Cover image courtesy of International Orthodox Christian Charities.
Written by Mikita Dzialendzik, The University of Oklahoma
Abstract
This blog post explores the conflict between providing help in the fight against Podoconiosis in Ethiopia and the distrust that the Ethiopian people have of Western aid. Ethiopians have had a long history of being skeptical about accepting help and information from other countries, particularly the West. This distrust makes it difficult for any Western humanitarian organization to reach the Northern Ethiopian community with any meaningful help. International Orthodox Christian Charities (IOCC), a humanitarian organization organized by Orthodox Christians in the West, has been establishing clinics and providing treatment to locals struggling with Podoconiosis, an infection affecting the feet and increasing the difficulty of walking. Podoconiosis, while treatable, is mostly fought through prevention, specifically wearing shoes, as the infection travels when feet are exposed in unsanitary conditions.
This blog post argues that the IOCC manages to foster trust in Northern Ethiopia despite it being an organization funded and managed by the West and present in a country that is notorious for distrusting Western aid. The IOCC does this by using established local institutions to promote their clinics. The post also explains that the use of existing local Church infrastructure facilitates the distribution of supplies and education to treat Podoconiosis in Northern Ethiopia, and provides an opportunity to disseminate information through sermons, as well as IOCC’s coordination with local and international groups to treat it more effectively.
A clinic with tubs to clean feet, treating Podoconiosis [1].
Background
Western aid to Africa has long been marred by a horrible reputation of exploitation and colonialism. In many cases, well-intentioned humanitarian work has failed to fix and often worsened the social positions of African countries. Many African countries now meet offers of aid with significant skepticism and distrust, even if they are in dire need of help.
This is the current situation of Ethiopia as it is struggling with Podoconiosis. Podoconiosis is a crippling disease that is present in this region of the world and in most countries close to the equator. Podoconiosis spreads when bacteria, festering in the dirt, enter broken skin and progressively causes severe inflammation along the foot and lower leg, causing pain that prevents those afflicted from working or even walking. It has recently been classified as an NTD (Neglected Tropical Disease), bringing international attention and aid to the disease. Approximately one million Ethiopians suffer from some form of Podoconiosis [2]. Impacts from this disease are not simply individual; when any person is infected, they may become unable to provide for their families instead becoming a burden, another person for whom to care. Dust-covered roads and a scarcity of adequate footwear, combined with an economy dependent on agriculture, all too common in Northern Ethiopia, create the perfect combination of conditions for this disease to negatively impact a significant part of the population [3].
Ethiopia has had a unique position in the history of Africa. It is one of two countries in Africa that was not under colonial rule for a significant amount of time during the 19th and 20th centuries, the other being Liberia [4]. Ethiopia was able to maintain its position as an independent and sovereign state due to its strong military response to both Egyptian and Italian aggression in the century before the Scramble for Africa – the colonization of nearly all the African continent by European powers [4]. Even during Italy’s short-lived occupation of the country, Ethiopia was able to maintain a strong national identity. This strong military response and independent identity protected the country from subjugation to many of the devastating effects of colonialism, but it contributed to a lasting cultural resistance to any foreign actors within Ethiopia, whether those workers come to hurt or to help.
Even in the contemporary era, Ethiopia tends to exhibit a certain tension with the international community; one clear example is commissions from the United Nations that focus on the promotion of human rights. In one case, the government in Ethiopia signed on to participate in an international agreement in promoting the rights of racial minorities. Although the government agreed to participate with the Commission on the Elimination of Racial Discrimination (CERD), it has not cooperated in sending reports on its progress. Another commission on women’s rights has stated that “to date, nothing has been received regarding the rights of Women in Ethiopia since this report, four years ago” [5]. This tension has caused frustration on the side of the international community, specifically, “the committee is forced to adopt concluding observations based on information received from other sources” [5]. A failure of communication perpetuates distrust on both sides: the local population and the international community.
The Ethiopian government’s reluctance to report on its own activities is not simply a function of not meeting deadlines or lacking resources to do research (although those are certainly factors affecting reporting). Even on a local level, the same report writes extensively on “Informal Justice Systems,” traditionally operating to enforce cultural norms [5]. Even if the national constitution prohibits certain discriminatory cultural behaviors, people, in their distrust, set up courts centered on religious or local leaders. Thus, the national government finds itself in a balancing act, does it trust the international community and risk alienating its own population, or does it continue this state of distrust in an attempt to grow closer to its citizens.
Fighting Podoconiosis
This distrust has hindered the ability of aid workers and medical professionals from Western charities to make significant progress in the fight against Podoconiosis. While other Western organizations struggle to access victims of Podoconiosis in Ethiopia, International Orthodox Christian Charities (IOCC) is able to succeed in garnering trust among locals in the fight against Podoconiosis due to its relationship with an important cultural structure, the Ethiopian Orthodox Church. Unlike much of Christianity throughout Africa, the Ethiopian Church has maintained a strong presence for over 1,000 years in Ethiopia’s local communities. Thus, it does not exist as an arm of Western culture; instead, it is a local and self-sufficient institution that has been integrated with the local culture for many generations. The Church, in addition to being a cultural structure, also provides much of the physical infrastructure necessary to conduct education and treatment surrounding this disease, especially in more rural regions of Northern Ethiopia.
The social stigma surrounding this disease compounds the existing distrust of aid. People suffering from Podoconiosis are often unable to participate in many societal functions, both because of difficulty walking and because of societal discrimination that can occur from their physical disfigurement [6]. One woman affected by the disease explains that she was constantly belittled, mostly because the community and her former fiancé saw her as “unfit to be a wife.” She relied on family and friends for practically any need that she had, causing her self-image to plummet [6]. This social pressure from the community has severe consequences for anybody unfortunate enough to contract the disease. It is an alienating situation, as the most trustworthy environment, her local community, continued to deny her social acceptance until she received treatment.
The data shows that this is not simply an individual case. One study found 55.8% of people in affected areas display unfounded discriminatory behavior toward those suffering from Podoconiosis [7].
International Orthodox Christian Charities began its work in Ethiopia in 2003 [8]. The organization chose to add the fight against Podoconiosis to its projects in the country after realizing just how widespread Podoconiosis is. Its focuses when treating the disease are education (both medical professionals and local leaders), prevention, and treatment.
Before starting, IOCC had to understand the communities they were helping in order to help build trust. Sara Tomczyk explains how IOCC had to learn about people’s current understanding of the disease. They interviewed community leaders, church officials, local laborers, and civilians in rural villages to create a framework of what people already knew about Podoconiosis and how to approach education about the disease [2].
Education is the most difficult of these and it is the most important, as the other two focuses rely on accurate knowledge. Without education, many rely on faulty information to learn about the disease. Ethiopian culture has already developed causes and legends surrounding the transmission of Podoconiosis before anybody could research the problem. One survey conducted in the area found that “the majority of participants reported that their beliefs about the causes of Podoconiosis were based on oral traditions and rumor” [6]. Some have falsely explained the disease as being the result of a curse. There are other popular proposals for potential causes: stepping on a dead animal, stepping on a snake, contacting an infected person, and mosquito/insect bites [6]. 47% of people in one survey did not realize that treatment even existed [6]. As more people become aware of the true causes of Podoconiosis, which is infection through the soil, societal discrimination is bound to subside. Coupled with the fact that Ethiopians tend to trust local sources more than doctors from abroad, a lack of education surrounding the disease becomes a critical obstacle in stopping the effects of Podoconiosis. Because of the significant misinformation spreading throughout the affected communities, it becomes even more critical to develop a sense of trust for the IOCC.
Education is conducted both at clinics and in churches. In clinics, run by partner organizations, usually the Mossy Foot Treatment and Prevention Association (MFTPA), people are taught how to wash their feet routinely in order to prevent infection. The IOCC advises priests in the churches to prepare homilies about the factual causes of Podoconiosis [3]. As a faith-based organization, their appeals for action are taken much more seriously by religious authorities, and the infrastructure of churches is much more accessible than it would be for other Western organizations. Using established local leaders to deliver information about Podoconiosis is more effective than other means because their roles in the community are treated as legitimate sources of authority. When people from outside of the community share information about the disease, even if it is good information, the message is much less likely to resonate. In addition to faith leaders, IOCC seeks cooperation with medical professionals in the country [3]. For those who trust medical professionals over the clergy, cooperation with medical professionals adds another layer of credibility and trust whenever distributing critical information to affected communities.
There is an important reason for IOCC’s focus on education over other forms of fighting the disease, again feeding into building trust with the community. Whenever educating the public, IOCC’s goal is to educate enough people for the community to become equipped to fight the disease on its own. The organization relies on people educated in these courses to then spread the information to their friends and neighbors. Not only, then, does the accurate information about Podoconiosis come from their religious leaders, but also from the community as a whole.
Prevention also plays a key role in combating Podoconiosis. Clinical literature surrounding the disease repeatedly states that wearing socks and shoes to prevent infection when exposed to unsanitary roads or fieldwork can largely eliminate the potential of contracting Podoconiosis. Wearing proper socks and shoes prevents contaminated dust particles from entering cracks in the skin. However, 46% of the affected Ethiopian population is unaware that the disease is spread through contaminated soil and another 9% is unsure of the disease’s cause [9]. Even if people understand the enormous impact that proper shoe wearing can have on preventing infection, “almost 70% of respondents state that they cannot afford them” [10]. This poverty presents another challenge for responding to Podoconiosis, and IOCC does find ways to make footwear more affordable for that 70% of people, primarily by distributing shoes through associated clinics.
Treatment for Podoconiosis is done at some clinics funded and managed by the IOCC, but most clinics are managed by a partner organization. Mainly, the clinics work on washing feet and providing resources (like soap, socks, and shoes) to prevent and treat the disease individually at home. The same woman who faced social stigma from the disease also described her experience in one clinic in Debre Markos. In her case, she received one week of daily treatment for her swollen feet after which she immediately felt better [11]. Treatment is not extraordinarily complicated, consisting mainly of cleaning and sanitizing legs and feet, meaning she was able to return home to continue receiving treatment separately from the clinic.
Consistent data collection is another challenge presented to those attempting to fight Podoconiosis. The government does not reliably collect or distribute information about Podoconiosis prevalence, so private organizations and universities are often tasked with the tedious work of mapping the spread of the disease. One such mapping, conducted by the organization Parasites and Vectors, had to travel to 659 districts to test and identify people with Podoconiosis [12]. International Orthodox Christian Charities, particularly in the Northern region, have access to the Ethiopian Orthodox Church, which reaches most of these remote areas, presenting an available infrastructure that may be used to collect data and statistics more efficiently than other international aid groups.
The IOCC also works with other local institutions to prevent the impacts of this disease. In one academic journal, representatives from IOCC mention that one of the strategies used by the IOCC is interacting with local universities and businesses to develop solutions for this public health crisis [7]. While international organizations still coordinate in responding to Podoconiosis, using local entities to combat the disease builds trust between the local population and IOCC. Using local resources also builds self-sufficiency in fighting Podoconiosis. If the international community had to limit or stop its involvement in the region, there would still be progress, as these local entities would continue to provide resources and information to the surrounding community, even if they do so less effectively. In contrast, reliance on international groups for the response would immediately halt any progress made if a similar situation was to occur.
Room for Improvement
A few weaknesses remain in IOCC’s response to Podoconiosis, some of which are beyond the organization’s control. One clear weakness is in the very name of the organization; its existence as a faith-based organization, while cultivating trust in many of the victims that it helps, also presents a difficulty when reaching others outside of the faith. As it explains on its website, IOCC does not have explicit barriers to obtaining treatment if a victim does not belong to the Church. The organization provides aid to many different countries and cultures around the world, many of which do not have a Christian majority. However, about 7% of the population in affected areas of rural Northern Ethiopia does not identify as Christian, and for those people, an organization based around a faith that they do not practice can present another reason to distrust the Western organization coming to help them [10]. If they are not Orthodox, they often will not hear about methods of preventing and treating the disease from their own religious leaders. Even if this is only a minority of people in the area, considerations must be made to relate any information to them as well. It will be more difficult for the IOCC to reach religious minorities by itself, and for this reason, it is important for the IOCC to continue its policy of working with other entities to make progress with Podoconiosis in those communities.
Treating Podoconiosis also relies heavily on accessing victims. This disease takes away people’s ability to transport themselves to a clinic. One study found that the most common reason for patients to discontinue treatment is due to their inability to walk to receive treatment. Some patients would need to walk 45km (28 miles) for treatment [10]. IOCC is able to reach small villages through the use of local churches and clinics that it or its partners set up, but many victims are still unable to walk to the nearest clinic or treatment center. The transportation difficulty is exacerbated because of the federal government’s failure of implementing resources and policies to assist people with disabilities. According to one UN commission focused on promoting the rights of those with disabilities, despite the fact that the Ethiopian federal government has laws defending those who happen to be disabled “the local enforcement of these rights in practice, however, is difficult” [13]. People who cannot walk or face social stigma also face difficulty in hearing the previously mentioned homilies about treatment and prevention. The information given in the churches is extraordinarily valuable in educating the public, as many Ethiopians or their loved ones go to church where they can learn about Podoconiosis without needing to travel to a clinic far from home, which is an improvement from relying solely on clinics. Traveling, particularly if it is by foot, remains a difficulty in treating Podoconiosis in Northern Ethiopia.
Conclusion
Nonetheless, when it comes to ending Podoconiosis, IOCC has positioned itself as a leader in Northern Ethiopia. In a country where people are still struggling to trust international aid because of its complex and brutal history, IOCC’s focus on establishing trusting relationships with the people that it is helping has proved critical to progressing in the fight against the disease. It primarily works through education, but the IOCC still significantly participates in prevention and treatment. Despite many hardships in its response to Podoconiosis, IOCC’s unique ability to garner trust among Ethiopian communities through the local churches and community leaders has made fighting Podoconiosis far easier, both for the IOCC and for its partnering organizations.
This post may have been edited by admin for clarity and length.
Bibliography
Primary Sources
Amorcos, “Fight Podo,” YouTube video, 2:16, May 17, 2012, https://www.youtube.com/watch?v=5bnxD8wTO1Q.
International Orthodox Christian Charities. Mark Hodde visit. 2013. Digital Image. Accessed April 15, 2021. https://iocc.org/wp-content/uploads/2019/04/2013-Health-Podo-Treatment-Patients-Mark-Hodde-visit-1024×683.jpg.
International Orthodox Christian Charities. “Health.” Accessed April 15, 2021, https://iocc.org/how-we-serve/health.
International Orthodox Christian Charities. “Tackling Podoconiosis.” Accessed April 18, 2021, https://iocc.org/how-we-serve/tackling-podoconiosis.
Tomczyk, Sara, Abreham Tamiru, and Gail Davey. 2012. “Addressing the Neglected Tropical Disease Podoconiosis in Northern Ethiopia: Lessons Learned from a New Community Podoconiosis Program.” Edited by Patrick J. Lammie. PLoS Neglected Tropical Diseases 6 (3): e1560. https://doi.org/10.1371/journal.pntd.0001560.
Tomczyk, Sara. “IOCC and Philoptochos Help Ethiopia Children Combat Dreaded Disease.” International Orthodox Christian Charities News & Needs 13, no. 1 (2010): 1. Accessed April 18, 2021. https://iocc.org/wp-content/uploads/2019/07/iocc-news-needs-spring-2010.pdf.
Secondary Sources
Ayode, Desta, Tsega Gebreyesus, Hendrik de Heer, Getnet Tadele, Emi Watanabe, Abebayehu Tora, Colleen M. McBride, and Gail Davey. 2012. “The Association of Beliefs about Heredity with Preventive and Interpersonal Behaviors in Communities Affected by Podoconiosis in Rural Ethiopia.” The American Journal of Tropical Medicine and Hygiene 87 (4): 623–30. https://doi.org/10.4269/ajtmh.2012.12-0204.
Campion, Alice, Abreham Tamiru, Girmay Tsegay, and Gail Davey. 2015. “Reasons for Loss to Follow-up of Patients with Podoconiosis in the Amhara Region, Northern Ethiopia.” International Health 7 (5): 367–73. https://doi.org/10.1093/inthealth/ihu099.
Deribe, Kebede, Sara Tomczyk, and Fasil Tekola-Ayele. 2013. “Ten Years of Podoconiosis Research in Ethiopia.” Edited by Richard O. Phillips. PLoS Neglected Tropical Diseases 7 (10): e2301. https://doi.org/10.1371/journal.pntd.0002301.
Maclachlan, Malcolm, and Leslie Swartz, eds. 2009. Disability & International Development. New York, NY: Springer US. https://doi.org/10.1007/978-0-387-93840-0.
Sime, Heven, Kebede Deribe, Ashenafi Assefa, Melanie J Newport, Fikre Enquselassie, Abeba Gebretsadik, Amha Kebede, et al. 2014. “Integrated Mapping of Lymphatic Filariasis and Podoconiosis: Lessons Learnt from Ethiopia.” Parasites & Vectors 7 (1): 397. https://doi.org/10.1186/1756-3305-7-397.
Yakob, Bereket, Kebede Deribe, and Gail Davey. 2008. “High Levels of Misconceptions and Stigma in a Community Highly Endemic for Podoconiosis in Southern Ethiopia.” Transactions of the Royal Society of Tropical Medicine and Hygiene 102 (5): 439–44. https://doi.org/10.1016/j.trstmh.2008.01.023.
Other
Lumen. “The Independent African States.” Accessed April 18, 2021. https://courses.lumenlearning.com/boundless-worldhistory/chapter/the-independent-african-states/.
[1] International Orthodox Christian Charities. Mark Hodde visit. 2013. Digital Image. Accessed April 15, 2021. https://iocc.org/wp-content/uploads/2019/04/2013-Health-Podo-Treatment-Patients-Mark-Hodde-visit-1024×683.jpg.
[2] Tomczyk, Sara, Abreham Tamiru, and Gail Davey. 2012. “Addressing the Neglected Tropical Disease Podoconiosis in Northern Ethiopia: Lessons Learned from a New Community Podoconiosis Program.” Edited by Patrick J. Lammie. PLoS Neglected Tropical Diseases 6 (3): e1560. https://doi.org/10.1371/journal.pntd.0001560.
[3] International Orthodox Christian Charities. “Tackling Podoconiosis.” Accessed April 18, 2021, https://iocc.org/how-we-serve/tackling-podoconiosis.
[4] Lumen. “The Independent African States.” Accessed April 18, 2021. https://courses.lumenlearning.com/boundless-worldhistory/chapter/the-independent-african-states/.
[5] Sime, Heven, Kebede Deribe, Ashenafi Assefa, Melanie J Newport, Fikre Enquselassie, Abeba Gebretsadik, Amha Kebede, et al. 2014. “Integrated Mapping of Lymphatic Filariasis and Podoconiosis: Lessons Learnt from Ethiopia.” Parasites & Vectors 7 (1): 397. https://doi.org/10.1186/1756-3305-7-397.
[6] Yakob, Bereket, Kebede Deribe, and Gail Davey. 2008. “High Levels of Misconceptions and Stigma in a Community Highly Endemic for Podoconiosis in Southern Ethiopia.” Transactions of the Royal Society of Tropical Medicine and Hygiene 102 (5): 439–44. https://doi.org/10.1016/j.trstmh.2008.01.023.
[7] Deribe, Kebede, Sara Tomczyk, and Fasil Tekola-Ayele. 2013. “Ten Years of Podoconiosis Research in Ethiopia.” Edited by Richard O. Phillips. PLoS Neglected Tropical Diseases 7 (10): e2301. https://doi.org/10.1371/journal.pntd.0002301.
[8] International Orthodox Christian Charities. “Health.” Accessed April 15, 2021, https://iocc.org/how-we-serve/health.
[9] Ayode, Desta, Tsega Gebreyesus, Hendrik de Heer, Getnet Tadele, Emi Watanabe, Abebayehu Tora, Colleen M. McBride, and Gail Davey. 2012. “The Association of Beliefs about Heredity with Preventive and Interpersonal Behaviors in Communities Affected by Podoconiosis in Rural Ethiopia.” The American Journal of Tropical Medicine and Hygiene 87 (4): 623–30. https://doi.org/10.4269/ajtmh.2012.12-0204.
[10] Campion, Alice, Abreham Tamiru, Girmay Tsegay, and Gail Davey. 2015. “Reasons for Loss to Follow-up of Patients with Podoconiosis in the Amhara Region, Northern Ethiopia.” International Health 7 (5): 367–73. https://doi.org/10.1093/inthealth/ihu099.
[11] Tomczyk, Sara. “IOCC and Philoptochos Help Ethiopia Children Combat Dreaded Disease.” International Orthodox Christian Charities News & Needs 13, no. 1 (2010): 1. Accessed April 18, 2021. https://iocc.org/wp-content/uploads/2019/07/iocc-news-needs-spring-2010.pdf.
[12] Sime, Heven, Kebede Deribe, Ashenafi Assefa, Melanie J Newport, Fikre Enquselassie, Abeba Gebretsadik, Amha Kebede, et al. 2014. “Integrated Mapping of Lymphatic Filariasis and Podoconiosis: Lessons Learnt from Ethiopia.” Parasites & Vectors 7 (1): 397. https://doi.org/10.1186/1756-3305-7-397.
[13] Amorcos, “Fight Podo,” YouTube video, 2:16, May 17, 2012, https://www.youtube.com/watch?v=5bnxD8wTO1Q.
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