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! Kate Winskell Hubert Department of Global Health Emory University Peter J. Brown Department of Anthropology Emory University Amy E. Patterson Department of Behavioral Science and Health Education Emory University Camilla Burkot Mailman School of Public Health Columbia University Benjamin C. Mbakwem Community and Youth Development Initiatives Owerri, Imo State, Nigeria Making Sense of HIV in Southeast ern Nigeria Fictional Narratives, Cultural Meanings, and Methodologies in Medical Anthropology _____________________________________________________________________________________ Fictional narratives have rarely been used in medical anthropological research This article illustrates the value of such narratives by examining how young people in s outh e ast ern Nigeria navigate the cultural resources available to them to make sense of HIV in their creative writing Usi ng thematic data analysis and narrative based methodologies, it analyzes a sample ( N = 120) from 1,849 narratives submitted by Nigerian youth to t he 2005 Scenarios from Africa scriptwriting contest on the theme of HIV The narratives are characterized by five salient themes: tragedy arising from the incompatibility of sex outside marriage and kinship obligations; female vulnerability and blame ; peer pre ssure and moral ambivalence; conservative Christian sexual morality; and the social and family consequences of HIV We consider the strengths and limitations of this narrative approach from a theoretical perspective and by juxtaposing our findings with those generated by Daniel Jordan Smith using standard ethnographic research methods with a similar Igbo youth population. [ HIV, Igbo, youth, narrative methodology ] _____________________________________________________________________________________ Narrative data of various kinds from illness narratives ( Kleinman 1988 ) to healing dramas and clinical p lot s ( Mattingly 1998 ) to parallel macro and micronarratives on health related issues ( Fassin 2007 ) have assumed an increasingly prominent place within m edical a nthropology. However, this interest in narrativ e rarely if ever, extends to f ictional narratives. Through the
! analysis of creative narratives contributed to a 2005 youth scriptwrit ing contest on the theme of HIV t his article examines how young people in s outh e ast ern Nigeria navigate the cultural resources available to them to make sense of the epidemic The strengths and limitations of this narrative approach are considered through juxtaposition with findings generated by Daniel Jordan Smith using standard ethnographic research methods with a similar Igbo youth population ( Smith 2003 2004a 2004b ) We highlight the applied dimension of our research arguing that by increas ing understanding of how young people make sense of HIV and of the social representations that inform this meaning making fictional narratives not only illuminat e the sociocultural context of youth sexuality and the social processes that may lead to stigmatization of those affected but also inform programmatic practice The theoretical underpinnings of this study build on the premise that narra tive and narrative understandings are primary modes of human thought. Narratives allow people to formulate and articulate the causes and consequences of human actions; as such, narrative underlies social knowledge ( Bruner 1990 ) On e of the reasons we tell stories is "to make sense of what we are encountering in the course of living . . ( Bruner and Lucariello 1989:79 ) Fictional narratives make manifest the di alectical relationship between personal experience and the creative imagination on one hand, and cultural norms and shared systems of representation on the other. Inherently dialogical, narratives draw on the lived experience of both teller and audience as well as on their shared cultu ral models I n their creative writing about HIV young people draw on their own lived or imagined experience and on other culturally determined sources of social understanding to create narratives imbued with context, meaning and values. In this way, the narratives provide insights into young people's explanatory models about HIV and into their appropriation of dominant cultural norms around gender, sexuality and stigma These are themselves embedded within cultural norms of performance, discourse and p ersuasion ( Farmer and Good 1991 ) H omo narrans the animal with the innate disposition to tell stories ( Fisher 1987 ) meets homo performans ( Turner 1985 ) a culture inventing and self making creature. Narratives like these are then both fictional and cultural arte facts produced within ( and assisting our understanding of ) complex social cultural formations ( Newell 2002:9 ) T he social c ontext of narration guides interpretation of narratives pointing to the narrator's positionality and factors that might have in fluenced their shape. The narratives in this study submitted by relatively well to do young pe ople from Igbo speaking Nigeria who chose to participate in an HIV themed scriptwriting competition, intersect with broader cultural narratives around HIV and sexuality associated with Igbo cultural traditions, evangelical Christianity popular media ( specifically Nollywood films), and public health The Use o f Narratives i n Medical Anthropology Medical a nthropology has a significant tradition in analysis of ethnographically collected narratives from the clinical setting as meaning making devices o n individual, family, and community levels ( e.g. Kleinman 1988 ; Mattingly 1998 ) More relevant for the current study because operating at a broader community level, Farmer's early ethnographic writings document the local historical formation of a cultural model of HIV in rural Haiti in the 1980s, describing the central role of illnes s narratives in this process of representation ( Farmer 1994 ) The present study is situated in relation to this and an evolving body of critical medical anthropological
! scholarship employing HIV related narrative ( Biehl 2007 ; Fassin 2007 ) and incorporates a distinctive multidisciplinary and applied perspective. Disciplines outside m edical a nthropology have offered compelling theoretical arguments for the impact of symbolic representations on HIV prevention, stigma, and treatment seeking, in addition to illness experience. In the late 1980s, Sontag wrote of the need to take "rhetorical owners hip" of illnesses like cancer and AIDS and detach them from the metaphors and myths with which they are associated in the popular imagination and which, she suggested, kill ( Sontag 1988:181 ) In her chronicles of the cultural life of AIDS, Treichler ( 1999 ) wrote of an "epidemic of signification" running parallel to the biomedical epidemic. More recently, from the perspective of folklore studies, Goldstein examined urban legends about AIDS to document how "AIDS discourse, in the form of narrative, shapes and creates vernacular responses to the disease" ( 2004: xiii ) These HIV related studies, using cultural studies and folklore perspectives and drawing on a broad range of cultural products including the media focus on narrative based and image rich representations The studies describe the complex social processes whereby a new and highly controversial disease is incorporated into lay meaning systems via symbolic processes dominated by relations of power. Some of the wo rk in this vein, like our own, situates itself theoretically within the theory of social repr esentations ( Joffe 1996 ; Jof fe and Bettega 2003 ; Markova and Wilkie 1987 ) Social representations communicate norms and values in symbolic form, reflecting social processes that take place between members of a social unit ( Raudsepp 2005 ) Narratives are intimately involved in the organization of social representations and have been identified as a particularly valuable and underused data source for their study ( Laszlo 1997 ; Murray 2002 ) Distinctive Characteristics of the Data T he research conducted in 2001 3 by Daniel Jordan Smith among young people from s outheast ern Nigeria provides a c ompelling point of comparison for our study In his research Smith used traditional ethnographic methods of participant observation and in depth interviews, supplemented by a quantitative survey. The current study, in contrast, focuses on the post hoc analysis of fictional narratives, collected for another purpose ( a scriptwriting contest), by young people from the same area at roughly the same time. Since 19 97, contests organized roughl y every two years by an HIV communication process called "Scenarios from Africa" (SfA) have invited young Africans to contribute scripts fo r short fiction films about HIV and AIDS ( Global Dialogues 2012 ; Winskell and Enger 2005 ) The winning ideas are selected by a series of juries and, f ollowing adaptation, transformed by Africa 's most prominent directors into films averaging five minutes in length. The films are donated to television stations and broadcast extensively; they are also widely distributed at the community level as educational resources In addition to 37 films currently available in around thirty languages ( Scenarios from Africa 2012 ) the SfA process had by 2011 generated an archive of over 50 ,000 narratives from 47 African nations covering a period of 1 5 years. The narratives analyzed for this article represent a small slice of this a rchive material from Igbo speaking s outheast ern Nigeria While there are notable examples within cultural anthropology of film and media ethnography, narrative ethnography, and research that incorporate literary or textual analysis, all
! of which have points of intersection with our approach t he SfA narratives are d istinctive as a form of data and have particular advantages for understanding how young people make sense of HIV R ich in imagery and emplotment, they reveal the social representations and cultural narratives that undergird this meaning making process They are the product of an activity of enjoyment undertaken at the initiative of the young author and offer a n opportunity to depersonalize s ensitive topics through the creation of fictional characters and situations I n comparison with ethnographic interviews or focus group discussions, the y represent a relatively non directive form of enquiry that enables informant s to shape the agenda Because the narrative s are produced directly by cultural insiders the SfA process allow s young people to situate HIV within their own cultural and moral logic ( Watkins and Swidler 2009 ) without contemporaneous c o con struction with the researcher To this extent, i t is unlike ethnographic data which are often filtered through an anthropologist's perspective and structured by specific research questions. L ike all narratives including those collected ethnographically the se are oriented to an audience. In the case of "entextualized" ( Silverstein and Urban 1996 :1 ) n arratives like these, i.e. ones which are "frozen" and isolated from the local discourse and context, the audience is called on to participate ex post facto in the act of co construct ion For the Scenarios contest, that audience may be presumed to be variously imagined by the young author (e.g. as contest selection committee, implementing organizations, Nigerian public, or African youth). The narratives may thus be informed by performative an d rhetorical considerations specific to the contest, reflecting the young authors' motivation, for example, to tell what they consider to be a good story and thereby win the contest, or to educate their communities about HIV. Although the narratives are explicitly performative, they exploit the tensions implicit in the term. Not only are they creative fictions, involving the construction of a narratorial persona and the persuasive telling of a story they also illuminate the more everyday performance and reproduction of social identities in language, actions, and values F or example, performances of the evangelical Christian or the Igbo adolescent may occur In a review of works by Victor Turner and James Clifford, Dwight Conquergood describes "cultural fa brications" like these as revealing "the possibilities and limits of everyday role playing and invention. They remind us that cultures and persons are more than just created; they are creative. They hold out the promise of reimagi ning and refashioning the world ( Conquergood 1989:83 ) Conquergood also question s, however, how a performance reproduces or challenges ideology and how it is situated "between forces of accommodation and r esistance" (84). These are critical questions for the present study The distinctive performative, rhetorical and persuasive dimensions of the SfA narratives have important applied medical anthropolog ical implications. Unlike a traditional social marketing approach in which audience research allows an externally derived message to be embedded in local idiom, the SfA process offers young people an opportunity to create their own instructive narratives about HIV for widespread dissemination The se narratives allow us to understand how HIV is constructed in the collective lay imagination and to identify communication needs, ranging from the cognitive (i.e. misconceptions and information gaps) to the ideological (i.e. stigmatizing cultural narrativ es that blame specific populations for spreading the disease) T h e narratives also provide a pool of youth focused characters, story lines and creative ideas and perspectives from which communication efforts can draw inspiration In addition, unlike a stereotypical social marketing approach, t he SfA films emerge from a deep rooted social
! process that centers on the narratives Informal analysis of all submitted SfA scripts by local expert judges has for example, been a consistent feature of the SfA pro cess F indings from this community based participatory research process (which also functions as the forum for selecting the ideas that will be turned into films) inform local priority setting and are fed into script adaptation and film production ( Winskell and Enger 2009 ) They also inform t he the matic priorities of the present research Methodology: Scenarios from Africa Analysis of the SfA archive incorporates comparison across African regions ( Winskell et al. 2011a ; Winskell et al. 2011b ; Winskell et al. 2011c ) and will, in the future, allow us to track social representations of HIV over a time period in which the context of the epidemic has changed dramatically. The research described in this article which is specific to s outheast ern Nigeria, is one part of a six country study of young Africans' so cial representations of HIV in 2005 The narratives were submitted to the SfA contest tha t was held continent wide from February 1 to April 15, 2005. In Nigeria, the contest was coordinated by a local Nigerian NGO, Community and Youth Development Initiatives (CYDI) in Imo State, an Igbo speaking region. In a region in which Christianity pervades social life, CYDI is a non religious development orga nization, committed to working with a broad range of partners, including government agencies, schools, private sector companies and faith based organizations, to reach its goal of improving "the health and socio economic welfare of young people and their guardians" ( Community and Youth Development Initiatives 2012 ) Although the 2005 SfA contest encouraged young people to work in teams to create and submit their ideas, over 90 % of N igerian participants chose to work alone. Contest participants were, however, encouraged to talk with organizations and individuals in their community who could provide them with good information about HIV and AIDS The contest was coordinated and publiciz ed b y a group of civil society organizations schools, state government agencies and media outlets, and independent local media. Participating organizations selected and coordinated by CYDI, included support groups for people living with HIV, non religious development organizations, including the Nigerian Red Cross, and faith based organizations from both Christian and Muslim communities Also participating were state and local action committees on AIDS, Ministries of Youth and Education, local sta te run broadcasting companies and schools both with and without overt religious affiliation. A contest leaflet, in English, provided instructions on how to participate in the contest encouraging young people up to the age of 24 to c ome up with a creative idea for a film about AIDS and see your film broadcast on national and international television. Take part in the contest and help other people learn about HIV/AIDS . . 1 The contest leaflet also inc luded a demographic questionna ire that participants submitted with their narratives Of participants in the SfA contest in Nigeria in 2005 ( N = 2,712 ), 95 % were in school, 71 % were female, and 85 % reported having a television at home. As such they were predominantly relatively well to do and literate young people who were motivated enough to participate in a contest. T o maximize representation of participants across demographic strata, we stratified the scenarios by sex, urban versus rural location and age (10 14, 15 19, and 20 24 years ) and then randomly selected up to 10 narratives for each of the 12 resulting strata, netting a
! total sample of 120 narratives. Scenarios were ineligible for inclusion in the study sample if they were team authored. Approximately one third of su bmissions were either non text based (e.g. pictures or video cassettes) or non narrative (e.g. essays). If sampled, these were excluded and replaced A scenario was eligible for inclusion as long as it incorporated a story component I n some cases, this was preceded or followed by commentary from the narrator however th e entire text was included in our analysis; for convenience, we use the term narrative to refer to it. I n light of the size and cultural diversity of the Nigerian population, narratives w ere eliminated if not from the Igbo speaking s outheast from which the overwhelming majority of entries were received The sampled narratives were predominantly handwritten, with a small proportion su bmitted as word processed text. They were transcribed verbatim preserving formatting as well as content, and entered into M AX QDA qualitative data analysis software (VERBI Software 1989 2010) Our analytical approach was situated at the intersection of grounded theory ( Corbin and Strauss 2008 ) and thematic narrative analysis ( Riessman 2008 ) and employed a combination of three types of methodology from which we triangulated the findings. These comprise d (1) thematic data analysis focusing on coding thematic segments and memoing for emerging analytical themes; (2) a narrative based approach, which included the use of keywords to identify central themes and the composition of a one paragraph summary, comprising the key elements of plot and message ; and (3) descriptive statistics for quantifiable characteristics of the narrative s (e.g. whethe r an HIV related death occurs). The approach was developed to enable cross national comparison in our six country studies and had three main advantage s: I t grounded the analysis in three distinct, though intersecting, dimensions of the data ; allowed triangulat ion ; and facilitated the generation and validation of inte rpretive hypotheses. However, it is important to stress that the narratives themselves, in their entirety, were our constant point of reference providing a holistic perspective to counteract any fragmentation and decontextualization of the data resulting from the other analytical components T he narrative summaries in no way replaced the narratives themselves for analy tic purpose, but they did provide an aide memoire which was valuable given the size of the data set Our r esearch team was multidisciplina ry with strengths in cultural context, subject matter and methodology. This study, comprising the secondary analysis of existing data, was approved by the Emory University Institutional Review Board. Comments made by jury members during the contest selection process ( Winskell and Enger 2009 ) provide d community level perspectives and a provisional point of departure for codebook development. 2 Emerging, inductive themes were identified based on recurrence and on similarities and differences noted across the texts ( Ryan and Bernard 2003 ) Codebook development proceeded via an extensive team based process of discussion and consensus building in which provisional codes were applied to the data and iteratively refined ( MacQueen et al. 2008 ) The final codebook included a detai led description of each code, inclusion and exclusion criteria, and examples of the code in use. Themes discussed in this article are those that through their existence or their volume, distinguished the Nigerian narratives from those from other countries in our six country study These are exemplified by intersecting codes such as "morality and blame or praise "only child and "female characterization." T o preserve the richness of th e ethnographic detail provided by the data, we have selected individual narratives
! that illustrate distinctive constellations of themes and examine these in some depth here citing them verbatim and in detail. Contextual Background T he Igbo speaking people of s outheast ern Nigeria were t raditionally organized in patrilineal clans and chiefdoms with an economy based on intensive agriculture ( Green 1941 ; Uchendu 1965 ) In modern history the Biafra war and famine (1967 70) during which several million Igbo died, is related to a pro natalist notion of "wealth in people." Despite the devastation of the war and its aftermath, which has led to a long standing sense of perceived marginalizatio n among the Igbo the economy was able to recover because of o il production in the neighboring Niger Delta and Igbo entrepreneurship. The Igbo were almost entirely Christianized during colonial times. Over recent decades, Pentecostalism has touched all forms of Christian ity in Nigeria ( Anderson 2004 ) and e t hnographic and his torical research strongly suggest s that b orn a gain moral attitudes are pervasive in s outheast ern Nigeria ( Smith 2007 ) However, the influence of evangelical c hurches is increasingly challenged by that of contemporary popular culture T he vibrant Nigerian film industry ("No llywood" ) is highly influential ; Africa's largest, it produces over 1 500 videos per year for th e home video market. The most celebrated Nollywood genre is the melodrama, with its extremes of fortune, emotion, and morality ( Haynes 2000 ) Pentecostal Christian themes notably issues of spiritual warfare and evangelism, have feature d prominently, with videos often framed as confessions or testimonials ; they includ e ample b iblical references ( Fuita and Lumisa 2008 ; Meyer 2006 ; Oha 2000 ; Ukah 2003 ) HIV also appears as a common, if inexplicit, motif ( Oha 2000 ) However, Nollywood is in creasingly moving away from epics about Igbo tradition culture and religion to contemporary love stories that emphasi ze sex and nudity with little or no reference to condoms Meanwhile, access to pornography is growing in line with access to the Internet. In 2010, 5.1 % of the s outheast ern Nigerian population between the ages of 15 and 49 was estimated to be living with HIV, up from 3.7 % in 2008 ( National Agency for the Control of AIDS 2012 ) Young people under the age of 25 are particularly vulnerable to HIV and represent almost half of all new infecti ons. In the 1980s and 19 90s, religious institutions either maintained silence on HIV or issued highly moralistic messaging, stigmatizing those infected and affected. Although efforts were made by NGOs and s chools to counter these messages with factual information it was not until this past decade roughly coinciding with increased access to antiretroviral therapy that denial has been replaced by more vocal and positive messaging from religious institutions. Analysis of Five Narrative Themes It is important to note that HIV infection dominates the plot lines of these narratives, a distinctive feature of the Nigerian sample when compared to SfA narratives from other countries in our six country study ( Winskell et al. 2011b ) and one that reflects the moralizing conservative Christian cultural c ontext. The following sections d escribe narratives selected as exemplary illustrations of or departures from five key cultural themes in the Nigerian data set: (1) tragedy arising from the incompatibility of sex outside marriage and kinship obligations; (2) female vulnerability
! and blame ; (3) peer pressure and moral ambivalence; (4) conservative Christian sexual morality; and (5) social and famil ial consequences of HIV. Some of these themes have been previously identified by medical anthropologists working in the field of the HIV epidemic in Africa ( Nguyen and Peschard 2003 ; Parker 2001 ; Pfeiffer 2004 ; Schoepf 2001 ) T he Tragic Incompatibility of Extramarital Sex and Kinship Obligation A scenario entitled "A Victim of Ignorance" begins: In Igbo land, there is a saying that a hen with one chick is always mindful of it. A woman with only one son is like a hen with one chick. A swoop of the hawk and she becomes empty handed. Sons are the pride of every homestead. They inherit the family lands and other properties. Most especially, they perpetuate the family line. . Did not a proverb say that: he who has kinsmen is greater than he who has money?' In Ibo land, it is a man's wor ld [ rural male, 20 24 ] The narrative that follows these lines, submitted by a 21 year old rural male, concerns the Igwes, an Igbo couple whose prayers and longings are answered with the arrival of a son, a brother to seven older sisters. Onoshi's parents are overzealous in their efforts to pro tect their only son. Their mother forbids him to play football or any other games with his age mates, especially his cousins who might want to harm him with a view to inheriting their lands and h is sisters dote on h im as their future protector. However, Onoshi is a brilliant pupil and wins admission to the Government Model School in the state capital. His father determines that he should go against the protestations of his wife: "Oh o, you want to take my only son t o that wicked city, in the name of educating him, to kill him for me. Then your kinsmen would pressurize you into taking another wife." When Onoshi returns home at the end of the school year, his English is polished and he has "that aura of city boys from upper class homes." As the end of the holiday approaches his mother calls him aside and reminds him of the pastor's warnings of the abominations being perpetrated in the city. She would prefer her son to grow up quickly and take a wife from a good family to fill the homestead with sons : "Those city girls are no good. They could transmit diseases to you, which could render you infertile. Besides, there is this AIDS flying about looking for whom to devour, nowadays." Back at school, the health official also talks about the harmful effects of AIDS, describing it as a destroyer of youthful dreams. Onoshi's narrative self conscious ly situates itself within a traditional Igbo value system but raises themes of modern life that permeate the data set : the vulnerability of women, especially in the absence of male kin; the demonization of city women; the parents' anxiety about peer pressure and libidinal temptations at school ; the preoccupation with reproduction and lineage; and the impending tragedy fo reshadowed in the frail ty of the Igwe's family line and encapsulated in the specter of AIDS However, this narrative is atypical in the way the plot proceeds. A school friend introduces 11 year old Onoshi to his U ncle Olisa a lawyer who ha s just returned from the U nited S tates On the pretext of a business meeting, the uncle takes Onoshi alone to a luxury hotel in the city, plies him with champagne and pornographic movies and rape s him. Onoshi "enjoyed his first sexual experience and the relationship w ith the uncle continues for many
! months. When he falls ill and tests positive for HIV, Onoshi, his doctor and family are perplexed as to how he could have contracted the virus as he had never slept with a woman: No one had mentioned homosexuality. Not eve n his Pastor who preached passionately of eternal damnation awaiting those who commit adultery and fornicators. His parents had repeatedly sounded it to him to avoid girls. His father had even said, Women are burning coals which a man heaps on his head. A few years later, Onoshi dies a victim o f ignorance about homosexuality, as indicated in the title given to the narrative Although this narrative, as one of only three narratives ( N = 120) th at involve homosexual transmission between males and the only narrative involving pedophilia, is an anomaly with the data set, it is paradigmatic of the larger sample in key ways. "A Victim of Ignorance" lead s the reader to expect a more representative story line whereby Onoshi, led astray by bad friends, would be infected with HIV by city women. However, though the details of sexual partners differ, both the anticipated and enacted plot lines demonize lax sexual morality or sexual deviance and focus on a story of infection with tragic consequences. Four fifths of the young Nigerian authors choose to focus on characters becoming infected with HIV and subsequent consequences, with fewer than 1 0 % imagining plot lines in which characters take action to successfully avoid infection. T rag ic outcomes are common: T wo thirds of the narratives end with diagnosis or death without envisaging a fulfilling life as an HIV positive person The narratives by young er authors and those from rural areas are particularly tragic in to ne T he element of tragedy is heightened by a comparatively high proportion (16 % ) of protagonists in the Nigerian narratives who, like Onoshi, are only children or only sons 3 This theme is particularly prominent in stories by female and rural authors. Such protagonists may be conceived after many years of infertility and are the repository of a family and lineage 's hope for the future Like Onoshi's story many narrative s feature young people with brilliant academic achievements the pride and hope of their families and communities. T wo thirds of the narrative s in the sample are about adolescents ; o ne third are explicitly set in a school or university location. For both young men and young women, educational success is revered as a ro ute to social and economic mobility and the fulfillment of kinship obligations : A s one character says, you go to school "so as to be sombody [ sic ] in life" ( urban female, 20 24 ). However the narratives also reflect strong moral ambivalence toward school with education settings presented as simultaneously the ultimate destination for academic achievement and a s typified by Onoshi's mother's premonition, sites of moral dissolution and sexual depravity In another narrative, the university setting is descri bed as a "corrupt and unfriendly environment" (rural male, 20 24) where peer pressure to be "modern" (e.g. sex in exchange for money or consumer goods) is rampant and difficult to resist. Across the narratives parents attempt to warn their children before they leave for school or university, voicing their fear s of bad influence, a blighted future, and social disgrace.
! Female Vulnerability and Blame Two thirds of all narratives center on a female character. In the context of poverty, the social v alue of education conspires to increase the vulnerability of poorer female students. In line with the fears of Onoshi's mother and sisters, narratives describe women as particularly vulnerable in situation s such as the following : when fathers abandon all f emale families in pursuit of a male heir; when fathers die and family assets are taken by relatives ; or when household resources are drained by illness and burial expenses. F emale students are vulnerable because the pressure to pay school fees, buy books, and succeed academically makes them easy prey for unscrupulous older men, including teachers. Yet s o great is the social sanction of education that when one female character from a poor family contracts HIV after engaging in transactional sex "for just one week" to pay her school fees, she feels that God h as let her down ( urban female, 20 24 ). The se tragic narratives focus primarily on the misdeeds of characters that lead to their infection A female character contracts HIV in twice as many narratives (almost 60 % ) as a male character Far from providing an opportunity to sympathize with the vulnerability of women in the face of the AIDS epidemic, the narrative s tend instead to conform to misogynistic stereotypes Females are characterized in line with the age old virgin whore dichotomy, al though with a distinct ive focus on Christian morality and academic achievement : Somewhere in the South East of Nigeria Joy is a believer, a true child of God. She concentrated in her studies and did marvelously well in academics. In the university Christian fellowship she was a prominent. On the other hand Anna belonged to a set cult, had many boyfriend, smoked cigarettes a nd drank alcohol. [ rural female, 20 24 ] Moral failings depicted as leading to a woman becoming infected include disobedience toward parents, partying, and excessive sexual appetite However, the most common is the pursuit of money. BECAUSE OF THE RUSH TO BE IN FASHION AND ENJOY A USELESS LIFE, MANY YOUNG PEOPLE HAVE SOLD THEMSELVES TO THE DEVIL BECAUSE OF MONEY [ sic ]. . Young girls should be called to order. Some of them dress almost naked, especially in higher institutions and walk in such a tantalizing manner as though they are inviting th e opposite sex for whatever. Even some secondary school girls dress immorally with expensive materials. They expose some parts of their body which need to be properly covered and when rapists pounce, they start to complain. [ rural female 10 14 ] Women are r aped in eight of the 120 narratives in the sample and five of these are gang rapes In one case, the young victim who is raped by a teacher, enjoys the experience so much that she become s a prostitute. In four cases (all gang rapes, three authored by females) the woman is blamed for wearing provocative often transparent or very revealing clothing. In one case, the blame of the rapist is mitigated with the comment that the victim "may not know the fire she enkindle wi th those rec kless dressing" ( rural female, 10 14 ). Another closes with the words, "You can see that Jane did not manage her self and she end up been HIV(+)" ( urban male, 15 19 ). In a third narrative the young woman raped at a party pleads for forgiveness from
! her boyfriend "for c heating on him" ( urban female, 10 14 ). These may be extreme cases, primarily by young er female authors but they nonetheless illustrate a deep vein of mi sogyn y evident throughout the s ample reflecting both patriarchal values and t he social anxiety provoked by the threat of rampant female sexuality [h2] Peer Pressure and Moral Ambivalence T he young female protagonists who become infected are above all led astray by bad friends who encourage them to use their sexuality as an economic resource. The descriptions of pe er pressure that permeate the data set provide rich insights into contemporary urban youth culture and pressures to pursue a modern lifestyle. In a narrative by a 20 year old rural woman, Je nnifer is a new university student led astray by a group of worldly wise older students. These women embrace a modern identity with all its trappings and use their sexuality to defy their disempowerment as women from poor backgrounds : QUEEN : Shine your eye and catch one bobo wey [ guy ] go fit take care of you. JENNIFER : But my mum says attending wild parties and havi ng sex before marriage is wrong QUEEN : Babes come and see this girl from the bush. . Baby girl you need to wake up. Can t you see us. We are the hottest babes on campus. SANDRA: We are fashionable, sexy and rich. We are connected we hold the powers that be in our hands. In fact we are the musketeers! (General laughter) [ rural female, 20 24 ] While some narrators express no sympathy for the characters who succumb to such p eer pressure, others seem less sure about whether peer pressure mitigates the blame of infection. This ambivalence suggests that young people are very aware of their vulnerability to the temptations of modernity when they step beyond the protective but also constraining circle of kin and home community The narratives acknowledgement of structural factors influencing women's vulnerability is generally overshadowed by vociferous moralizing and heavy handed cautionary tales. One illustrative narrative by a teenage rural male opens with a dictionary definition of morality : A function of human beings and not animals. It deals with those basic values that give people security and dignity and guarantees stability and posterity of the society . ( rural male 15 19) The narrator then states that sex for purposes other than procreation within marriage falls foul of this standard and present s a scenario to illustrate this. Lydia and Mary are friends at the university. Lydia does not believe in HIV and thinks that adults and health workers "want to discourage [them] from this pleasurable adventure." Against Mary's advice that she abstain, Lydia decides to spend a week with her boyfriend. One month later a counselor bluntly informs her she is both pregnant and HIV p ositive. Lydia's remorse is met by the narrator with dispassion: This repentance is late because Lydia is now on the danger list. She enlisted herself. Despite the unrelenting blame of its to ne and outcome, the narrative proceeds to advocate a range of pragmatic strategies for HIV prevention that ally it more with a public health value system than religious ideology. For example it suggests adequate sex education for young pe ople to help them avoid HIV It also provide s "moral advice on elimination of HIV/AIDS for young girls," a list of situation defined strategies that young women should use to protect themselves in face of gendered structural constraints. These include
! 2. Keep to an honest living with what you can afford. 3. Do not go looking for favours, accepting gifts from men some of these men may compel you to pay back with your body and that is through sexual intercourse. 4. Avoid the habit of asking lift from men. They w ill carry you to where you will carry them. [emphasis added] 5. Th e narrative illustrate s two contradictory cultural discourses that young people must navigate in their attempts to make sense of the epidemic a moral message of obdurate blame and a more nuanced recognition of structural factors that create gendered vulnerability to infection. The tension between these discourses m ay lead to blunt contra diction or uneasy ambivalence. Conservative Christian M orality In line with the definiti on of morality proffered above, narrative s present sex drive as uncontrollable and even bestial once unleashed. For example, o ne male character describes a friend's sex addiction in the following graphic terms : F or him to leave it will be like driving the dog away from the excreta" ( rural male, 20 24 ) In other cases, for a woman to surrender to her sexual desires is explicitly regarded as a masculine act. Female characters who are unable to control their sexual appetite are described by male authors in a way suggesting an uneasy combination of wishful thinking and moral outrage. T he viability of sexual abstinence until marriage is undermined by individual characters' inability to resist libidinal urges Alongside repeated assertions of the importance of a bstinence are representations of the illusoriness of romantic relationships that do not involve sex which are beleaguered by peer pressure or desire. Plot lines describ e abstemious romantic relationships destined for marriage that are derailed by infidelity and align with a pronounced proclivity toward imaginative melodrama in the stories, reminiscent of Nollywood productions. One male character, for example, returns from a study trip in the United States to find pornographic picture of his betroth ed, with whom he had had a chaste relationship for the previous five years, exhibited in a luxury hotel. Moralizing language drawn from the least forgiving Christian traditions is pervasive Terms like "sexual immoralities," "sin ," "the work of Satan," and "fornication" recur. One female author addresses her readers directly with the impassioned (and capitalized) entreaty: "MY FELLOW YOUTHS OF NIGERIA, AVOID AIDS NOW BECAUSE AIDS IS . THE DEVIL'S WEAPON OF MASS DESTRUCTION" ( rural female 15 19 ). The re are repeated references to the body as the temple of God and the need to maintain its purity. AIDS is reported to have originated as a result of bestiality or homosexuality and is pervasively represented as a punishment for immoral behavior F rank public healt h discourse around sexuality legitimized by HIV is combined with Pentecostalist moral ideology and religious symbolism such that a mother does not flinch at instructing her school age daughter to "avoid lewd sex practices such as anal or ora l sex" ( urban female 10 14 ) However, in this evangelical reinterpretation of HIV serious misconceptions are given moral sanction: unprotected sex with an infected character inevitably leads to infection; kissing is described as a means of transmission; disease timelines are truncated so that characters die on diagnosis; there are two cases of lesbian infection
! Similarly, condoms are conspicuously absent from any mention i n three quarters of the sample. Of over 20 individual acts of sex described in the narratives, only three involve condom use ; in each case the condom fails and the male character is infected ( Winskell et al. 2011c ) Malicious intentional infection occurs in about 10% of the Nigerian sample 4 Characters deliberately infect others or plan to do so in a spirit of revenge, on the pretext that "after all someone gave it to me or in order not to die alone In one case, a female university student decides to give her professor his just rewards for pressuring students to sleep with him in exchange for good grades and leaves him a note, "You gave me 89 percent and I gave you a share of my HIV/AIDS ( urban male 20 24 ). M oral behavior ( combined with premarital testing ) is depicted as the way to avo id the terrible fate of HIV Moral behavior may be depicted as a duty toward family and community ; it is religiously ordained, socially rewarded, and related to "being true to oneself." In parallel, i mmorality is a transgression against God, community, family, and self. For example, one narrative by a 16 year old rural male contrasts the fruits of a moral life with the consequences of promiscuity and premarital excesses In the story Angela pressures her "God fearing and intelligent" boyfriend Peter to have sex with her When he refuses, she leaves him in search of "a real partner who will take good care of her ." Two years later she is a sex maniac (one who wants having sex all the time) and she is also a prostitute and she became a school dropout." M eanwhile the abstinent Peter is rewarded with a "very fine job after graduation and is transferred to London with his beautiful wife and their five children (3 boys and 2 girls) ( rural male 15 19 ) in a conclusion redolent of Pentecostalism's Prosperit y G ospel. Although it is more commo n for female characters to succumb to peer pressure there are notable examples of peer pressure influencing the behavior of male characters T hese cases are particularly in teresting because they emphasize how two contrasting cultural understandings of modernity and masculinity are pitted against each other O n one hand, there is the theme of sexual appetite, modern hedonism and the double standard of male priv il ege in a patriarchal society. O n the other hand there is moral willpower and the ability to postpone gratification in the interests of longer term goals that implicitly or explicitly fulfill responsibilities toward kin It is important to reiterate the absence of successful condom use in any individual acts of sex described in the sample because c ondoms could theoreticall y provide a solution to the competing demands of satisfying sexual pleasure, peer pressure and responsibilities to family and kin. The Social and Family Consequences of H IV While t he tragic outcome serves as a v ehicle for presenting a message of conservative Christian sexual morality in the majority of narratives, in other cases, the message is more nuanced. With infection dominating the plot lines of the narratives t he tragic c onsequences of HIV are highlighted by emphasis on the social and financial impact of infection on the family For example, one narrative begins with the statement : All of us are aware of the social stigma, shame, embarra s sment ridicule and disgrace et c that a fa mily faces when someone fr om that family dies of HIV/AIDS" ( rural male 15 19) Other narrative s focus on familial consequences of i nfection such as parents drop ping dead or hang ing themselves in response to a child's diagnosis with HIV weddings being cancelled or families losing business or employment because of d iscrimination Yet if parents are to be pitied because of the shame of their child's behavior and infection, they are also repres ented as bear ing their share of the blame. One
! narrative by a young rural male describes in secular terms the consequences of irresponsible parenting and the ill effects of modernity An overtly religious framework is thus not a precondition for authors attributing the epidemic to moral decay, fuelled in particular by the pursuit of money. Alluding to Chinua Achebe's ( 1994  ) classic novel about the collision between traditional Igbo society and British colonialism, one narrator blames the epidemic on a loss of African culture and concomitant growth in materialism. B efore or when things have not fallen apart, when the center still hold. that is the time in africa, when african people abide b y their culture and tradition. when sex is for purpose, the purpose is for procreatio n and is only for the married . if things happen to be like that today, the issue of HIV/aids woun't have been for us (africans). the madness of people about wealth and materials things have create dictum called poverty. this dictum (poverty) have made some people think that they are superior by rich wh ile others believe think that they are in f erior by been poor. oh! what a psych. [ rural male 10 14 ] The narrator then tells how the myth of poverty led a brother and sister into "harlotry Worried about their family's poor background, the siblings decide to drop out of school and migrate to the city to comply with their parents' materialistic expectations. Here, they are infected through homos exual and heterosexual transactional sex in efforts to support their family. In this story, however, despite the mo de of transmission, blame is attributed to the fiction of poverty, introduced by the f all from g race" of colonization, and not to the young protagonists Across the narratives it appears that the o lder the author, the more nuanced the moral message. I n the context of an epidemic of indiscriminate infection t he question W ho's to blame ? recurs as a theme One storyline features a man, infected via blood transfusion, who is now a widower and deserted by friends O n his deathbed he wonders who will ta ke care of his two children. The narrative closes: "NOTE: HIV/AIDS is not a spiritual problem neither does it have a con s cience ( urban male 15 19). A nother narrative about a young woman who has been orphaned and who is infected then abandoned by her womanizing partne r ends: Some say she should not have been born, others say she suffered for what she did in her first life. May she is carefree or it is God ordained she suffer that much. Wha t do you think? ( rural female, 20 24 ) Soul searching of this kind contextualizes the recourse to religio us and moral certainties that are so prominent in other narratives in the data set Soul searching also underscores the seductiveness of culturally established explanatory frameworks in the quest to make sense of HIV Comparing Narrative Analysis and Ethnographic Findings Daniel Jordan Smith's work is particularly valuable as a point of reference for our study because of its focus on the sy mbolic frameworks within which young people make sexual decisions. Multiple themes outlined in the analysis of the SfA narratives in this article closely echo Smith's ethnographic finding s However, there are also subtle differences The ethnographic findings for our comparison focus on the question of why many young Igbo migrants perceive themselves to be at very low risk of contracting HIV Smith attributes this to the confluence of religion, morality, and stigma in understa ndings of sexuality and HIV
! He describes how many young Igb o draw on an increasingly pervasive born again Christian perspective to construct sexuality and the risk of AIDS in strict ethical and moral terms. This allows them to project immorality and danger onto imaginary "others His study highlights the limitations of public health intervention strategies which fail to deal with the dangers inherent in the moralization of risk that fuels both stigma and the deflection of personal risk Smith has written extensively about the Igbos' moral preoccupation wi th biological and social reproduction in the context of appropriate marriage His work emphasizes the moral and practical importance of kinship networks or "having people" to ensure access to modern opportunities and resources He provides cultural historical context to this strong moral precept by linking it to the marginalization of the Igbo people in the wake of the Biafra war ( Smith 2005 ) In addition, Smith's ethnographic findings delineate the tensions between kinship an d modernity These tensions are expressed in romantic and sexual relationships, on one hand, and collective family and community interests on the other Moral discourse about female sexuality, in which girls are represented as "out of control" and female sexuality is feared, are linked by Smith to wider discontents with the consequences of social change, as society confronts an extended period of female sexual maturity before marriage. Schools, the central symbol of modernity in Nigerian society, are also perceived as places of moral decay above all as the locus of sexual corruption, with education contributing to the loosening of the grip of parental, fa mily and community authority ( Smith 2001 ) The focus of Smith's 2001 0 3 study is "understanding the social processes whereby HIV risk is equated with religious immorality" ( Smith 2004b : 426 ) In this study, h e devotes less attention to question s of gender and agency, which emerged as key themes in the current analys i s of SfA scenarios Social representations of AIDS, such as those in the narratives above have been interpreted as serving an "identity protective" or "system justifying" function ( Joffe and Bettega 2003 ; Moscovici 2001 ) In their analysis of social representations of HIV among Zambian youth, Joffe and Bettega (2003) note that both male and female respondents blamed young women for infect ion, whereas their older sugar daddies were seemingly absolved from guilt ; this representation allow s gendered power relations to remain un challenged. There is a similar mechanism at play in the data from this study On one hand, young female authors tend to blame the young female protagonists for immoral behavio r s that result in HIV infection. On the other hand, the older men who are their sex partners are poorly delineated in the stories. Parker and Aggleton argue: Those who are stigmatized and disc riminated against in society so often accept and even internalize the stigma that they are subjected to . because they are subjected to an overwhelmingly powerful symbolic apparatus whose function is to legitimize inequalities of power based upon diffe rential understandings of value and worth [ 2003:18 ] The SfA narratives provide a n opportunity to observe young female authors playing an active role reproduc ing the very social representations and discourses that disempower them. Within the data set t h is victim blaming pattern diminishes with the age of the authors sug ge st ing the progressive development of a more critical stance toward gender ideology. Smith's 2001 0 3 study suggest s that for many young Nigerians risky sexual behavior was related to the failure to personalize the risk of AIDS that was project ed onto immoral others. In this study the deflection of HIV risk onto immoral others is certainly explicit What is
! interesting, however, is that the conspicuous gender disequilibrium aside t he vast majority of young authors choose to focus on characters who could be their peers, often young people from middle class families facing real temptations of life at school and university. Thus, those who are demonized are less the easy target of commercial sex workers than young women from good homes who, on an informal basis, use their sexuality for material gain Although many of the SfA narratives subscribe to a strategy of "othering" AIDS, depicting the bad or fool hardy becoming infected, some authors make a clear and concerted effort to identify with their protagonists and vicariously experience their vulnerabilities. Th is empathetic act may, however, be an artifact of the narrative writing process, pointing less to an attitudinal perspective on the part of young people than to the potential of the narrative writing process by eliciting identification to provide a valuable vehicle for counteracting stigma Smith's methodology combining surveys, interviews and participant observation allowed him to address individual risk assessment and behavior linking reported sexual decision making with broader social values. In contrast, the d ata reported here focus on the cultural resources including normative beliefs and cultural scripts available to young people as the y seek to make sense of HIV In this cultural context t he narrative writing process often elicit s narrative s framed in terms of moral absolutes that may not reflect the ambiguities and contradictions of young people's actual practices or do so only in the form of an ambivalent subtext Conclusions: Fictional Narratives, Cultural Meanings, and Methodologies The social representations in young people's HIV related fictional narratives reveal cultural resources available to them as they seek to make sense of the epidemic and of what they see and experience in their own communities The SfA narratives from s outheast ern Nigeria situate HIV within the competing pressures on young people to pursue a modern lifestyle, on one hand, and to fulfill kin expectations of academic, financial, marital and reproductive success on the other. The narratives are characterized by tragic outcomes, a focus on female protagonists, and an unforgiving moral agenda in which Christian dogma on sexuality is intertwined with kinship obligations. When HIV infection occurs there are multiple tragic consequences for the young primarily female characters who are blam ed for their fate With few exceptions, the se narratives fail in Conquergood's (1989) words, to reimagine and refashion the world and situate themselves within forces of accommodation, not resistance. T he young authors tend to echo traditional Christian and Igbo value systems a nd to situate these within tragic and melodramatic cultural frames that are reminiscent of Nollywood films. P ublic health discourse on HIV is much less pervasive in the narratives This suggests that public hea lth messages around HIV are not being communicated in such a way that they are readily incorporated into youth meaning making. It also points to the mismatch between the cultural frames within which HIV is being interpreted by young people and those of pub lic health messaging. Public health perspectives on HIV are incompatible with Nollywood frames, whereas Pentecostal and Igbo cultural themes lend themselves to melodrama and stigmatizing and moralizing representation s. This points to the need for greater c ollaboration among the various social institutions that influence young people's sense making around HIV It also suggests the potential value of narrative based community activities, drawing on the legacy of Paulo Freire
! (1970) to deconstruct the web of representations that sustains the devaluation of women and of people infected with HIV and to increase acknowledgment of the structural factors that constrain the exercise of the absolutist b orn a gain moral individualism that is so prevalent in the narratives. Lack of progress in addressing the symbolic representations that perpetuate stigma moralization and gender inequity will continue to compromise both the quality of life of affected populations and access to HIV prevention treatment and related services The absence of condoms in the narratives reflects a missed opportunity to reconcile short term desires and pressures with long term responsibilities. The 2003 Demographic and Health Survey from s outheast ern Nigeria ( National Population Commission [Nigeria] and ORC Macro 2004 ) revealed extremely low condom use by young people and very low adult support for youth edu cation on condom use. If young people are unable to envisage or feel unable to publicly represent condoms as a viable prevention option and to integrate them into th eir sense making around HIV they are hardly likely to use them. The normalization of condo ms and their recognition as a viable and valuable HIV prevention tool must remain a high priority for health communication efforts in s outheast ern Nigeria ( Winskell et al. 2011c ) The data described here ha ve some clear advantages for programmatic practice and further research. The narratives communicate needs and provide youth focused ideas perspectives and contextual understanding that can inform the development of both mass media and community based communication efforts. The method ology is consistent across multiple sites across Africa allowing for systematic cross cultural and longitudinal comparison of a large number of nar ratives The concurrence of the SfA narrative analysis for s outheast ern Nigeria with Smith's ethn ographic result s should be considered evidence of the feasibility and val idity of this research method. The analysis of f ictional narratives can be a powerful methodological tool in medical anthropology [h1] Notes Acknowledgments The research described here was supported by Grant 1R03 HD054323 01 A1 from the National Institute of Child Health and Human Development. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute of Child Health and Human Development. This research was also supported in part by the Emory Center for AIDS Research (P30 AI050409) and by Emory Global Health Institute. We are grateful to research assistants Chris Barnett, Laura Beres, Liz Coleclough, Wendee Gardner, Rosalie Haughton, Samantha Huffman, Elizabeth Neri, Caddie Putnam Rankin and Kanaka Sathasivan. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 1 The contest leaflet stated: You are invited to come up with an original idea (a scenario ) for a short film up to 5 minutes in length. The best ideas will be adapted by professionals and turned into films by some of Africa s greatest directors. It s up to you to decide what form your idea will take. It can be a short story, a comic strip, a song . . You can even record your idea on an audio cassette, complete with music, if you would like! Anything is possible as long as the text is in English. It s also up to you to decide if your scenario will be serious, sad, full of hope or funny! As you create your scenario, please talk to organisations or individuals in your community who can provide you with good information on AIDS.
! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!! The contest leaflet provided a series of "story starters" but also gave participants the option to write on any topic of their choi ce; all narratives in this study belonged to this latter category, which accounted for 60% of all submissions. 2 Jury composition reflects a range of perspecti ves: people living with HIV and other specialists in HIV prevention, treatment and care; young people, including former contest winners; and communication specialists. 3 The theme is virtually absent from narratives from other countries in our six country study. 4 This is very high in comparison to all other country samples in our six country study with the exception of Senegal (Winskell et al. 2011b). References Cited Achebe, C hinua 1994 Things Fall Apart. New York: Anchor. Anderson, A 2004 An Introduction to Pentecostalism: Global Charismatic Christianity. Cambridge: Cambridge University Press. Biehl, Jo o 2007 Will to Live: AIDS Therapies and the Politics of S urvival. Princeton: Princeton University Press. Bruner, J. 1990 Acts of Meaning. Cambridge: Harvard University Press. Bruner, J., and J. Luci arello 1989 Monologues as Narrative Recreations of the W orld. In Narratives from the C rib. K. Nelson, ed. Pp. 234 308. Cambridge: Harvard University Press. Community and Youth Development Initiatives 2012 Community and Youth Development Initiatives www.cydi.org accessed September 17, 2012 Conquergood, Dwight 1989 Poetics, Play, Process, and Power: The Peformative Turn in Anthropology. Text and Performance Quarterly 1:82 95. Corbin, J. and A. Strauss 2008 Bas ics of Qualitative Research: Techniques and Procedures for D eveloping Grounded T heory. Thousand Oaks, C A : Sage. Farmer, P aul 1994 AIDS Talk and the Constitution of Cultural Models. Social Science and Medicine 38(6):801 809. Farmer, Paul, and Byron J. Good 1991 Illness Representations in Medical Anthropology: A Critical Review and a Case Study of the Representation of AIDS in Haiti. In Mental Representations in Health and Illness. J. A. Skelton and R. T. Croyle, eds. Pp. 132 162. New York : Springer.
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