By Acquineau Azetsop, editor
Call Number: RA643.86.A35 H55125 2016
This comprehensive look by African scholars at the HIV/AIDS pandemic in Africa features contributions from noted scholars from across the continent, offering analysis from theological, sociological, ecclesiological, and public health perspectives. It is a valuable resource for social analysis and theological reflection from an African perspective, something badly needed for theologians and academics alike. Several prominent American theologians are also contributors, including Lisa Sowle Cahill and James Keenan.
Jacquineau Azetsop is associate professor in the School of Social Sciences of the Gregorian University in Rome. His teaching and research focus on issues of health policy, public health ethics, social dimensions of health, health systems, and the inclusion of the destitute poor.
Text above from the Orbis books website
Elochukwu Uzukwu C.S.Sp.
Theology Department, Duquesne University
I thank Azetsop, Jacquineau, the editor of the collection HIV and Aids in Africa: Christian Reflection, Public Health, Social Transformation (Maryknoll, NY: Orbis Books, 2016) for enabling me to present this collective work. The African Jesuit AIDS network committee has done a lot in encouraging and enabling theological voices to be heard on this important issue of HIV/AIDS. It is also important to thank Rev Joseph Healey, a Maryknoll priest, and Orbis Books Africa consult that encouraged the fruits of the wide-ranging research to be published by Orbis Books.
We have come a long way in Africa and the world in our various families, communities, and countries, from denial through disregard to acceptance and engaging in collaborative work that this epidemic, the stigma attaching to persons, families, countries and continents, is not just about Africa, about them, but about all of us (Kofi Annan); in particular as Church-community, all us is “the body of Christ” (Copeland).
HIV/AIDS is a public health issue that reveals, according to Azetsop, “a social immune system that is deeply compromised.”
This raises a major challenge for the contributors to this volume. Healing calls for “a new vision of society grounded in a social justice perspective that integrates all social constituencies and seeks to promote the welfare of all.” (xvii) Consequently, the power of this book, what makes it different from so many books on HIV/AIDS in Africa these past 30 years is the firm conviction that “social transformation” is “the best means of HIV prevention and AIDS management.” (xvi)
This point is important for policymakers worldwide, community health providers, and the Church spread throughout the world ready to tap the insight of ethicists and theologians who reinterpret the Church’s Social Teachings. Indeed interdisciplinary conversation between bioethics (ethical social discourse that includes global ethics that researches and promotes healthcare for everyone on the planet eliminating “disparities in access to health” Egan 240) and Catholic social ethics may reveal “official catholic teachings on AIDS prevention that seem to emphasize personal sexual behavior at the cost of broader justice, health, and flourishing, and a more pastoral, pragmatic, and social ethic…reflects a broader and deeper approach to Catholic theological ethics.” (Anthony Egan, 250)
When reading this collection, note that this is an initiation into an interdisciplinary research process in a disease that has revealed the limitation of facing disasters/catastrophes in isolated ways. But of course it is not the last answer. Questions are raised, questions are answered, and many more unanswered questions remain: Wilfred Okambawa inspired the project of this book through a book chapter “African HIV/AIDS theology: Towards a Holistic Approach to the HIV/AIDS issue”.
The theological questions he raised led organizers to include pastoral, moral, spiritual and healing dimensions as well as systematic theological reflection called by this whole discussion. Wilfred Okambawa’s theological-biblical response to HIV/AIDS in the present collection can be summed up in what he tried to argue about the potency of vicarious suffering in Isaiah 53—the suffering healer, images of healers emerging from profound suffering as found in Jewish, African and Hindu literature and practice; this is the style of moving, as in a rite of passage, from suffering to intercessory ministry. Questions remain: is such vicarious or redemptive suffering defensible in the case of HIV/AIDS?
The conclusion to my contribution in this collection favors redemptive suffering and the school of care that sufferers transform into through ritual passage that makes sufferers and community of caregivers so fragile: “God is present and speaks in the cry of the sufferer and the cry of the Just, in the cry of the HIV/AIDS victims and the abandoned Ebola patients, not in violent wind and earthquake, not in the fire and brimstone of condemnations, but as participant/motivator in quiet and silent solidarity, in the services and research, to bring the succor that alleviates Ebola and HIV/AIDS, enable the excluded to reclaim their humanity and to renew the community.”
This optimistic conclusion is verified even more profoundly than I could have imagined in the pastoral care of HIV/AIDS carriers provided by Home-Based Care in Zambia (1980s; when mere announcement of HIV/AIDS was a death sentence): the “caring women” stepped into the void created by pure “despair”—absence of a cure, increasing number of infected, failure of the health system, rejection by society, “collective paralysis” (Leonard Chiti, 382: “initially the home-based-care system emerged as a community/grassroots-based initiative to deal with a very serious matter of inadequate capacity of the state health delivery to cope with the challenge of increasing numbers of patients testing positive for HIV”, 378). Instead of abandoning the sufferers, the “Caring women”, nurses, family and friends took over the responsibility of caring for those rejected and abandoned to die; and patients felt they belonged and had hope of finding meaning in their life (382).
Problems persist all over Africa and the world, but HIV and Aids in Africa: Christian Reflection, Public Health, Social Transformation appears to be part of the solution to the problem.
A Healthcare Professional’s Reflection on HIV & AIDS in Africa: Christian Reflection, Public Health, Social Transformation: Beyond the Medication
Jordan R Covvey, PharmD, PhD, BCPS
Assistant Professor; Division of Pharmaceutical, Administrative and Social Sciences, School of Pharmacy, Duquesne University
Thank you for the opportunity to speak today on this important topic. I am currently an Assistant Professor in Pharmacy Administration here within the Duquesne University School of Pharmacy. I am originally trained as a pharmacist with experience in both community and hospital-based clinical settings. I transitioned to become a clinically based researcher and now my teaching focuses on public and global health, of which HIV/AIDS is a continually important topic. I speak today not as an expert on this particular topic (either in HIV/AIDS or theology), but as a general healthcare professional, educator and global citizen with interest in how society can eventually move toward an AIDS-free generation.
As I read aspects of this text, I reflected back to one of my earliest clinical experiences working with patients with HIV/AIDS here in the USA, on an advanced pharmacy practice experience in one of four Ryan White-funded HIV/AIDS clinics in my state, a program that provides comprehensive care to over half a million patients with HIV/AIDS across the USA. As a young pharmacy student, I helped provide care to patients within the clinic in concert with other healthcare professionals, with a focus on medication adherence, adverse effects and other related issues.
What perhaps struck me as most eye-opening through the experience was that access to primary care and support services through the clinic was an essential piece of the puzzle, but the ‘cure’ to HIV/AIDS would involve so much more. Patients recounted stories of how they worked to maintain their lifestyle with confidentiality, scenarios of stigmatizing behavior among family and friends, feelings of guilt over how they contracted HIV or fear for their quality of life moving forward. But not all sentiments were discouraging; many others expressed hope in how care had advanced since the first discoveries of the virus, opportunities to educate others on the disease, and how the disease had inadvertently led to a healthier view of their life.
What I took away from that clinic more than anything was that HIV/AIDS, perhaps in a way unlike any other condition, was a societal issue relevant to all of us. The biomedical model of disease which I had first studied under was not completely explanatory, and the psychological, social and economic aspects of HIV/AIDS were just as relevant.
The text of today’s discussion, HIV & AIDS in Africa: Christian Reflection, Public Health, Social Transformation, examines these issues within the African context and from a theological perspective. What I found most informative within the text as a clinician was the examination of the factors underlying the origins and prevalence of the disease on the continent. While the spread of the virus may be commonly thought of in a solely behavioral context, the text of the book discusses several key non-biomedical contributors within Africa: poverty, the status of women in society, cultural norms, and familial structures. It has taken time to understand the disease within these influences, and how society’s response will ultimately fail without incorporating them into policies and strategic plans.
That is not to say that the biomedical origins and treatment of the disease are not just as important. HIV/AIDS denialists who reject the science of the disease are a dangerous opposition that hamper progress in the fight against the epidemic, as evidenced by the effect of policies set in place by former South African president Thabo Mbeki.1 Our understanding and response to HIV/AIDS must be shaped by all contributors to the disease and how they are interconnected.
As a pharmacist, it is natural for my focus on HIV/AIDS within the African context to drift to effective antiretroviral access on the continent, and how government and organizational policies can continue to support this lifeline. Significant progress has been seen in recent years in expansion of treatment provision. The World Health Organization estimates that in sub-Saharan Africa, antiretroviral access increased more than 100-fold between 2003 to 2014.2 However, gaps are still largely prevalent, particularly within healthcare infrastructures being modernized and financially stable enough to support delivering effective treatment to individuals in need. Diverse and renewable funding sources for HIV programs are needed across the continent. It is also essential to work to remove barriers to antiretroviral access, including high pharmaceutical costs, political unrest and government regulation through tariffs/taxes. Here in the USA, PEPFAR, or the President’s Emergency Plan for AIDS Relief, has been a key initiative in the expansion of funding for HIV/AIDS globally since 2003. However, the volatile political climate in the USA may render the future of this program shaky.
In conclusion, it is my belief that all opportunities in life begin with education. The text we discuss today provides a unique social perspective on HIV/AIDS in Africa, and is a first step for any of us to learn, grow and challenge our understanding of this topic. In my lifetime alone, HIV/AIDS in the USA has shifted from an acute and deadly illness to a chronic and manageable disease. It is essential that we strive to achieve the same goals in Africa as we continue to work toward a global AIDS-free generation.
Thank you for your time today.
To HIV & AIDS in Africa: Christian Reflection, Public Health, Social Transformation
Dr. Bridget C Calhoun
Chair and Associate Professor, Department of Physician Assistant Studies, Rangos School of Health Sciences, Duquesne University
The world-wide burden of HIV infection is almost unimaginable. We now know that HIV-infection is a life-long disease with no cure. Much of my work in HIV/AIDS research involves working with people living with HIV-infection. In many cases, they aren’t just living, they’re thriving! What was once a fatal infection, with an expected life expectancy < 10 years, is now a manageable, chronic condition when antiretroviral medications are taken as prescribed. Much of the research in HIV/AIDS in developed nations is now concentrated on the chronic, adverse effects of the medications, rather than on the infection itself. However, antiretroviral medications aren’t available to everyone, and for those who don’t have access to them, or who can’t take them on a consistent basis, there is a highly likelihood of succumbing to the infection.
The science of HIV is not particularly difficult to understand. The human immunodeficiency virus is an intracellular parasite. It requires a living host, and is easily transmitted from one person to another via exposure to blood, semen, vaginal secretions or breast milk. World-wide, the primary modes of transmission include sexual activity, and transmission from mothers to infants during birth, referred to as vertical transmission. A secondary mode of infection is exposure to infected blood.
Once HIV enters the body, it selectively infects human T cells which are very abundant in the circulation. T cells are crucial to immunity by fighting infection and destroying native cells that are dysplastic, precancerous or cancerous. Infected T cells can no longer perform their normal duties, and are destroyed by other cells in the body. The bone marrow produces more T cells to compensate for the loss, but the rate of destruction often exceeds the rate of production, leading to a gradual decline of T cells over time. The selective destruction of T cells among those not treated for their HIV infection explains why they are most likely to eventually die from co-infections and cancers.
Without antiretroviral medications, those with HIV infection will die, usually within a decade or so of becoming infected. Modern treatment involves using a combination of medications to interrupt viral replication within the human host. Unfortunately, these medications remain very expensive. When taken as prescribed, modern antiretroviral therapy can suppress the virus to undetectable levels in most people. Life expectancy among those well treated for HIV infection is now several decades.
So, the science of HIV is relatively simple. The deadly virus, easily transmitted from host to host can devastate a village, region, country or continent. What complicates HIV as a communicable disease is that the host is highly sophisticated!
The human host, the person infected with HIV, experiences many emotions in addition to the physical changes associated with the infection. They experience fear, isolation, guilt, desperation and in some cases, a sense of worthlessness. Many times neighbors are victim-blaming and may even be violent towards those infected. HIV infected individuals have a long history of been marginalized by their own social and cultural world. The extent to which this happens varies from region to region and nation to nation. Important topics such as these are well explained in HIV& AIDS in Africa. The well known public health principles of social determinants are also explained. Social determinants are strong predictors and health and disease everywhere in the world, but especially in the face of poverty.
Social determinants such as social class, economic status, literacy skills, position within the cultural hierarchy and self-efficacy are highly influential, and can directly contribute to whether someone lives with HIV infection or prepares to die with HIV infection.
This book, HIV & AIDS in Africa is a collective piece of public health, public policy, social transformation, history, theology, politics, anthropology, human rights, compassion, concern and hope for the future in the context of HIV/AIDS. The text considers the social determinants mentioned above, and identifies reasons why prevention strategies effective in industrialized nations, are often ineffective in developing or underdeveloped nations, particularly within Africa.
It is well documented that the African continent was disproportionately affected by the AIDS epidemic, and explanations for this are provided within this text. Relevant statistical information is also included, and reflects the fact that within the first 20 years of the epidemic, 17 million Africans died. These tragic deaths left 12 million orphans. In 2008, Africa had 11% of the world’s population, but approximately 67 % of people living with HIV or suffering from AIDS. This disproportionate burden of disease reflects informal stratifications of social class, culturally acceptable sexism, little understanding of viral transmission, and a large population with few marketable skills. The combinations of these things make some African nations particularly susceptible to HIV epidemics. There is compelling evidence that social inequalities not only affect the distribution of disease, but also the outcome of the disease.
The book further explains the particular risk of HIV infection among women. Among the poorest women, commercial sex work (either formal or informal) develops and evolves as a survival strategy for themselves and their families. Many times, these disadvantaged women cannot safely demand their partners wear condoms or negotiate safer sex practices.
One of the most widely publicized HIV prevention strategies is the ABC approach, which is described in the text. “A” for abstinence “B” for be faithful and “C” for condoms. This approach is meaningless for women coerced into sex, forced into sex, married when young teens, or infected by their husband.
HIV & AIDS in Africa appropriately describes a more appropriate approach, “SAVE”, which means safer practices, access to treatment, voluntary counseling and testing, and empowerment. This likely serves more women, particularly in cultures where widow inheritance, marrying underage girls, genital mutilation, polygamy, and urban migration of men in search of jobs (with casual sex in the process) are prevalent.
The book further explains how public health practice is different in resource poor areas. In developed nations we can focus our efforts on medical research and advancements. In underdeveloped nations, efforts must be focused on the basics of acquiring medications, providing proper nutrition, and training health care providers.
Frequently, in resource poor nations, such as many within Africa, the only people present when a person dies of AIDS are the healthcare workers and clergy members. Sadly, many of the victims have been disowned by their family, ignored by their former friends and shunned by neighbors. What happens on the personal level is amplified by what happens on a national level. Many national governments were slow to act, and in some cases even initially denied the devastating AIDS epidemic, which delayed acknowledgement of the epidemic.
The Catholic Church, with its extensive network of hospitals and clinics in Africa and elsewhere, is the world’s largest private provider to medical care to people living with HIV. This is reinforced throughout HIV & AIDS in Africa. The crucial roles of faith, and the faithful followers, are stress throughout this text. HIV & AIDS in Africa will be of interest to anyone interested in gaining a comprehensive understanding of the HIV/AIDS pandemic. For me, the context of this book can be best summarized by a statement within the book which reads, “for Christians, our neighbor is not the person who lives close, but rather the one who is in need.”
