There’s a stupid anecdote about condoms that I have been hearing since the 1980s, and that I most recently heard last week. It is normally told at expat dinner parties, or by someone who has never been near a health promotion programme. If you are lucky you might find it on a comment thread below an article on overseas aid. It goes something like this:
I heard about an AIDS prevention/family planning programme that showed some Africans how to use condoms to prevent HIV/pregnancy by putting them on bananas/broom handles, and that when they went back to evaluate everyone was still getting HIV/pregnant but they found that all the bananas/broom handles had condoms on them.
I’m sure you’ve heard it too. The way it is normally told, it is very much about making the [presumably] illiterate villagers seem at best stupid and at worst beyond hope. The undertone often being that aid doesn’t work (even though you don’t need an aid programme to give out condoms), that Africa is a basket case…
Either way, apart from being racist, the story is bullshit. Firstly, as anyone who actually does health promotion knows, it’s actually quite hard to persuade people to do anything just by saying “do this”. Secondly, this is even more true when you are asking people to do something as weird as putting a condom on a broom handle (or a penis for that matter). Thirdly, and here’s where the monitoring and evaluation geekiness comes into it’s own, changes in outcomes like HIV infection simply can’t be observed that easily. So there.
But can the anecdote teach us anything about health promotion? Well, if anything like this ever has happened, it says much more about the people delivering the programme than about the beneficiaries. Unfortunately a lot of health promotion does take shortcuts: explaining the mechanics of conception or viral transmission to people with hardly any education is daunting. Perhaps in a programme like this one, beneficiaries weren’t told about sperm or penises but rather, the programme emphasised the importance of phallic objects being covered by latex. Sex can be hard to talk about openly too: but too many awkward euphemisms, not enough straightforward discussion, also help make discussions pretty ineffectual.
Lots of poor health promotion work operates like this – “nudging”, taking the path of least resistance, and not paying much attention to the people concerned – and in the long run it tends not to be helpful because it often deals with just one part of a much more complex set of determinants influencing the health problem in question. This article on sanitation in the Guardian, (which I also talked about in my last blog post) illustrates the problem well: “Several [people] described toilets as dirtier than the fields. The vast majority of facilities did not have soap for hand washing, which meant the expected health gains were lost… This lack of knowledge testifies to the failure of the education programme that makes up a critical component of the campaign. Most people did not realise that microscopic pathogens cause disease”.
Similarly, if you want to have an impact on HIV, you need to do more than increase condom use: in particular you also need to deal with reproductive health, STIs, gender norms, discrimination, and violence. Presumably the only pretend objective in the pretend programme described by the broom handle anecdote was to increase condom use. I’m also guessing that this pretend programme just involved people popping into the village, telling people to use condoms, and then leaving, rather than working in an ongoing way to improve the health and education system, and supporting individuals to figure out what was best for each of them.
Inasmuch as the anecdote allows us to imagine what might lead to such a poor outcome in health promotion, it may be a parable of sorts. But I don’t think it’s a particularly good one, because I think there are enough real examples of bad practice to be getting on with and more importantly, because I think it is malicious. I’m fed up of hearing it.
After this was posted, @DrPetra on twitter pointed out that this tale is a bit reminiscent of the constant undermining of sex education in the UK, a recent example being claims that 7 year olds are being taught how to put condoms on bananas… this claim seems unlikely, but even if it is true it is incredibly uncommon and not something most people involved in sex education would endorse. It’s easy to use individual horror stories to undermine a whole principle, but it is incredibly disingenuous.