The Journal of HIV/AIDS & Social Services is pleased to present the first special issue focusing exclusively on countries in eastern Africa. This issue presents research on populations in Ethiopia, Tanzania, and Zambia, which reflect some of the innovative research and practice activities that social workers are undertaking in these areas. In many ways, this volume reflects the profession's international vision of social work, having the goal of assessing and conceptualizing the strengths and challenges experienced by the people in these countries, especially as it relates to HIV disease.
This special issue, in part, is the byproduct of a series of strategic collaborations. An impetus for the call for papers came from the editors who participate in the Social Work Education in Ethiopia Partnership (SWEEP). The Partnership includes faculty from Addis Ababa University, Jane Addams College of Social Work at the University of Illinois in Chicago, and The Council of International Programs USA, with participation from faculty at a number of other U.S. and international schools and a network of other agencies. This collaboration, under the leadership of Abye Tasse and Alice Johnson Butterfield, resulted in the reconstitution of a master's degree in social work, as well as the development of bachelor's and doctoral programs in social work at Addis Ababa University. The program has also stimulated considerable master's and doctoral level research including HIV research, and the inspiration for this issue came from these projects.
In part due to the success of the Ethiopia project, two additional collaborations have occurred in partnership with the national Tanzania Institute of Social Work. This has entailed collaborations with Jane Addams College of Social Work as well as Addis Ababa University to develop a range of support for both the Tanzania and Ethiopian social work programs as well as outreach to the community to address HIV-related issues through social work–based case management training for people with HIV and their families. In the Tanzania case, the focus is largely on the most vulnerable children and their communities. These Twinning Projects are supported through PEPFAR's American International Health Alliance Twinning Center. The goal of both the Ethiopia and Tanzania educational efforts is to support and enhance social work education being delivered in an African context. The anticipated outcome is to produce credentialed social work practitioners engaged in the “professional use of self” in the service of their communities and country.
This issue of the Journal of HIV/AIDS & Social Services primarily illuminates the work of some HIV practitioners and researchers within these countries, some of whom are affiliated with these educational partnerships, as well as several additional articles. Their manuscripts give rise to an embryonic understanding of “starting where the client is” (Jockel, Citation1937).
Locating the Context
Like many countries in the continent, East Africa is sometimes defined by geography and sometimes by geopolitics. In many geopolitical categorizations, Ethiopia, Tanzania, and sometimes Zambia are considered within East Africa. Additionally, Ethiopia is known as occupying the Horn of Africa and all three countries are considered sub-Saharan Africa, which is the region below the Sahara Desert. By geography, Zambia is farther south and inland. It is, however, above what is typically considered southern Africa, as it is north of both Zimbabwe and Botswana.
Like the continent, the eastern region of Africa is geographically stunning. Mount Kilimanjaro, the tallest mountain in the world, is located in Tanzania. Lake Tanganyika is the world's largest lake and shares the boarders of Burundi, the Democratic Republic of the Congo, Tanzania, and Zambia. It is also second largest freshwater lake by volume. Within the countries, vast rivers give rise to scenic waterfalls. Much of the east African landscape is defined by the Great Rift Valley, which runs from Ethiopia south through Africa to Mozambique.
While its natural resources are some of its strengths, challenges are found within the same context. Despite these vast natural resources, each identified country continues to be challenged by many extraordinary factors. These factors include issues related to the weather conditions that promote either rain or droughts. The volume of rain is one factor related to food production. In each country, food production has consequences for family life on a basic level and all of these factors contribute to the challenges of HIV prevention and support.
Constructing a View of HIV in This Region
In this volume, we frame our thinking using person in environment in an expanded sense. We further structure this issue on the premise that HIV disease does not occur in a vacuum. By expanding both person and environment, we are able to think more broadly about the various systemic and contextual issues influencing the HIV proliferation in the identified countries. Both social work practice and research in this context must incorporate the political economies and sociobehavioral contexts of the eastern region of Africa in order to conceptualize a framework to help understand HIV in this part of the world. Factors that need to be considered include but are not limited to issues related to population mobility, food crisis, and gender rights–especially from a female perspective, knowledge of HIV disease, stigma, sexual behavior, male circumcision, and alcohol use. In examining the impact of these factors, the indicators may include the macroeconomic impact, labor force issues, the health sector, education, family level or household indicators, orphans and other vulnerable children, agriculture, other industries including the military and jails, as well as how the various classes of the society are able to care for those who are dying or dead.
As these political economies and sociobehavioral contexts are illuminated, identifying and understanding the existence of potential resources to mitigate increased infection and prevalence rates may prove useful. These resources include but are not limited to the various governments, national and international donors, various ministries including health and related areas, nongovernment organizations, community-based organizations, and faith-based organizations. Equally relevant are the country's conceptualization of human rights, traditional leaders, and traditional healers; these are all important when considering public health and medical efforts that include preventing mother-to-child transmission of HIV, treatment of opportunistic infections and antiretroviral therapies, external (male) condoms, and female-controlled prevention technologies. Recently emerging as critical but only rarely addressed are the hidden aspects of the epidemic among men who have sex with men, who may be highly stigmatized or subject to structural discrimination where same-sex behavior is illegal, subject to imprisonment and torture, or not recognized as existing. We are suggesting that it must be understood that “infectious diseases in the population are influenced by a dynamic interplay among the prevalence of the infectious agent, the effectiveness of preventive and control interventions, and a range of social and structural environmental factors” (Aral, Adimora, & Fenton, Citation2008; Gupta, Parkhurst, Ogden, Aggleton, & Mahal, Citation2008). In addition to behavioral and structural contexts, understanding political histories is also important.
Brief Political Context of the East African Countries
While the political histories of Ethiopia, Tanzania, and Zambia are extraordinary in their own right, the full explication of their development is beyond the scope of this text. However, brief statements regarding each country are warranted.
Ethiopia is unique among the three for several reasons, primarily because its original governance was through a dynastic rule of monarchies. It is also one of two African nations that has never been colonized. While it was invaded by Italy in 1931, the Ethiopian armed forces expelled the Italian military in 1935. (Note: Liberia is the other African nation that has not experienced colonization.) Ethiopia's dynastic rule came to an end in 1974 when military forces overthrew the Haile Sellassie government. Since then, the country had a military regime for 16 years, which was then overthrown through an internal rebellion. The current government purports to be moving in a democratic manner; however, the country maintains centralized government control of many institutions and has been ruled for almost 20 years by a single party, and recent elections have included considerable turmoil.
Tanzania's history is influenced by the presence of Arab traders, occupation by the Portuguese government, and colonization by the German and British governments. Germany reached Mount Kilimanjaro in 1840, and the British reached Lake Tanganyika in 1857. Autonomous democratic rule was established in Tanzania in 1962, under leadership of the beloved Julius K. Nyerere, and the union of Tanganyika and Zanzibar spawned Tanzania in 1964. Multiparty elections occurred for the first time in 1995.
Zambia, a Bantu-speaking country, was invaded for its mines by Cecil Rhodes in 1889, and the country was ruled by the British South African Company until 1924, when the British government established control. The nation won its independence in 1964.
The Specific Context of HIV Disease
HIV is a significant problem in the eastern region of Africa. While southern Africa still has some of the highest incidence and prevalence rates, HIV has a devastating grip in Ethiopia, Tanzania, and Zambia. Tanzania experienced its first AIDS case in 1983, followed by Zambia in 1984 and Ethiopia in 1985. Table 1 provides demographics describing each country's size and its number of people living with AIDS and the numbers who have died from the disease.
TABLE 1 HIV Profiles for East African Countries, as of 2007
The numbers in this table indicate that much work is needed related to understanding and preventing HIV transmission. The life expectancy in Zambia is less than 40 years. It is also striking that while Ethiopia has nearly double the population of Tanzania and nearly seven times the population of Zambia, it has fewer AIDS cases than both countries combined (980,000 HIV cases versus 1.4 million and 1.1 million HIV cases, respectively). Tanzania's 1.4 million HIV cases are only surpassed by five countries with more AIDS cases. According to the Central Intelligence Agency World Fact Book (2007 estimates), the countries in the world with the most people living with HIV/AIDS are South Africa (5.7 million), Nigeria (2.6 million), India (2.4 million), and Mozambique (1.5 million). Other East Africa countries affected by HIV include Kenya with 1.2 million and Uganda with 940,000 HIV cases.
Overview of the Articles
While statistics do not tell the whole story of any one particular event, it is against these demographics that we present the East Africa special issue of The Journal of HIV/AIDS & Social Services. The authors provide an important initial conceptualization through their research to begin understanding some of the contexts that result in the demographics presented earlier. The range of reports is consistent with the extraordinary range of factors that present social service concerns in dealing with HIV disease but here within the cultural contexts of these countries and communities.
Kaijage and Wexler in Dar Es Salaam, Tanzania, describe the impact of stress on medication adherence, health-maintaining behaviors, and sexual risk behaviors in clients of local AIDS service organizations. This article explores the interface between health behaviors and perception of self or external control over these behaviors, indicating that women are more likely to perceive higher locus of control. The mixed findings about the role of social support, HIV-related stress, and sexual risk highlight the need to consider social support within an African context, including both the immediate and extended family, in all strategies for HIV/AIDS prevention. These findings provide additional support for exploring the social determinants of health put forth by researchers in other areas of the world.
Berhanu's article, Holy Water as an Intervention for HIV/AIDS in Ethiopia, is an example of the juxtaposition of culture and religion as it impacts health and wellness. The author's use of narratives provide an in-depth insight to people seeking sanctuary from persistent and difficult stigmatizing communities to places where living with HIV disease is an opportunity for spiritual as well as physical “healing.” The underlying challenge in these holy water sites is managing the potentially competing modalities of care: “holy water” versus antiretroviral treatments.
Tadele provides one of first documented studies describing the phenomenon of homosexuality in Ethiopia. Given that homosexuality is illegal in Ethiopia, this work is both extraordinary and courageous. His qualitative findings, however, raise the specter of compelling data given how the informants reveal their misinformation related to HIV disease. His work suggests a profound need to more deeply understand the challenges to provide effective HIV prevention efforts among this population, in both the urban and rural areas.
Lentz's article is the sole report from Zambia. Yet the structural issues of organized religions, donor countries, and challenging economic conditions causing a health worker shortage area are not unique to Zambia. Lentz's work provides an opportunity to explore how national governments work with international donors and nongovernment faith-based organizations to increase the capacity of health-related institutions as they combat issues of misogyny and other “gender-based” oppression in the provision of quality HIV service delivery.
The final article by Pardasani and colleagues describes the collaborative efforts of a community-based organization and the resources of a committed community to provide for the care of children orphaned by AIDS in Tanzania. Describing the program components and the outcomes on children, this article is one more example of finding resources within communities to support the most vulnerable members of the community who are in crisis.
The following pages are examples of how these researchers have chosen to examine and understand the issues of HIV. Understanding the assault HIV continues to have on countries whose economic and world standing cannot compete with the economies of Europe or the United States remains an important undertaking. The issues and stakeholders range from national and international security to the inherent right for quality health care and dignity for all people, especially their most vulnerable populations.
Finally, while this special issue focusing on five particular sets of research questions in three countries is not going to stop the virus, it is an effort at open communication about the dynamics in play in communities that have too long been isolated. As social work emerges in countries like these, a base of knowledge and strategy needs to emerge. This issue is a call to action. May this issue encourage you to look to Africa to see how you might contribute? May it also encourage your colleagues to refocus their efforts to make a difference through practice, policy, or research? The needs are great. We must marshal our collective talents to meet the needs.
Notes
Sources: Central Intelligence Agency. (Citation2007). World Factbook. Retrieved on June 21, 2010 at https://www.cia.gov/library/publications/the-world-factbook/rankorder/2156rank.html?countryName=Tanzania&countryCode=tz®ionCode=af&rank=6#tz.
UNAIDS, (2009). AIDS Update 2008. Geneva, Switzerland, World Health Organization. Retrieved on June 20, 2010 at http://data.unaids.org/pub/Report/2009/JC1700_Epi_Update_2009_en.pdf.
REFERENCES
- Aral , S. O. , Adimora , A. A. , & Fenton , K. A. ( 2008 ). Understanding and responding to disparities in HIV and other sexually transmitted infections in African Americans . Lancet , 372 , 337 – 40 .
- Central Intelligence Agency . ( 2007 ). The world factbook. Country comparisons: HIV/AIDS – people living with HIV/AIDS. Retrieved on August 24, 2010 at https://www.cia.gov/library/publications/the-world-factbook/rankorder/2156rank.html
- Gupta , G. R. , Parkhurst , J. O. , Ogden , J. A. , Aggleton , P. , & Mahal , A. ( 2008 ). Structural approaches to HIV prevention . Lancet , 372 , 764 – 75 .
- Jockel , E. ( 1937 ). Movement toward treatment in the application interview in a family agency . Journal of Social Work Process , 1 ( November ), 32 – 40 .