HIVcontructionafrica SS&M 06

ARTICLE IN PRESS
Social Science & Medicine 64 (2007) 11281150 www.elsevier.com/locate/socscimed
HIV/AIDS and the construction of Sub-Saharan Africa: Heuristic lessons from the social sciences for policy
Ian E.A. Yeboah
Department of Geography, Miami University, Oxford, OH 45056, USA Available online 29 November 2006
Abstract There is no doubt that Sub-Saharan African countries face major problems due to the HIV/AIDS pandemic that has ravaged the region. Yet the Eurocentric construction of the region as the source of the virus not only creates negative stereotypes in social science disciplines like geography, but also glosses over the potential of social science disciplines to provide knowledge and inuence policy about HIV/AIDS. This oppositional construction of the region has unfortunately contributed to a glossing over of many aspects of Sub-Saharan Africas people, their environment, culture, history, politics, economics, gender relations, and the regions global status that would provide important input for policy aimed at curbing the devastating spread of HIV in the region. This paper argues that once we recognize that HIV is a global virus with transcultural implications, social science disciplines, such as geography, can reveal certain attributes about the region and its HIV/AIDS pandemic that can be used in policy formulation to combat the spread of the virus. r 2006 Elsevier Ltd. All rights reserved.
Keywords: Geography; HIV/AIDS; Eurocentric; Sub-Saharan Africa; Discourse; Health policy
Introduction: construction of Sub-Saharan Africa In both historical and contemporary senses SubSaharan Africa has been constructed as inferior to the Western world and thus the other. Explorers and missionaries (such as Livingstone, Stanley, Park, and Burton) who rst ventured into the interior of the region in the late 19th century, and literary writers (such as Stanley, Conrad, and Cary) who rst wrote about it constructed the region in oppositional terms to Europe (Jarosz, 1992). Thus, Sub-Saharan Africas environment, its people, and their cultures were constructed as dark, barbaric, savage, hot, diseased, uncivilized, heathen, lost, and
Tel.: +1 513 529 5013.
E-mail address: yeboahie@muohio.edu. 0277-9536/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2006.10.003
child-like. The link between climate and moral economy that was based on the geographical work of Huntington (1917) and Taylor (1919), as well as Semples (1911) ideas of environmental determinism were used in justifying the alleged environmental, cultural, and racial inferiority of Sub-Saharan Africa (Livingstone, 2000). It is this set of theories that were used by the medical community, and subsequently colonial administrators, in justifying the perks which colonial administrators could enjoy because of neurasthenia (Livingstone, 2000). As exemplied by both Conrads (1902) Heart of Darkness and Carys (1939) Mister Johnson, the African environment uncivilized the civilized European. Jarosz (1992) argues that these Eurocentric, stereotypical, and negative constructions of SubSaharan Africa during the colonial era are present
ARTICLE IN PRESS
I.E.A. Yeboah / Social Science & Medicine 64 (2007) 11281150 1129
even today and that the HIV/AIDS pandemic is perhaps the latest of such negative constructions of the region. By ascribing Sub-Saharan Africa as the origin of HIV there is a tendency to construct the region as a problem region rather than a region with a problem. This idea of Sub-Saharan Africa as a problem region supports what has been described as the whitemans burden of civilizing Africa as a rationale for imperialism after Kiplings (1899) poem of the same title. Unfortunately, this construction obscures the reality of HIV/AIDS in the region and thus researchers do not seem to generate knowledge that can be used in policy formulation aimed at curbing the spread of the virus. Jaroszs (1992) views on the general stereotyping of Sub-Saharan Africa as inferior are not unique (Danaher, 1994; Toler, 1995). There has emerged a counterview to Eurocentric constructions of Sub-Saharan Africa (Jarosz, 1992; Lussaga-Kirondi, 1992; Sanders, 1992; Yeboah, 1998). The impression generated by the oppositional construction of the region and the counterview to such constructions suggests that knowledge of the region is both incomplete and unrealistic. Power relations between Africa and the Western world (what Said refers to as the oriental versus occidental opposition) have also played a role in this oppositional construction of SubSaharan Africa (Toler, 1995). The fact of the matter is that HIV is a global virus whose implications are international and trans-cultural. Finger pointing at this stage in the epidemic will not eradicate the human toll and misery of HIV/AIDS. What is needed is knowledge that will help us understand the social dimensions of the virus and thus help us relieve human suffering from it. The long debate about the origin of HIV/AIDS, (Ankomah 1999; Harrison, 1999; Gao et al., 1999; Fennell & McNabb, 2000) although moot at this stage in the development of the global epidemic, has revealed the important role of the social sciences (such as geography) in generating realistic knowledge of the region and providing insights into the making of policy. In the early 1990s when the effects of HIV/AIDS on the region were beginning to be manifest, Barnett and Blaikie (1992) argued that the social sciences have a role to play in unraveling the nature of the HIV/AIDS pandemic in the region as well as providing input for policy formulation. Based on their eldwork in Rakai district in Uganda, they advocated that the social science research on HIV/
AIDS, although limited, was important to understand the downstream and demographic impacts, household, family, and community coping mechanisms to the virus and, the policy implications of HIV/AIDS in Sub-Saharan Africa. Since their suggestion, signicant social science research has emerged to conrm their advocacy. It is germane that the role of the social sciences in understanding the nature and effects of HIV/AIDS in Africa as well as the policy implications be ascertained. The key question of this paper therefore is what can social science disciplines, such as geography, contribute towards the generation of more realistic knowledge of Sub-Saharan Africa and its HIV/ AIDS pandemic and how best can such knowledge be used in managing the pandemic? This paper is in effect a challenge to the social science community working on Africa to reexamine knowledge generation on the region and its HIV/AIDS pandemic in an effort to inform policy that will curb the spread of the virus and relieve the human suffering, and death toll of the virus on the region and its people. To do this, the paper rst briey describes the geography of HIV/AIDS of the region in relation to other regions of the globe. It then considers the potential of geography, specically medical geography, in knowledge generation about HIV/AIDS in the region. With this basis, the paper presents the heuristic potential of geography in providing knowledge for policy on HIV/AIDS. In this regard this paper extends the work of medical geographers such as Curtis (2004); Gatrell (2002); Gould (1993); Meade and Earickson (2000); Smallman-Raynor, Cliff and Haggett (1992); in the discussion of the role of the social science in knowledge generation and policy formulation. The paper concludes with guidelines for policy formulation on HIV/AIDS in the region. Geography of HIV in Sub-Saharan Africa There is no doubt that Sub-Saharan Africa faces a major problem in terms of HIV/AIDS. Table 1 presents summary HIV/AIDS statistics on a regional basis around the globe in 2002. Table 1 reveals a denite geography to HIV/AIDS. Of the 42 million people living with HIV/AIDS around the globe, 29.4 million or about 73% live in Sub-Saharan Africa. It should be noted that the region accounts for only 9% of global population. Although the global adult prevalence rate is about 1.2% of 1549 year old cohort, Sub-Saharan Africa has a
ARTICLE IN PRESS
1130 I.E.A. Yeboah / Social Science & Medicine 64 (2007) 11281150 Table 1 Regional HIV/AIDS statistics for 1549 years around the Globe for 2002 Region People living with HIV (millions) Adult prevalence rate (%) % HIV positive who are women Main modes of transmission
Sub-Saharan Africa North Africa & Middle East South & South-east Asia East Asia & Pacic Latin America Caribbean Eastern Europe & Central Asia Western Europe North America Australia & New Zealand World
29.40 0.55 6.00 1.20 1.50 0.44 1.20 0.57 0.98 0.015 42.0
8.8 0.3 0.6 0.1 0.6 2.4 0.6 0.3 0.6 0.1 1.2
58 55 36 24 30 50 27 25 20 7 50
Hetero Hetero, IDU Hetero, IDU IDU, hetero, homo Homo, IDU, hetero Hetero, homo IDU Hetero, IDU Homo, IDU, hetero Homo
Hetero heterosexual sex; homo homosexual sex, and IDU intravenous drug use. Source: Extracted from UNAIDS/WHO, Report on the Global HIV/AIDS epidemic, 2002 at /www.who.int/hiv/pub/epidemiology/ hiv_aids_2001.xlsS.
prevalence rate of 8.8% (UNAIDS/WHO, 2002). This compares to North America with a 0.6% prevalence rate. Perhaps the only region that comes close to Sub-Saharan Africa, in terms of prevalence rate, is the Caribbean (2.4%). With these statistics, it is not surprising that the region has been blamed in some circles as the origin of the virus. For the most part HIV is spread heterosexually in SubSaharan Africa. The only other regions where this is the dominant mode of spread are North Africa and the Middle East, South and South-east Asia, and the Caribbean. All regions of heterosexual spread, like Sub-Saharan Africa, are associated with a low status of women. In all other regions either homosexuality or intravenous drug use, or both, are more important spread methods. Fig. 1 maps the adult prevalence rate of HIV/ AIDS in Sub-Saharan Africa countries. Within the region as a whole, there is also a geography of HIV prevalence. There is a concentration of HIV/AIDS in southern Africa with a sliding gradient to eastern, central, and then western Africa. Because of this sliding gradient, the nexus of southern and eastern Africa has been called the AIDS belt. Estimates of prevalence are as high as 24.1% and 20.1% in
countries like Botswana and Zimbabwe, respectively. Swaziland and Lesotho lead the region with 33.4% and 23.2% prevalence rates, respectively. South Africa, the potential leader of African development, has a prevalence rate of 18.8% and others like Ghana, Nigeria, Cameroon and Kenya have an adult prevalence rate of 3%, 3.9%, 5.4%, and 6.1%, respectively (UNAIDS/WHO, 2006). These statistics are more startling considering the abject poverty that most people of the region live in and the inability of governments to provide safety nets for citizens. The implications of such high prevalence rates for orphans, stress on health care systems, availability of drugs, and underdevelopment of agriculture, famine, and national economies are all too apparent (Barnett & Blaikie, 1992; Dowell, 1999; Harman, 2002; Lemonick, Hawthorne, & Robinson, 2000; Masland, et al. 2000). Based on these statistics, it is safe to say that the circumstances of Sub-Saharan Africa with respect to HIV/AIDS are dire. For example, Kusina and Kusina (2004) argue that HIV/AIDS is not just a health issue but also a development issue. They state that HIVs effect on agriculture in southern Africa has resulted in declines in productivity and
ARTICLE IN PRESS
Fig. 1. HIV prevalence rates in Sub-Saharan Africa (2006).
incomes that threaten food security and nutrition. The implication of this is that there is a loss of skilled labor and an erosion of assets and credit. Thus, in real terms, individuals and national development are being impacted adversely by HIV/AIDS. A logical question that this sliding gradient of prevalence rates raises is what exactly about the various regions and countries within them generates this spatial pattern of HIV/AIDS? That is, what are the underlying processes at various scales (settlement to district to national to regional) that manifest in the geography of HIV/AIDS presented
in Fig. 1? To answer this question, we must understand the nature of geography, specically medical geography, and its heuristic and predictive potentials in establishing relationships between phenomena at various scales. This is important in the light of the increasing interconnectedness (between people and places) or globalization that has emerged since the 1980s. It is this heuristic and predictive potential of geography that makes it a valuable ally in the global ght against HIV/AIDS. The broader question to address therefore is what is medical geography and what is its heuristic potential in HIV/AIDS knowledge generation and policy?
ARTICLE IN PRESS
1132 I.E.A. Yeboah / Social Science & Medicine 64 (2007) 11281150
Heuristic potential of medical geography The heuristic potential of geography, especially medical geography lies in the nature of geography, its traditions, its ideologies and its methods of analysis. For non-professionals, the nature of geography is that it is concerned with the location of mountains, rivers, countries, and their capitals. Often, Americas popular television show Jeopardy has a category titled geography that deals with these attributes, amongst others. Although geography deals with these attributes, its scope and focus are much broader and intense than that. At its core, geography (human geography to be precise) is a social science that deals with phenomena in space or place (Chisholm, 1975). These phenomena can be naturally occurring, such as rivers, mountains, climate, vegetation types, etc., or human-made phenomena, such as cities, parks, roads, societies, countries, etc. (de Blij & Muller, 1994). The concern of this paper is with human-made phenomena thus human rather than physical geography per se. Many humanities and social science disciplines deal with phenomena but the crux of geography is that it deals with the spatial manifestations of phenomena. The purpose of geographic inquiry therefore is to generate knowledge about patterns of phenomena in place, the process that underlie these patterns, and to project the implications of these patterns and processes into the future (Chisholm, 1975). Place(s) refers to a part, or all, of the earths surface. Places are dynamic, inuence peoples life chances, contribute to peoples collective memories, are socially constructed, are arenas of social interaction, and are centers of innovation and resistance (Knox & Marston, 2004). Places are interconnected and because of this, the concern of geography is with both the commonality and uniqueness of places (Hartshrone, 1959; Knox & Marston, 2004). Geographys concern with place spans three main attributes of phenomena. These are location, distribution, and interaction of phenomena with each other in places, and with place itself (Chisholm, 1975; de Blij & Muller, 1994; Fellman, Getis & Getis 2001; Knox & Marston, 2004). Four traditions are utilized in geographic analyses and it is these traditions that generate questions that give geography its heuristic value. These traditions are human-land, spatial, regional, and earth science traditions (Pattison, 1964). Meade and Earickson (2000) show how these traditions have been used in medical geography and the kinds of
questions that they generate. For example, the human-land tradition has been at the core of the study of ecology of diseases since it focuses on the nexus of environment and culture. The earth science tradition has also been included within the cultural ecology of disease approach since it concerns itself with how environmental factors inuence diseases (Meade & Earickson, 2000, p. 8). The spatial analysis tradition has been the most inuential in medical geography partly because of its concern with precision of location, distribution and interaction (diffusion) of medical phenomena. As Meade and Earickson (2000, p. 9) state spatial analysis is so intrinsic to geographic thinking that many geographers would nd it strange to discuss it separately. The regional tradition reduces variance through classication thus regions like Sub-Saharan Africa that exhibit a high prevalence of HIV can be differentiated from others like Europe and North America that have low prevalence rates. In all the other traditions, methodologies of spatial analysis, especially cartography and geographic information systems (GIS) are utilized. GIS has become an important tool in revealing spatial patterns that geographers deal with. For example, a map of HIV/ AIDS prevalence rates in Sub-Saharan African countries can be overlain on a map of elevation in the region to reveal the close relationship between HIV/AIDS and topography. As to whether the relationship revealed by this simple GIS is meaningful or spurious is addressed by geographic analysis concern with processes. These four traditions are interrelated and geographers work within and between all four of them. Often it is the traditional geographic tools of maps and GIS that unite geographic enquiry within these traditions. It is almost impossible to speak of the spread of diseases without referring to attributes of origin, distribution and interconnectedness or diffusion as Gould (1993) does in his analysis of the AIDS pandemic. Gould (1993) uses tools of spatial analysis to discern or reveal the slow plague of HIV/ AIDS in the United States (as a region). He illustrates how issues of poverty and a culture of drug use and avoidance of condom use have enabled HIV to spread from Africa to the Bronx in New York City. Thus, not only is the analysis one of spatial analysis but it considers the regional question, the human-land question, and the ecological questions that arise out of the four traditions of geography. These four traditions will guide the analyses in this paper.
ARTICLE IN PRESS
The value of these geographic traditions is that they raise revealing questions that guide research. In general, Amedeo and Golledge (1975) identify six such questions that originate out of these traditions and provide geography with its heuristic value. Meade and Earickson (2000) have modied these questions to tease out their relevance to medical geography in particular. For this paper, these questions are tailored to specically help in revealing the geography of HIV/AIDS in Sub-Saharan Africa. First, why is there a high concentration of HIV/AIDS in Sub-Saharan Africa relative to other regions, and is there a uniformity of distribution in various sub-regions of the region? Second, why does HIV/AIDS spread in particular ways, and how do culture and environment (both broadly dened) inuence the location, distribution and diffusion of HIV/AIDS? Third, how do movements of populations affect HIV/AIDS spread in various parts of Sub-Saharan Africa? Fourth, do attributes of people such as their class or gender affect their vulnerability to HIV/AIDS? Fifth, how does access to health facilities such as clinics, education, military installations, etc. affect vulnerability and susceptibility to HIV/AIDS? Sixth, how does the context of political economy (poverty, war, failed states) inuence the spread of HIV/AIDS and how do these attributes interact to manifest the spatial patterns of HIV/AIDS found in the region? It is obvious from the nature of these questions that all four traditions combine in revealing the geography of HIV/AIDS in Sub-Saharan Africa. Geographic enquiry is not only concerned with spatial patterns but also focuses on underlying processes that explain spatial patterns of phenomena (Cloke, Philo, & Sadler, 1991; Johnston, 1991). In this regard, the process of generating geographic knowledge is just as revealing as the knowledge generated. For example, why is the distribution of HIV/AIDS in Sub-Saharan Africa graduated from sub-regions to sub-region? Geographers seek deepseated reasons why phenomena are located, distributed, and interact the way they do. Because of this, ideologies of the social sciences such as positivism, phenomenology, realism, structuralism, and post-modernism (see Cloke et al., 1991; Johnston, 1991) underlie medical geographic enquiry. As Gatrell (2002) shows geographic analysis can be informed by ideologies of positivism that facilitate spatial analysis and the use of quantitative methods as well as through social interaction approaches such as structuralist (such as realism),
structuration, and post-structuralist approaches (such as phenomenology). Structuralism, structuration and post-structuralist ideologies engender qualitative methods of analyses and are more in line with the human-land, regionalization and earth science traditions. As both Kearns (1993) and Kearns and Joseph (1993) argue, the engagement of social theory debates (such as structure/agency) is crucial to medical geography. Thus, they call for a reformed medical geography that considers space, not just as a geometric entity but also, as an experienced space in which socio-spatial conceptualizations that are reproduced by societal structures occur. This has advanced the eld of medical geography to consider socio-cultural space as a factor in health and wellness (see Curtis, 2004; Gatrell, 2002). In the light of the importance of ideology in generating medical geographic knowledge, recent research has focused on the value of place in inuencing inequality and accessibility of health care and wellness. For Gatrell (2002), therefore, health should be contextualized within a social environment of place that considers inequality in service provision and utilization, migration, air and water quality, and the effects of globalization on health care in particular places. Similarly, Curtis (2004) focuses on how power, poverty, wealth, consumption, and pollution affect health and wellness in particular landscapes. Kalipeni and Oppong (1998) therefore utilize a political ecology approach to examine the geographies of exile and refugee movements and their implication for re-emerging and newly emerging infectious diseases such as Ebola and HIV/AIDS in various places in Africa. Disruption of livelihoods, sanitation, crowding and food shortages, reproductive health, and trauma and mental health needs of refugees increases their vulnerability to such re-emerging and new diseases in particular places. Irrespective of the tradition and ideology used in medical geographic research, methodology is an important component of the heuristic potential of medical geography. Depending upon the tradition and ideology utilized, the methods used in analysis can range from quantitative through qualitative and a combination of the two. If data is quantiable (e.g. movement of populations), such data can be manipulated in a positivist manner and incorporated into maps and a GIS to aid in, not just spatial analysis and regionalization, but also in teasing out underlying processes that inform
ARTICLE IN PRESS
human-environment relationships. In cases where data is of a qualitative nature, various qualitative methods can be used to establish associations that may reveal, not just knowledge but also, causal relationships between phenomena. Smallman-Raynor et al. (1992) utilize quantitative methods to generate the London International Atlas of AIDS for various regions of the globe. For each region, they use a combination of maps, tables, graphs and other quantitative tools to depict the geography of HIV/ AIDS. This methodology falls within both the spatial analysis and regional traditions and they focus on establishing relationships often of positivist causality. In this case attributes such as measurement, scale, and visualization are of prime importance. Yet, for other analysis, qualitative methods that consider interconnectedness of phenomena in the political economy of society and the role of culture and environment of particular places is stressed (see Gould, 1993; Kalipeni & Oppong, 1998). In this regard the human-land tradition which stresses cultural ecology is paramount. More often than not, a combination of both quantitative and qualitative methods that stress the importance of place, not just a geometry but, as social-cultural construct is necessary for revealing attributes of the geography of health of a region (see Curtis, 2004; Gatrell, 2002). This hybrid method characterizes the analyses presented in this paper. Last but not least, in terms of the heuristic potential of medical geography, is its value in policy formulation. Projections of how patterns and processes of phenomena will change through time imply that the utility of medical geographic inquiry for policy are immense. The questions that geographers deal with in terms of policy relate to the potential outcomes of spatial patterns and processes of phenomena and how change or continuity can be maintained (Chisholm, 1975; Knox & Marston, 2004). Effectively, the policy implications of phenomena in various places are important dimensions of geographic inquiry. This implies that geographers have to be skilled in understanding the interconnectedness of phenomena at various scales of places. These places can range from the human person through neighborhoods, communities, settlement, district or county, nation, regions, and the globe. Often, what happens in one place will have implications for other places. This interconnectedness of places and phenomena within them has increased in economic, cultural, and political terms since the 1980s under the process of globalization.
Thus, the heuristic potential of medical geography lies in the nature of the discipline itself, its traditions and underlying ideologies, its methods and its projective value. In this paper, a combination of the regional tradition (the focus is on SubSaharan Africa), the spatial analysis tradition (in which location, distribution and interconnectedness are studied), and the human-environment tradition (that focuses on the nexus of culture and environment both broadly dened) will be utilized at various stages. The underlying ideology will be informed by realism in which deep-seated structures interact with human agency to manifest particular spatial patterns in specic locales or places will be utilized. More importantly, space in this paper is conceptualized as a social-cultural construct rather than geometric space. The implication for methodology is that both quantitative methods that help explore relationships and qualitative methods that help explain deep-seated interconnectedness in places will be utilized to reveal the geography of HIV/AIDS in Sub-Saharan Africa. It is based on these kinds of analyses that projections of HIV/ AIDS can be made. This paper therefore extends the work of medical geography in knowledge generation and policy formulation about HIV/AIDS in Sub-Saharan Africa (see Curtis, 2004; Gatrell, 2002; Gould, 1993; Kalipeni & Oppong, 1998; Meade & Earickson, 2000; Smallman-Raynor et al., 1992). It is the concerns of medical geography, described above, that give it its heuristic and predictive power as a social science. It is the understanding of the interconnectedness of places and their phenomena depicted in Fig. 2 that medical geography can provide us in generating knowledge about, and managing HIV/AIDS and its spread. Medical geography is, therefore, in a unique position to provide a macro-level framework within which micro-level social science studies like the ones presented in this collection can be contextualized and used in policy formulation. In a sense, Barnett and Blaikies (1992) prediction of the role of the social sciences with germane to geography today. Generating knowledge about Sub-Saharan Africa: HIV/AIDS web A medical geographical analysis of HIV/AIDS in Sub-Saharan Africa reveals that the region is caught within an HIV/AIDS web that will surely continue to cause hardship and suffering or will potentially
ARTICLE IN PRESS
History
Environment and Natural Resources
Eurocentrism and Racism
HIV/AIDS Culture Gender Construction
Globalization and Poverty
Government Attitude
Fig. 2. Sub-Saharan Africas HIV/AIDS web.
result in an extinction of Sub-Saharan Africans unless more realistic knowledge of the virus and its spread in the region and policies are implemented. This HIV/AIDS web encompasses the culture and environment of the region and illustrates the ecology of HIV/AIDS. Yet the web illustrates variance in HIV/AIDS in various places and scales of the region. Also, various places or spaces of the region are socio-spatial constructs that embody the coming together of differential history, culture, politics, economics and environments. As Fig. 1 illustrates, HIV/AIDS prevalence rates are much higher in southern Africa than in eastern, central and western Africa. This is the rst dimension or the macro nature of the pandemic in Sub-Saharan Africa and it illustrates that regionalization at various scales is important in the pattern of spatial distribution of HIV/AIDS. This level of analysis begs the question why such spatial variations from place to place exist in Sub-Saharan Africa. The second dimension, or the micro nature of the pandemic, is depicted in Fig. 2 which conceptualizes factors that account for the HIV/AIDS pandemic. Spatial variations in history, environment and resource endowments, mobile populations, Eurocentrism and racism, culture, gender construction, government attitudes, globalization and increased
poverty of Sub-Saharan Africans have contributed toward the explosion of HIV/AIDS in various parts of Sub-Saharan Africa. In reality, papers presented in this collection are at the micro-scale and they t into the conceptualization of the HIV/AIDS web where underlying process help to understand why the spatial pattern identied in Fig. 1 exist. By themselves, none of the factors identied in Fig. 2 will place Sub-Saharan Africans in peril but their coming together has conspired to promote an environment conducive to the proliferation of HIV/ AIDS. In effect the web of these factors is stiing the development of the region because it is loosing its human capital and increasingly resulting in governments of the region spending their scarce resources on taking care of HIV/AIDS related problems rather than on developing their economies. For example, estimates are that because of its high HIV/AIDS prevalence rate, all the economic and social gains made by Botswana will be eroded by life expectancy falling to as low as 38 from about 70 years (Lemonick et al., 2000). The mutuality of factors in the HIV/AIDS web identied in Fig. 2 are the underlying processes to the spatial pattern revealed in Fig. 1. It is the interconnectedness of these underlying factors that reveals what is really happening in various places of the region and this is
ARTICLE IN PRESS
where medical geography has analytical and heuristic relevance. Since space is a socio-cultural construct, the manifestation of each variable in the web will differ from place-to-place in Sub-Saharan Africa and in some places, some variables may not even be a factor of signicance. For example, racist policies of colonialism did not play a role in the emergence of a migrant labor system in West Africa as it did in Southern Africa. Yet, cultural cherishing of child bearing and its implication for the limited use of condoms in sexual relations seems to be universal in the region as a whole. An elaboration of the HIV/AIDS web is necessary, not only to understand its conceptualization but also, to reveal how it can be sued to generate realistic knowledge of HIV/AIDS in Sub-Saharan Africa. The labeling of factors in the web is only an abbreviation for a series of rather complicated variables. Environment and natural resources refers to the physical features of the region (such as climate, vegetation, topography, etc) and the regions raw material wealth or opportunities and constraints that its physical features offers it people in their development efforts (Osei & AryeeteyAttoh, 2003; Stock, 2004). Some of these opportunities include gold, diamonds, copper, cocoa, cotton, tea, tobacco, corn, and lumber. The regions indigenous, Islamic and western heritages (Mazrui, 1986; Yeboah, 2003a), and the conict between them, make up the totality of the regions history but in the context of HIV/AIDS, the colonial period and its policies and the kinds of conicts that it engenders with indigenous and Islamic heritages are of importance. For example, is it coincidental that areas which experienced the last stand of colonialism (mostly Southern Africa) seem to have the highest prevalence rates of HIV/AIDS in the region? How has this historical fact affected the psyche of populations and governments in these places to put HIV/AIDS on the back burner in order to ght for independence in countries such as Mozambique? These are germane questions that are in many ways related to the emergence of mobile populations within Sub-Saharan Africa, especially in Southern and Eastern Africa. Mobile populations are primarily migrant workers who have to seek work in other places other than their origin. Often, SubSaharan Africans engage in these activities because colonial racist policies (see Crush, Jeeves, & Yudelman, 1991; Jarosz, 1992) structured economic activity to occur in spaces separate from social spaces. Examples of mobile populations are
military personnel, transportion workers, mine workers (especially in Southern Africa), construction and industrial workers, agricultural workers, informal traders, domestic workers, sex workers, and refugees and internally displaced persons due to civil wars (IOM/UNAIDS/SIDA, 2003; SmallmanRaynor & Cliff, 1991). In the context of the HIV/AIDS web, culture refers to various culture traits that are common to people of the culture realm. These traits dene the ideological, sociological, and technological subsystems of the cultures found among peoples of the region (Fellmann et al., 2003). Perhaps the most misunderstood aspect of sub-Saharan Africa is its culture and this misunderstanding of its culture has contributed toward the region being stereotyped as the dark origin of HIV/AIDS. Culture plays a very important role in providing an environment for the spreading of the virus in various places in SubSaharan Africa (Caldwell & Caldwell, 1996). Even though gender and its construction are a part of culture, this concept has been separated form culture in the HIV/AIDS web presented in Fig. 2 for one specic reason. Table 1 shows that HIV/ AIDS in Sub-Saharan Africa is increasingly gendered in its victims and effects, thus the specic gender constructions within cultures of this region should be considered as a key variable in the spread of the virus. The roles and expectations in terms of valuing gender, sexuality, economics, and power relations that society places on both men and women in various Sub-Saharan African societies will be used both as explanatory and exploratory tools for understanding and informing policy on HIV/AIDS, respectively. Globalization and its ability to cause or intensify poverty through structural adjustment programs (SAPs) have inuenced behaviors of both individuals and governments with respect to HIV/AIDS risk and attention, respectively. Because of the poverty in various countries of the region, womens dependency on men has increased resulting in their powerlessness in sexual decision-making. In addition to this, the role of the state in this era of neoliberalism, has meant that access to, and availability of, medical facilities and care (as well as other social services such as education) have been restricted (Ko, 1994; Konadu-Agyeman, 2000). What does the minimalist agenda of neoliberalism mean for the spread and ght against HIV/AIDS? This question becomes more important in the context of the initial inaction and ambivalence of
ARTICLE IN PRESS
many national governments in the region to take bold actions against the spread of HIV. Increasingly, this attitude seems to be changing but what will the HIV/AIDS situation be like today in countries like Uganda and Zimbabwe if governments had not taken, or had taken, specic actions, respectively. The coming together of these factors provides a web or conceptual framework of cultural ecology within which to analyze processes associated with HIV/AIDS in various sub-regions of Sub-Saharan Africa. Since none of the factors in the HIV/AIDS web by itself can fully explain the high incidence of the virus in Sub-Saharan Africa and the spatial variations within it, it is apparent that these factors are interconnected and they interconnect places at various scales within the region with each other and with other places around the globe. In a sense therefore, the variables that help us understand the spread of HIV/AIDS in Sub-Saharan Africa lend themselves to geographical analyses since they are the underlying factors behind the spatial pattern revealed in Fig. 1. Illustrating heuristic potential of medical geography in knowledge generation How these variables of the HIV/AIDS web can provide realistic knowledge of the pandemic in the region is provided here solely as an illustration. Since this illustration is not intended to be exhaustive of the totality of variables, only a selection is used here. Other variables can be interjected in this illustration. Obviously, the hot and humid environmental conditions found in the tropics have provided fuel for the region being singled out as the origin of the virus. Although such speculation may sound ridiculous, the physical geography of the region has had more pervasive effects on HIV/AIDS than the mere opportunities that the tropics may provide for the breeding of bacteria, viruses, fungi, and other parasites. SubSaharan Africas physical environment has been both a blessing and a curse. Fig. 3 shows both a generalized topographic map of Sub-Saharan Africa. Superimposing Fig. 1 on Fig. 3 will generate a rudimentary GIS that illustrates spatial associations between HIV/AIDS prevalence rates and topography. There is no doubt that both southern and eastern Africa have the highest HIV/AIDS prevalence rates and higher land (high Africa). West and central Africa (low Africa)
have the lowest of both phenomena in the region. Initially, this relationship between HIV and higher land may look spurious but geographical analysis shows that this relationship can be used to explain what is happening in the region. The high prevalence of HIV/AIDS in the AIDS belt (southern and eastern Africa) is strongly related to the interconnectedness of physical environment, history, mobile populations, and Eurocentric and racist views of the region. The concentration of mineral wealth in southern Africa and the modied temperatures of the southern and eastern African plateaus (Osei & AryeeteyAttoh, 2003; Stock, 2004) contributed to European settler colonialism of the region rather than the pure extractive colonialism of West Africa (Mazrui, 1986; Yeboah, 2003a). A map of mineral wealth of the region as a whole reveals that southern African countries are blessed with minerals such as gold, diamonds, copper, uranium, chromite and cobalt. The gold and diamond mines of South Africa and Zimbabwe that Europeans established during the colonial era were worked by African labor. The history of colonialism in this region is characterized by the settlement of Europeans. Moderated temperatures that the relatively elevated topography of this region provides aided this. Most of southern and eastern Africa lies closer to 4500 ft above sea level, whereas most of West Africa lies closer to 1500 ft above sea level. Because of the lapse rate (for every 300 ft increase in elevation, temperatures drop by one degree Fahrenheit) temperatures in southern (and eastern) Africa are about ten degrees cooler than in west Africa. Eurocentric European settlers believed that subhuman (see Jarosz, 1992; Livingstone, 2000; Toler, 1995) SubSaharan Africans should be excluded from social aspects of European life yet their labor was needed for the extraction of these economic resources such as gold, diamonds and copper. Thus, Black workers were included in economic extraction of resources, albeit peripherally. It is this kind of racism, and its social exclusion yet economic inclusive policy, that underlay the alleged separate development of Apartheid in racist South Africa and Zimbabwe (Christopher, 1994). The coming together of physical geography (elevation and resource endowments), history of settler colonialism, and racism was that a particular political economy emerged in southern Africa during the colonial era and this has not changed much since independence. A system of migrant labor (see ; Crush
ARTICLE IN PRESS
Fig. 3. Topography of Sub-Saharan Africa.
et al., 1991; Dale, 1995; McDonald, 2000; Wilson, 1972 for the scale and magnitude of this system and its contribution to source and destination economies in Southern Africa) was developed in this region where mostly male workers, who could provide brawn for the mines, truck drivers in East Africa (see Marck, 1999), agriculture and domestic workers (IMO/UNAIDS/SIDA, 2003) moved from countries all over Southern Africa in search of jobs, especially in South Africa. Capitalists who employed such labor were unwilling to pay for the social overhead costs, such as housing and schools for the families, so these male migrants often moved alone and stayed in mining
and agricultural camps or dormitories for substantial periods of time. Thus, the capitalistic drive combined with racism to produce a political economic system of inclusionexclusion of Black migrant labor that separated public, and even private, spaces in urban areas by race. With their wives being absent (and mining work being dangerous, for example, IMO/UNAIDS/SIDA, 2003), there was a tendency for mine, agricultural and transportation workers to use the services of sex workers to meet their sex needs. Reliance on sex workers was facilitated by the fact that women in mining towns, such as Johannesburg, had limited opportunities for employment and acquisition of
ARTICLE IN PRESS
assets and wealth. Thus, commercial sex became a way for women to make a living on their own terms in colonial towns such as Nairobi (see White, 1990). It is within such a system, that HIV/AIDS has spread so much in southern and, to a lesser extent, in eastern Africa. Once these men returned to their families for vacations, HIV/AIDS could then be spread in the source areas of these migrants. In fact, another argument in support of this view is that once men leave for the mines, for such long periods, women in the villages are susceptible to extramarital affairs for essential goods and thus their contraction of the virus (IMO/UNAIDS/SIDA, 2003, p. 48). A component of mobile populations that is not necessarily related to resource endowments but is often related to the conict between the indigenous and western heritages of the region (especially the southern part); is military deployments. Because of the nature of settler colonialism, countries in southern Africa were the last to attain independence from colonial powers. By the early 1960s most countries in west, eastern and central Africa had followed Sudan and Ghanas lead in attaining independence. Yet, Mozambique, Zimbabwe, Namibia and South Africa itself did not have majority Black rule till much later. Often the struggle for independence was characterized by civil wars (such as the guerilla civil wars that ZANU and ZAPU waged against the racist regime in Zimbabwe or the struggle for independence that FRELIMO and RENAMO rebels waged against Portugal in Mozambique and the subsequent struggle for power that ensured) or civil unrest (as in the Sharpeville Mascara and SOWETO uprisings in South Africa). Between 1963 and 1989, South Africa often waged war against UNITA in its bid to destabilize Angola. Such struggle often entailed military deployments in particular places in these countries. Considering that high HIV/AIDS prevalence rates are associated with military forces (IMO/UNAIDS/SIDA, 2003) these deployments had potentials for the spread of the virus. For example, it is rumored that the Zimbabwean armed forces had an HIV/AIDS prevalence rate of 50% during two key deployments, one in Matabeleland between 1983 and 1987 and the other in the Zimbabwe/Mozambique Biera Corridor to safeguard oil pipelines against RENAMO insurgency prior to the 1993 peace plan (Africa Analysis, 1990). Considering the susceptibility to, and high prevalence of HIV/AIDS of militaries, especially in war-torn regions such as those that
existed in southern Africa, the implications for the spread of the virus can be disastrous (see Yeager, 2000). By the very nature of their jobs (danger and loneliness) and their young ages ((IMO/UNAIDS/ SIDA, 2003, p. 29), military personnel sleep with local women (either legally or by rape) in places of their deployment and upon return home they sleep with their spouses and girlfriends. These ndings from southern Africa beg questions as to what may be happening in war-torn or war-recovering countries (such as Sudan, Liberia, Sierra Leone, D.R. Congo, Rwanda) in todays Sub-Saharan Africa. Smallman-Raynor and Cliffs (1991) regression analysis of the effect of civil war on HIV/AIDS spread in Uganda is revealing in this regard. Their view is that civil war and military deployments post-Amin era are associated with the southnorth spread of HIV/AIDS in the county. Similarly, refugees associated with civil wars have been shown by Kalipeni and Oppong (1998) to be associated with the spread of HIV/AIDS and Ebola in Africa as a whole. Mobile populations associated with wars have to be resettled and this effort seems to raise a set of circumstances that contribute to the spread of HIV/ AIDS in various countries in the region. MalazaDebose (2001) argues that post-conict societies are associated with military deployments, a breakdown of institutions such as post-trauma counseling and rehabilitation, the isolation and poverty of women, and the lack of services to adolescents who have lost their innocence and sense of purpose. Because of this, there is a tendency for violence (especially rape of women) against women, the lack of employment options that drive women to prostitution, and the breakdown of marriage-life to contribute towards the spread of sexually transmitted disease and HIV. This scenario characterizes the resettlement of war-displaced people in countries such as Angola, Rwanda, Democratic Republic of Congo, Liberia, and Sierra Leone. In east Africa, the mobile population that has been studied most, in relation to HIV/AIDS, by social scientists is truck drivers. Marck (1999) describes sexual cultures of truck drivers in a variety of African and Asian counties in relationship to HIV/AIDS spread. For Kenya and Zimbabwe he argues that heterogeneous pattern of sex cultures is practiced by truck drivers. This view is supported by Mupemba (1999) for Zimbabwe. Even though a large number of drivers claim to be abstainent on the road, others regularly have extramarital girlfriends, or rely on sex workers. These drivers do not
ARTICLE IN PRESS
seem to be reducing their sex partner numbers even though they tend to use condoms and rely upon sex clinics where available. Marcks (1999) view is that the continued reliance on numerous sex partners by drivers is a reection of resistance to change (see Amuyunzu-Nyamongo et al. 1999; Varga, 1999; Malungo, 1999), the belief that it is unmanly to reduce sex partners and the fact that these drivers are on the road for long periods of time, thus their dependence on numerous sex workers. Sex cultures of mobile populations such as long-distance truck drivers who ply routes that serve landlocked countries in Sub-Saharan Africa (e.g. Uganda, Malawi, Zambia, Congo, Mali, Chad, Bukina Faso) and their surrounding countries form which goods are transported to and fro will reveal many cultural dimensions of the HIV/AIDS pandemic in the region. If the connection between physical geography, Eurocentrism, mobile populations, and history explain the high prevalence rate in southern and eastern Africa, what accounts for HIV/AIDS in other parts of Africa such as west and central Africa? In these two sub-regions the interconnectedness of culture, gender construction, and poverty help to explain the spread of HIV/AIDS. This is not to say these factors are not important in southern and eastern Africa but, unlike southern and eastern Africa, culture, gender construction and poverty take center stage in west and central Africa. In addition, governmental attitudes, and global factors also help explain the spread of HIV/AIDS in the region as a whole. Perhaps one of the most difcult issues to write about in terms of HIV/AIDS in Sub-Saharan Africa is culture(s). This is because one may fall to the fallacy of portraying African culture as inferior. Culture refers to the learned ways of life of a group of people. It encompasses the interrelated sociological, ideological, and technological subsystems of the group (Fellmann et al., 2001). A groups attitudes and beliefs towards sex, men and women, and new technologies such as condoms are all part of their culture. Culture is dynamic and is subject to change. It is the context of changing culture that provides hope for the ght against HIV/AIDS in Africa. Numerous attributes of African culture have been linked to the spread of HIV in the region. The belief that HIV is a result of witchcraft (Anderson, 2002), that condoms contain the virus, that eastern Africans, for example, prefer skin-on-skin (SOS) sex and that in South Africa for example, gang raping
of girls by their soon-to-be jilted boyfriends and their friends in a practice called ifoli have been documented in popular literature (Masland et al. 2000). The role of cultural practices, such as sexual cleansing and levirate marriage, in the spread of the virus has been researched (Malungo, 1999). The contribution of polygyny toward the spread of the virus has also been noted. Attitudes towards sexual promiscuity are illustrated by King Mswatis ban on pre-marital sex in Swaziland (Haworth, 2002). Although these factors are important in the spread of the virus, recent micro-level social science research on Sub-Saharan Africa suggest that attitudes towards sex cultures, multiple sexual partners, and HIV/AIDS may be changing. A focus on culture change can, therefore, help stem the tide of the pandemic. For example, Mbugua (2004) argues that unlike a mere generation ago, when sex was a taboo topic between parents and the children of middle-income families in urban Kenya, attitudes towards talking about sex and sex education seem to be changing. Parents seem to be talking more about sex with their children. In the past, traditional barriers such as European Christianity, middle-income status, inept sexual education, and the construction of sexual language as indecent language, implied that houseboys and house-girls were the main agents of socialization of middle-income urban children about sex. Today though, Kenyan middle class parents and their kids seem to be dancing more to the tune of the song Lets talk about sex, baby. Also, Chimbiri (2004) argues that although condom use seems to be an intruder in marriage in Malawi it seems to be more acceptable outside marriages by even women whose husbands have extra marital affairs. This means that both mens and womens attitudes towards condom use are changing even when husbands are not faithful to their wives. So even though exclusivity is not the norm in marriage, condom used is discussed more often. This is not to say that there is no resistance to sex culture change and condom use (see Amuyunza-Nyamong et al., 1999; Meursing, 1999; Preston-Whyte, 1999). In some regards, changing attitudes to condom use supports Zulu and Chepngenos (2004) assertion that increasingly men and women (as spouses) in Malawi are having more conversations about condom use and HIV/AIDS. This reects, among other things, the faith that they have between them and the fact that increases in both mens and womens networks and womens knowledge of
ARTICLE IN PRESS
acquiring HIV makes the discussion of sex more rampant. Thus, condom use, which is behavioral, is what most African governments stress. Dodoo and Klein (2004) suggest that the kinds of relationships that people engage in, affects sexual exclusivity and sex culture change. Their view is that women, especially, perceive marriage and cohabitation as having protective effects for them. As to whether this is true of class status or rural or urban residence is yet to be determined. Yet, Kalipeni and Ghosh (2004) argue that even though there is much awareness and worry amongst men in Malawi about HIV infection, limited condom use suggests that high awareness is not necessarily congruent with practices of HIV prevention. Similarly, Moore and Oppong (2004), based on a sample from Lome, Togo in a consideration of people living with HIV positive partners, state that condom availability does not necessarily translate into condom use, despite the risk of not just infection but also recombinant infection. Moore and Oppong conclude that condoms are still seen as intruders in sex, when love and trust are the basis of sex. Thus, denial of HIV infection, the desire for child bearing, power relations between men and women, and difculty of changing habits are some of the factors behind such barriers to behavior change (AwusaboAsare, 1999; Caldwell, 1999). Sub-Saharan African cultures have obviously contributed towards the phenomenal spread of the HIV/AIDS so culture change is an important part of arresting the spread and devastating effects of the virus. Moore and Oppongs (2004) association of HIV/ AIDS with gendered power relations seems to support a large literature that suggests that gender construction in Sub-Saharan Africa is at the heart of the explosive spread of the virus. As Table 1 shows, HIV/AIDS in Sub-Saharan Africa is gendered. Mill and Anar (2002) in an analysis of gender and HIV in Ghana (based on HIV infected women) conclude that the unequal relations between men and women make women dependent upon men for basic elements of sustenance therefore increasing their risk of HIV infection. Even though they do not categorically refer to androcentrism and patriarchy, their argument is that the unequal access of women to education, especially in situations where one parent (obviously the father) dies while girls are young means womens life-chances, as adults, are limited. They therefore rely upon men to provide their basic needs. Thus, women are not able to insist on condom use by their spouses. In
addition, the value of fertility of women and the purpose of marriage (ensuring immortality through procreation) in African cultures makes it more difcult for women to be empowered in their sexual relations with men. Gender inequality is often associated with violence and Jewkes, Levin, and Penn-Kekana (2003) conclude that because of gender inequality, women are prone to violence in their relationships with men and thus are powerless in terms of protecting themselves with condoms. Mkandawire-Valhum (2004) supports some of these views with respect to domestic workers (house-girls) in Malawi. Her ndings are that house-girls usually end up in their line of work because of changing life circumstance such as the loss of a parent, separation of parents, or being orphaned by HIV/AIDS. In situations where their employers husbands try to take advantage of them, some house-girls endure the sexual abuse and continue to live with their employer because the girls lack alternatives. Those who leave, fake sickness since they cannot take the assault anymore. Mkandawire-Valhmus work shows the intersection of gender construction and poverty in Africa. Obviously the inferior construction of women in some African cultures is a culture trait that needs to change if the spread of HIV/ AIDS is to be controlled and to a certain extent, Zerai (2004) is right in asserting that liberation of women will go a long way to help curb the spread of HIV/AIDS in Zimbabwe. Sub-Saharan Africas poverty seems to be an underlying factor in the spread of HIV/AIDS. The World Bank (2001) argues that there has been an Africanization of poverty with income poverty getting worse and social indicators of poverty increasing more slowly in this region relative to others. Estimates from the World Bank are that one in two Africans lives on less than a United States dollar a day and 205 million out of the estimated 580 million population of the region had no access to health care in 1995 (World Bank, 2001, p. 6). The stark reality of abject poverty implies increasing dependency of people, especially women, on men who provide for their needs. The arguments of Mill and Anar (2002) cited above are relevant here. Basic elements of survival that will not require women to submit to mens sexual desires in the Western world have been known to make women submit to men in African countries. So, African places constructed as poor affects life chances of women by making them dependent. Although a lot
ARTICLE IN PRESS
of magazine articles talk about this, limited research on the effect of poverty on HIV/AIDS transmission seems to exist. Obviously, the need for such research is paramount. In this regard, Masanjalas (2004) attempt at developing a framework for the nexus of HIV/AIDS and poverty is a welcome effort. His view is that poverty reduction strategies have under-predicted either the economic inputs or the demographic factors. To arrive at more realistic models he considers livelihood frameworks that link agricultural and business resources. His ndings so far indicate that when cultural differences are considered, because men in southern Africa, for example, migrate and women are invincible in their households, shocks such as death of men affect households differently depending upon their mix of agricultural and business assets. The vulnerability of people in rural areas to HIV/AIDS is therefore affected by their economic circumstances. The urban implications of such a model should be revealing since van Donk (2001) argues that there is a mutually reinforcing relationship between poverty, inequality, and HIV/AIDS and that urban poverty exacerbates the spread of the virus. Poverty is worsened by the inability of SubSaharan African states to provide health care for their populations. This to a large extent has been attributed to the peripheral linkage of the region to todays global economy through structural adjustment programs (SAPs). Although there is debate as to whether SAPs have had positive or negative effects on Sub-Saharan Africa (see Konadu-Agyeman, 2000; Yeboah, 2000), it is evident that the effects of SAPs seem to be sector specic (see Ko, 1994). There, however, is no doubt that the health sector of Sub-Saharan African countries has been adversely affected by globalization. After all, the minimalist government and the privatization emphasis of neoliberalism that underlies SAPs demands that governments spend less on social services such as health and education, and emphasize more on cash and carry and cost recovery systems (Konadu-Agyeman, 2000). Not only are governments unable to provide medicines, hospital beds, and basic medical equipment for their populations, salaries and conditions of service for health workers trained in these countries have deteriorated relative to those in the Western world. With shortages of health workers in the Western world, it is not surprising that African trained health workers, such as physicians and nurses, have
left their countries for greener pastures elsewhere. A recent article in The Lancet discusses how the loss of health professionals from Sub-Saharan Africa is affecting health care delivery for already ailing systems. Eastwood et al. (2005) argue that with the loss of 5880 healthcare professionals from South Africa, 2825 from Zimbabwe, 1510 form Nigeria, and 850 from Ghana in 2003 alone, countries whose healthcare systems are already facing daunting challenges also have to contend with further attrition of health professionals due to the loss of life and productivity form HIV/AIDS on the health sectors of these countries, Apart from poverty and the loss of health professionals through brain drain, another implication of globalization for HIV/AIDS in Sub-Saharan Africa is that treatment of people orphaned and living with HIV/AIDS has become a problem for most countries to the extent that they rely on international aid. For the Democratic Republic of Congo, Lombela (2004) argues that access to HIV/ AIDS drugs from international donors has had very limited coverage of only one percent of infected people. His view is that for the 3 million people target by 2005, there has to be political commitment and the empowering of national programs rather than government ofcials enriching themselves with grants from abroad. Considering that healthcare budgets for most Sub-Saharan African countries are miniscule, efforts such as the World Health Organizations (WHO) 3-by-5 target will face challenges of inadequately funded healthcare systems to work with. This issue of Sub-Saharan Africas poverty and affordability is stressed by Craddocks (2004) assertion that the absence of a global HIV vaccine is tied to poverty of the people that would benet most from it; Sub-Saharan Africans. Her view is that because of patent laws that companies with retroviral drugs on the market enjoy, the incentive to develop vaccines that will compete with such drugs is rather low. This is more so since the most infected region (Africa) can least afford vaccines and thus can least contribute towards the prots of drug companies. It is therefore not surprising that the National Institutes of Health (NIH), rather than drug companies, fund research on the potential 30 vaccine candidates under development. Craddocks view is that the politics of NIH funding, which require that vaccine testing is incompatible with condom use, requires that private-public partnerships would be a good way to develop vaccines.
ARTICLE IN PRESS
Governments in Africa have a major responsibility in curbing the spread of HIV/AIDS. It is therefore not surprising that President Thambo Mbeki of South Africa made the headlines when he wondered whether HIV actually was the underlying cause of full blown AIDS (Karon, Hawthorne, & Tumulty, 2000). Similarly, King Mswati of Swazilands ban on sex for maidens for the next ve years was featured in Marie Claire (Haworth, 2002). In his case, the publicity may have been more a result of his breaking his own imposed ban! The issue though is that the role of government in prevention through education is paramount and part of the success of Uganda in reducing its HIV prevalence rate has been attributed to the role of the state in embarking upon education and preventive measures (Lemonick et al., 2000). There seems to be limited academic research on ` -vis HIV/AIDS, yet the role of the African state vis-a state policies and their formulations are relevant. This is because policy formulation on HIV/AIDS seems to be inuenced by global players. Watkins (2004) analysis of HIV policy in Malawi reveals that discord exists in the construction of women and sex between what international agencies, such as the WHO, the state government in Lilongwe, and what Yao women in Balaka district in Malawi actually do. Scale, which reects geography, in policy is important because the state government policy treats women as passive agents who do not desire sex, yet the women in Watkins free history study reveal that even though men have extra marital affairs because of their ability to provide for women, women actually enjoy sex! Women should therefore be seen as active agents in policies designed to prevent infection of HIV/AIDS. States responses to HIV/AIDS are a critical part of reducing the death and devastation of the virus. Ugandas success of reducing HIV/AIDS prevalence rates from about 20% in the 1980s to about 6.7 % today has been partly attributed to deliberate state action to educate citizens about HIV/AIDS. However, it has been argued that the relative success of Uganda in reducing it HIV/AIDS prevalence rate is a reection of the dying off of HIV positive persons in the 1980s rather than the direct effect of state policy. Despite Ugandas efforts, other governments in the region have been characterized by inaction. For example, in order to ensure the continued inow of tourists, the Kenyan government was very slow to admit it had an HIV/AIDS problem. Similarly, inaction on the part of Zimbabwes
President Mugabe earlier on in the pandemic and South Africas President Mbekes skepticism about the link between HIV and AIDS have been blamed for the explosion of the pandemic in their respective countries. Based on the experience of countries like Uganda and Zambia, increasingly, countries like China and India are beginning to acknowledge the importance of state openness about HIV/AIDS in their countries as part of their overall effort to minimize the spread of the virus (Hwang, 2001). None of the factors in the HIV/AIDS web used to illustrate the above sets of interconnectedness is new. For example, historians have long documented the nature of settler colonialism. There is welldocumented knowledge of the racism under Apartheid. The physical geography of southern and eastern Africa is nothing new. Migrant labor in southern Africa has been well researched, and commercial sex work by women is well known. The effects of culture on sexuality and the spread of sexually transmitted diseases are well known, the link between unequal gender relations and empowerment is also not new. The effects of poverty on health access are well documented. The ability of medical geography to tie such knowledge together in a cultural ecology framework which recognizes variation from place to place as well as the importance of place not just as geometry but as socio-culturally constructed, is what makes it revealing. Geography, because of its concern with location and distribution of phenomena in places at different scales, interconnectedness between phenomena in places and between places at different scales has the potential of revealing to us the nature of HIV/AIDS in the Africa. This is by utilizing both quantitative and qualitative techniques of analysis that reveal spatial patterns and identies processes that underlie such patterns. Thus, the nature, traditions, ideologies and conceptualization of space that characterize geography make medical geography uniquely positioned to understand HIV/AIDS in Sub-Saharan Africa. Apart from medical geography revealing such knowledge, it can also help project trends in the future. This implies that there is policy utility to geographic analysis. Medical geography, therefore, has the potential to provide us with a macro framework for making connections between micro studies like the ones presented in this special issue. More importantly, geography can point us in directions of policy that will help relieve the toll associated with HIV/AIDS in Sub-Saharan Africa.
ARTICLE IN PRESS
Medical geography and HIV/AIDS policy in SubSaharan Africa McGraths (2004) view is that prevention measures or policies on HIV/AIDS have mostly been behavioral rather than structural and biomedical in nature. There is no doubt that consideration needs to be given to those sets of policies that will inuence behavior (these will rst be addressed). Equally, policies that will change structures and potentially nd biomedical solutions to the pandemic in the region should also be given serious attention. Considering what has been presented in this paper so far, Barnett and Blaikies (1992, pp. 15277) strong sentiments of the value of the social science in HIV/AIDS research needs to be revisited. In their concluding chapter, they provide elements of a way forward and stress the role of non-governmental agencies (NGOS) and information and education provision for populations, as two important ways forward. Social science research on HIV/AIDS in the region reinforces Barnett and Blaikies initial suggestions but the heuristic model presented here suggests that more than behavior-changing policies should be addressed. In addition, structural and biomedical aspects in policy making should be considered. Irrespective of its nature, caution should be made about policy formulation. The purpose of policy should not be to generalize for the region as a whole or prescribe specic programs. Rather, the culture specics of each place or sub-regions should be emphasized in policy. After all, geographys concern with place is about both the commonalities and uniqueness of places (Knox & Marston, 2004) so variance between places should not be ignored. The cultural-ecology framework of the HIV/AIDS web provided in this paper provides us the opportunity to establish connections and relations within variables in particular places. We can better interpret the specic situations of places because of the crosscounty and cross-cultural comparisons that the framework offers. Thus, the unique yet similar occurrences of HIV/AIDS in different places within Sub-Saharan Africa can be captured in policy formulation. The implication of this is that certain variables within the framework will be more important than others in specic places, and vice versa. Thus, we should expect to formulate differentiated policies for specic cases yet, the broad framework of policy will bear similarity all over the region and differences across space will be of degree rather than kind.
Following Barnett and Blaikies (1992) lead, a rst way forward to try ease the suffering and devastation inicted by HIV/AIDS is to consider behavioral change through various ways to educate populations in the region. This is especially the case for mobile populations such as migrant workers (in mining, agriculture, construction, manufacturing, informal trade, and domestic work), military personnel, truckers, and internally displaced persons due to war, for example. As research shows, these groups, because of the nature of their work and the loneliness experienced due to long separation from family members, are vulnerable to sex outside marriage with potentially numerous partners and are least likely to protect themselves by using condoms (see Malaza-Debose, 2001; Marck, 1999; Yeager, 2000). Education should be followed up with monitoring of such groups and testing for HIV since monitoring and testing give better indications of the scale of the problem and provide the opportunity for treatment. In addition, these groups can be considered as targets of a second way forward: providing information through culturally sensitive or appropriate education that will contribute to behavioral change. Culturally sensitive and appropriate media should be utilized for getting the message about what HIV is, how it is spread, how to protect oneself from acquisition, and how to treat people living with AIDS. In most countries of the region, radio and television advertisements as well as billboard have already been utilized in this effort. The question though is, how effective is the message being delivered and how appropriate are these media in getting the word out? This calls for using more appropriate media such as popular songs, drama and theatre in local languages, the burgeoning movie industry in West Africa (usually produced on video), and relying upon churches to spread the word about the pandemic. The purpose should not be to scare but, to inform people about what the virus is, how is can be acquired, what its effects are, how to deal with people living with AIDS, and how condom use and abstinence can help protect persons from infection. There is no doubt that despite such efforts at education, certain groups will not hear the message. As Marck (1999) suggests, even though truck drivers know about HIV/AIDS, some are resistant to change and demonstrate fatalism (see Orubuloye and Oguntimehin, 1999; Awusabo-Asare, Abane, Badasu, & Anar, 1999).
ARTICLE IN PRESS
To combat fatalism, education about HIV/AIDS can be mandated as part of employment (on the job seminars) for both mobile and stationary populations employed in the formal sector (military, miners, agricultural workers, etc) and for those in the informal sector, education programs can be required as part of their licensing requirement. For example, to acquire a renewal of a drivers license or a venders permit, truck drivers and street traders may be expected to go through a short education program (about a day or two) on HIV/AIDS. Such measures may sound draconian but in Western countries, drivers are expected to go through a drivers education program before they can be licensed. Considering the enormity of the HIV/ AIDS pandemic in the region, this should not be seen as a violation of a civil right but rather an empowerment of persons to make decisions based on knowledge. Education should be designed toward culture change about attitudes towards sex cultures in various societies and more importantly the status of women. Culture change related to the use of condoms, the value and status of women, the purpose and desire of marriage to procreate will be the most difcult to change in various cultures of the region (Ayiga, Ntozi, Ahimbisibwe, Odwee, & Okurut, 1999; Caldwell, Orubuloye, & Caldwell, 1999). In the short-run, the various forms of media identied above can be used to spread the message about condoms. But as Moore and Oppong (2004) and Kalipeni and Ghosh (2004) both demonstrate, knowledge about condoms does not necessarily translate into condom use, even though both Chimbiri (2004) and Zulu and Chepngeno (2004) both suggest that in specic circumstances, such as outside marriage or extra-marital affairs, condom use may be increasing. Even if condoms are provided free of charge, deep-seated issues related to who has power in making sexual decisions have to be addressed. Thus, policy has to focus on longterm measures that have to begin with raising the status of women and minimize androcentrism by means of education. Ghana, for example, has embarked on such a policy in the past four years by establishing a Ministry dedicated solely to the education of the girl-child. As illustrated by Mkandawire-Valhum (2004), Mill and Anar (2002), and Zerai (2004), it is by empowering women to be independent in their economic and thus sexual decision making that they will be able to dictate the use of condoms in their relationships
with men. A good start to achieve the empowerment of women will be by establishing afrmative action programs for girls in education. After all, accessibility to education after the death of a father seems to be a main deterrent to continuing education in the sample that Mill and Anar (2002) drew from Ghana. Apart from educational reform to bring about culture change, the content of education itself needs to be changed. As Mbugua (2004) suggests, it is high time Africans talked about sex rather than reserve it as a taboo subject. This should occur not only in home as parents are doing with her urban Kenyan sample but also should be incorporated into the educational systems. There is not doubt that sex is a taboo subject, even in Western culture (West, 1994) but the enormity of the HIV/AIDS problem in SubSaharan Africa, with all its traditional values, needs to be addressed formally. This is more so in the context of cultures that value procreation to ensure immortality. Perhaps a good way to conceptualize HIV/AIDS policy will be to do so in conjunction with family planning. If mothers and fathers who wish to have children are informed about birth spacing, child caring, and other attributes of family planning, perhaps they will be more receptive if the message of family planning is tied to that of HIV/ AIDS and its prevention. As Mazrui (1986) argues, the problem with Africas population growth is not that the mothers do not know about birth control, rather they are not empowered to control death of their new-born children. The likelihood of the message of HIV/AIDS being heard is much higher if it is couched within this framework of family planning for both mothers and fathers. In a sense, therefore, HIV/AIDS and its prevention should be linked to family development and survival. This is where Dodoo and Kleins (2004) suggestion to consider the nature of relationships between men and women would be helpful. The question to be addressed is whether marriage and cohabitation, irrespective of class, inuences sexual exclusivity or not, if not, how can they be made to have an effect on exclusivity? Issues of the nature of relationships, culture change, and the status of women sound like structural ones but more fundamentally structural are issues related to the role of the state, globalization and poverty, and Eurocentrism associated with Sub-Saharan Africa as a whole. These structural issues are a second focus of policy formulation. Barnett and Blaikies (1992) second suggestion was
ARTICLE IN PRESS
the utilization of NGOs in the ght against HIV/ AIDS in Sub-Saharan Africa. Considering the general paucity of most states discussed above, their suggestion still holds for policy today. The inaction or unwillingness of states in the region to acknowledge their HIV/AIDS problem at the beginning of the epidemic has contributed to the explosion of the virus today (see Haworth, 2002; Karon et al., 2000). Yet when states take responsibility, such as in the case of Uganda, HIV/AIDS can be brought under control (Lemonick et al., 2000). Even if states are willing to take responsibility, their capacity to implement programs seems limited because of nancial and technical constraints. The lack of medical personnel, pharmaceuticals, well trained sex counselors for schools and the general public, and appropriate counseling for people living with HIV/AIDS and orphans of HIV/ AIDS mean that Sub-Saharan African states are incapable of solving problems due to HIV/AIDS alone. It is in areas like these that Western (such as developed countries) and global partners (such as WHO and UN) and NGOs, because of their ability to work with grassroots groups and to marshal nancial and technical resources from external donors are capable of collaborating with state agencies to work against HIV/AIDS. Botswanas MASA program that makes available anti-retroviral drugs to all its citizens is an excellent start. Caution should however be used in such collaborative relations to ensure that policy reects reality at the local level rather than adhere to conditionality of global donors or NGOs (Watkins, 2004). Poverty eradication and the effects of globalization in perpetuating poverty are major structural elements in curbing the spread of HIV/AIDS. Ideally, policy aimed at eradicating poverty in the region as a whole will go a long way in mitigating the environment within which HIV/AIDS is spreading in both rural and urban places (see Masanjala, 2004; van Donk 2001). This can be achieved by targeting the eradication of female poverty (see World Bank, 2001) and thus their dependence on males (Mill & Anar, 2002). As Ko (1994) argues, SAPs have had a negative effect on health sectors of Sub-Saharan African economies. State capacity to care for people living with AIDS and provide pharmaceuticals has all been restricted by the entrenchment of poverty due to SAPs. In this regard, policy should be aimed at achieving, at the barest minimum, the UNs Millennium Development Goals, in order to minimize poverty of states
in the region. Perhaps, more importantly, a structural change in Sub-Saharan African economies designed to generate employment, both in the private and public sectors, would go far in eradicating individual poverty. Specically poverty eradication policies should be structurally couched within a framework of external and internal causes of poverty and underdevelopment (see UN, 2001). Externally, policies of global donations that are designed to provide direct assistance in the form of grants to countries (such as the WHOs 3-by-5 program that Lombela, 2004 writes about) as well as direct grants to individual countries designed to rebuild their economies should be stressed. Also, Sub-Saharan African countrys debt canceling by countries of the core of the global economy should be considered as an element of development. Internally, Sub-Saharan African countries should take responsibility for the corruption, conict, and internally weak policy environment that have engendered poverty in the region (see Stock, 2004; Yeboah 2003b for a litany of such internal problems). If Sub-Saharan African countries are able to resolve their internal problems that reduce poverty and underdevelopment, they will have gone a long way in eradicating the Eurocentrism that has existed in its relations with the West. In this regard, the strengthening of regional institutions such as the New Partnership for African Development (NEPAD) and the African Union (AU) and their embarking upon policies that will ensure internal coherence and stability in various African countries will help in making the West move away from its perception of the region as a problem region rather than a region with a problem. Obviously, countries like Botswana and Ghana that have attained some element of internal stability are viewed more favorably, and consequently have a greater potential to receive Western development assistance, than countries such as Sudan, Zimbabwe, Liberia, and Sierra Leone. Africans must endeavor to put Occidental values at the forefront of global discourse. Finally, policy geared towards biomedical solutions to the problem of HIV/AIDS, will not only benet Sub-Saharan Africans but, will benet humanity as a whole. It is therefore interesting to note that even though pharmaceutical Trans National Companies (TNCs) have nally succumbed to providing HIV/AIDS drugs at subsidized rates to peripheral countries (Dowell, 1999),
ARTICLE IN PRESS
they are not as enthusiastic about the development of an HIV vaccine (Craddock, 2004). After all, the people who can benet most form a vaccine are the least able to pay. Because of the weak economies that are unable to retain professionals capable of research and development (R&D) in the region (see Eastwood et al., 2005), the development of an HIV vaccine will probably come from the West. In this regard, there is a need for global organizations such as the UN, WHO, etc. to lobby pharmaceutical TNCs to work toward an HIV vaccine. Conclusion HIV/AIDS is a global virus that cuts across cultures. Furthermore, even though the medical and scientic communities have been at the forefront of the ght against the virus, the social sciences, such as geography, have a unique contribution to make towards understanding the epidemiology of HIV/ AIDS. In addition, geography, because of its concern with phenomena in place at various scales and the location, distribution, and interconnectedness of phenomena, has heuristic potential in policy formulation. Barnett and Blaikies (1992) advocacy for the social sciences in HIV/AIDS research has come to fruition. It is obvious that policy for HIV/ AIDS in Sub-Saharan Africa should be multifaceted. What is needed now is an intensication and funding of social science research on HIV/ AIDS by funding agencies. References
Amedeo, D., & Golledge, R. G. (1975). An introduction to scientic reasoning in geography. New York: Wiley. Amuyunzu-Nyamongo, M., Tendo-Wambua, L., Babishangire, B., Nyagero, J., Yitbarek, N., Matasha, M., & Omurwa, T. (1999). Barriers to behavior change as a response to STD including HIV/AIDS: the East African experience. In J. Caldwell, P. Caldwell, J. Anar, K. Awusabo-Asare, J. Ntozi, I.O. Orubuloye, J. Marck, W. Cosford, R. Colombo & E. Hollings (Eds.), Resistance to behavioral change to reduce HIV/AIDS infections in predominantly heterosexual epidemics in Third World countries (pp. 111). Health Transition Center: Australian National University (www.htc.anu.edu.au/html/ resistancenews.html). Anderson, J. A. (2002). Sorcery in the era of Henry IV: Kinship, mobility and mortality in Buhera District, Zimbabwe. Journal of Royal Anthropological Institute, 8(3), 425449. Ankomah, B. (1999). Did AIDS really originate in Africa? New Africa, April, 1416. Awusabo-Asare, K. (1999). Obstacles and challenges to sexual behavior change. In J. Caldwell, P. Caldwell, J. Anar, K. Awusabo-Asare, J. Ntozi, I.O. Orubuloye, J. Marck, W.
Cosford, R. Colombo, & E. Hollings (Eds.), Resistance to behavioral change to reduce HIV/AIDS infections in predominantly heterosexual epidemics in Third World countries (pp. 235240). Health Transition Center: Australian, National University (www.htc.anu.edu.au/html/resistancenews.html). AwusaboAsare, K., Abane, A.M., Badasu, D.M., & Anar, J.K. (1999). All die be die: Obstacles to change in the face of HIV infection in Ghana. In J. Caldwell, P. Caldwell, J. Anar, K. AwusaboAsare, J. Ntozi, I.O. Orubuloye, J. Marck, W. Cosford, R. Colombo, & E. Hollings (Eds.), Resistance to behavioral change to reduce HIV/AIDS infections in predominantly heterosexual epidemics in Third World countries (pp. 125132). Health Transition Center: Australian, National University (www.htc.anu.edu.au/html/resistancenews.html). Ayiga, N., Ntozi, J.P.M., Ahimbisibwe, F.E., Odwee, J. & Okurut, F. (1996). Deaths, HIV testing and sexual behavior change and its determinants in northern Uganda. In J. Caldwell, P. Caldwell, J. Anar, K. AwusaboAsare, J. Ntozi, I.O. Orubuloye, J. Marck, W. Cosford, R. Colombo, & E. Hollings (Eds.), Resistance to behavioral change to reduce HIV/AIDS infections in predominantly heterosexual epidemics in Third World countries (pp. 6480). Health Transition Center: Australian, National University (www.htc.anu. edu.au/html/resistancenews.html). Barnett, T., & Blaikie, P. (1992). AIDS in Africa: Its present and future impact. New York: Guilford Press. Caldwell, J. (1999). Reasons for limited sexual behavioral change in the sub-Saharan African AIDS epidemic: possible future intervention strategies. In J. Caldwell, P. Caldwell, J. Anar, K. AwusaboAsare, J. Ntozi, I.O. Orubuloye, J. Marck, W. Cosford, R. Colombo, & E. Hollings (Eds.), Resistance to behavioral change to reduce HIV/AIDS infections in predominantly heterosexual epidemics in Third World countries (pp. 241256). Health Transition Center: Australian, National University (www.htc.anu.edu.au/html/resistancenews.html). Caldwell, J., & Caldwell, P. (1996). The African AIDS epidemic. Scientic America, 274(3), 6268. Caldwell, J., Orubuloye, I.O., & Caldwell, P. (1999). Obstacles to behavioral change to lessen the risk of HIV infection in African AIDS Epidemic: Nigerian research. In J. Caldwell, P. Caldwell, J. Anar, K. AwusaboAsare, J. Ntozi, I.O. Orubuloye, J. Marck, W. Cosford, R. Colombo, & E. Hollings (Eds.), Resistance to behavioral change to reduce HIV/AIDS infections in predominantly heterosexual epidemics in Third World countries (pp. 113124). Health Transition Center: Australian, National University (www.htc.anu. edu.au/html/resistancenews.html). Cary, J. (1939). Mister Johnson. New York: New Directions Books. Chimbiri, A. (2004). The condom as an intruder in marriage: Evidence from rural Malawi. Paper presented at 30th annual spring colloquium of the Center for African Studies, University of Illinois at UrbanaChampaign on the theme: HIV/AIDS in Africa: Gender, agency and empowerment, 24 April. Chisholm, M. (1975). Human geography: Evolution or revolution?. Hamondsworth: Penguin. Christopher, A. J. (1994). The atlas of apartheid. London: Routledge. Cloke, P., Philo, C., & Sadler, D. (1991). Approaching human geography. An introduction to contemporary theoretical debates. New York: The Guilford Press. Conrad, J. (1902). Heart of darkness. New York: Penguin Books.
ARTICLE IN PRESS
1148 I.E.A. Yeboah / Social Science & Medicine 64 (2007) 11281150 Johnston, R. J. (1991). Geography and geographers: AngloAmerican human geography since 1945. London: Edward Arnold. Kalipeni, E., & Ghosh, J. (2004). Perspectives on HIV/AIDS in low socio-economic income areas of Lilongwe, Malawi. Paper presented at 30th annual spring colloquium of the Center for African Studies. University of Illinois at UrbanaChampaign on the theme: HIV/AIDS in Africa: Gender, agency and empowerment, 24 April. Kalipeni, E., & Oppong, J. (1998). The refugee crisis in Africa and implications for health and disease: A political ecology approach. Social Science & Medicine, 46(12), 16371653. Karon, T., Hawthorne, P., & Tumulty, K. (2000). When the president is a dissident. Time, 156(4), 3941. Kearns, R. A. (1993). Place and health: Towards a reformed medical geography. Professional Geographer, 45(2), 130147. Kearns, R. A., & Joseph, A. E. (1993). Space in its place: Developing the link in medical geography. Social Science and Medicine, 37(6), 711717. Kipling, R. (1899). The white mans burden. McClures, February Knox, P., & Marston, S. (2004). Human geography: Places and regions in global context. New Jersey: Pearson. Ko, T. A. (1994). Structural adjustment in Africa: A performance review of World Bank policies under uncertainty in commodity price trends: The case of Ghana. United Nations University Institute for Development Economic Research. Konadu-Agyeman, K. (2000). The best of times and the worst of times: Structural adjustment programs and uneven development in Africa: The case of Ghana. Professional Geographer, 52(3), 469483. Kusina, J. & Kusina, N. (2004). The impact of AIDS/HIV on agricultural production in southern Africa. Paper presented at 30th annual spring colloquium of the Center for African Studies. University of Illinois at UrbanaChampaign on the theme: HIV/AIDS in Africa: Gender, agency and empowerment, 24 April. Lemonick, M. D., Hawthorne, P., & Robinson, S. (2000). Little hope, less help. Time, 156(4), 3840. Livingstone, D. (2000). The geographical tradition. Oxford, UK: Blackwell. Lombela, W. (2004). Elements of management of a health care program for having access to AIDS drugs in Africa: Case of Democratic Republic of Congo. Paper presented at 30th annual spring colloquium of the Center for African Studies. University of Illinois at Urbana-Champaign on the theme: HIV/AIDS in Africa: Gender, agency and empowerment, 24 April. Lussaga-Kirondi, J. M. (1992). Received concepts and theories in African urbanization and management strategies: The struggle continues. Urban Studies, 28(1), 12771292. Malaza-Debose, M. (2001). Preventing and coping with HIV/ AIDS in post-conict societies: Gender based lessons form SubSaharan Africa. Paper presented at World AIDS Conference in Durban, South Africa, 2529 March /www.certi.org/ publications/AIDSS. Marck, J. (1999). Longdistance truck drivers sexual cultures and attempts to reduce HIV Risk behavior amongst them: A review of the African and Asian literature. J. Caldwell, P. Caldwell, J. Anar, K. Awusabo-Asare, J. Ntozi, I.O. Orubuloye, J. Marck, W. Cosford, R. Colombo, & E. Hollings (Eds.), Resistance to behavioral change to reduce HIV/AIDS infections in predominantly heterosexual epidemics Craddock, S. (2004). AIDS vaccines in a corporate economy. Paper presented at 30th Annual Spring Colloquium of the Center for African Studies, University of Illinois at Urbana Champaign on the theme: HIV/AIDS in Africa: Gender, agency and Empowerment, 24 April. Crush, J., Jeeves, A., & Yudelman, D. (1991). South Africas labor empire. A history of Black migrancy to the gold mines. Boulder: Westview Press. Curtis, S. (2004). Health and Inequality. Geographical Perspectives. London: Sage. Dale, R. (1995). Botswanas search for autonomy in southern Africa. Westport, CT: Greenwood Press. Danaher, K. (1994). Myths of African hunger. In F. J. Ramsay (Ed.), Africa: Global studies (pp. 201204). Guilford, CT: Dushkin Publishing. De Blij, H., & Muller, P. (1994). Geography, realms, regions and concepts. USA: Wiley. Dodoo, F., & Klein, M. (2004). Cohabitation, marriage and sexual monogamy in Nairobi, Kenya. Paper presented at 30th Annual Spring Colloquium of the Center for African Studies, University of Illinois at Urbana-Champaign on the theme: HIV/AIDS in Africa: Gender, agency and empowerment, 24 April. Dowell, W. (1999). Ethics and AIDS drugs. Time, 154(2), 49. Eastwood, J. B., Conroy, R. E., Naicker, S., West, P. A., Tutt, R. C., & Plange-Rhule, J. (2005). Loss of health professionals from Sub-Saharan Africa: The pivotal role of the UK. The Lancet, May 28th. Fellman, J., Getis, A., & Getis, J. (2001). Human geography. Landscapes of human activities. Boston: McGraw Hill. Fennell, T., & McNabb, L. (2000). The slim disease. McLeans, 113(28), 3234. Gao, F., Bailes, E., Robertson, D. L., Yalu, C., Rodenburg, C. M., Michael, S. F., et al. (1999). Origin of HIV-1 in chimpanzee Pan troglodytes troglodytes. Nature, 397(6718), 436441. Gatrell, A. C. (2002). Geographies of Health: An introduction. Oxford: Blackwell. Gould, P. (1993). The slow plague. A geography of the AIDS pandemic. Oxford: Blackwell. Harman, D. (2002). How AIDS brings famine nearer. Christian Science Monitor, 94(247), 1. Harrison, R. (1999). Welcome to the mad world of AIDS research. New Africa, April, 1719. Hartshorne, R. (1959). Perspective on the nature of geography. Washington: Association of American Geographers. Haworth, A. (2002). Where sex is against the law. Marie Claire, 9, 108114. Huntington, E. (1917). Graphic representation of the effects of climate on Man. Geographical Review, 4, 401403. Hwang, A. (2001). AIDS has arrived in India and China. World Watch, 14(1), 1220. IMO/UNAIDS/SIDA (2003). Mobile populations and HIV/ AIDS in the southern African region. Geneva, Switzerland: International Migration Organization. Jarosz, L. (1992). Constructing the dark continent: Metaphor as geographic representation. Geograska Annaler, 74B, 105 115. Jewkes, R. K., Levin, J., & Penn-Kekana, L. (2003). Gender inequalities, intimate partner violence and HIV preventive practice: Findings of a South African cross-sectional study. Social Science and Medicine, 56(1), 125134.
ARTICLE IN PRESS
I.E.A. Yeboah / Social Science & Medicine 64 (2007) 11281150 in Third World countries (pp. 91100). Health Transition Center: Australian National University (www.htc.anu.edu.au/ html/resistancenews.html). Masanjala, W. H. (2004). The poverty-HIV/AIDS nexus: A conceptual framework for analyzing rural livelihoods, gender relations and social safety net in Africa. Paper presented at 30th annual spring colloquium of the Center for African Studies. University of Illinois at UrbanaChampaign on the theme: HIV/AIDS in Africa: Gender, agency and empowerment, 24 April. Masland, T., Nordland, R., Kaheru, S., Santora, L., Haller, V., & Begley, S. (2000). 10 million orphans. News week, 135(3), 42 45. Mazrui, A. A. (1986). The Africans: a triple heritage. Boston: Little Brown. Mbugua, N. (2004). Traditions that hurt, traditions that heal: Inept adolescent socialization in Africa. Paper presented at 30th annual spring colloquium of the Center for African Studies. University of Illinois at UrbanaChampaign on the theme: HIV/AIDS in Africa: Gender, Agency and Empowerment, 24 April. McDonald, D. (2000). On borders perspectives on international migration in Southern Africa. New York: St. Martins Press. McGarth, J. (2004). Shifting paradigms in HIV prevention for women: Redening risk, control, and empowerment for women in Africa. Paper presented at 30th annual spring colloquium of the Center for African Studies. University of Illinois at Urbana-Champaign on the theme: HIV/AIDS in Africa: Gender, agency and empowerment, 24 April. Meade, M., & Earickson, R. J. (2000). Medical geography. New York: Guilford Press. Meursing, K. (1999). Barriers to sexual behavior change after an HIV diagnosis in sub-Saharan Africa. In J. Caldwell, P. Caldwell, J. Anar, K. Awusabo-Asare, J. Ntozi, I.O. Orubuloye, J. Marck, W. Cosford, R. Colombo, & E. Hollings (Eds.), Resistance to behavioral change to reduce HIV/AIDS infections in predominantly heterosexual epidemics in Third World countries (pp. 3539). Health Transition Center: Australian National University (www.htc.anu.edu.au/ html/resistancenews.html). Mill, J. E., & Anar, J. K. (2002). HIV risk environment for Ghanaian women: Challenges to prevention. Social Science and Medicine, 54(3), 325337. Mkandawire-Valhum, L. (2004). The challenges of HIV prevention for women in Malawi: The case of domestic workers and their experience of violence. Paper presented at 30th annual spring colloquium of the Center for African Studies. University of Illinois at UrbanaChampaign on the theme: HIV/AIDS in Africa: Gender, agency and empowerment, 24 April. Moore, A. & Oppong, J. (2004). Sexual risk behavior among people living with HIV/AIDS in Togo. Paper presented at 30th annual spring colloquium of the Center for African Studies. University of Illinois at UrbanaChampaign on the theme: HIV/AIDS in Africa: Gender, agency and empowerment, 24 April. Mulango, J.R.S. (1999). Challenges to sexual behavioral changes in the era of AIDS: sexual cleansing and levirate marriage in Zambia. In J. Caldwell, P. Caldwell, J. Anar, K AwusaboAsare, J. Ntozi, I.O. Orubuloye, J. Marck, W. Cosford, R. Colombo, & E. Hollings (Eds.), Resistance to behavioral change to reduce HIV/AIDS infections in predominantly heterosexual epidemics in Third World countries (pp. 4157). 1149 Health Transition Center: Australian National University (www.htc.anu.edu.au/html/resistancenews.html). Mupemba, K. (1999) The Zimbabwe HIV prevention program for truck drivers and commercial sex workers: a behavioral change intervention. In J. Caldwell, P. Caldwell, J. Anar, K. Awusabo-Asare, J. Ntozi, I.O. Orubuloye, J. Marck, W. Cosford, R. Colombo, & E. Hollings (Eds.) Resistance to behavioral change to reduce HIV/AIDS infections in predominantly heterosexual epidemics in Third World countries (pp. 133137). Health Transition Center: Australian, National University (www.htc.anu.edu.au/html/resistancenews.html). Orubuloye, I.O., & Oguntimehin, F. (1999). Death is preordained, it will come when it is due: attitudes of men to death in the presence of AIDS in Nigeria. In J. Caldwell, P. Caldwell, J. Anar, K. Awusabo-Asare, J. Ntozi, I.O. Orubuloye, J. Marck, W. Cosford, R. Colombo, & E. Hollings (Eds.), Resistance to behavioral change to reduce HIV/AIDS infections in predominantly heterosexual epidemics in Third World countries. (pp. 101111). Health Transition Center: Australian, National University (www.htc.anu. edu.au/html/resistancenews.html). Osei, W. Y., & Aryeetey-Attoh, S. (2003). The physical environment. In S. Aryeety-Attoh (Ed.), Geography of subSaharan Africa (pp. 1247). New Jersey: Pearson Education, Prentice-Hall. Pattison, W. D. (1964). The four traditions of geography. Journal of Geography, 211216. Preston-Whyte, E. (1999). Reproductive health and the condom dilemma: identifying situational barriers to HIV protection to South Africa. In J. Caldwell, P. Caldwell, J. Anar, K. Awusabo-Asare, J. Ntozi, I.O. Orubuloye, J. Marck, W. Cosford, R. Colombo, & E. Hollings (Eds.), Resistance to behavioral change to reduce HIV/AIDS infections in predominantly heterosexual epidemics in Third World countries (pp. 139155). Health Transition Center: Australian National, University (www.htc.anu.edu.au/html/resistancenews.html). Sanders, R. (1992). Eurocentric bias in the study of African urbanization: A provocation to debate. Antipode, 24(3), 203 213. Semple, E. (1911). Inuence of geographic environment on the basis of Ratzels system of anthropo-geography. New York: Henry Holt. Smallman-Raynor, M. R., & Cliff, A. D. (1991). Civil war and the spread of AIDS in Central Africa. Epidemiology and Infection, 107, 6980. Smallman-Raynor, M., Cliff, A., & Haggett, P. (1992). London international atlas of AIDS. Oxford: Blackwell. Stock, R. (2004). Africa south of the Sahara: A geographical interpretation. New York: Guilford Press. Taylor, G. (1919). Climatic cycles and evolution. Geographical Review, 8, 289328. Toler, D. (1995). Which continent is it? Food First, 17(59), 14. UNAIDS/WHO. (2002). Report on global HIV/AIDS epidemic. /www.who.int/hiv/pub/epidemiology/hiv_aids_2001.xlsS. UNAIDS/WHO (2006). Report on the global AIDS epidemic (www.unaids.org/en/HIV_data/2006GlobalReport/default.asp), May. van Donk, M. (2001). HIV/AIDS and urban poverty in South Africa. Paper prepared for UN general assembly special session on HIV/AIDS. Varga, C.A. (1999). South African young peoples sexual dynamics: implications for behavioral responses to HIV/
ARTICLE IN PRESS
1150 I.E.A. Yeboah / Social Science & Medicine 64 (2007) 11281150 Yeboah, I. E. A. (1998). Whats so informal about the informal sector? Culture and the construction of development in Africa. The East African Geographical Review, 20(1), 110. Yeboah, I. E. A. (2000). Structural adjustment and emerging urban form in Accra, Ghana. Africa Today, 47(2), 6189. Yeboah, I. E. A. (2003a). Historical geography of Sub-Saharan Africa. In S. Aryeety-Attoh (Ed.), Geography of sub-Saharan Africa (pp. 78104). New Jersey: Pearson Education, Prentice Hall. Yeboah, I. E. A. (2003b). Political landscape of sub-Saharan Africa. In S. Aryeetey-Attoh (Ed.), Geography of sub-Saharan Africa (pp. 105133). New Jersey: Pearson education, Prentice-Hall. Zerai, A. (2004). Addressing HIV in Zimbabwe: Militarism or African feminism as liberatory method. Paper presented at 30th annual spring colloquium of the Center for African Studies. University of Illinois at UrbanaChampaign on the theme: HIV/AIDS in Africa: Gender, agency and empowerment, 24 April. Zulu, E., & Chepngeno, G. (2004). Spousal communication about the risk of contracting HIV/AIDS in rural Malawi. Paper presented at 30th annual spring colloquium of the Center for African Studies. University of Illinois at Urbana-Champaign on the theme: HIV/AIDS in Africa: Gender, agency and empowerment, 24 April. AIDS. In J. Caldwell, P. Caldwell, J. Anar, K. AwusaboAsare, J. Ntozi, I.O. Orubuloye, J. Marck, W. Cosford, R. Colombo, & E. Hollings (Eds.), Resistance to behavioral change to reduce HIV/AIDS infections in predominantly heterosexual epidemics in Third World countries. pp. (1334). Health Transition Center: Australian National University (www.htc.anu.edu.au/html/resistance news.html). Watkins, S. (2004). Sex in Geneva, sex in Lilongwe, and sex in Balaka. Paper presented at 30th annual spring colloquium of the Center for African Studies. University of Illinois at UrbanaChampaign on the theme: HIV/AIDS in Africa: Gender, agency and empowerment, 24 April. West, C. (1994). Race matters. New York: Vintage Books. White, L. (1990). The comforts of home: Prostitution in colonial Nairobi. Chicago: University of Chicago Press. Wilson, F. (1972). Labor in the South African gold mines, 1911 1969. Cambridge: Cambridge University Press. World Bank. (2001). African poverty at the millennium: Causes, complexities, and challenges. Washington, DC: The World Bank. Yeager, R. (2000). AIDS brief: Military populations. Prepared fro sectoral AIDS brief series, U.A. Agency for International Development and World Health Organization.

HIVcontructionafrica SS&M 06

Enviado por

Dados do documento

Descrição original:

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

HIVcontructionafrica SS&M 06

Enviado por

Direitos autorais:

Formatos disponíveis

ARTICLE IN PRESS

Social Science & Medicine 64 (2007) 11281150 www.elsevier.com/locate/socscimed

Fig. 1. HIV prevalence rates in Sub-Saharan Africa (2006).

Environment and Natural Resources

Eurocentrism and Racism

HIV/AIDS Culture Gender Construction

Globalization and Poverty

Fig. 2. Sub-Saharan Africas HIV/AIDS web.

Fig. 3. Topography of Sub-Saharan Africa.

Você também pode gostar