug users who were HTV positive in this study reported that they did not know how HIV was transmitted at the time they became infected. Their infections appeared in the late 1980’s prior to Bahrain’s HTV/AIDS information campaign. Some drug users reported seeing articles in the newspaper about HIV/AIDS but most of the drug users mentioned their peers as their primary source of information regarding HIV transmission. They knew in general how the infection was transmitted but were unaware of many of the details surrounding transmission. The findings 252 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. of the study showed that while the IV drug users interviewed were aware that HIV could be transmitted by using contaminated needles, they were not taking careful precautions to prevent transmission. They only rinsed their needles with water, sometimes hot water, and they felt it was safe to use with their friends whom they believed were not infected. They felt they could tell who was infected by looking at them and because Bahrain was small they believed they knew who was infected and who was not. It is very likely that they are aware of who is infected because drug users sometimes shared this information with one another. However, they felt safe in knowing who was not infected because they trusted the testing done by the jails, and most of the drug users interviewed had been tested for HIV infection while they were in jail. Once the jail notified them that they were not HIV positive, they felt no need for further testing, so many users were relying on information about their HIV status that was two to three years old. Users continued to share needles with their friends based on the belief that their friends were safe. No drug user mentioned going voluntarily for HIV testing. Another reason mentioned for needle sharing was the scarcity of needles. Drug users had to either get needles from diabetic friends or family 253 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. members2, or they purchased them on the black market for a nominal price. The government does not allow needles to be bought openly at the pharmacies. Users reported using the same needle for two weeks because they could not obtain another or that if they wanted to use badly enough, they would not take the time to sterilize their own or find a sterile needle. Drug users had the least prejudiced attitudes towards those who were HIV infected. They often sat with friends who were HIV infected and also showed compassion towards HTV infected people possibly because they knew they were members of this high risk group and as drug users they too had been stigmatized by the community. The drug users were also interested in learning more about the virus so they could protect themselves. Recommendations At present Bahrain’s HIV/AIDS educational efforts are concentrated into their annual HTV/AIDS prevention campaign. However, effective prevention requires an on-going effort to develop in greater detail their campaign messages and make a concerted effort to target high risk groups. Information about the virus is essential, but without explicit discussion on 2 Diabetes is a common problem in Bahrain so many people have family members who are diabetic. 254 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. how to protect themselves, it is unlikely to motivate behavior change. The Ministry of Health should reconsider their highly centralized educational approach and make a greater effort to train village leaders, more of the religious community, students, and anyone who is willing to be involved in the educational process to be educators themselves. Educators need to engage in continuous dialogue about this life-threatening illness in a less formal, comfortable setting where frank discussion can take place. The education process has to be brought to the local level where individuals feel responsible for themselves and their communities. The masses in Bahrain may not want to hear advertisements promoting condoms for safe sex practices, but there is no reason that such information can not be delivered during group discussions in the villages. If educational information only comes from the state, it is easy for people to live in denial believing that AIDS is something that only happens to foreigners or “bad” people. Women, in particular, have to be taught to take initiative to protect themselves. The modeling of conversations that they might engage in with their husbands as a way to show them prevention methods could be taught. Even with information about the disease, cultural restrictions on women may prevent them from taking preventative action. This is why it is so important that 255 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. methods to deal with these cultural realities are brought into the educational setting so women have the opportunity to explore these issues by asking questions that they might normally feel embarrassed about or to identify with other women who share similar concerns. Men need to be made aware as to how they could endanger their families by engaging in high risk behavior. If prevention education is brought to the local level, the greater the latitude for more open and detailed discussion because people will be engaging in dialogue with small groups, the same sex and with people whom they have known for a long time. Health centers could also try to implement some kind of couples counseling to help to facilitate discussion of these issues between husband and wife. By localizing educational efforts, there would be greater opportunities to understand prevention methods, and reduce the labeling or stigmatizing of those who are HIV infected by having a more comprehensive knowledge of the disease. HIV/AIDS also needs to be seen not as something that happens to certain high risk groups but as something that comes from risky behavior that can affect anyone. Health educators should continue to promote the following of Islamic values as a prevention model, but must also offer information about how people can protect themselves should they believe they are at risk. 256 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Indeed there is a fear that discussion of prevention alternatives may be interpreted as condoning sexual relationships outside of marriage. However, education programs must address the behaviors of the existing society, whether or not they are in accordance with the cultural/moral ideal of that society. Such debates are not limited to the Arab world. America has been dealing with the same conflicts regarding the type of content to offer in sex education courses in schools. Traditionalists are against explicit discussion and the realists argue it is necessary because sexual behavior among teens is a reality. Thus, the dilemma is not a new one, nor is it limited to a particular region of the world. Stigmatizing HIV/AIDS patients as those who have sinned will inhibit open dialogue about the disease and may make those who believe they are risk reluctant to be tested. To localize education efforts will need time and need to involve numbers of people. Bahrain has a large number of women who are training to be nurses at the local college. They could play an effective role in HIV/AIDS education at the local level because many of these young women come from villages. It is critical, however, that the educational process be an on-going one that includes follow-up and evaluation as an essential component of preventative education. 257 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. At present, HIV/AIDS prevention in Bahrain reaches IV drug users only though the state’s drug rehabilitation unit. So unless a user has been treated in the drug unit, no education has been specifically targeted to IV drug users. Because they are often unemployed, and exist within their own subculture, they are a harder group to target. The most important message that needs to reach users is that they have to use sterile needles and they cannot trust that there friends are not HTV infected. Using sterile needles depends on the availability of needles and since they are not openly sold in the pharmacy, users do not always have access to them. Black market availability may fluctuate and when a user needs an injection, finding the injection will be more important that finding the sterile needle and syringe. Therefore, the government should consider making needles available to IV drug users in order to reduce the risk of transmission because in countries where needles exchange programs have been implemented, HTV infection rates have dropped. HTV/AIDS prevention education could also take place in the state’s jails where many users continue to be held. There are very viable ways to reach high risk groups, but the state must first been sincere in its desire to do so. Other groups that have not been targeted in Bahrain’s HTV/AIDS campaign are the large numbers of 258 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. expatriate workers who come from India, Pakistan, Sri Lanka, Thailand, and Philippines and who comprise over 100,000, or one-fifth of Bahrain’s population. This segment of the population are usually contract workers who have come to earn money because of the poor economic situation in their own countries. Education materials in their native languages need to be obtained from their own government representatives on the island and leaders within these communities should be trained to provide HIV/AIDS information to them. The Bahrain Ministry of Health should start by requesting the HIV/AIDS literature from their local embassies and finding doctors, nurses and other respected members of these communities to get involved. It would be foolish and risky to overlook this segment of the population simply because they are non-Bahraini. The biggest advantage that Bahrain has in terms of health promotion is that is it a small island and information travels very quickly among the residents. With an on-going comprehensive program that includes follow-up, the de-centralization of information, and more involvement by the people, all segments of Bahrain’s population could be effectively educated regarding HIV/AIDS transmission. 259 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. It is also imperative that further research is done in the field of HIV transmission in the Middle East. The traditional status of women in the Arab world may contribute to unknowing exposure to the HIV/AIDS virus. A study that would examine women’s perceived risk of exposure to HIV and their actual risk would help to clarify the scope and the type of education prevention needed to protect women and their families from exposure to HTV. Throughout the Middle East there is a shortage of evaluation programs to determine the effectiveness of their health campaigns. This is an essential part of HTV/AIDS education and it is urgent that officials take it more seriously. HTV/AIDS is an illness that lies within a social context; it is the context of this illness that needs to be examined more thoroughly. Therefore, any study that examines the social problems of the region will directly or indirectly contribute to research in preventing the spread of this disease. Concluding Comments To initiate educational change or a different approach to an existing program will need members from the Ministry of Health to assess the current program and realize its pitfalls. Most importantly, the country’s citizens can not be deprived of education as to how to best protect themselves from 260 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. HIV/AIDS transmission. It is indeed a challenging problem, because the provision of more explicit information will affect current cultural norms. But there is an inherent danger in waiting too long as was seen in the drug users who reportedly were HTV infected because they did not know exactly how the virus was transmitted or how to take precautions against it. Those who are engaging in high risk behavior are not going to learn how to protect themselves against HTV by a health campaign that does not mention the use of condoms nor does it teach drug users how to properly sterilize their needles. It is not sufficient to provide the information on a such a small scale that only a few drug users will receive it if they happen to go to the state hospital for treatment or to teach about condoms to those who have already been involved in high risk behavior. Health campaign messages must be clear and direct and always take into account the actual behavior that is putting individuals at risk. Finding appropriate education does not have to be an immense task. The Islamic religion provides more explicit information about sex that most other religions. The issue of appropriate education needs to be redirected into considerations of appropriate setting for education and training individuals to be educators. The people can be spoken to in an open manner, but the 261 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. setting has to be right, and the person providing the instruction has to be properly trained. Bahrain’s health campaign exists at one level, the provision of information about HIV transmission to as many people as possible. For the campaign to be effective, educators will have experiment with new dimensions of education to find what will really work in their culture. People learn best when learning is related in some way to their own lives. That is why lectures that are given to hundreds of people that preach the benefits of a moral lifestyle are not going to succeed in changing actual practices or encourage questions or any form of dialogue. They will only enhance stigmatization and inhibit open discussion. The transmission of HIV/AIDS is a sensitive issue for any culture because to understand how one is at risk, sexual behavior has to be openly discussed. Gender roles may also have to be addressed because the woman’s role in sexual decision making may be limited given her status or traditional role in society. Educating those who engage in tribal rituals such as self-mutilation has to be perceived as educating for inherent risks of behavior that may cause the transference of contaminated blood rather than an annihilation of local customs. These can not be addressed in a large public format but rather dealt 262 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. with in an intimate setting, such a village meeting places, the local maa’tam, where small discussion groups can take place in a non-threatening manner. Bahrain needs to re-focus its campaign from a superficial campaign of numbers to one of quality and depth that will target individuals in a meaningful way. Finally, there are political issues involved in the prevention and prioritizing of HTV/AIDS education. The social context of the disease should not be ignored. There is an increasingly young, unemployed population in Bahrain, and the use of illegal drugs has become a more common way for them to pass their time. Unemployed young men spend enormous amounts of time sitting around with little to do. More training programs or apprenticeships to involve young people should be created to help reduce drug usage, particularly in the villages. Because many of these problems are rooted in Bahrain’s complex political history, it is questionable whether Bahrain’s monarchy is willing to address the current social inequalities. Government priorities also affect the scope of health education programs in Bahrain. Since all health education efforts are conducted by the state’s health ministry, there is a constant prioritizing of not only the amount of funds allocated for health education, but for what health issues are perceived 263 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. as most urgent. Hepatitis B, sickle cell anemia and diabetes are health problems among the local population that need to be addressed and some believe even more urgently than the AIDS virus. The state’s health ministry works year- round to include education about a large number of health issues. Without the proper funds or manpower, they are unable to effectively implement the widescale health promotion programs needed for the population. Social values, particularly the country’s religious conservatism, have affected the content and implementation of HIV/AIDS education programs in Bahrain. They have also affected the population’s perception of HTV/AIDS infected people. Individuals engaging in high risk behavior have been targeted the least in the state’s health campaign. It is time Bahrain rethinks their approach to HTV/AIDS education so that cultural norms do not affect the quality of the health message being presented. Preferably, more effort will be made to focus on the quality of delivery, and the training of health educators to provide such information to the community. The emphasis of the current HTV/AIDS campaign should shift from concerns over what constitutes a culturally suitable message to prevent HTV infection, to providing a culturally suitable setting for the discussion of the behaviors that 264 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. put people at risk for HIV infection, including the precautions needed to prevent transmission. 265 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix A Kuwait’s First International Conference on Acquired Immune Deficiency Syndrome “AIDS” Sponsered by State of Kuwait & World Health Organization February 3-6, 1986, Kuwait INAUGURAL ADDRESS H. E., Abdul-Rahman Abdullah Al-Avadi Minister of Public Health & Minister of Planning Kuwait "Ladies and Gentlemen, I am honored to join you today on the occasion of the opening of the Kuwait First International Conference on Acquired Immune Deficiency Syndrome (AIDS), and I am pleased to welcome you all, and to salute the scientists, researchers and brothers, representatives of neighborly Arab and Eastern Mediterranean Region countries and other friendly nations who have come to Kuwait to participate in this Conference, to wish them a happy stay, and to hope for this Conference all success and good fortune: This Conference on Acquired Immune Deficiency Syndrome takes place for the first time in our region, at a time when reports of this disease have predominated over reports of armed, bloody conflicts and natural disasters, which annually claim thousands of victims all over the globe. News of AIDS, transmitted over all mass media, is claiming priority over other news. Fear and alarm are evident whenever AIDS is mentioned. People from all over have communicated various statistical data and information on AIDS, the accuracy of which often requires more definition or more explanation. For these reasons, the Kuwait Ministry of Public Health has deemed appropriate the holding of this Conference in cooperation with the World Health Organization's Regional Office for the Eastern Mediterranean4 and with the participation of a prominent selection of. distinguished scientists, among them some who would claim the distinction of discovering the organism of the disease, and others who play active roles in current scientific research on the disease. In holding this Conference, we aim to accomplish three goals, as follows: Firstly, informing doctors and all categories of health workers on the latest medical information about the disease, in addition to gaining an acquaintance with the opinions and experiences of distinguished scientists and researchers in the field. Secondly, an exchange of viewpoints between doctors and medical core personnel in our region on the means capable of preventing the spread of AIDS into countries of our region, the joint efforts that may be expended in formulating preventive measures, and agreement on dissemination and exchange of vital data on AIDS. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Thirdly, and most importantly, is to create public awareness of the nature of this disease, its modes of transmission and methods of prevention, as well as assuring the citizenry that no cause for fear, panic or hysteria about AIDS need exist as long one avoids its sources. AIDS has attained international significance in our day. It has developed into a disease the likes of which humanity has never before had to confront. Perhaps the situation brings to mind the case of smallpox, a disease that eventually claimed thousands of victims, and which left indelible scars on all those who lived through it. Smallpox was eradicated and humanity freed from its scourge. In Hay 1981, while serving as Head of the World Health Association, I had the honor of signing the International Document signifying its eradication. We pray Allah that we will witness the day we are able to eliminate AIDS, a day that ought not to be too far were we to avoid the sources of the disease. Perhaps what really causes astonishment is the fact that AIDS has appeared only during our lifetime. Scientists explain this by showing that the AIDS virus lay dormant in the African Green monkey; in other words, the virus has an animal origin, but eventually spread to man. Here, another question arises: Why did the virus spread from animal to man, specifically during our lifetime? To answer this query, ladies and gentlemen, we must cast a discerning and thoughtful eye at the prevailing vice and immorality of our times, the levels of which have never before been witnessed. To our everlast ing regret, man today is heard boasting of his immoral acts. We observe many so-called emancipated and progressive societies in which currents of irresponsible promiscuity flow, and wherein various forms of unsanctified sexual relationships are practiced. This unchecked sexu.al liberation has been the cause for the spread of a wave of homosexuality in many parts of the world. You are no doubt aware, my brothers, that all the divine religions, in general, and our true Islamic religion, in particular, have incited their followers to shun immoral acts, no matter how insignificant. Despite this, the current of immorality has resulted in the abandonment of religion, culminating in no less than in the abandonment of self. Were we to examine the world-wide statistics on those afflicted with AIDS, the numbers would reveal that 7SZ of those afflicted are homo sexuals, while 17Z are drug addicts. An unfortunate group has also been affected: patients in need of blood transfusion. The latter group appears to be on the wane, as blood banks all over are taking pre cautionary measures to ensure the suitability of blood prior to its use. AIDS has also appeared in a few other cases of AIDS-afflicted mothers transmitting the disease to their newborn babies. In a word, dear brothers, we are facing a disease phenomenon that brings together an irrefutably difficult-to-diagnose causative disease factor, social reactions that may be extreme and non-scientific, as well as fear and alarm that siezes almost everyone. All this occurs because our knowledge of much about the disease is incomplete, and we lack any effective weapons. Regrettably, this is what is most pernicious about the disease. 267 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. At this Conference, we salute the efforts of those scientists and researchers who work tirelessly and earnestly to unlock the secrets of this disease. We hope that the speakers and researchers gathered here today will cast a light on the essence of this syndrome, that we may all become more cognizant of its true nature. We would wish that this Conference becomes a starting point for the serious contemplation of means to confront this dreadful phenomenon. We must continue our meetings, studies and scientific research that we may, Allah willing, overcome the disease. Before -closing, I would like to assure our fellow citizens and expatriates in Kuwait that the country is devoid of AIDS. We have taken all precautionary measures possible to prevent the spread of AIDS to our country, and we shall work in cooperation with public health officials from countries of the region to ensure that our countries are protected from the spread of the disease. We need not express fear or alarm, because, as I mentioned earlier, the individual himself is responsible for contacting the disease. I would implore you to ignore the misinformation that is being circulated by some about the disease. Let me be perfectly clear: the belief in Allah, abidance by the teachings of our true religion, and the avoidance of all that would displease Allah, Praise be on Him, are the protective / safeguards against this disease. In closing, I extend thanks again to the scientists and participant guests of this Conference, those who worked to prepare for this Conference .and provide the requirements for its success and the achievement of its goals. On this occasion, I wish also to convey the wishes of His Highness the Amir and Crown Prince for the success of your Conference and the attainment of resolutions that would ensure the protection of mankind from AIDS. I pray to Allah, Praise be on Him, to bestow health and well-being on the sons of the Arab and Islamic nations, and to ward off the disease from us." Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. T H E SOCIAL IM PACT O F AIDS M. M. Khogali Faculty of Medicine, University of Kuwait Kuwait Health authorities world-wide are under pressure from all quarters- the medical profession, the press and the public- concerning the spread of AIDS. Authorities face a yet unresolved dilemma; AIDS frightens the public, who demand action, but action emphasises the seriousness of the situation and may lead to panic and hysteria. Historically, outbreaks of the black death, smallpox, cholera and, more recently, Lassa fever, Marburg and Ebola epidemics, all generated hysteria. Syphlis was much more of a health hazard than AIDS has been and it killed thousands more than this new peril ever will. But to a great extent, the apprehension and fear are understandable, being founded on the reality that: (1) doctors know relatively little about the disease; (2) although identified, AIDS is still obscure; (3) no one knows why it strikes men and women in about equal numbers in Central Africa, while in the U.S.A. it attacks only 7Z of females; (A) in the U.S.A., the number of cases doubled annually, with an eventual mortality rate of virtually 100Z. The alarm is generated by the non-sufferers as opposed to the sufferers. Should society wish to tackle the problem of sexually-transmitted diseases, we will need to examine our attitudes towards these diseases and those who become afflicted with them. Society wants to believe that only homosexuals, the promiscuous, drug abusers and certain other "undesirables" suffer these illnesses. The knowledge that the upright, stable, heterosexual university professor (or even Rock Hudson) can also suffer generates panic and fear. Social attitudes play an important role in perpetuating the disease and its eventual control. Fear and ignorance about AIDS can so weaken peoples' senses as to render them susceptible to panic. To allay fears, we have to educate the public, society and the medical profession. This can only be achieved by stating the facts and examining them. We are dealing with a disease of low infectivity similar to hepatitis-B virus which, if handled sensibly, is not a risk to health workers. No doctor, nurse or health provider is known to have picked up the disease from a patient. No known cases of infection through casual contact have been described. These facts alone allow us to approach this new disease with more sense than fear. 269 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix B English Version of Questionnaire Research Study Health Education The purpose of the following study is to help health educators determine what people know and what people still need to know about the AIDS virus. All information below is confidential. Please take your time when answering the following questions. Name (Optional):______________________ Sex :______________________ Age ______________________ Education Level:______________________ 1) Please explain what you know about the AIDS virus? 2) Explain how or where you learned about the AIDS virus. 3) Who do you think is most likely to get the AIDS virus in your country and why? 270 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4) What would you do if someone you knew were carrying the AIDS virus? Would you still visit him/her? What kind of relationship would you have with him/her? 5) If you were a health official in your country, what would you do with people carrying the AIDS virus (expats and Bahrainis)? 6) How can you keep yourself from contracting the AIDS virus? 271 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix C Arabic Version of Questionnaire L P J J i-* 0 - c £ — £s-*H *—i A - j j j u U Jl a J • jjk (j-» j i j J i i l •Aj j ** ^jjS u u i »UaX<tll J& '■ «*C-«tl Ac.!i*5l u ^ ;- ^ j v V ' .A l^V I ^le. A jL * . 5 U JLS& jll xki C UJ\ ( )jd ( ) j£ i: ^ < _^_____^___i _ _ _ I ^ejLull i_5j5j»< al! ■ j-^V' A ijJuL a ^ > i L s e - L a k jll ( S jX.VI C-J>e oLji ( X 272 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ^ jL c . f jl,l ~ I - > « Jji S I J^.IW I ^ (jl jJ J » * IjL* ( * ? (+ j/ o lilkjjlui U ^ L a JI (j- » (flj ^ * J-ffV1 u-Jj-JJ U>U^J uf jU J* i ~ I... IjL.« doL ■ - Jj •■ ... . jJ ( 0 ( u j J IJ J A I l l j l_ h j|^ b U ) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix D English Translation of HIV/AIDS Information Pamphlets AIDS BROCHURES DOCUMENT 1 cover 1 - Aids Information Exchange Center Message to you dear citizen International Health Program Regional Office East Mediterranean - Alexandria Second Edition - 1992 cover 2 - The straightforward marriage relationship, based on honesty, religious regulations, and moral behavior protects from Aids. Picture Box: Kith knowledge and fidelity you can avoid Aids Page 1. Dear Citizen. Since 19>1 "the world talks about the sweeping disease that spread all over the globe causing oain. fear, disability and desth to an increasing number of people. Although there are allot of continuous efforts and scientific research almost everywhere to create a medicine against Aids, still the positive result looks unreachable. That is the Aids disease, or ‘alcida,* or acquired immune deficiency syndrome. But now we have knowledge of how the disease starts and how it spreads and who are most susceptible to get it, and how it develops inside the human body and leaves it open for different viruses and diseases. We have knowledge about how to avoid it and how to protect • ourselves and our families from this kining_disease. If every one of us knows the simple and vital faucs about ATO& there will be no reason tc worry or fear and we will all know how to avoid it. The target of this booklet is to provide you with basic in formation about this disease that you should te aware of, and that you should tell you friends and family members about. After that it's up to you to take precautions. It's- so easy to avoid this killing disease if you know more about it. We always (care lessly) ignore the evil spots. Page 2. The AIDS virus is spread all over the world. The inter national health organization estimates that there are 10 million virus carriers in the world. And if we did not gather and exert efforts to stop this disease the number will quickly double which creates a serious, threat .to humankind. AIDS is a very d^uS^rous disease as death is its end. Until now no medicine or pre«wA>.citxve medicine has RvC yet been found, but any one can avoid AIDS if he follows the correct precautions. It's a matter of socia] beh»viop that each individual is respon sible for, since uiis oeuav^v. could affect the whole society. The AIDS disease has very dangerous social affects in addi tion to its affect on health. The disease usually hits the pro ductive segment of society. This segment plays a vital role in -their country's social and economic development. What is AIDS? AIDS, ‘alcida* are the two English and French names for the scientific name acquired immune deficiency syn drome. It means that the AIDS carrier will loose the ability to fight diseases in its final stages of infection as the natural body defenses collapse and the body becomes open for various dis eases, microbes, and tumors. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Page 3. The AIDS 3 7 1 0 9 1 :0 0 8 night appear individually in other diseases, but when all these symptoms appear together, then we have AIDS. Also there is a time span between getting infected by the AIDS virus and the AIDS disease itself as the disease symptoms appear after the infection in a period that fluctuates between a few weeks or a few years. During this period the virus carrier could infect other people although his appearance doesn't show he is ill. What are the AIDS symptoms? AIDS symptoms vary, some happen because of the virus itself and others because of the collapse of the immune system which causes other diseases. Some of the symp toms are as follows: * Inflammation of the glands especially in the throat, under the arms, and thigh curve. * Feeling tired for weeks for no specific reason. * Weight loss. The sick person would loose 4.5 kilograms in two months. * High temperature with heavy sweating during the night for sev eral weeks. Page 4 S 5 illustrations, (right to left) Infection does not happen through casual connections as shown in the following illustrations. Illus: - Insects - Eating or drinking or using eating and drinking tools in public places - Using public telephones - Shaking hands or hugging - Using public toilets and bathrooms - Coughing-or sneezing - Sitting next to each other in studying places - Meeting with people in crowded places - Meeting with people in work places or transportation places - Visiting sick people in hospitals - Using public swimming pools Page 6. * Diarrhea for several weeks * Difficulty in breathing and very dry coughing that will con tinue for a longer period than any serious cold * Purple spots on skin or in the mouth or on the eyelids. You should remember that AIDS will happen if a group of all these symptoms will occur for a long period. How does the virus get transferred? All the studies have informed that the infection comes through blood, sperm, vaginal liquids. The virus is transmitted in three different ways. 1. Through sexual relationships: The disease is transmitted through the sexual contact between the male and female or through sexual contact between homosexual males if on of the partners carries the virus. .« * • • Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Page 7. 2. Through blood: It happens when the blood o£ an infected person is transferred to a healthy person. A connection was found between the infection and the repetitive use of unsterilized needles and injections. For example AID infection averages are very high among the injection drug users. Also infection could be transmitted in some other cases such as Chinese needle medication (acupuncture) and piercing ears, tattooing. If the tools used in all the above mentioned cases carry the virus, it will transmit the disease. 3. Pregnant mother to child: Infection might be transmitted through the pregnant moth er to her baby during pregnancy or after delivering the baby. Bow to avoid AIDS infection? AIDS represents a very serious and dangerous phenomena. It has no effective medication or successful treatment however, it could be avoided by following necessary precautions. END DOCUMENT 2 Cover - State of Bahrain Ministry of Health Health Education Division Facts about AIDS AIDS Committee & Subsidiary Committee for Health Education Page 1. FACTS ABOUT AIDS Fact number one: AIDS, a disease that threatens the whole world. * There are more than 484,000 registered AIDS cases reported in 164 countries. * AIDS invades all the continents as it has the capability to transgress 3ui.i.ai and geographical borders. * The World Health Organization estimates the virus carriers until the beginning of 1993 were 10 to 12 million individuals. Fact number two: Disease stages First comes the infection of the virus and then the disease itself. The time span between the two stages could take more than 10 years. So the infected person will look healthy although he carries the virus and also he can transmit it to other indi viduals . Fact number three: Virus transmission It is known that the AIDS virus can be transmitted by one of the three registered ways. (Shannon it says three but gives four bullets — Amr says its a very poorly written brochure.) * Sexual contact with a disease carrier * Infected blood transmission from a disease carrier. * From a pregnant mother to its child before birth, during, or after. * Using infected tools like shaving tools Fact number four: Daily practices do not transmit the virus AIDS virus could not be transmitted through casual contacts in work or school or by shaking hands or hugging. Also the virus does not spread through food, or drink, or eating or drinking tools, or coughing, or sneezing, or using toilets, or swimming pools. Also there is no proof the virus could be transmitted through flies or insects. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Fact number five: Precautions * The most guaranteed way to stop the virus is to avoid homosexuality and to maintain only legal sexual relations between husband and wife. * Having a blood test to make sure that the blood is not infected before transfusion * Using sterilized needles and other tools before use. Also to avoid repetitive use of those tools especially among drug takers. Fact number six: Dealing with infected individuals * There is no reason to fear the AID's carriers. • Virus carrier should be given proper physical and psycho logical treatment to help them face their problem. Fact number seven: Importance of AIDS health education * Health education is the ideal method of preventing the spread ot AIDS. * In the absence of successful treatment and until medical research finds effective medication for AIDS health education remains to be the,strongest weane- in fcci«VT the disease. * Media and eaucauuu have vital jthpQ-$ati£e m the fight against AIDS. Also health education is the main entrance of changing the individual's behavior and practices aiming at avoiding the virus. Fact number eight: The danger of AIDS threatens everyone * AIDS does not discriminate between sex, color, class, or age. It threatens the societies. And it requires to change the daily lifestyle of the individuals and people. Fact number nine: Together we can get rid < - f AIDS * AIDS represents an international problem and it cannot be stopped in one country. Because of this efforts, resources, and ideas, should be gathered to create the best opportunities to control this disease. * Societies should play a vital role in changing the life style of some individuals especially in regulating the legal sex ual relationships and moral attitudes. Fact number ten: Your role to limit the spread of AIDS * You can participate in controlling the spread of the virus by understanding and knowing the aspects of the disease and the ways of precaution, and also you can help others to understand. * The international day of AIDS is a special annual occasion to focus on the AIDS danger and it will be our opportunity to overview the aspects of the disease and its danoer to humanity. (Participate with us in the fight against AIDS jnd put a limit to this dangerous disease on the International Day of AIDS and every day.) END DOCUMENT 3 Cover - Ministry of Health State of Bahrain BEWARE OF AIDS Text - Ministry of Health - State of Bahrain Dear Traveler. As you are preparing yourself to travel to spend an enjoyable vacation, we would like to remind you of the follow ing. 1. AIDS is one of the very dangerous diseases which doesn't have 277 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. a medication for it yet. 2. The virus could be transmitted to the healthy person through sexual contact with an in£ected person or virus carrier, or through blood transfusion, or also through taking drugs through infected needles. 3. Precaution is the only way: see God in yourself and your brother. AIDS Committee END DOCUMENT 4 COVER: MINISTRY OF HEALTH - AIDS Committee What you should know about AIDS Page 1. AIDS is anger of God * What should we know about this disease? - It's the acquired immune deficiency syndrome. - When it happens the human body the natural immunity first line is destroyed. In the normal cases the immune system in the body protects it from diseases. But in case of AIDS the human body cannot deal with those diseases and a simple disease could kill the person. * Is AIDS a new disease? - The first registers AIDS case was in 1981 when two cases were found among the homosexual groups. First it was similar to a very rare type of cancer. But when Dr. Michael Gottleib from University of California received the second case then he real ized that he was facing a new disease. The first report on this disease was issued by the Center for Disease Control in Atlanta, Georgia in 1981 stating that five cases were reported with AIDS. Since that date several eases were reported all over the world and the average of terminal cases because of this disease has increased as it reached about 75 percent of the people who contracted it in 198- . (Shannon check copy for exact date, fax copy not clear.) All the information about this disease created a great panic and the normal people started to seek information to avoid this danger. It's of great importance to know about this disease in order to eliminate any fear or panic. AIDS is a very dangerous disease and there is no cure for it until now, but it'-S So easy " to avoid it. ' * From where did it come? Reports stated that the disease virus came from Africa and started invading the world through the infected individuals who traveled through northern Europe and Haiti. Page 3. * Causes of the disease. Latest researchers proved that AIDS is a kind of virus that has the ability to change the natural structure of the cell, es- pecia.’.y in the nerve system cells which badly affects the natu- 278 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 ral immune system in the body. In case o£ infection the immune cells become inefficient and cannot deal with any diseases. * Who are the most likely people to get the disease? - The male homosexuals in case one of the two parties is infected. - Injection drug takers as the virus is transmitted because of the repeated use of the needle. - Persons who had blood transfusions and it happens when the blood is infected. It happens most likely to people who have hemophilia as sometimes the plasma transmitted to their blood is infected. - Also the disease could be transmitted through normal sex ual contact if one of the two parties is a disease carrier. - A pregnant mother could transmit the virus to her child before or during or after the birth. * How is the disease transmitted? Aids disease is related to the lifestyle and the individual behavior. It might be transmitted through male homosexuality or by using drugs needles or through infected blood. Until now there is ho proof the disease could be transmitted through sweat or daily practices or insects or by swimming in public swimming pools. * Is there any possibility of getting infected in case of donating blood? It's impossible for the disease to be transmitted to the blood donator because the blood bank normally uses clean needles. * Is it a must that every virus carrier feels sick because of the virus? When the virus enters the blood of the human, the body pro duces some kind of anti-body which is easy to be discovered dur ing six to 12 weeks from entering the body. Page 6. * Who is the disease carrier? We consider the person who carriers the infection from € to 12 weeks a virus carrier. After 12 weeks the carrier could transmit the infection. * How does AIDS cause death? AIDS is a very killing and dangerous disease spreading slowly by surely in the world causing panic and fear to everyone. However we should explain that 25 percent of those who got infected one can see symptoms of related diseases to AIDS. Six to 20 percent of the 25 percent of AIDS infected people might be sick by AIDS in two years. 279 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. AIDS is dangerous because of the following: - There is no treatment or medication for *Tpg - Because of the high death averages . - Because of panic and fear related to AIDS. Necessary precautions to avoid BIDS: - The blood should be tested before transmission. That nor mally happens in Bahrain. - Disposable needles should be used, which is happening in Bahrain. - People should know details about the disease in general and about the dangers of the illegal sexual relationships. Conclusion: We thank God because AIDS is away from us. It' s because of our religion as we all know that AIDS _ happens because of homosexuality and drug taking. So the family should play an important role in raising their children according to tl s Islamic religion. God's words are true Lute tribe did not believe their son Lute when he blamed them for homosexuality. Lute said, *1 am your messenger. Please obey God and follow his sayings, and you and me will be rewarded. You ignore the normal life, wives, and you take men in a homosex ual way instead. You are not faithful.* The tribe said to Lute | if you don't stop talking we will send you out (expel you). Lute, to God said, "God save me and save my family. * God saved him and his family except one old person from his family, a homosexual_ and God flooded the whole tribe with very heavy rain and the vil lage was destroyed completely. That was a sample of God's punish ment. Ending Clause Shoar'a Chapter (Verses 159-175) END 280 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix E Arabic HIV/AIDS Information Pamphlets 1 $ V “ P! U > f U * p: m * 1 V £ e r r t r- £ ~ I' $ . £ \ ! c f • * • 3 : T-=-s — 281 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. V FV t \ } i ' W 1 * ^ l f L f v - v < v r ■ C > I f U t ! . & V - r y C. v*.. - r - S F v.. U \ . a - t l r « 1 ■ c . . -rf 1 f (_• V I: t- * 7 n * ■ - : v r. V - £ c- c l V " ) c ^ T ^ ’ S > 'v ■ c. X - V v. ^ c. .r v *• -■ 1 r ^ o ^ ^ * £ ? i i/ r w - ^ f c > t, F ^ S t u t s t fc r t if® — C - * • » V * c > f -L v .. •f u / Ss - * . t F < L 'i * i ; t c s , F -«£ - 1- ■ 0 \ {' \ * \ . u U * r i tr 'fc e: fe S. ^ £ ^ C 4 F £ a .r F i - • f ' u. \ v •4 s_ v * - * I s - .t X r ' t - C . - r I'- t i v ^ f v * # u - r. i t c £ k . ' * V * •> v ' t i ^ E - c t C. c*. S k I f* E e. x — t H « } I \ t -t t-1 - U * ' f c t t t ^ T r » / fe (T ^ I y r £ C - v * f U ^ 'fc * ■ • • * * F V . S . i E* F \ 1 Tin n q ^ l c - > ^ £ S c.- v j S f * f S S’ w fe * * J rf v.. r V t £ v \ ^ *s- ^ V V > s i? 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J: -c* 11 V f ■ fefs c* »r . 4E c* .t f s F 288 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. V . . . t - i s. £ c. 1 f t £ »• t : f it if f e J C w - E V c : U . t t*V .t C 7 ■ C . - I -t V r • a- b < E u % I H k - ■ '" V 0 0 s . u p m ^ < 1 i \ i IH IH it - s . ? ? C * */ c u g * i I t ^ 4 s* - s . .k - - J u f h i E c » s . * * v t El 289 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 290 c . * £ . \ . s i' & \ ^ £ lA £ ^ : V C . t 't - f J-tv . * - ± 1 — ^ - _ l r — - Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. •r f c i f * ^ ' ' r C — IVfe \ I I 1 b V r - s - iu U ) l i t f-%£ t v H I J tH * l i l t e -t H i a n mnn i m h l > w U h * n iihl m S c c' - '" T ^7 * » t-C i- F VdT? I: 291 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. BIBLIOGRAPHY AI-Awadi, A. R. (1986). Inaugural Address. Kuwait First International Conference on Acquired Immune Deficiency Syndrome. State of Kuwait & World Health Organization. Feb. 3-6, 1986. Al-Haddad, M. K., Khashaba, A. S., Baig, B. Z. H., etal. (1994). “HIV Antibodies among Intravenous Drug Users in Bahrain.” Journal of Communicable Diseases. VoI26, No. 3: 127-132. Altman, D. (1993). Expertise, Legitimacy and the Centrality of Community. In Aggleton, P., Davies, P. &Hart, G. AIDS: Facing the Second Decade, (pp. 1-12). UK: The Falmer Press. Ameijden, E. J., Hoek, A. R. &Coutinho, R. A. (1994). “Injecting Risk Behavior among Dug Users in Amsterdam, 1986 to 1992, and Its Relationship to AIDS Prevention Programs.” American Journal of Public Health. Vol. 84, No. 2:275-281. Armenian, H. (1980). Model Systems for Primary Health Care in Developing Countries. Human Resources for Primary Health Care in the Middle East. (pp. 194-205). Beirut, Lebanon: American University of Beirut. Baby, S. (1994). "Task Force is Planned to Combat AIDS.” Gulf Daily News. April 24, 1994. Manama, Bahrain. Backscheider, P. R. (1992). In Daniel Defoe, Journal of the Plague Year. London: W. W. Norton & Company, Inc. Balzar, John. “In Uganda, a Scourge on Families.” Los Angeles Times. Nov. 18, 1995. pp. 1, 14-15. Barnard, D. (1983). “Religion and Religious Studies in Health Care and Health Education.” Journal of Allied Health. Vol. 12, No. 3. Battjes, R. J., Lleukefeld, C. G., &AmseI, Z. (1990). Community Prevention Efforts to Reduce the Spread of AIDS Associated With Intravenous Drug Abuse. AIDS and Intravenous Drug Use: Future Directions for Community-Based Prevention Research, (pp. 288-298). Rockville, MD: U.S. Departmentof Human Services. Berer, M. (1993). Women and HIV/AIDS. UK: Pandora Press. Blendon, R. J., Donelan, K., &Knox, R. (1992). “Public opinion and AIDS: Lessons for the Second Decade.” Journal of American Medical Association., Vol. 267, (pp. 981-986). Des Jarlais, D. & Choopanya, K. (1994). “AIDS Risk Reduction and Reduced HIV Seroconversion among Injection Drug Users in Bangkok.” American Journal o f Public Health. Vol. 84, No. 3:452-455. 293 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Fajans, Peter, Ford, Kathleen & Wirawan, DewaNyoman. (1995). “AIDS Knowledge and Risk Behaviors Among Domestic Clients of Female Sex Workers in Bali, Indonesia.” Social Science & Medicine. Vol.41, No. 3:409-417. Fakhro, A. M. (1980). A General Description of the Health Care System. Human Resources for Primary Health Care in the Middle East. (pp. 185- 103). Beirut, Lebanon: American University of Beirut. Fennell, R. (1992). “Cross-Cultural Perspectives and Understanding: Providing HIV Education for People of Color.” Effective AIDS Education on Campus. No. 57, pp. 39-54, San Francisco, CA: Jossey-Bass Pub. Fernando, Daniel.(1993). AIDS and Intravenous Drug Use: The Influence o f Morality, Politics, Social Science, and Race in the Making of a Tragedy, (pp. 1-42). Westport, CT: Praeger. Fox, Laurie J., Bailey, Patricia E., Garke-Martmez, Kazu L., etal. (1993). “Condom Use among High-Risk Woman in Honduras: Evaluation of an AIDS Prevention Program.” AIDS Education and Prevention. Vol. 5, No. 1: 1-10. Franklin, R. (1985). “Migrant Labor and the Politics of Development in Bahrain.” Middle East Research and Information Project. No. 132. Fumento, M. (1990). The Myth of Heterosexual AIDS. New York: Basic Books. Genasci, Lisa. (1988). “Brazil steps up AIDS campaign.” AIDS Watch. No. 2: 6-7. Gezairy, H. A. (1992). The Role of Religion and Ethics in the Prevention and Control o f AIDS. Alexandria, Egypt: World Health Organization, Regional Office for Eastern Mediterranean. Ghazizadeh, M. (1992). “Islamic Health Sciences: A Model for Health Education and Promotion.” Journal of Education. Vol. 23, No. 4:227-231. Global Programme on AIDS. (1992). 1991 Progress Report. Geneva, Switzerland: World Health Organization. Gould, J. & Keeling, R. (1992). “Principles of Effective Sexual Health Promotion on Campus: Theory into Practice.” In R. Keeling, Effective AIDS Education on Campus. No. 57: 5-22. San Francisco, CA: Jossey-Bass Pub. Grmek, M. (1990). History of AIDS. Princeton, New Jersey: Princeton University Press. Gwede, Clement and McDermott, Robert J. (1992). “AIDS in Sub-Saharan Africa: Implications for Health Education.” AIDS Education and Prevention. Vol. 4, No. 4:350-361. Hamilton, J. (1995). “AIDS: Where Are We Now?”. American Health. Vol. 14, No. 4: 52-57. 294 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Herek, G. M. &Glunt, E. K. (1991). “AIDS - Related Attitudes in the United States: A Preliminary Conceptualization” Journal of Sex Research. 28:99-123. The Holy Bible. New King James Version. (1982). New York: Thomas Nelson, Inc. The Holy Qur’an. Ali, A. Y., translator. (1946). Middlesex, UK.: Islamic Propagation Centre. Hunt, M. (1989). An Invitation to Rethink Sexuality: A Christian Feminist Liberation Perspective. In Hallman, D. G. AIDS Issues: Confronting the Challenge, (pp. 213-232). New York: Pilgrim Press. Ismartono, Yuli. (1989). “Thailand’s head-on approach.” AIDS Watch. No. 8:4-5. Jones, David-Pryce. (1989). The Closed Circle. London: Weidenfeld and Nicholson. Jonsen, A. & Stryker, J. (1993). Religion and Religious Groups. The Social Impact o f AIDS in the United States, (pp. 117-153). Washington, D.C.: National Academy Press. Jue, Sally. (1987). Identifying and Meeting the Needs of Minority Clients AIDS. In C. G. Leukefeld&M. Fimbres (eds.). Responding to AIDS - Psychosocial Initiatives, (pp. 65-79). Silver Spring, MD: National Association of Social Workers, Inc. Kagimu, Magid, Marum, Elizabeth & Serwadda, David. (1995). AIDS Education and Prevention. Vol. 7 No. 1 : 10-21. Kalibabla, S. & Anderson, S. (1993). “AIDS in Africa: a family disease.” World Health. No. 6:8-10. Kapiga, Saidi H., Lwihula, George K., Shao, John F., etal. (1995). “Predictors of AIDS knowledge, condom use and high-risk sexual behaviour among women in Dar-es-Salaam, Tanzania.” International Journal of STD & AIDS. Vol. 6: 175-183. Kendall, Sarita. (1989). “Colombia: crusading efforts bring signs of progress.” AIDS Watch. No. 7:4-6. Kendall, Sarita. (1988). “Latin America conference increases AIDS awareness.” AIDS W atch. No. 1:4-5. Klouda, Tony. (1990). ‘The Caribbean - reflecting global contrasts.” AIDS Watch. No. 9:2-4. Landau-Stanton, J. & Clements, C. (1993). Correcting AIDS Metaphors and Myths with a Systems Approach. AIDS, Health, and Mental Health: A Primary Sourcebook, (pp. 3-26). New York: Brunner/Mazel. Levine, B. (1995). ‘The Changing Face of AIDS.” Los Angeles Times. June 16, 1995. Los Angeles, CA. 295 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Li, Virginia C., Clayton, Serena, Cheng-Zhang, Chen, etal. (1992). “AIDS and Sexual Practices: Knowledge, Attitudes, Behaviors, and Practices of Health Professionals in the People’s Republic of China.” AIDS Education and Prevention. Vol. 4, No. 1:1-5. Lofland, J. & Lofland, L. (1984). Analyzing Social Settings. Belmont, CA: Wadsworth Publishing Co. Luna, G. Cajetan& Rotheram-Borus, Mary Jane. (1992). “Street Youth and the AIDS Pandemic.” AIDS Education and Prevention. Supplement, 1-13, Fall 1992. Mann, Jonathan. (1992). AIDS in the World. Cambridge, MA: Harvard University Press. Mariasy, Judith. (1988). “Education campaigns: pointers and pitfalls.” AIDS Watch. No. 4: 2-3. Marshall, C. &Rossman, G. (1989). Designing Qualitative Research. Newbury Park, CA: Sage. Maticka-Tyndale,Eleanor, Kiewying, Monthira, Haswell-Elkins, Melissa, etal. (1994). “Knowledge, Attitudes and Beliefs about HIV/AIDS among Women in Northeastern Thailand.” AIDS Education and Prevention. No. 6, Vol. 3: 205-218. Mattar, A. M. (1985). “AIDS.” Bahrain Medical Bulletin. Vol. 7, No. 2:64. Mattar, A. M. (1985). “Drug Abuse.” Bahrain Medical Bulletin. Vol. 7, No. 2: 53-55. Merson, M. H. (1994). Global Programme on AIDS. Press release. April 27, 1994. Geneva, Switzerland: World Health Organization. Mnyika, K. S., Kvale, G. &Klepp, K. I. (1995). “Perceived function of and barriers to condom use in Arusha and Kilimanjaro regions of Tanzania.” AIDS CARE. Vol. 7, No. 3: 295-305. Murphy, J. S. (1989). The AIDS Epidemic: A Phenomenological Analysis of the Infectious Body. In E. T. Juengst & B. A. Koening (eds.). The Meaning of AIDS - Implications for Medical Science, Clinical Practice, and Public Health Policy, (pps. 50-59). New York: Praeger. Mwale, G. & Bumard, P. (1992). Women and AIDS in Rural Africa. Hants, U.K.: Avebury. Patai, R. (1973). The Arab Mind. New York: Charles Scribner’s Sons. Patton, M. Q. (1987). How to Use Qualitative Methods in Evaluation. Newbury Park, CA: Sage. 296 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Pivnick, A. & Jacobson, A. (1994). “AIDS, HIV Infection, and Illicit Drug Use within Inner-City Families and Social Networks.” American Journal of Public Health. Vol. 84. No. 2:271-274. Porter, S.B. (1993). “Public knowledge and attitudes about AIDS among adults in Calcutta, India.” AIDS CARE. Vol.5, No. 2: 169-176. Rajab, K. (1979). “Milestones in the Medical History of Bahrain with Special Reference to Maternity and Child Welfare.” Bahrain Medical Bulletin. July 1979:6-9. Rafaelli, Marcella, Siqueira, Eliana, Payne-Merritt, Alice, etal. (1995). “HIV-Related Knowledge and Risk Behaviors of Street Youth in Belo Horizonte, Brazil.” AIDS Education and Prevention. Vol. 7, No. 4:287-297. Ross, J. W. (1989). Ethics and the Language of AIDS. In E. T. Juengst & B. A. Koening (eds.). The Meaning of AIDS - Implications for Medical Science, Clinical Practice, and Public Health Policy, (pps. 30-39). New York: Praeger. Russell, R. D. (1983). “Old Ideas Still Valuable: A Review of Cross-Cultural Case Studies.” The Journal of School Health. Feb. 1983. (pp. 112-115). “Saboteurs ‘Evil Plot’ Foiled Says Premier.” Golf Daily News. March 15, 1995. Manama, Bahrain. Sallam, S. A., Mahfouz, A. A. R., Alakija,W., etal. (1995). “Continuingmedical education needs regarding Egyptian physicians in Alexandria, Egypt and in the Asir Region, Saudi Arabia.” AIDS CARE. Vol. 7, No. 1, 49-54. School Health Education to Prevent AIDS and Sexually Transmitted Diseases. Geneva, Switzerland: World Health Organization & United Nations Educational, Scientific and Cultural Organization. Series 10, 1992. Schopper, Doris, Doussantousse, Serge, Ayiga, Natal, etal. (1995). “Village-based AIDS prevention in a rural district in Uganda.” Health Policy and Planning. Vol. 10, No. 2: 171-180. Scott, Sally J. and Mercer, Mary Anne. (1994). “Understanding Cultural Obstacles to HIV/AIDS Prevention in Africa.” AIDS Education and Prevention. Vol. 6, No. 1:81-89. Sheppard, G. T. (1989). Biblical Revelation and Human Sexuality. In Hallman, D. G. AIDS Issues: Confronting the Challenge, (pp. 223-247) New York: Pilgrim Press. Sills, Y. G. (1994). The AIDS Pandemic - Social Perspective. Westport, CT: Greenwood Press. Soloway, I. & Walters, J. (1977). Workin’ the Corner the Ethics and Legality of Ethnographic Fieldwork Among Active Heroin Addicts. In R. S. Weppner (ed.). Street Ethnography, (pp. 159-178). Beverly Hills, CA:Sage. 297 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Sontag, S. (1989). AIDS and Its Metaphors. New York: Farrar, Straus & Giroux. Stimson, Gerry V. (1995). “AIDS and Injecting Drug Use in the United Kingdom, 1987-1993: the Policy Response and the Prevention of the Epidemic.” Social Science & Medicine. Vol. 41, No. 5:699-716. Strauss, A. & Corbin, J. (1990). Basics of Qualitative Research. Newbury Park, CA: Sage. Tan, M.L. (1993). “Socio-economic impact of HIV/AIDS in the Philippines.” AIDS CARE. Vol.5, No. 3:283-288. The Torah. 2nd edition. (1962). Philadelphia, Pennsylvania: Jewish Publication Society of America. Van der Straten, Ariane, King, Rachel, Grinstead, Olga, etal. (1995). “Couple communication, sexual coercion and HIV risk reduction in Kigali, Rwanda.” AIDS. 9:935-944. Wahdan, M. H. (1993). Epidemiology of Acquired Immunodeficiency Syndrome. Egypt: World health Organization, Regional Office for the Eastern Mediterranean. White, Edmund. (1993). “Life, Love and Death.” The Guardian. Nov. 30, 1993. Williams, J. R. & Stafford, W. B. (1991). “Silent Casualties: Partners, Families, and Spouses of Persons With AIDS.” Journal of Counseling and Development. Vol. 69:423-427. Wong, K.H., Lee, S. S., Lo, Y. C., etal.. (1994). “Condomuse amongfemale commercial sex workers and male clients in Hong Kong. ” International Journal of STD & AIDS. Vol. 5: 287-289. Yep, Gust A. (1994). “Notes From The Reid.” AIDS Education and Prevention. Vol. 6, No. 2: 184-186. Yin, R. K. (1989). Case Study Research. Newbury Park, CA: Sage. Zapata, V. & Blanton, C. (1994). “AIDS and Intravenous Drug Use: A Growing Menace.” Journal of Drug Education. Vol. 24: 133-138. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
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O'Grady, Shannon Kathryn
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HIV/AIDS education in the Arabian Gulf state of Bahrain
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Doctor of Philosophy
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Education
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University of Southern California
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education, health,health sciences, public health,OAI-PMH Harvest,political science, public administration
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500708
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O'Grady, Shannon Kathryn
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education, health
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political science, public administration