Introduction to Transitions
Transition dynamics describes a process of development. There may be many different transitions, but they all share a characteristic shape, when graphed, of a sigmoidal curve. In any process, the beginning stages rise very slowly. At some point, though, this growth begins to take off and will rise at an exponential rate. This characterizes the most volatile region of the transition, but this time will not lave for very long. Soon, there will be factors that counteract the exponential growth, slowing it down, and bringing growth once again to what appears to be a stable level. Here is a graph of a typical transition:
The above graph lacks the appropriate labels, but could be used to describe the transition of any process. First, and probably most common, it is used to describe the population transition. In looking at any area, country, or even the world, throughout history there had been relatively little growth in the human population. Only recently, human population growth has begun to take off, and it is currently in the exponential growth phase. Eventually, however, factors such as fewer resources to sustain life will begin to limit the growth of the population and it will level off at some certain value. Unfortunately, experts do not know now what that level will be and can only extrapolate current estimates.
Second, the graph could represent demographic movements, such as urbanization. In any country, it appears as though the population begins by living in small, rural areas. There is a period of rapid rural to urban migration, increasing the percent of the population urbanized, until finally a stabilizing effect becomes apparent. There is also a transition of industrialization as a country shifts from an agrarian to production-based economy. Normally, the two transitions appear to coincide, but it is important to note that this may not always be the case.
Third, this graph could be used to describe an environmental phenomenon, such as deforestation. This shows the percent of the land deforested. At some point, the low level will start to increase as humans clear forestland. There will be a point where deforestation will reach a plateau, and the graph will level off. One could see how urbanization and industrialization could lead to clearing of land for cities and a need for timber for production, respectively, and so there may be an interaction between all three. This graph can thus apply to numerous factors, such as education, health care, agriculture, etc.
In any case, it appears as though every individual transition can be a part of the transition of a country, from developing to developed status. The transitions are not only important by themselves, but also as how they relate to one another for the gestalt of the developing country transition.
This paper will attempt to view only a couple of these transitions to get a better understanding of their mode of action and interaction. Specifically, I will be looking at the population, demographic, political, and familial transitions of Uganda, which in part are shaped by the agricultural transition. This will then be applied to show how these factors may have led directly to the emergence and current distribution of the human immunodeficiency virus (HIV) and the disease that it causes, acquired immune deficiency syndrome (AIDS). HIV/AIDS itself is a complex example of an epidemiological transition.
Introduction to the HIV/AIDS Epidemic
The Epidemiological Transition
Before exploring more profoundly how the HIV/AIDS epidemic manifests itself in Uganda, it is good to get a feel for how profoundly HIV/AIDS has affected the world. The emergence of HIV/AIDS, in only a few short years has developed into one of the largest public health problems in history. Indeed, HIV/AIDS is a world problem, as over 190 countries on all continents have been affected. (Mertens, 1996) Yet, any attempt to simplify the view of the global HIV/AIDS pandemic into one comprehensive picture would prove to be futile. No dichotomy is greater than that explaining the epidemic between developed and developing countries. However, even among these two groups, the epidemic is composed of multiple facets of smaller epidemics, sub-populations, and vast differences in transmission and risk groups.
The first cases of HIV/AIDS were recognized in Europe in 1976 and in North America in 1981. The introduction of the disease into South and Southeast Asia occurred later, probably in the middle to late 1980’s. Regardless of the time of introduction, there has been a characteristic transition pattern of prevalence. At first, there is introduction of the virus into a population and an initial period of slow growth in the number of new cases. Once established, infection takes off and there is an explosion in prevalence. Finally, as incidence goes down to a lower level, prevalence will begin to stabilize. The transitional period for rapid growth in the number of AIDS cases has been thought to be around 10 years, but recent theories found that in certain sub-populations, the transitional period may be as short as one to four years. (Mertens, 1996)
A current profile of the pandemic indicates that an estimated 30 million people have contracted HIV/AIDS worldwide, and around six million of these people have died. (Worldbank, 1998) This number is also increasing: there are 11 people per minute becoming infected with the HIV virus. (UNFPA, 1997) Although AIDS has had a devastating effect here in the United States, an exclusive domestic focus sometimes causes us to loose sight of the international impact of the disease – an impact much more profound than here. Indeed, the burden of disease in much greater outside of the United States, for as a region with only 10% of the world’s population, sub-Saharan Africa accounts for 63% of the worlds HIV/AIDS cases. (World Bank Group) At the end of 1995, North America had an estimated HIV/AIDS prevalence of 788,000. By contrast, the highest prevalence region of sub-Saharan Africa had a prevalence of 12.9 million. (Mertens, 1996) Of countries in this region, Uganda has experienced one of the highest burdens of disease. According to UNAIDS and the World Health Organization (WHO), the prevalence of HIV in adults (aged 15-49) at the end of 1997 was 9.51%. (UNAIDS, 1998) Although this is extremely high, this is down from the estimated 14.5% prevalence rate in 1994. (Center for International Health Information, 1996) Even so, we can see the difference in disease rates between Uganda and the United States. Ten percent of Uganda’s population of around 20 million corresponds to around 2 million persons. This is in comparison to the 788,000 persons out of almost 275 million.
One of the major differences in the shape of the epidemic curve between developed and developing countries is the mode of viral transmission. In most industrialized areas of the world – North America, Western Europe, and Australia for example – HIV/AIDS is spread primarily by men who have sex with men (MSM) and those who report injecting drug use (IDU). (Mertens, 1996) In South and Southeast Asia, IDU and male and female sex workers are the highest risk groups. In both situations, however, the distinctive high-risk groups are associated with a high prevalence. Low-risk groups, though, show a marked decrease in prevalence. Africa, on the other hand, experiences a different situation over 90% of all HIV viral transmission occurs through heterosexual sex. Maternal to child transmission is also a considerable factor in transmission. (Mertens, 1996) There are definite high-risk groups (for example commercial sex workers and truck drivers), but these groups seem to be driving the infection through the general population. As we will see, this has a large effect on AIDS mortality as well as implications for future population growth.
One of the scariest aspects of the HIV/AIDS epidemic has been the age of the individuals most affected. Eighty percent of AIDS cases in Uganda have been found among people aged 15-45 (UnicefUSA, 1997) and AIDS is currently the leading cause of death of adults, 25-44 years old. In fact, in Africa, HIV/AIDS-related mortality accounts for more than half of all adult mortality (Mertens, 1996) as well as one-third of the mortality from all infectious diseases. (World Bank Group) Across sub-Saharan Africa, there is a 1:1 female to male sex ratio of seroprevalence. Yet in the 15-19 year age range, Ugandan girls have an HIV infection rate that is six times that of boys (UnicefUSA, 1998). This has profound effects considering the high rate of adolescent pregnancy. In fact, the percentage of teenaged girls who are pregnant with the first child increases over this age range from 7.7% in 15 year old girls to 70.8% in 19 year old girls (UNAIDS, 1998). Uganda is therefore facing a crisis whereby it is loosing its most productive members of society, as well as parents, while leaving a large (and increasing) number of AIDS orphans. The impact of AIDS orphans will be discussed in context of HIV/AIDS and the familial transition.
The transition from a world without AIDS to one with it has been a tumultuous one. We can now get a better idea of how factors in Uganda have caused the epidemic curve to display its current pattern. In particular, we can see the role of sociopoliticism, urbanization and migration as responsible factors for the emergence of HIV/AIDS. Then, we will see the impact of HIV/AIDS on the population transition and the role of the changing family structure.
The Emergence of HIV/AIDS
The Historical/Political Transition
Any attempt to understand how sociopolitical factors may have led to the emergence of HIV must first be preceded by an understanding of the history of Uganda.
Before 1900, the country of Uganda did not exist. Instead, the region consisted of many independent tribes and kingdom monarchies. British colonizers around the turn of the century, through force, threat of force, or peaceful treaty alliances, incorporated the kingdoms into the Uganda Protectorate. (Furley, 1987) There was no logic into the incorporation of these diverse populations, except for the drive for imperialism. The most powerful of these kingdoms, Buganda, was located in the southern region of what is now Uganda, a very fertile region on the coast of Lake Victoria.
Throughout the colonial period, the British tried to increase development and a sense of national unity. However, many differences existed between the northern and southern regions of the Protectorate -- differences that would have far-reaching effects. (Furley, 1987) The people of Buganda, the Baganda, were more receptive to British imperial thought. Therefore, most of the early transitions, including those in education and agriculture, occurred in this region. The South was a much more fertile region, and therefore much more suitable for growing crops to be exported. Kampala, although not the capital of the Protectorate, became the main commercial center. (Furley, 1987) In effect, British policy reinforced and natural transitions occurring by forcing agriculture to occur in the South and preventing a large growth in this sector in the North. This was due mainly to the proximity of the agricultural area to main trading routes. In any case, growth in agriculture and commerce created a demand for an educated workforce, thus beginning the educational transition. Schools began to develop all over the region. Although the Baganda did become more educated, they did not fully contribute to the development of the region. The British began recruitment of Indians into the modern trade sector, and soon the "Asians" began to fill every role in Kampala and came to dominate the commercial economy. (Furley, 1987)
In contrast to the educational, commercial, and agricultural transitions that were experienced in the South, the North was still stagnant. The land in the North was more arid and therefore not as suitable for growing crops. In addition, as the people in the North did not as readily accept British influence, they were considered hostile and barbaric. Therefore, there was no educational transition, as schools did not exist in the area before World War II. One important note, though, was that the British considered the Lango and Acholi tribes of the North to be "martial races," (Furley, 1987) and so would heavily recruit these members into the military. The following map shows how the transitions of the time resulted in the development of the Southern region. Large urban areas (red dots) are predominantly located in this region, as are many of the primary roads in the country.
Uganda became an independent state in 1962, and was headed by Milton Obote. The agricultural and commercial transitions, set up under British rule, continued. Also unchanged was the military recruitment from northern tribes. What did change, however, was national unity. In 1966, Obote set into motion a political transition as he expelled the leader of the Buganda kingdom and abolished all kingdoms. (Furley, 1987) Obote’s action of abolishing the kingdoms made him incredibly unpopular in the South. It also began a period of great social unrest and civil wars that has only recently stabilized.
Obote was overthrown in 1979 by Idi Amin, who then began a reign of terror that lasted for the next eight years. The actions of Idi Amin in effect destroyed Uganda. In 1972, Amin expelled all of the Asians from the country. His reasoning was that this move would bring the Ugandan economy into domestic control. However, the action removed the entire commercial and industrial class from Uganda, destroying the economy and dissolving all foreign confidence in the country. Again, industry and agriculture were in transition. . This time, though, production in both sectors decreased. (Kasozi, 1994) The can be represented on the graph of urbanization (p10). Although urbanization will be discussed below, we can see how the expulsion of the Asians for a time caused a cessation of urban development. One can assume that this is representative of many transitions at the time, with either a slow down or a reverse, depending upon the effect on the particular transition.
Amin further destroyed the economy of Uganda by allowing Kenyan trucks to use Ugandan roads. The truck traffic increased dramatically, destroying the Ugandan infrastructure, setting up principle corridors of smuggling, and establishing Kampala as an illegal trade center. (Kasozi, 1994) The map above shows how the development of the region was conducive to illegal trade, with major roads leading out of the cities and directly to neighboring countries. These economic policies –along with his social terror – set the stage for his overthrow in 1979.
From the time of his exile in 1962, Obote had resided in Tanzania, and received support from the Tanzanian government. In January 1979, Amin had launched an invasion of Tanzania, allowing retaliation and an opportunity to " ‘liberate’ Uganda from this tyrant." (Furley, 1987) Along with Ugandan exiles and Tanzanian forces, there was a recruitment of the northern tribes, Lango and Acholi, still supporters of Obote, into the Ugandan National Liberation Army (UNLA). The Ugandan military dictatorship, headed by Amin, was effectively destroyed with the fall of Kampala on April 11, 1979. This is not to say that events occurring after this date are not important in the epidemiological transition. However, it was during this time that Uganda was in the midst of a political transition. It was also during this time, as we will see, that AIDS first emerged into worldview.
The Urbanization/Industrialization Transitions
The above historical/political transition was not the only one taking place during this time in Uganda. In fact, this transition was the impetus for other transitions: urbanization and industrialization. The below graph represents the urbanization of Uganda
As was said earlier, the southern region of the country, in the area
of the Buganda kingdom, underwent the greatest developmental transitions
as the British colonized the area. Demographic changes that were set up
under British colonial rule were intensified after Uganda’s independence
in 1962, (Quinn, 1994) and there began a trend of migration towards a growing
urban area. Uganda is typical of much of the sub-Saharan African region
in the urbanization began late, mainly after gaining independence in the
1960’s. The above graph shows how this region has been the least developed,
with less than 10% of the total population being urbanized throughout the
1960’s. (Quinn, 1994) The country is only at the beginning of its exponential
In any case, the South region became one of labor supply, while regions in the North and West became regions of labor demand, setting up definite vectors of internal migration. (Smallman-Raynor, 1991) The trends of rural to urban migration were not representative of the population as a whole. Due to several factors, there was at first a one-sided bulge of young males into urban areas. (Quinn, 1994)
One main factor causing predominantly male migration was a "push" factor that forced males away from their villages. (Little, 1974) This was, in effect, the result of an agricultural transition of land fertility. Traditionally, land was owned communally by a clan (family structure unit). It was cultivated to provide for all of the food needs of the family. However, as the village resources grew, villages and families increased in size. Crops were planted and harvested in shorter and shorter cycles. In addition, due to the British influence of agricultural exportation, there as also a shift towards single cash crop plantings, such as coffee. These factors reduced the fertility of the land, resulting in families having less food for themselves. Young men would therefore leave their families for the cities, to reduce the burden of having another mouth to feed.
A second factor for male migration involved societal attitudes. It was socially acceptable, and even encouraged, for men to leave their families to gain employment in an urban setting. He would leave to make money and then return to help provide wealth to the family. These factors led many young men to the city. (Little, 1974)
Women, on the other hand, were not encouraged to migrate. Economic necessity, though, forced women to go to the cities in an attempt to find employment. Women were not as lucky at finding jobs as their male counterparts, and so many were forced into the commercial sex trade.
It is also necessary to look at how urbanization and industrialization are related. At the time of increasing (albeit slowly) urbanization, Kampala was also starting to develop as a commercial and industrial center that was drawing people into the city to look for work. Yet, as urbanization was responsible for internal migration from rural to urban areas, industrialization caused international migration, especially from India. We have noted that the Asian immigrants developed into the economy-controlling segment of the population. They controlled most, if not all, of the commercial and industrial sector. This makes sub-Saharan Africa a relatively unique region in that the industrialization transition is actually independent of the urbanization transition. (Quinn, 1994) Resultant of these factors was a lack of available employment opportunities for uneducated workers.
Both urbanization and industrialization thus ushered in a whole new era of brining people together in one central area. This was accompanied by a change in both attitudes and behaviors that brought not only a change in sexual contact patters, but also the development of a core group of individuals that could drive the HIV/AIDS epidemic.
Sociopolitical Transition, Urbanization, and the Flow of HIV
Since the first few cases of AIDS emerged, there has been much discussion into the origins of the disease. It is now commonly accepted that the virus had its origins in the Lake Victoria region of central, sub-Saharan Africa. Several theories have been developed into how the virus developed. The first hypothesis suggests that HIV is a variant of an analogous virus, Simian Immunodeficiency Virus (SIV), found in monkeys in Central Africa. This is supported by some computer models, which have suggested that HIV has evolved from SIV within the last 100 years or so. It was only recently, due to increased human-primate contact occurring from changing human activities that the virus has crossed species into Homo sapiens. A second hypothesis is that the virus has existed in the human population for a very long time, going unnoticed in local villages. This is supported by retrospective evidence, which found AIDS cases in the human population in Central Africa as early as the late 1950’s. (Quinn, 1994) The virus probably existed at a low level for 20 to 30 years without being detected by hospitals or other health resources of the small villages. In any case, it is postulated that recent changes in human demographics, resulting from social and political upheavals that occurred during the 1960’s and 1970’s, were responsible for the emergence of a true HIV/AIDS in Uganda, and indirectly worldwide.
There are three main hypotheses that have been linked to the emergence of HIV/AIDS in Uganda: (1) the migrant labor hypothesis, (2) the truck-town hypothesis, and (3) the military involvement hypothesis. (Smallman-Raynor, 1991 and Quinn, 1994) All of these theories probably had a role in the emergence of HIV and were intricately related to the sociopolitical forces operating at the time.
The migrant labor hypothesis views the emergence of HIV as the result of population movement from one area to another in search of labor. The policies of British imperialism, followed by developmental transitions following independence resulted in internal migration towards the southern region. It seems that this migration occurring during the 1950’s and 1960’s brought the virus from areas of low endemnicity to this southern region of Uganda (Quinn, 1994). A large, young male population with a high prevalence of multiple sex partners, and female commercial sex work trade were probably then the contributing factors to HIV amplification of infection in the urban population. In fact, this was probably the initial driving force in the epidemic.
Second, although the urbanization transition is one of population movements from rural to urban areas, return migration of workers has also been important. AIDS first became evident in the professional urban class of Kampala. Then, it started to manifest in the lower professions and commercial sex workers used by the professional class. Through disease, or fear of disease, people would leave the city and return home. Some of those would go home to be cared for by their family, but a majority would return not even knowing that they were infected. This was an important factor in bringing the infection back to the villages. (Monk, 1997) In this way, we can assume a smaller transition of urban to rural movement of migrant workers is responsible for helping to disseminate the virus.
In any case, migration has been shown as an independent risk factor for HIV infection. One study was done, which investigated the seroprevalence of individuals who had migrated. It was found that the prevalence rate for those who had not moved during the study was 5.5%. Those who moved within a village had an 8.2% prevalence rate, while that of people who had moved to a neighboring village was 12.4%. Finally, those who had joined the cohort during the study had a 16.3% seroprevalence rate. (Nunn, 1995) This should give a clear indication that the HIV epidemic and population migration are intricately related.
The second hypothesis for the emergence of HIV is the truck-town hypothesis. This seems to account for the spread of the newly amplified AIDS epidemic out from the urban Kampala area. It also appears that the truck-town hypothesis accounts for much spread of the virus during the tumultuous reign of Idi Amin during the 1970’s.
As Amin destroyed the economy and opened Ugandan roads to international trucking, there began a boom of illegal trading and smuggling of goods across the country. Typically, there would be heavy truck traffic moving out from Kampala along main corridors towards other countries. As trucking spread out along the roads through towns, so too did commercial sex work. HIV-infected truck drivers would pass along these roads and infect the commercial sex workers. This would provide for further transmission to truck drivers and the chain of transmission continued. One study found that 35.2% of truck drivers were infected with the HIV virus. (Quinn, 1994) On the map of Uganda above,
Finally, the military involvement theory is one that implicates the overthrow of Idi Amin in 1979 to a specific spread of HIV to the northern regions. As I have noted previously, Obote had continued the recruitment of members of the northern tribes of Lango and Acholi into the military. Therefore, they made up a good deal of the Ugandan National Liberation Army (UNLA) that fought to bring down Amin. UNLA servicemen are thought to have used commercial sex workers while in the urban area of south Uganda. After the coup, the soldiers would return to their villages in the North and bring with them the HIV virus. A study (Smallman-Raynor, 1991) which used regression showed a significant positive statistical relationship between UNLA recruitment patterns and later cases of AIDS. The migrant worker or truck-town hypotheses alone could not account for this relationship.
The above three hypotheses account for a majority of the spread of HIV/AIDS in the beginning of the epidemic. They also show the importance of many different factors on the emergence of an infectious disease, in particular HIV/AIDS. Industrialization, urbanization, agriculture, education, migration, commerce, and politics are all necessary in the development of a country. However, they also bring processes that may make the human species susceptible to the emergence of new infectious diseases. This situation has been especially portrayed in the case of the HIV/AIDS epidemiological transition. Any attempt to control the epidemic must not loose sight of these very important factors as well.
The Impact of HIV/AIDS
The Population Transition
The population transition is a prototype transition dynamic model and is fundamental in the development process of any country. Developing countries have a characteristic pattern of a high birth rate and a high death rate. Factors relating to increasing the survival of individuals start taking effect to cause a decrease in death rates. The population transition is the successive period of high fertility and low mortality, which corresponds to an exponential growth in population. Eventually, there will be a decline of birth rates, and population growth will diminish to a more stable level. Developed countries will thus have patterns of a low birth rate and a low death rate. Along with this population transition is an increase in life expectancy.
One can represent the population of a country in terms of numbers of
individuals in each of may age ranges, covering the age range of the entire
population. For countries in the midst of a population transition, the
representation will have the characteristic appearance of a pyramid. The
representation will be narrow at the top, corresponding to few individuals
in the upper age range, and which will get progressively wider for each
younger age range, with the base group representing the greatest number
Uganda is in a region of the world currently in the exponential phase of the population transition. The entire region has an average 3% increase in population per year, ad is expected to contain over one billion people by the year 2025. (Worldbank) Uganda currently has a population of 20,791,000 with an annual population growth of 3.2% over the range from 1980-1995. (UNAIDS, 1998) Here is a graph depicting population growth by the number of people, projected to 2050, from data by the World Resources Database.
We also see the crude birth and death rates for the country. As long
as the large gap exists between the number of births and the number of
deaths, there will be a great increase in population
The population transition has great implications for the status of the HIV/AIDS epidemic. We will see that not only is the population transition important in shaping the epidemiological transition of HIV/AIDS, but the reciprocal relationship is also important.
We have seen how different transitions (social, economic, demographic, etc) have played out in Uganda alone, in combination with each other, and how they have all affected the HIV/AIDS epidemiological transition in that country. Here we have the opportunity to see the reciprocal of how the HIV/AIDS epidemic is interacting with the demographic transition.
The HIV/AIDS epidemic, occurring at such a volatile time in the population transition of Uganda, threatens to make a drastic effect on the outcome. With such a high mortality rate associated with this disease, there is bound to be an effect on the future population, both on numbers and on growth rate. Current estimates are that Uganda will face an additional 1.5 million deaths directly due to AIDS by 2025. (United Nations Population Division, 1996) The total effect on population is therefore the object of many studies, in hopes of coming up with a more accurate estimate of the population transition. One of these studies (Low-Beer, 1997) looked at the effects of HIV/AIDS mortality on the demography of Uganda, in particular the Rakai district.
Within high seroprevalence parishes within the district, there was found negative population growth by 1990-1995. This was seen as a direct consequence of mortality from AIDS. The effects of AIDS mortality on a population must be extremely severe in order to reverse the trend of a high population growth rate. These dramatic effects seen on a local level, though, were muted as the view was expanded. As of yet, there were not even moderate effects on the district level and indeed, there was still strong national population growth.
Also attributable to direct effects of AIDS mortality is the shape of the population pyramid in severely afflicted parishes in Rakai. (Low-Beer, 1997) The youngest age ranges (0-9) are most affected, with the pyramid contracting inwards. The age range 10-14 years is the widest category of the pyramid, corresponding to the greatest number of individuals. There are fewer individuals in the 5-9 year age group and still fewer in the 0-4 year age group.
Besides these direct effects of having fewer people in the population, there will be indirect effects as well. As those individuals in the lowest segment of the population mature to reproductive age, there will be fewer to give birth (than predicted) and so population growth will be slower than first thought. This effect will be reinforced as the epidemiological transition shifts the burden of AIDS mortality to the younger age groups.
Included with the decrease in fertility is the decrease of life expectancy. Currently, the life expectancy for a child born today in Uganda is 41. (UNAIDS, 1998) This represents greater than a five-year drop in life expectance already, and it is expected to continue to drop in the near future. (United Nations Population Division, 1996) Increasing mortality and decreasing life expectancies will be the rule, as the prevalence of HIV/AIDS remains high. The above graph shows how the AIDS epidemic has affected the entire sub-Saharan region. We can see that although the effect is great in Uganda, it is less severe than that of other countries of the region.
This data highlights two points. First, it shows the interrelatedness of the epidemiological and population transitions. Second, this highlights the instability of the exponential growth phase of any transition. Exogenous events, occurring at an inappropriate time, can alter the course of a transition and make the future more uncertain. It will be necessary to revise current estimates of population in the future as epidemiological models change and the direct and indirect effects of HIV/AIDS mortality is taken into account.
The African Family Structure in Transition
A factor intimately tied to the HIV/AIDS epidemic in Uganda is the role of the family, as well as the changing family structure. Most of the sub-Saharan region of Africa, including Uganda, is characterized by extremely poor health resources. Most of the time, the family is called upon to provide support, both emotionally and economically, to those suffering from disease. This is one of the largest roles for the traditional family unit. However, two factors are challenging this role in the modern day HIV/AIDS epidemic. First, the sheer numbers of people afflicted with both sickness and death is taxing even the most stable traditional family structure. Second, the family structure itself is in a state of transition, which serves to both impact and be impacted by the HIV/AIDS epidemiological transition. In order to understand how the family functions in the face of this current crisis, it is first necessary to understand the traditional family structure, and how this structure has changed.
Throughout its history, the family in Africa, and Uganda in particular, was the principle unit of social organization. A basic understanding of a family is "…a social group characterized by common residence, economic co-operation and reproduction…." (Ankrah, 1993) Families consisted of, in order of increasing complexity, the nuclear family – husband, wife, and children; extended family – several nuclear families living together in a common residence; and clan network –a social unit with a common ancestor and common totem. (Ankrah, 1993) A clan network has indeed been found throughout Uganda through the course of history, and even today provides strong kinship ties for most Ugandans.
The purposes of the clan are several. In the largely agrarian society, the clan was the basic social and economic unit of productivity. As land was owned communally, labor needed to be divided accordingly. Men traditionally would perform such duties as land clearing, while women and children would plant and harvest the crops. (Kilbride, 1990) Thus, the clan would be larger and more productive as the fertility of the family increased and more children were produced. In addition, the clan consisted of many extended families with a common residence, strengthened by solidarity and lack of mobility. (Ankrah, 1993)
In addition to the economic purpose, the clan also served to socialize the younger members into the family unit. In the social hierarchy, elders carried wisdom that was involved in the continuous operation of the clan. The younger members, on the other hand, would be the productive force which would not only provide for themselves, but also for the elders who were approaching the twilight of their life; a sort of social welfare. The socialization also involved learning the clan’s norms of behavior, both on the individual and collective levels. An action by an individual reflected on the entire clan. It is through those intergenerational roles that the individuals would learn the most appropriate internal and external social activities.
Most importantly, the clan provided a support network. A characteristic of a clan is its permanence, contrasting to the short duration of the individual members. The clan functioned to maintain its continuity across multiple generations. Any "phenomenon which threatens the survival of the clan system is undoubtedly a major concern of the elders." (Ankrah, 1993) Therefore, the clan network assumed the role of caring for all members of the group. As far as the sick are concerned, extended family members would usually try to support them, both socially and economically. In addition, if there was a death of one or both parents, the children were normally cared for by the clan network.
This traditional view of the social network of the African family is still evident in some rural areas of Uganda today. However, there has been a change recently in the structure of the family unit. Euro-centric ideals as well as influence by the urbanization transition have been responsible for the familial transition seen in Uganda.
As we have seen, there has been a trend towards urbanization as people migrate from rural areas in hopes of getting better opportunities. Concurrent with the increasing urban population has been a reduction in family size and a trend towards nuclearization of the family unit. (Ankrah, 1993) this is mainly due to the inability of urban jobs to provide for enough economic resources for many members of extended families. In addition, as industrialization has resulted in a shift from agrarian to market-based production, there has been a reduced need for many offspring. An important point to note, though, is that the size of the modern African family is small compared with the traditional African family, and not with the modern family of most developed countries. The "small" family still has, on average, five to six member per family. (UnicefUSA, 1998).
The smaller, more urban African family experiences less pressure from clan members than the traditional African family. Socioeconomic interests as well as Euro-centric thought have been shown to undermine the capacity with which the clan influences the behaviors of its individual members. (Ankrah, 1993)
Finally, the social network that was seen as so central a purpose to the kinship has been weakened. For many, a lack of economic resources and/or social desire prevents extended families form aiding other clan members unconditionally. "Only when one family in a kinship is seriously hit by famine, disease, or death does the traditional social obligation of sharing and support become obvious." (Ankrah, 1993) Instead, associations and non-governmental organizations of welfare and common interests, typically seen in Western, industrialized countries, are replacing the support networks of the traditional families. This is seen mostly in Kampala for those families who can afford them. In rural areas and for the less affluent families, the family network may sill be important and called upon in times of crisis. How the family responds is important, as well will see, in how individuals, and indeed the entire population, cope with the AIDS crisis.
So far, I have concentrated on the study of various transitions occurring on a general level in Uganda. It has been through the study of these transitions, in particular population, sociopolitical, urbanization/industrialization, and familial that we can put into context the emergence and resultant HIV/AIDS epidemiological transition. As no transition is entirely independent of any other, I will show that the current AIDS epidemic is intimately linked to the above four transitions.
The African Family Molded by HIV/AIDS
The emergence of the HIV/AIDS epidemic has brought a serious challenge to not only the traditional family structure still seen in some rural areas, but also to the transitioned modern urban family. Indeed, this epidemic has forced most individuals to reform their concept of family and to produce social networks not previously seen in African family life.
One consequence that was previously stated is the heavy mortality of parents. The death of a parent due to AIDS has a devastating effect on the immediate family. Normally, this is the result of the loss of the most productive members of the family. As the mother/wife has the role of being the essential health provider, her death has "profound socioeconomic consequences for her orphans and for her husband, if he survives." (Ankrah, 1993). There have been an estimated 1.2 million children orphaned due to AIDS by May of 1997 (UnicefUSA, 1998). Traditionally, to maintain the continuity of the clan, the extended family was called upon to take up and care for orphaned children. A study in Uganda found that 38% of the orphans were indeed taken by their grandparents, 7% by aunts, 5% by uncles, 5% by sisters/brothers, and 2% by children themselves under 16 years of age (UNAIDSb). However, the role of the extended family has changed due to the shift from traditional to modern family structure.
With smaller, urban families, parental death may cause irreversible damage on the immediate family unit. Unlike in traditional systems, there may not be an extended family nearby. Even if there is, the family may be unwilling or unable to help financially. This was illustrated in the case of a 40 year old man, for example, who was unassisted by a brother living nearby. His brother stated that he was unable to help due to financial responsibilities of his own (Seeley, 1993).
HIV/AIDS has also challenged the socialization role of the family. The data show that a majority of the AIDS orphans is taken in by grandparents. Grandparents are thus forced to provide economically and productively for the grandchildren. In addition, they must continue to provide for themselves because the system of social welfare has been disrupted by the death of the producer generation (Ankrah, 1993).
As HIV/AIDS has a large stigma attached to it, many families will refuse to care for members afflicted with the disease. In some cases, sickness of a member is seen as arising from their behavior – behavior contrary to the social norms adopted by the group. If individual behavior has consequences for the entire clan, then a clan may reject an HIV/AIDS victim to preserve their own integrity. Such is the case for a 35 year old woman studies who was blamed for her own illness by her family and left to die alone (Seeley, 1993).
The impact of the AIDS epidemic on the structure of the Ugandan family has been great. In destroying a large portion of one generation, the resilience of the family in the face of this crisis has been tested. In urban areas, the formation of modern, Westernized institutions of medicine and interest association resources have helped some families to reduce the impact of disease and suffering. However, this assistance is given only to the small proportion of the families who can afford it. For the rest, the family unit still needs to be a strong coping and support mechanism for the needs of its sick members. In any case, the interaction of family structure and the HIV/AIDS epidemic is one that will determine how easily a devastated country can retain some stability.
What do we do now?
Policy in the face of the epidemic
The above discussion has illustrated the effect of transitions on the emergence and spread of HIV/AIDS. It has also considered the present status of the epidemic as well as the potential for future impact. The role of public health is one not only to observe the status of the epidemic, but also to develop strategies to counteract the problem. However, the initial optimism of ridding the world of HIV/AIDS has been replaced by a more resigned attitude of managing a world containing HIV/AIDS. It is said that, "The question is not one of winning or losing the fight against AIDS but rater of cutting our losses. It is time to move from crisis management to epidemic management." (Hearst, 1997) This crisis management is much different, depending upon whether the crisis takes place in the developed or the developing world. As Uganda is very much a developing country, the context of developing country policy recommendations can be directly applied to Uganda.
First, one must consider briefly HIV/AIDS management in the developed world. The perception of a person living with AIDS in the United States is one of a person living with a chronic disease. With the introduction of combination therapy, most people can continue with their daily life activities throughout most of their significantly extended course of infection. However, these drugs come with a price tag of around $10,000 per year per person. Nevertheless, the availability of wealth in the United States has allowed for most of the infected individuals to obtain this sort of treatment.
Such is not the case in developing countries in Africa, where the per capita annual health expenditures typically range only from US$5-10. A study in 1991 found that in Uganda, 97% of the mean cost of care of individuals suffering from AIDS was spent on drugs, although this corresponded to only roughly US$6.40 per episode of treatment. (Okello, 1994) The same study also concluded that the cost of essential drugs for AIDS alone could total more than the entire health budget of the country. Therefore, as a review of much literature has supported, future policies should not focus on drug treatment. Rather, resources should be spent on interventions leading to the prevention of HIV transmission.
With the limited number of resources available in developing countries, the best possible strategy for intervention (and the one used so far) is education. As it is through behavior that people are infected, the ultimate goal of education should be behavior modification. Yet, despite the fact that the epidemic has been around for 15 years or so, many people still do not know how HIV spreads or how to protect themselves from infection. This must be the first priority for prevention education. It is only through understanding the disease that people can be proactive, change their behavior, and protect themselves. There are two behavior modification methods that have been emphasized to curb HIV transmission: abstinence and condom use.
Since abstinence is the only sure way to prevent HIV transmission, this is a logical target for behavior modification education. As strict avoiding of sexual contact is overwhelming and, in reality, unrealistic there has been rather a stress on the importance of avoiding casual sex partners, as well as monogamy with the primary sexual partner. As we have seen, one of the initial factors for the amplification of HIV/AIDS was the use of female commercial sex workers by young, urban, male professionals. Reducing the number of sexual contacts with this high-risk group will have two effects. First, direct effects will predict that those who abstain from this sexual behavior will not become infected. Second, as those men are not becoming infected, they will not be passing on the infection to their primary female partners, and the chain of transmission will be broken. In addition, as the men are not infected, they will not further infect other female sex workers, and the pool of amplification will not occur. This will result first in a decline of the level of infection in the high-risk population, will subsequent decline of levels of infection in the general population. The importance of abstinence, particularly of high-risk sexual behavior, and monogamy as the two most important behaviors leading to decreased transmission is well documented. Recent widespread evidence supports the trend that education is working and the number of men having sex with casual partners is decreasing.
The effects of condom use on infection in the population are similar to those for abstinence. However, the risk of transmission with the use of condoms, albeit low, is still higher than the risk associated with abstinence. Therefore, one could say that interventions stressing condom use are not as effective, in terms of resource use, than those stressing abstinence. In reality, though, behavior modification leading to the use of condoms is probably much more realistic than trying to prevent sexual contact at all. Therefore, increasing condom use is a goal that one should not underestimate. Research done to achieve this goal has identified problems inhibiting condom use, such as embarrassment or not knowing how to use a condom. (Kamya, 1997) This study gives targets for educational interventions aimed at promoting condom use among men. Widespread evidence indicates that due to such research, condom use is on the rise.
The above two interventions are indeed extremely important in reducing transmission, and have been two targets of resources so far in Uganda. Yet, these interventions will not be completely successful. The main reason for this is that these interventions are very specific and reactionary to the HIV/AIDS epidemic. As I have discussed above, the epidemic did not emerge simply because men were having sexual contact with casual partners without the use of condoms. Indeed, this behavior has occurred throughout the whole of human history. A mixture of many exogenous variables (imperialism, civil war, migratory patterns, developmental processes, etc.) resulted in a particular dynamic of sexual behavior. With the introduction of the HIV virus, this dynamic set up the characteristic processes of spreading infection. Therefore, the goals for interventions must address the root causes of the sexual behavior dynamic, as well as address the grand scope of development. (Topouzis, 1998) I will highlight two of these more basic factors in particular.
First, cultural norms have established sexuality as a taboo in Uganda. It is socially not acceptable to openly discuss sexual behaviors. Even if they are aware, women are not supposed to talk about their husbands’ other casual sex partners. It is not acceptable to ask a partner to wear a condom, or for men to talk about using condoms. This has several negative impacts, when considering the above behavior modification interventions. Men may neither feel pressure to be monogamous nor to wear a condom with his sex partners. A second cultural factor limiting these interventions relates directly to sexual practices. When a man dies, his widow is expected to have sexual intercourse with her husband’s brother. In this way, the brother is cleansing the brother’s death. (Magezi, 1991) This practice is an important factor in HIV transmission. These two examples show the importance of trying to understand why contact patterns exist in order to look for ways to change them.
Just one example of a more broad-spectrum intervention would be the empowerment of women. As it is now, 25% of women in a town in Rwanda with one lifetime partner are infected with HIV. (DeCock, 1994) The poor status of women plays a direct role in causing this infection. One expects a woman to be dependent on her husband. In addition, the taboo prevents women from talking about sexual practices or the use of condoms. The result is that many women, even if they are aware of how HIV is transmitted, have no choice but to submit to their husbands. Many of these women will thus become infected due to their husband’s sexual pattern.
Empowerment of women will allow them to resist this dependence on men. They will be educated on how to protect themselves, and encouraged to stand up for their own rights. This may force men to become monogamous, use condoms, or face loss of their wife. In addition, empowerment of women would give women increased economic opportunity. Further, increased competition for jobs could reduce the number of sex workers, reducing the high-risk core group. Empowerment of women may be able to prevent HIV transmission to a much greater extent than other interventions presently in place. However, it is an intervention that requires a reevaluation of an entire society as well as a much more profound commitment to change. Even if this commitment is taken, there has to be an availability of resources, which is even more difficult in a developing country. This is one example of an issue that is much more difficult to resolve than by distributing pamphlets and free condoms.
We have seen how the emergence of HIV/AIDS was intricately linked to exogenous causal factors and transitions. In addition, the HIV/AIDS epidemic has the potential to have an impact in many spheres of Ugandan society. Policies developed to manage a world with HIV/AIDS must not lose site of this fact and must address the development of the country as a whole in order to combat this horrible crisis.
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