In Nicola Bulled’s new book, Prescribing HIV Prevention, she challenges a basic assumption of public health research—that knowledge impacts behavior. Bulled uses both qualitative and quantitative methods to examine the impact that multiple competing sources of information about HIV prevention has on Basotho people’s knowledge about HIV, their sense of risk, and their sexual relationships. As her sample, Bulled selected a group of teachers-in-training—primarily young men and women—in both urban and rural areas of the small mountainous kingdom of Lesotho, a small country completely surrounded by South Africa.
While most Basotho people know something about HIV, they have difficulty both teasing out the validity of information and acting on information even if they perceive it to be true or important. A less rigorous study might find that young people in Lesotho know quite a lot about HIV/AIDS. But by tracing the ways in which biomedical knowledge is produced (by experts), disseminated (by well-informed citizens), and acquired (by the man-on-the-street), Bulled’s study shows how the top-down flow of information is insufficient to make any real dent in improving HIV-prevention strategies. Perhaps this is why, several decades into the AIDS pandemic in southern Africa and despite great improvements in access to antiretroviral drugs, prevalence rates and new infection rates remain high.
In the preface of her book, Nicola Bulled powerfully situates herself as growing up white in South Africa, and coming to terms with her own place in an unequal system of poverty and risk. It is this same unequal system that allowed Bulled to move to America for her education and return to southern Africa as a public health worker and then a researcher. And it is the unequal structures produced by this system that have historically shaped health communication, privileging the voices of those in power, diminishing the voices of the subaltern, and putting the onus on individuals to change their behavior with very little regard for the impediments that make seemingly rational health choices difficult for marginalized people like Basotho to act on.
Contemporary health communication strategies demand that rational actors (patients) change their behaviors through acquiring new knowledge (from experts). However, as Bulled demonstrates throughout this book, the assumptions underlying this approach to health communication completely mask the social and political origins of disease and also act as a smoke screen that draws attention away from states’ failure to address the structural inequalities that lead to health inequalities in the first place. These narratives focusing on individual behavior are put forth by government agencies, NGOs, churches, and the like (basically, all the places where health interventions and services take place, at least in an African context), with very little concern for “the complex relationship among knowledge, morality and health” (p. 28). Thus, Bulled poses the essential question: Why have health communication efforts failed? In particular, why and how have they failed to address the HIV/AIDS epidemic in Lesotho and elsewhere in southern Africa? The answer, it seems, lies in the failure not only to address culture but to address culture appropriately, from a “culture-centered” approach.
Early in the book, Bulled does the tedious but necessary work of establishing the detailed progress of HIV in Lesotho and the response to it by the government and the global health community. She provides a comprehensive account of who is at risk and how that risk is measured. Most importantly, she considers what an overreliance on statistics does to obscure both the local lives of people who make up those numbers, as well as the science that dictates how these data should be acted on. Bulled is not the first to note the “complexity of factors that mediate the structure of risk in each distinct population group” (p. 63). Yet, as Bulled reminds us, global responses to health problems still fail to account for these nuanced differences.
In an increasingly important trend in anthropology, Bulled employs mixed methods to collect data for her study, including a survey of nearly 500 students to assess levels of student knowledge about HIV/AIDS, a cluster analysis to examine a self-generated question exercise about gaps in students’ biomedical knowledge, and extensive ethnographic fieldwork. Instead of starting with the assumption, as many studies of health communication do, that knowledge is being disseminated—in schools, churches, health facilities, through social networks, and from various media sources—Bulled examines what is being taught, how the messages are received, what training those disseminating these messages have had, the accuracy of the information being presented, and the perceived authority of the messenger.
It is no surprise, then, that multiple conflicting sources of information are confusing Basotho youth as to the best way to prevent HIV. This confusion is particularly alarming given the emphasis on individual responsibility for one’s health and the health of others—whether from religious leaders pushing premarital abstinence or from health care providers encouraging responsible health behaviors. Young people in Lesotho are not only responsible for acting rationally on acquired knowledge but must seek out that knowledge themselves, then sort out the “good” information from the “bad.” In drawing attention to the ways in which knowledge production and dissemination are problematic, Bulled calls on those who control biomedical knowledge to ensure that marginalized voices become more “purposely involved” (p. 173) in shaping not only the content of such information but also its structure and flow.
Culture, Bulled argues, cannot be ignored when considering how to effectively communicate health prevention messages to diverse populations. Yet this book shows how global health campaigns’ typical modes of knowledge production and dissemination do not lead to the culture-centered strategies that are critical to effective health communication. Instead, top-down strategies employed in global health communication circulate knowledge based on Western logics, resulting in a series of moralizing and value-laden binaries: global/local, urban/rural, and modern/traditional. These binaries lead to a series of assumptions that impact Basotho youth: for example, that biomedical knowledge can easily replace misconceptions about HIV and that rural people are more likely to hold such misconceptions because they can’t escape their cultural milieu. Such assumptions impede meaningful change when it comes to successful HIV-prevention strategies. A truly culture-centered approach would necessitate real and honest reflexivity on the part of all those at the top of the communication food chain to consider how the voices of marginalized individuals are suppressed and ignored in the production and dissemination of health information.
While in the first half of the book ethnography takes a back seat to the important and painstaking work of tracing the sources of knowledge top-down from global health institutions to the average lay person, the book comes alive in the second half as Bulled demonstrates with increasing poignancy how global health knowledge—and the communication strategies that stem from it—addresses population-level risks while failing to meet the needs of actual people. This book is a crucial read for graduate and upper-level undergraduate students interested in global health. Although essential for students and scholars of anthropology, it would likely be most transformative for those in other fields who are less familiar with ethnographic research and less attuned to the pitfalls of relying too heavily on data alone and not enough on the everyday experiences of people. It is well worth the read for anyone interested in why health communication strategies fail, and is a valuable contribution both for those familiar with HIV and those who are not.