Mali

1.  General and Epidemiological Data

1.1.    General Data

Located in the heart of West Africa of which it is the largest country, Mali covers an area of 1,240,000 km². Its population is estimated today at over 10,000,000 inhabitants. There are 51% women and 49% men. Seventy five (75%) per cent of this population live in the rural areas. Mali shares its borders with seven countries including the Ivory Coast and Burkina-Faso, where the HIV/AIDS prevalence rate is very high. Mali is divided into eight administrative regions outside Bamako the capital.

Agriculture, livestock and fishery are the basis of Mali's economic development. Unfortunately, the country has experienced periodic cycles of drought which have had a negative impact on the economy and which also encourage immigration: aCCording to the statistics, 3,000,000 Malians are said to be residing abroad particularly in the neighbouring countries. The economic crises has undermined traditional values and morals do not resist the negative effects of globalisation.

Mali is also one of those African countries which has a relatively low education rate: the official figures indicate that only 30% of men and 17% of women could aCCede to primary education.

With regard to religion Muslims are largely in the majority, the country is however a secular State. Christians of all denominations aCCount for less than 5%.

1.2.    Epidemiological Data

A national survey conducted in 1992-93 covering 5,326 subjects from 7 regions of the country showed a gross sero-prevalence of roughly 3%. Sero-prevalence was, on the whole, the same in all the regions studied (both rural and urban). Two exceptions were however noted: a 2% prevalence in the Northern region (Gao and Timbuctoo) and 5.2% sero-prevalence in the Sikasso region located at the crossroads of the highway leading to the Ivory Coast. Sero-prevalence among a group of 178 prostitutes was 52%.

Today, the new survey shows that sero-prevalence varied significantly aCCording to the regions and the populations studied. When the new figures are reconciled with those of the 1992-1993 years, prevalence in the general population could, on the whole, be estimated at between 3-4%. The number of persons infected with HIV/AIDS is said to be 135,000. However, considering the figure of 130,000 reported by UNAIDS two years earlier, it could be deduced that the current estimates are well below the reality.

There is a wide disparity between the regions and in general, a lack of information on the behaviour and the characteristics of the population studied; nor is there any data on the rural areas which represent 75% of the population. Information on mother-child transmission and infant AIDS cases is also lacking.

The factors of HIV/AIDS propagation are linked to the greater mobility of the population, namely internal and international migration and the resultant prostitution. There has also been a gradual relaxation of social control caused by the disintegration of family supervision, early extramarital sexual relations or sexual relations in early marriages. The rapid propagation of HIV/AIDS is also explained by the fact that persons living with HIV transmit it inadvertently to others, due to lack of information on their serological status. Most of the health personnel, including doctors, are not prepared to disclose the results of the test, if positive.

The population segment considered as particularly vulnerable are: migrants, drivers and their apprentices, hawkers, the military, prostitutes, youth within and outside school, women of child-bearing age, and prison inmates. The vulnerability factors identified are mobility (internal and international migrations) precarious economic conditions, prostitution network and the weak ethical and legal framework.

2.  National AIDS Control Policy

2.1.    Background to AIDS Control in Mali

It was in 1985 that the first AIDS case was diagnosed. The Government has, since then, embarked on the struggle against AIDS and entrusted responsibility for it to the Ministry of Health, the Aged and Solidarity. The latter established the National HIV/AIDS Control Programme (NACP) with other supervisory and monitoring structures.

2.2.    Strategy Thrusts of the HIV/AIDS Infection Control Policy

The action of the government through the NACP falls in line with the overall health policy determined in 1990 and called PRODESS - programme de dévelopement sanitare et sociale (Health and Social Development Programme). The objective of PRODESS is to expand health cover and improve the utilisation of services by users at all the levels of the health system.

With regard to AIDS control, considered as a national priority, the objectives of PRODESS are:

• Reducing from 3% to 2% the HIV sero-prevalence among the general population
• Reducing by 50% the STD (sexually transmissible diseases) incidence rate

The strategies adopted and implemented by the NACP are as follows:

· Prevention of transmission by sexual means through an intensification and adaptation of IEC activities (Information, Education, Communication) in favour of the vulnerable groups, particularly migrants and medium and high risk groups. This is reflected in the use of the media, films, pamphlets and through the organisation of cultural and sporting events

· Prevention of transmission through blood by ensuring the safety of transfusions and activities in the health establishments and protection measures of health professionals

· Prevention of mother-child transmission, the systematic use of the anti-retroviral therapy such as AZT and nevirapine in pregnant HIV positive women

· Care of PLWAs

· Increased vigilance on STDs during medical consultations at all levels

· Implementation of this programme is done through local AIDS control committees in the various regions of Mali and aims at providing as much information as possible on AIDS in order to ensure its prevention

The current targets of the NACP are school children, migrants and transport operators. A new strategic plan was drawn up for the 2000-2004 period and is urgently awaiting adoption by the Ministry of Health. Its general objectives are always to reduce HIV prevalence by 1% and reduce the impact of the epidemic on the persons infected and affected, on the communities and on the economy of the country. Its priorities which are the extension, reinforcement and improvement of the past actions cover the following fields:

· Information, Education and Communication (IEC) directed to the general population

· The promotion of the use of condoms through social marketing

· Primary prevention of STD, at the same time as HIV/AIDS prevention. The main strategies remain the prevention of transmission, improvement of the well-being of infected persons, alleviation of the impact of the most affected sector such as that of health and a number of particularly vulnerable enterprises

2.3.    Stakeholders Involved in AIDS Control

In its struggle against AIDS, the Malian government has received multiple forms of assistance and support from United Nations agencies, international organisations, international and national NGOs. UNAIDS plays an important role through resource mobilisation in favour of the national and technical support programme. It ensures coordination between the UN Agencies (UNFPA, WHO and UNICEF) and strives to develop a common vision at the level of all the other German, Dutch, Swiss, French and Canadian partners. The new 2000-2004 strategic plan under which the private sector should also be involved, is the result of this collaboration and common vision.

International NGOs such as Plan International work not only with the government but also support the national NGOs through the subsidies granted to their projects.

Through its objectives, the NACP is expected to work with the stakeholders of civil society, however, collaboration with the religious world is still at the embryonic stage.

3.  Position and Involvement of the Churches

3.1 Perception of the Churches and Religious Communities

We were able to meet religious officials or heads of the Department of Health of the Catholic Church, the association of the grouping of Protestant and evangelical Churches and missions of Mali, the Adventist Church, and the Muslim community.

In the view of the various parties involved, the HIV/AIDS epidemic is a scourge which is negating the efforts of Mali in addressing the economic crisis into which it has been plunged for many years. Worst of all, the churches are increasingly dealing with crises within the families affected by HIV/AIDS. The Muslim community is seeing the number of its widowers, widows and orphans increase daily because a number of cultural and religious practices related to Islam - such as polygamy, sexual mutilations, Levirat - are factors of propagation of the disease.

However, aCCording to religious officials, the crux of the problem is poverty, unemployment and misery, which in view of the permeability of the country's borders, causes a very large migratory flow especially towards the Ivory Coast and Burkina-Faso where the sero-prevalence rate is very high. It should be pointed out that over three million Malians are today living outside the country.

Apart from economic difficulties, the propagation of the disease is aCCelerated by the relaxation of morals and irresponsible sexual behaviour.

This is why Muslims say that AIDS is a divine punishment. “Praise to Allah who said in the Holy Koran: ‘Approach not adultery. In truth, it is a turpitude and what a bad way! Salvation and peace be to the prince of Messengers who said: “The turpitude should never be widespread in a community..., or the scourge and the various ills will be visited on it in a manner unknown among their ancestors of old.” AIDS “is a human catastrophe which does not spare anyone among the youth of this desperate world, who believe in only material things and do not acknowledge any spiritual virtue”.

Catholics for their part try to consider HIV/AIDS as any other disease even if they realise that it poses complex problems.

With regard to the Protestant family, it was observed that there was some ignorance about the causes of the illness and the general tendency is to associate it solely with sexual promiscuity. In the view of pastor Daniel Tangara, Vice President of the Protestant Church of Mali, which represents the Association in this field, the disinterest shown by men of the Church is partly due to an erroneous presentation of HIV/AIDS: “In most cases, many stakeholders involved in the awareness-raising, presented AIDS as emanating from a life of debauchery. ”Many Church and religious community leaders have thus looked on PLWAs with condemnation and rejected them instead of demonstrating their compassion towards them. Awareness-raising work should therefore be carried out in this regard.

With regards to prevention, Catholics and Muslims are against the promotion of condoms. The former are adhering to the position of the Vatican and see in the utilisation of condoms an easy solution which may pave the way for all sorts of uncontrolled behaviour. Furthermore, the condom is not foolproof considering the debate which it has generated within the medical profession. The utilisation of the condom can therefore be recommended only in exceptional cases for legally married couples.

Furthermore, the Catholic Church of Mali is also of the view that its action, while falling within the framework outlined by the State in the field of AIDS control, must maintain its own identity and communicate its own messages. It is for this reason that the Church is reluctant to speak publicly and bluntly about sexuality. The African ethics should be adopted and opportunities sought to tackle the issue, for instance taking advantage of an awareness-raising session on female genital mutilation problems to indirectly give a sexual education course.

It is on the same ground that Muslims are reluctant to tolerate the condom and lift the veil on “sexual matters”. There is also the viewpoint that condoms are a trick by the western world to control births in Africa. However, it appears that the real reasons for the resistance might be connected with the refusal to allow women the freedom to use their body as they wish.

Among the Protestant and evangelical churches, there is no official position concerning the use or otherwise of the condom. However, in private, viewpoints are quite mixed.

3.2.    Action of the Churches

3.2.1.   The Catholic Church in Mali and AIDS control

The Catholic Church seems to be the pioneer in this field. A few months preceding the celebration of the world's first AIDS day (1 December 1989), Archbishop Martin Happe, then Chairman of the Social and Charity Committee “Justice and Peace”within the Episcopal Church of Mali, initiated an HIV/AIDS control project.

The project, which was expected to spread over a three-year period and be renewable, envisaged two components, namely a prevention action through information and training and a support action to PLWAs and their families.

In its design, the project was expected to affect 22 health centres and 45 social and women's promotion centres as well as diocesan training centres. Material assistance to PLWAs (food and sharing of hospitalisation costs) was envisaged in six dioceses of Mali. The printing of 3,000 information and awareness-raising posters was also on the agenda, as well as the supply of teaching aids. Unfortunately for reasons of coordination, the scope of the project has not been as extensive as expected.

Today, it is the National Secretariat of the National Committee for Socio-Pastoral and Charity Work which wants to take over responsibility. This Secretariat is Caritas Mali, the former Catholic relief service of Mali (SECAMA) established in 1958 and restructured in 1988 by the Bishops. Ever since, this committee, whose objective is to work towards the full development of the human being, has undertaken activities relating to health, agriculture, the environment, women's promotion, justice and peace, specialised education and assistance.

In the field of AIDS control, the important phase was the national consultation organised by the socio-pastoral unit from 15 to 20 February 1999. It brought together 70 participants around three main objectives, namely:

• Technical knowledge of the disease,
• Knowledge of the position of the various religions,
• Sharing of experiences and the search for the lines of action
• Pursuant to these objectives the national coordination appealed to specialists, particularly doctors, and must be credited to the different representatives of the religious world (Catholics, Protestants and Muslims).

This meeting made it possible to highlight, amongst others, the Malian population's perception of HIV/AIDS: some hold the view that it is connected with poisoning or bewitchment whereas another category considers HIV/AIDS as a divine punishment resulting from immorality and debauchery. Others who are even more incredulous affirm that HIV/AIDS does not exist and that it is an invention of the Whites...

During this conference, testimonies from the various parties showed that many members of the congregation of the Catholic Church live with HIV/AIDS, even if it is difficult to provide the statistics. Based on this observation the following lines of action were identified:

1.  Preliminaries

·  Report at the parish level

·  Provision, as much as possible, of health centres for rapid testing

·  Fostering relations with other partners in the field (NGO, State), amongst others and participation in World AIDS Day (1 December)

· Establishment of a concrete programme taking into aCCount the orientation outlined aCCording to the three areas defined

2.  Knowledge of the disease

· Information through local radio stations, posters, audio and video cassettes, drama and tools

· Training: training sessions for the communities (village associations, Catholic action movement), training of trainers (health personnel, pastoral personnel)

3.  Prevention of the disease

· Establishment of AIDS Control Committees

· Sexual education, taking into aCCount the orientation of the church

· Awareness-raising by insisting on:

• the sterilisation of materials and asepsis in the health centres;
• combating illegal medicine;
• testimonies and sharing of experiences.

4.  Support

· Creating support structures: support team, support committee for the sick

· Supervision and treatment of the sick

· Creating solidarity funds

· Income-generating activities

5.  Conditions for the implementation of action steps

At the national level, the bureau of the sub-committee is mandated to monitor the implementation of action steps in each diocese.

The diocese is free to involve the diocesan coordination of socio-pastoral activity with a view to the implementation of the resolutions.

Difficulties: It is an extensive programme which requires substantial financial resources which are not always at the disposal of the church. At present, for instance, many health centres have a chronic lack of rapid screening equipment and are therefore not in a position to confirm or reject the HIV/AIDS symptoms which they observe in patients.

Furthermore, it is urgent to intensify awareness-raising in view of the fact that the little work that has already been done is already yielding results:

· People are beginning to “dare” to speak about AIDS: the population has even created a terminology in the various languages of the country

· There are also voluntary requests for screening

· Day after day, discreet visits are paid to the representatives of the church even if it is not easy to find solutions to problems posed in homes affected by HIV/AIDS

3.2.2.   Evangelical and reformed churches

It was difficult to collect information from the Protestant Churches and Missions in Mali without passing through the Groupings of Protestant and Evangelical Churches of Mali (AGEMPEM). This association brings together 30 members including 8 national Churches, 14 Foreign Missions (African and Western) and 8 associate members. ACCording to the statutes, each member maintains its autonomy. The biggest churches of the Association are:

• The Christian Evangelical Church in Mali, established mainly in the East of the country
• The Evangelical Protestant Church in Mali
• The Protestant Church of the Kayes region
• The Federation of Baptist Churches
• The Evangelical Lutheran Churches
• The Assemblies of the Church of God
• The Grouping of Southern Baptist Churches
• The Union of Evangelical Churches in Mali

AGEMPEM functions with three departments, namely: evangelisation, youth and women. It also established a Non Governmental Organisation (NGO) to promote social development.

With regard to AIDS, AGEMPEM does not undertake any activity outside the work of the Protestant Association of Mali (APSM) which is an associate member of some health facilities belonging to a number of members. To date, it has simply played an observer's role by contenting itself with participating in the information and reflection sessions organised by the governmental structures and others. The association thus took part in 1993 in a reflection forum which brought together religious personalities, doctors and other stakeholders of civil society with the objective of collating the reactions of the various parties involved in addressing the HIV/AIDS problem.

This forum was followed by another meeting organised by the Rotary Club of the capital Bamako and which mainly focused on the practical problems posed by AIDS: what attitude to be adopted towards PLWAs? What are the rights and duties of the latter? How should the PLWAs be informed in order to avoid shocks? At the end of the meeting a committee was established whose work consisted, for three months, in drafting the legal texts which must be submitted to the Ministry of Health.

AGEMPEM also participated in the consultation meeting organised in 1999 by the General Secretariat of the National Pastoral Committee.

3.2.3.   The 7 th Day Adventist Church

In Mali, the Adventist Community is said to be about three hundred members strong. Here, just as elsewhere, the Adventist Church is generally very committed in community development with programmes for village water supply, road construction and health. Unfortunately, no specific programme has, for the time being, been developed in the field of AIDS control.

Conscious however of the seriousness of the situation, the officials have been trying, should the oCCasion arise, to embark indirectly on counselling couples who are preparing for marriage to go for a medical check up including a serology test. However, contrary to what oCCurs elsewhere, the medical certificate is not a condition for the celebration of the wedding.

3.2.4.   The Muslim Community

The action of the Muslim community coordinated by the AIPEF (Islamic Action for the Progress and Development of the Family) is still at the planning phase. In August 2000 the leaders organised an Islamic seminar called “Preparatory Workshop of Islam and AIDS Forum”. The themes covered were: the viewpoint of Islam on the causes of the epidemic, the ways and means of checking its propagation, the role of Ulemas and Imams in AIDS control. The focus was also put on the assistance to be provided to the PLWAs since in Muslim communities death from AIDS is increasing the number of widows, orphans and others who are without any support.

The following stage, which was to see the organisation of the “Islam and AIDS”forum, is under preparation. Initially scheduled for October 2000, it will not only have a national but also a sub-regional character with the participation of the representatives of the Muslim communities of the following countries: Senegal, the Gambia, Niger, Libya, Burkina-Faso, the Ivory Coast, Mauritania, Egypt, and Guinea-Conakry.

This forum will pave the way for a mutual understanding of the AIDS problem aCCording to the Islamic strategy for AIDS control. The Ulemas whose role in AIDS control will be clearly defined, will be involved in making an inventory of the verses and hadiths with a view to the publication of an information booklet on HIV/AIDS. A plan of action will also be drawn up and a monitoring committee established.

This forum could also discuss a number of practices which are common in Muslim circles and which encourage the propagation of the disease, such as genital mutilation.

4.  Human Rights and Poverty

For a great majority of the churches, the violation of human rights and poverty is contingent on development, namely aCCess to education, health care and training. This explains why they have been trying to complement and reinforce the action of the government in this field through the opening of schools, the construction of health centres and hospitals, and the creation of projects in the urban or rural areas. Apart from this approach, the churches in Mali do not undertake advocacy vis-à-vis the government for an effective taking into aCCount of the population in the distribution of wealth. However, Catholics and Protestants have been working together with the trade unions in order to foster the spirit of reconciliation whenever there are differences.

5.  Involvement of Ecumenical Organisations and Health Facilities

5.1.    Ecumenical Movements

The ecumenical movements include the Biblical Alliance of Mali which brings together all the foreign churches and missions for the evangelisation and establishment of churches. In addition to the dissemination of the Holy Scriptures and Christian literature, the Biblical Alliance of Mali produces books on the life of the patriarchs, particularly in the Bambara language, one of the most widely spoken local languages in Mali.

The AIDS has not yet retained the attention of the officials of the Biblical Alliance, which is, however, a good channel for collaboration with the churches.

5.2.    Health Facilities

5.2.1.   CESAC

CESAC (Listening, Care Motivation and Counselling Centre) is the only governmental structure which ensures the care of PLWAs. Established in September 1996, CESAC brought together two AIDS control associations namely AFAS (Women's Association for Assistance and Support to Widows and Orphans of AIDS) and AMAS (Malian Association for assistance and support to PLWAs).

CESAC ensures the screening and psychological care with the financial support of the French Cooperation Mission. The consultations and screenings are free. Since its inception, nearly 5,000 persons have consulted there.

With regard to care, CESAC provides meeting places for PLWAs. Psychological care is provided for them, welcoming them, and providing comfort. They also receive group psychotherapy. At the social level, donations and other specific support (food, transport expenses) are provided for the most underprivileged. However, more than the donations, CESAC has been trying to safeguard the dignity of the PLWAs by avoiding their having to ask for help. Income-generating activities are proposed to them individually or in groups, particularly the making of chairs, dolls, and the sale of second hand clothes. In the event of death, the orphans can benefit from multiple support if there is no other alternative: responsibility for school fees, food, clothing, etc. In 1999, through WFP (World Food Programme) assistance, CESAC was able to distribute 33 tons of food.

Unfortunately, the CESAC where one doctor sees 15 to 20 persons a day, is limited in its action and faced with several difficulties: financial partners are withdrawing systematically in order to allow the State to take over. This is reflected in the lack of, for instance, reagents, antiviral (those which some sick persons receive aCCount for only 2% of real needs), generic drugs and financial resources. The need to expand the activities of CESAC to other regions was also felt.

5.3.2.   The Protestant Health Association of Mali (APSM)

An associate member of the AGEMPEM, the APSM (Association of Evangelical and Protestant Groupings of Mali) was established in 1992 by the Health Personnel of the Protestant Churches and Missions in Mali. Its objectives are to encourage its members to provide quality health care to the Malian population, and facilitate the coordination of the medical activities of the churches and missions. The APSM designs, amongst others, literacy and health education programmes for women and children.

In the specific area of AIDS, APSM undertakes prevention exercises, and has produced information and awareness-raising documents in Bambara, the most widely-spoken national language. APSM is currently planning to design a specific programme on AIDS which could affect all the strata of the country's population.

5.3.3.   Union of Protestant and Evangelical Churches in Mali

This Union has a health structure on AIDS control in the north of the country aCCording to the information provided by officials of the AGEMPEM.

5.3.4.   The Mission Alliance

The Mission Alliance (not to be confused with the APSM) runs a programme for the care of PLWAs in the town of Sevare, located at more than 600 km from Bamako in the Mopti region. In view of the remoteness of this centre, we could not visit it, however, the various testimonies which we heard indicated that significant work had been aCComplished by the German missionaries.

6.  Resource Structures

Even though this item does not fall directly within the scope of our study, it appears expedient to highlight the presence of a number of resource structures considering the role which they play in the capacity building of the structures of the churches and ecumenical movements.

6.1.    Enda Third World

Enda Third World Mali is among the NGOs which support the Malian government in its fight against AIDS through its health development department. It is different in that after a long period of action in the field of AIDS, it has already gone beyond the stage of evaluation and is currently seeking to reorientate its action. The current challenge is not only to maximise the results but also to cause a real change in attitude among the population. Enda has thus opted for a more participatory method and defined a new method based on the review situation of the target population. The latter is made to submit solutions itself based on factual situations.

Enda Third World Mali is also one of the few local NGOs involved in the care of HIV/AIDS cases with the financial support of Catholic organisations.

Any action in favour of AIDS in Mali could effectively benefit from Enda's expertise. It is also desirable to maintain contact with this NGO in order to keep in touch with its new approach.

6.2.    The Djoliba Center

Headed by a religious official, namely, father Francis Verstaete, the Djoliba Centre is a non-profit making apolitical association of national and international reputation. Established in 1964, it is specialised in documentation, training and social analysis, gender issues and promotion of women. It was in fact the first to be involved in AIDS control. The activities which it developed in this field were very diversified:

· Mobile and popular “education – information”sessions in the neighbourhoods and neighbouring villages of Bamako

· Training of trainers sessions in the local languages and French with GRAAP material. Several national NGOs benefited from it

· Session for 63 teachers of a diocese of Mali (Mopti),

· Loan and reproduction of cassettes and audio-visual media for exchanges

· Dissemination of documents on AIDS, since the Djoliba Centre is in relation with Enda Third World (Dakar) and “Strategies of Hope”based in Oxford

· Organisation of numerous exhibitions on AIDS

In 1990, nearly 2,535 persons attended the sessions and in 1991, 625 persons had benefited from it. The Djoliba Centre was also entrusted with the mission of ensuring a presence of the Catholic Church on the National AIDS Committee.

Today the Djoliba Centre has passed its responsibilities to the Health Committee of the Church. Besides the events organised in commemoration of World AIDS Day, it now concentrates its efforts on other centres of interest such as combating genital mutilation, including female circumcision. However, it remains prepared to collaborate with any programme concerning AIDS control and could even encourage collaboration work between the Churches and religious communities.

7.  AIDS Control Network

Our study in Mali made it possible for us to realise that the different religious and ecumenical institutions foster within their own system partnership relations or work in networks in order to build their intervention capacity.

The Catholic Church thus forms part of a regional network which deals with health problems. A grouping with other denominational health facilities is even envisaged in each country. The Church officials are prepared to join this network provided their own identity is not called into question. The AGEMPEM is a member of the national NGO network which has nothing to do with AIDS.

Enda Third World Mali forms part of the national network of nearly 500 centres which mainly ensure the training of trainers.

However deplorable this may appear, the Churches and ecumenical institutions do not yet have formal partnership relations among themselves.

The Muslims claim they are in favour of collaboration with the other religions in order to halt the spread of HIV/AIDS. The Christian organisations are also said to be prepared, but nobody is taking the initiative.

8.  Conclusion

The Catholic Church is the only Church which has made advances in the field of AIDS control. Its action falls within the area of prevention and slightly less in the area of care.

With regard to AGEMPEM, only the health facilities are involved, whereas it seems that the officials need to be sensitised and informed. This is an urgent need.

One can sense that the Muslims have a real desire to tackle the problem of AIDS.

There is therefore an open door in Mali through which the WCC and WAYMCA could enter.