Mind the gap: bridging cultural differences to tackle HIV among Israel's Ethiopian Community

Mind the gap: bridging cultural differences to tackle HIV
among Israel's Ethiopian Community

source MSD Israel

The exodus of Ethiopian Jews (Falashas or 'outsiders') from Ethiopia to Israel began in 1977, reached its peak in the 1980s, and continues to this day. Fleeing persecution, famine and war, Ethiopian Jews in Israel now number 110,000.

"How a Jewish community first came to settle in Ethiopia is still a mystery today, sustained by the lack of written records and a taste for oral traditions. Some Jewish Ethiopians claim to descend from King Solomon and Queen of Sheba (the Ethiopian legend says that she went to Jerusalem to drink from his wisdom, she enjoyed more than his hospitality and returned home pregnant with his son, Menelik I).

This historical romance is challenged by those who believe they are either descendants of the lost ancient Israelite tribe of Dan, or of Jews who left Israel for Egypt and then Ethiopia following the destruction of the First Temple in 586 BCE.

Supporter or detractor of this story, one has to admit that for thousands of years, the Jewish community maintained a strict Judaism in Ethiopia."

Israel granted the Ethiopian Jews Israeli nationality upon their arrival, and also gave them language classes, health coverage, social counseling, job training, housing, mortgage loan facilities, access to higher education and jobs in the armed forces. Government efforts to integrate the Ethiopian Jews into employment focused on providing basic skills through specially developed vocational training programs to help in the transition from agricultural activities to careers in an industrial society.

The assimilation challenge

Whilst Israel is an old hand at assimilating newly-arrived Jewish communities, the integration of the Ethiopian Jews has not been smooth.

The biggest challenge for the Ethiopians has been to move from a rural developing nation with low educational standards into a Western nation with a high-tech market economy. Language is a major barrier, with most of the adults still communicating in their native Amharic and Tigrinya. The most recent wave of immigration is controversial, for the rate of HIV-positive cases among the members of the Ethiopian Christian community arriving from Addis Ababa (Ethiopia's capital city) is rather high (between 5 to 10%).

Until 1996, no-one had ever questioned the fact that unlike other immigrant communities, Ethiopians aged nine and over were systematically screened for HIV on their arrival in Israel. But an incident occurred in January 1996 which jeopardized the whole integration process. The newspaper Maariv reported that blood donated by Ethiopian immigrants had been thrown away because of fear of HIV contamination. Since every Israeli citizen is entitled to give his/her blood to save lives, throwing away the Ethiopian's blood was in violation of the Israeli Blood Bank's policy. It also implied that it was not good enough for Israelis. The effect was a double blow to the Ethiopian community. Not only did they now feel like second-class citizens, they were also shunned by the rest of Israeli society as potential HIV carriers. Ten years later, the Ethiopian community still recalls this incident as the start of their ostracism by Israeli society.

The HIV/AIDS challenge

At present, Israel is dealing with three distinct HIV problems:

An epidemic among men having sexual relationships with men (MSM)
An epidemic among intravenous drug user (IDU) immigrants from the former Soviet Union
Heterosexual transmission among immigrants from Ethiopia

The HIV prevalence rate among Ethiopian immigrants is currently 6%. For many among older generations of Ethiopians, there are different possible explanations for the disease; for them its cause is neglect of their ancestors, failing to observe taboos and poor social and moral conduct.

The government's main weapons in its war on HIV/AIDS include HIV/AIDS awareness programs, health education, social support, sexual education and women's empowerment. The National HIV/AIDS program has a vast array of services on offer: free antiretroviral drugs, free condoms for life and breastfeeding substitute programs. But without being tailored to the specific needs of the Ethiopian community and in the absence of partnerships with Ethiopian immigrant religious and political leaders, these services are often failing to reach their intended target.

The situation is not helped by the communications issues between the Ethiopians patients and the medical community. Very few Israeli doctors and nurses speak Amharic or Tigrinya. Whilst health professionals may use translators, lack of cultural knowledge is a serious obstacle, particularly when it comes to HIV/AIDS. With little common ground between the Ethiopians and the Israeli medical system, many Ethiopians infected with HIV consult traditional healers, sometimes making special trips back to Ethiopia if they are not satisfied with the diagnosis of local physicians. Limited trust in the efficacy of drugs partially explains the low adherence rates, despite the availability of free antiretroviral therapies, fully subsidized by the Israeli government.

Communication issues start already in absorption centers: the challenge triggered by the Israeli society in their daily life regarding their culture, their customs, their religion, their knowledge and understanding of the disease led the older immigrants to face barriers to a successful integration. Furthermore, stigma and fear of being identified as HIV-positive are huge obstacles to their use of the national health services and the seven national HIV treatment centers across the country. They also prevent people from disclosing their HIV status.

Israel

According to Dr Eliyahu Trunh, an Ethiopian family doctor in Hadera, the Ethiopian family unit exacerbates the spread of HIV. Some men are very mobile and enjoy a return to bachelorhood a few weeks now and then, during their many trips to Ethiopia to visit friends and relatives. Their insertion to the Israeli society gives them access to a relatively high disposable income compared to locals which indirectly puts them at risk of infection: while certain travel alone for visit trips back to Ethiopia, they might be having at risk behaviors and, at their return to Israel, they might pass HIV to their wives. At the same time, some women in difficult social situation (especially those who need to raise children alone and whose social status weaken their possibility to ask for protected contacts) are involved in non-protected contacts with other men who are supporting them in their everyday life. These contacts have been identified as a strong factor for HIV spreading among the community... The older generation is struggling with their traditional beliefs and losing its authority. Thus the generation gap between parents born and raised in Ethiopia and their adolescent children raised in Israel is fast becoming a chasm. However, Dr Trunh is more optimistic about the future for young Ethiopians: 'Kids know more about HIV/AIDS via the Internet and newspapers. They understand the situation. They have the same culture as the Israeli youth. The next generation will be safer, but in the meantime we have to do something for the adults'.

A change of perspective

Partnerships, between the government and NGOs or organizations specialized in community outreach, such as the Israel Family Planning Association (see Box), are badly needed if the national goals of integrating the Ethiopian Jews and simultaneously controlling the HIV epidemic are to be achieved.

In 1997, the Ministry of Health created an HIV awareness program targeted at the Ethiopian community. It includes HIV prevention workshops at the absorption centers, where groups of 15 to 20 people are trained to talk about sexual relationships. Actors are often brought in to facilitate the talks on HIV/AIDS through community theatre groups, and movies are shown to younger children. Once a week, there was a radio program in Amharic that talked about general subjects, including health issues like HIV/AIDS. This broadcast used to be very popular among Ethiopian housewives.

Ruth Weinstein (Director of the Department of Health Promotion and Education at the Ministry of Health) and her colleagues are proud of their first support group for HIV-positive men who recently talked about their lives, in Amharic, on the local radio. They had so much success that they intend to replicate the experience in other towns.

Israel is at a crossroads: maintaining its peace process and seeking religious pluralism are tough challenges. The country cannot afford to fail the integration of the Ethiopian Jews into its multi-cultural society. It is using paraprofessional mentors from the early wave of Ethiopian immigrants to act as cross-cultural mediators between the government social services, Israeli employers and the Ethiopian community members.

Talking the Same Language: the Israel Family Planning Association

The Israel Family Planning Association (IFPA) is an NGO created in 1966 to promote reproductive and sexual health, especially among adolescents and young people. Its services include Open Door counseling centers, a training center, a library and an information center on sexual health.

Dr Ilana Ziegler, IFPA's Executive Director, is an expert in reaching immigrant communities. Following some amazing results with Russian immigrants she was asked by the Ministry of Health to replicate the same strategy for the Ethiopian Jews. She and her team of psychologists and health workers adopt a culturally-sensitive approach when working with communities and consider the special needs of each community:

'The problem with us is that we do not listen enough, we do not evaluate our progress or failures. Israeli doctors misdiagnose the Ethiopian patients because they do not interview them properly. They lack the knowledge of Amharic and totally rely on translators' understanding; they lack the "sexuality language" and are unable to understand the African "body language". It is not done intentionally, but at the end money is wasted. Professionals from the Ethiopian community should be provided with the necessary scientific information and professional skills to work in their own communities'.

Ilana criticizes the paternalism of some organizations towards the Ethiopian community: 'We must listen to what they have to tell us, show them alternatives when they beat their wives just because it is part of their culture. This is not acceptable in our society but the solutions must come from them. We must empower women, but also men', she adds. Like Dr Trunh, she thinks that the parents are in greater difficulty than their children. Unlike him, she thinks that throwing money at the problem is not the best way to promote integration and awareness. She suggests that the solution is to build their understanding and acceptance of the problem, and from there they will come to adopt the Israeli family model themselves. Women's ability to insist on protected sex with their partner would be a great achievement, for instance.

Ilana has organized an HIV/AIDS awareness competition for high school children in collaboration with the Ministry of Education. She indicates the collection of posters: 'Look at all these marvelous concepts and representations. I would not be surprised if some of them came from Ethiopian students.'

The Israel Family Planning Association (IFPA) is one of the prospective partners in a public-private pilot partnership that MSD Israel and MSD HIV Access Programs plan to initiate with the municipality of Ashdod to respond to the HIV epidemic in a comprehensive and cost-effective manner. Ashdod is Israel's fifth largest town. Created in 1956, it has an estimated population of 9,500 Ethiopian Israelis out of a total population of 196,000.

This pilot partnership will have two major goals: to evaluate ways to improve adherence rates to Highly Active Antiretroviral Therapy (HAART) among Ethiopian Israelis living with HIV/AIDS, and, together with the IFPA, evaluate pilot activities focused on decreasing the risk of HIV transmission among this group. It will coordinate the response to HIV/AIDS across and within sectors, and reduce HIV-related stigma and discrimination in Ashdod and especially within the Ethiopian community.

IFPA will bring to the project its vast experience in managing successful projects in different populations, as well as its huge network of collaborative organizations, and its recognized legal management and budgeting skills. An initial assessment will gather baseline data, including key epidemiologic, ethnographic and behavioral information.

Evaluation, monitoring and publication of the project's impact on behavior and public health is expected to provide effective leverage for government resources, will reduce stigmatization of the Ethiopian community and to improve management of Ethiopian Israeli HIV-infected patients. Thus there is still hope for Israel's ostracized and marginalized Ethiopian community.

Interview and article by S. d'Aurelle de Paladines, Editor: Fiona Hall